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97 Exploring Urban-Rural Disparities in Alzheimer’s disease: Clinical characterization of a southern Nevada cohort
- Justin B Miller, Christina Wong, Jessica ZK Caldwell, Jeffrey L Cummings, Samantha E John, Jayde Powell, Kaley Brouwers, Jessica Rodrigues, Kimberly Cobos, Raelynn de la Cruz, Aaron Ritter
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 397-399
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Objective:
As the US population ages, the prevalence of Alzheimer’s disease and related dementias (AD/RD) is on the rise. This is especially true in rural America, where mortality rates due to AD/RD are rising faster than in metropolitan areas. To date, however, people living in rural communities are severely underrepresented in aging research. The Nevada Exploratory Alzheimer’s Disease Research Center (NVeADRC) seeks to address this gap. Here, we present preliminary cognitive data from our rural-dwelling cohort, as well as relevant demographic and clinical characteristics.
Participants and Methods:Individuals with normal cognition (NC), mild cognitive impairment (MCI), and dementia due to Alzheimer’s disease (AD) living in rural communities, defined as a rural-urban commuting area (RUCA) code of 4 or higher, were enrolled through either clinic or community outreach. Eligibility for the observational cohort required: age >55 years, primarily English-speaking, primary residence in a rural community, and availability of a study partner. Measures included the Uniform Data Set (v3), blood-based biomarkers, structural brain MRI, and portions of the PhenX Social Determinants of Health toolkit. Participants are seen at baseline and followed annually, with interim remote visits every 6 months. A multidisciplinary consensus diagnosis is rendered after each visit. Where feasible, a harmonized urban cohort followed by the Nevada Center for Neurodegeneration and Translational Neuroscience (CNTN) was used for comparison.
Results:Fifty-six rural-dwelling (age=70.4±7.1 years; edu=15.2±2.6 years; 61% female) and 148 urban-dwelling (age=72.9±6.8 years; edu=15.8±2.7 years; 46% female) older adults were included; age significantly differed between cohorts but education did not. The rural cohort was 46% NC (MoCA=26.8±2.3; CDRsob=0.3±0.6), 32% MCI (MoCA=22.8±3.1; CDRsob=1.2±1.0), and 22% AD (MoCA=16.9±5.5; CDRsob=5.2±3.0). The urban cohort was 39% NC (MoCA=26.4±2.6; CDRsob=0.3±0.8), 44% MCI (MoCA=22.3±3.1; CDRsob=2.0±1.5) and 17% AD (MoCA=18.6±3.9; CDRsob=4.7±2.3). Rural communities were significantly more disadvantaged, as measured by the Area Deprivation Index (ADI), than urban communities (rural ADI=6.3±2.6; urban ADI=3.4±2.3; p<.001). Fifty-percent of the rural cohort lives in a moderate to severely disadvantaged neighborhood (ADI Decile>7) compared to 12% of the urban cohort, and 11% of individuals in the rural cohort reported living more than 30 miles from the nearest medical facility. Across the combined cohort, education was significantly correlated with ADI deciles (r=-.30, p<.001), with people in the areas of highest disadvantage having the lowest education. Verbal memory was also inversely associated with ADI. There were no differences in clinical diagnosis as a function of ADI rank.
Conclusions:Living in a rural community conveys a multifaceted array of risks and benefits, some of which differ from urban settings. The literature to date suggests that older adults living in rural communities are at significantly increased risk for morbidity and mortality due to AD/RD, though it is unclear why. Preliminary data from the NVeADRC show that increasing levels of neighborhood disadvantage were associated with lower levels of education and worse verbal memory in this convenience sample. The combined effect of low education and increased disadvantage account for some of the urban-rural differences in mortality that have been reported, though additional research on representative samples in this underrepresented population is critical.
46 Comparison of Anxiety Measures in a Memory Clinic Sample
- Raelynn Mae de la Cruz, Jessica Rodrigues, Rachel M. Butler-Pagnotti, Filippo Cieri, Shehroo B. Pudumjee, Sonakshi Arora, Kimberly L. Cobos, Jessica Z. K. Caldwell, Lucille Carriere, Christina G. Wong
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 725-726
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Objective:
As the presentation of anxiety may differ between younger and older adults, it is important to select measures that accurately capture anxiety symptoms for the intended population. The 21-item Beck Anxiety Inventory (BAI) is widely used; however, its high reliance on somatic symptoms may result in artificial inflation of anxiety ratings among older adults, particularly those with medical conditions. The 30-item Geriatric Anxiety Scale (GAS) was specifically developed for older adults and has shown strong psychometric properties in community-dwelling and long-term care samples. The reliability and validity of the GAS in a memory clinic setting is unknown. The present study aimed to compare the psychometric properties of the GAS and the BAI in a memory disorder clinic sample.
