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D R Royall

Publications and source records attributed to D R Royall.

33 records · Page 2Linked to original sources
PubMed1993

Risk factors for the onset of depression in middle age and later life.

Using prospectively gathered data to study first-time occurrence of major depression rather than its persistence, this inquiry tested whether the risk of major depression might be elevated among middle-aged and older adults who were not currently working for pay and among those with less than 12 years of schooling. Diagnostic interviews were administered 1 year apart to identify incident cases of major depression among 7,737 continuing participants of the Epidemiologic Catchment Area Program aged 40 years and older. After all subjects were sorted into risk sets by age and residence census tract, and after persons with a prior history of major depression were excluded, in 162 risk sets, there were 180 incident cases as well as 960 subjects at risk for future occurrence of major depression. The estimated risk for persons not currently working for pay was not reliably greater than the level of risk for those currently working for pay [estimated relative risk (RR) = 1.48; 95% confidence interval (CI), 0.85-2.56]. Compared with adults who had 12 or more years of schooling, those who had less schooling were at increased risk (RR = 2.22; 95% CI, 1.42-3.46). Compared to men with more than 12 years of schooling, women with less schooling were at especially increased risk for major depression over the course of the 1-year follow-up interval (RR = 3.26; 95% CI, 1.78-5.95).

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PubMed1993

Executive impairment among the functionally dependent: comparisons between schizophrenic and elderly subjects.

OBJECTIVE: Executive deficits have traditionally been associated with frontal lobe brain damage. They are relevant to a variety of disabling mental conditions, including schizophrenia and Alzheimer's disease. To measure these deficits, the authors developed the Executive Interview, a 25-item, 15-minute interview. It has been validated among elderly subjects across a wide range of functional impairment. METHODS: Forty young, chronically ill schizophrenic residents of a state mental health facility and 104 elderly residents, representing three levels of care, of a comprehensive retirement community were tested with the Executive Interview and the Mini-Mental State. RESULTS: When age, gender, education, and number of prescribed medications were controlled, cognitive impairment on the Executive Interview and Mini-Mental State rose with level of care. The Executive Interview alone discriminated between subjects at each level of care, and it was more sensitive to cognitive impairment than the Mini-Mental State. Executive Interview scores correlated the strongest with level of care. Mini-Mental State scores, number of prescribed medications, and age also correlated significantly. Schizophrenic patients showed as much executive impairment on the Executive Interview as elderly subjects at the same level of care despite significant differences in age, sex, and neuroleptic use. Executive Interview and Mini-Mental State scores were highly correlated among the elderly but less so among the schizophrenic patients. Cross-group differences were also found in the pattern of failure on selected Executive Interview items despite similar total Executive Interview scores. CONCLUSIONS: Increasing executive dyscontrol is associated with the need for increasing levels of care and supervision. This finding is neither age nor disease specific. Cross-group differences on selected Executive Interview items suggest the existence of disease-specific patterns of failure. Their recognition could prove useful in the identification of anatomically or pathophysiologically distinct subgroups among patients with executive dyscontrol.

Activities of Daily Living↗
PubMed1992

Bedside assessment of executive cognitive impairment: the executive interview.

OBJECTIVE: This study is a pilot validation of the Executive Interview (EXIT), a novel instrument designed to assess executive cognitive function (ECF) at the bedside. DESIGN: Inter-rater reliability testing and validation using inter-group comparisons across levels of care and measures of cognition and behavior. PARTICIPANTS: Forty elderly subjects randomly selected across four levels of care. SETTING: Settings ranged from independent living apartments to designated Alzheimer's Special Care units in a single 537-bed retirement community. MEASUREMENTS: The EXIT: a 10-minute, 25-item interview scored from 0-50 (higher scores = greater executive dyscontrol) was administered by a physician. Subjects were also administered the Mini-Mental State Exam (MMSE) and traditional tests of "frontal" executive function by a neuropsychologist, and the Nursing Home Behavior Problem Scale (NHBPS) by Licensed Vocational Nurses. RESULTS: Interrater reliability was high (r = .90). EXIT scores correlated well with other measures of ECF. The interview discriminated among residents at each level of care. In contrast, the MMSE did not discriminate apartment-dwelling from residential care residents, or residential care from nursing home residents. The EXIT was highly correlated with disruptive behaviors as measured by the NHBPS (r = .79). CONCLUSIONS: These preliminary findings suggest that the EXIT is a valid and reliable instrument for the assessment of executive impairment at the bedside. It correlates well with level of care and problem behavior. It discriminates residents at earlier stages of cognitive impairment than the MMSE.

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PubMed1981

Dopaminergic mediation of reward: evidence gained using a natural reinforcer in a behavioral contrast paradigm.

Previous studies suggest a dopaminergic basis for the apparent reward properties of self-stimulation of certain brain areas with electrical current. The data of this present study indicate that there may be a dopaminergic role in the perceived hedonic quality of natural reinforcers. Using a classical behavioral contrast paradigm, we observed in rats that the perceived reward of a saccharin solution was decreased by haloperidol and increased by apomorphine, in doses that did not cause non-specific performance effects.