Participants and Methods:Participants included 35 older adults (age=73.3±5.0 years; edu=15.3±2.8 years; 42% female; 89% non-Hispanic white) referred for a neuropsychological evaluation in a memory disorders clinic. In addition to the GAS and BAI, the Geriatric Depression Scale (GDS) and Montreal Cognitive Assessment (MoCA) were included. Cutoffs for clinically significant anxiety were based on published data for each measure. A dichotomous anxiety rating (yes/no) was created to examine inter-measure agreement; minimal anxiety was classified as “no” and mild, moderate and severe anxiety were classified as “yes.” Internal scale reliability was examined using Cronbach’s alpha. Convergent and discriminant validity were examined using Spearman rank correlation coefficients. Frequency distributions determined the proportion of yes/no anxiety ratings, and a McNemar test compared the proportion of anxiety classifications between the two measures.
Results:Both measures had excellent internal consistency (BAI: a=.88; GAS: a=.94). The BAI and GAS were highly correlated with each other (r=.79, p<.001) and positively correlated with a depression measure (BAI-GDS: r=.51, p=.002; GAS-GDS: r=.53, p=.001). Discriminant validity was supported by lower correlations between the anxiety measures and cognition (BAI-MoCA: r=.38, p=.061; GAS-MoCA: r=.34, p=.098). The BAI classified 14 participants as having anxiety (40%) and 21 participants as not having anxiety (60%), whereas the GAS classified 21 participants as having anxiety (60%) and 14 participants as not having anxiety (40%). The proportion of anxiety classifications were significantly different between the two measures (p =.016). For 28 participants (80%), there was agreement between the anxiety ratings. Seven participants (20%) were classified as having anxiety by the GAS, but not by the BAI; GAS items related to worry about being judged or embarrassed may contribute to discrepancies, as they were frequently endorsed by these participants and are unique to the GAS.
Conclusions:Results support that both anxiety measures have adequate psychometric properties in a clinical sample of older adult patients with memory concerns. It was expected that the BAI would result in higher classification of anxiety due to reliance on somatic symptoms; however, the GAS rated more participants as having anxiety. The GAS may be more sensitive to detecting anxiety in our sample, but formal anxiety diagnoses were not available in the current dataset. Future research should examine the diagnostic accuracy of the GAS in this population. Overall, preliminary results support consideration of the GAS in memory disorder evaluations.
Listening to voices: understanding and self-management of auditory verbal hallucinations in young adults
- Peter Denno, Stephanie Wallis, Kimberly Caldwell, Jonathan Ives, Stephen Wood, Matthew Broome, Pavan Mallikarjun, Femi Oyebode, Rachel Upthegrove
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- Journal:
- BJPsych Open / Volume 7 / Issue S1 / June 2021
- Published online by Cambridge University Press:
- 18 June 2021, pp. S19-S20
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Aims
Auditory Verbal Hallucinations (AVH) are a hallmark of psychosis, but affect many other clinical populations. Patients’ understanding and self-management of AVH may differ between diagnostic groups, change over time, and influence clinical outcomes.
We aimed to explore patients’ understanding and self-management of AVH in a young adult clinical population.
Method35 participants reporting frequent AVH were purposively sampled from a youth mental health service, to capture experiences across psychosis and non-psychosis diagnoses. Diary and photo-elicitation methodologies were used – participants were asked to complete diaries documenting experiences of AVH, and to take photographs representing these experiences. In-depth, unstructured interviews were held, using participant-produced materials as a topic guide. Conventional content analysis was conducted, deriving results from the data in the form of themes.
ResultThree themes emerged:
(1) Searching for answers, forming identities – voice-hearers sought to explain their experiences, resulting in the construction of identities for voices, and descriptions of relationships with them. These identities were drawn from participants’ life-stories (e.g., reflecting trauma), and belief-systems (e.g., reflecting supernatural beliefs, or mental illness). Some described this process as active / volitional. Participants described re-defining their own identities in relation to those constructed for AVH (e.g. as diseased, 'chosen', or persecuted), others considered AVH explicitly as aspects of, or changes in, their personality.
(2) Coping strategies and goals – patients’ self-management strategies were diverse, reflecting the diverse negative experiences of AVH. Strategies were related to a smaller number of goals, e.g. distraction, soothing overwhelming emotions, 'reality-checking', and retaining agency.
(3) Outlook – participants formed an overall outlook reflecting their self-efficacy in managing AVH. Resignation and hopelessness in connection with disabling AVH are contrasted with outlooks of “acceptance” or integration, which were described as positive, ideal, or mature.
ConclusionTrans-diagnostic commonalities in understanding and self-management of AVH are highlighted - answer-seeking and identity-formation processes; a diversity of coping strategies and goals; and striving to accept the symptom. Descriptions of “voices-as-self”, and dysfunctional relationships with AVH, could represent specific features of voice-hearing in personality disorder, whereas certain supernatural/paranormal identities and explanations were clearly delusional. However, no aspect of identity-formation was completely unique to psychosis or non-psychosis diagnostic groups. The identity-formation process, coping strategies, and outlooks can be seen as a framework both for individual therapies and further research.
Auditory verbal hallucinations in first-episode psychosis: a phenomenological investigation
- Rachel Upthegrove, Jonathan Ives, Matthew R. Broome, Kimberly Caldwell, Stephen J. Wood, Femi Oyebode
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- Journal:
- BJPsych Open / Volume 2 / Issue 1 / January 2016
- Published online by Cambridge University Press:
- 02 January 2018, pp. 88-95
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Background
In dimensional understanding of psychosis, auditory verbal hallucinations (AVH) are unitary phenomena present on a continuum from non-clinical voice hearing to severe mental illness. There is mixed evidence for this approach and a relative absence of research into subjective experience of AVH in early psychosis.
AimsTo conduct primary research into the nature of subjective experience of AVH in first-episode psychosis.
MethodA phenomenological study using diary and photo-elicitation qualitative techniques investigating the subjective experience of AVH in 25 young people with first-episode psychosis.
ResultsAVH are characterised by: (a) entity, as though from a living being with complex social interchange; and (b) control, exerting authority with ability to influence. AVH are also received with passivity, often accompanied by sensation in other modalities.
ConclusionsA modern detailed phenomenological investigation, without presupposition, gives results that echo known descriptive psychopathology. However, novel findings also emerge that may be features of AVH in psychosis not currently captured with standardised measures.
1 - Introduction to Population Diversity and Genetic Testing
- from I - Critical Concepts
- Edited by Russ B. Altman, Stanford University, California, David Flockhart, Indiana University, David B. Goldstein, Duke University, North Carolina
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- Book:
- Principles of Pharmacogenetics and Pharmacogenomics
- Published online:
- 05 June 2012
- Print publication:
- 23 January 2012, pp 3-11
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Summary
Overview of How Genetic Diversity Arises
Genetic diversity arises from differences in the genome of humans. Mapping of the human genome has revealed that humans are approximately 99.9 percent identical relative to their DNA sequences, with differences occurring at the rate of one change in every 100 to 300 bases along the sequence of 3 billion bases that comprise the human genome (1, 2). These differences in coding sequences at these sites are termed single-nucleotide polymorphisms (SNPs) and are considered significant when they occur with a minimum frequency of 1 percent in a given population. Whereas genetic differences of 0.1 percent among individual humans appear negligible, occurrences of ∼10 million SNPs have been cataloged to date. These SNPs may occur in coding or noncoding regions of the genome and may affect gene expression or disease susceptibility. Whereas SNPs are estimated to account for 90 percent of all genetic variability, other genetic differences have been detected and may stem from errors during DNA replication, including copy number variations, insertions, deletions, inversions of bases, or other mutational events caused by environmental factors (3). This genetic variability contributes to genetic diversity among populations as well as its individual members. Genetic diversity has an impact on all manner of human traits from external appearance to disease susceptibility and response to pharmacological agents.
To gain a greater appreciation of the magnitude of the impact that genetic diversity has on human phenotypes, it is best to begin with an exploration of its historical development in modern humans. In general, race and ethnicity, which are largely defined culturally by phenotypic traits or defined by man-made designations of geographic origin, become much less distinct at the genomic level. Mutations can occur within alleles that occupy a distinct site within a given gene or genomic region and thereby help to define traits. It is thought that population genetic diversity is largely due to a combination of allelic mutation at specific sites along the genome and the selective pressure from population segregation that occurred during the migration of humans out of Africa over a period of about 200,000 years (4). Each offspring inherits two alleles, one from each parent. Thus, if either parent is not a carrier of the wild-type allele originally encoded in the genome due to local mutations within the allele, the offspring may inherit the mutant allele and be heterozygous for a given trait. The mutation may be dominant (i.e., expressed), recessive (carried silently), or, in some cases, coexpressed. When a new mutation is associated with a beneficial trait, it is thought that positive selection occurs, allowing those carrying the beneficial allele to survive, reproduce, and pass on the trait to their offspring at a frequency dictated by its pattern of inheritance. However, the major contribution to genetic diversity occurred because of the geographical isolation that resulted from tribal resettlement following migration that produced colonies of individuals with a reduced genetic pool representative of the founders of each new colony.