Animals↗
PubMedDate not supplied

Frontal MRI findings associated with impairment on the Executive Interview (EXIT25).

We examined the association between the Executive Interview (EXIT25), a bedside measure of executive control, and regional magnetic resonance imaging (MRI) pathology among 52 consecutive geriatric patients presenting to a university dementia assessment clinic. Left frontal (p < .002), left medial (p < .03), right frontal (p < .02), and right medial (p < .02) cortical lesions significantly worsened EXIT25 scores, even after adjusting for age, global cognitive impairment (on the Mini-Mental State Examination), and the severity of cortical dementia on the Qualitative Evaluation of Dementia [QED]. The EXIT25's associations with right hemisphere lesions did not persist after adjusting for left frontal lesions. Left posterior lesions did not significantly affect the EXIT25. Similarly, left frontal circuit pathology worsened EXIT25 scores (p < .05). Pathology in left anterior subcortical structures showed a trend (p = .052). EXIT25 scores were not affected by right subcortical pathology, nor by pathology in either hippocampus. We conclude that the EXIT25 is specifically affected by frontal system MRI lesions, particularly on the left. This conclusion is consistent with earlier functional neuroimaging studies associating EXIT25 performance with left mesiofrontal perfusion.

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PubMedDate not supplied

Precis of executive dyscontrol as a cause of problem behavior in dementia.

Frontal lobe executive control functions (ECF) are proposed as a source of problem behavior in dementia. The behavior and personality changes that follow frontal lobe brain damage overlap with those seen in dementia, and frontal lobe structural and metabolic lesions can be demonstrated across a variety of dementing illnesses. ECF help explain the importance of social and environmental cues in the production of disruptive behavior and suggest interpersonal strategies for their control. This model has considerable face validity and leads to several testable hypotheses.

Behavior↗
PubMedDate not supplied

Bedside assessment of frontal degeneration: distinguishing Alzheimer's disease from non-Alzheimer's cortical dementia.

Two instruments, the Executive Interview (EXIT) and the Qualitative Evaluation of Dementia (QED), that are useful in the evaluation of frontal system failure are discussed. The ability of these instruments to discriminate frontal-type dementia (FTD) from Alzheimer's disease (AD) and the dementia of major depression (DMD) was examined in 100 consecutive elderly dementia patients presenting to a multidisciplinary geriatric clinic. All groups showed executive impairment by the EXIT, and 46% of the FTD patients were found to be unimpaired by the Mini-Mental State Examination (MMSE). The AD and FTD groups differed significantly from the DMD group on the QED. The QED alone could not distinguish AD from FTD cases. However, mapping of EXIT scores against MMSE (errors) scores revealed that AD and FTD follow very different regression lines.

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PubMedDate not supplied

Executive control and the comprehension of medical information by elderly retirees.

This study examined the independent contributions of executive control function, general cognition, age, education, and medication usage to the comprehension of medical information. Randomly selected elderly retirees (N = 105) more than 70 years of age completed the Executive Interview (EXIT25), the Mini-Mental State Exam (MMSE), and the Hopkins Competency Assessment Test (HCAT). Cognitive measures were stronger predictors of HCAT scores than age, education, or number of prescribed medications. A discriminant model based on EXIT25 and MMSE scores correctly classified 91% of subjects relative to their HCAT scores. It was concluded that executive impairment is strongly associated with impaired comprehension of medical information. As many as 88% of probable Alzheimer's disease patients, 69% of institutionalized elderly retirees, and 49% of noninstitutionalized retirees may be impaired in their ability to comprehend medical information, even when it has been presented well below their educational level.

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PubMedDate not supplied

Executive control function: a rational basis for the diagnosis of vascular dementia.

Problems with diagnostic criteria for vascular dementia (VaD) stem from the inadequacy of the current dementia concept, a paradigm based on amnestic and other cortical deficits typical of Alzheimer disease (AD). However, most cases of VaD are due to subcortical lesions such as Binswanger-type periventricular white matter ischemia, or strokes causing decreased frontal activation and diaschisis-mediated cerebral hypoperfusion. We propose a new definition of dementia based on executive dysfunction and a formal assessment of executive control functions (ECF) for the diagnosis of VaD. The instruments proposed are the rapid screening executive clock-drawing task (CLOX; Royall et al. J Neurol Neurosurg Psychiatry 1998;64:588-94), and the more comprehensive Executive Interview Test (EXIT25; Royall et al. J Am Geriatr Soc 1992;40:122-6). Extensive application of these tests in elderly subjects in retirement communities has shown that both are brief, simple to administer, and more sensitive case-finding tools for cognitively impaired individuals than the Mini-Mental State Examination (MMSE). These three tests (CLOX, EXIT25, MMSE) accurately separate nondemented subjects from those with cortical or subcortical (frontal system) dementias. In addition, for controlled clinical trials of VaD, formal evaluation of motor and frontal sphincter functions--usually not considered part of the dementia syndrome--should also be included. Evaluation of gait and falls, timed-walk, manual dexterity, timed finger-tapping, and frontal bladder control (urge incontinence and nocturia) should improve determination of functional status and disability, and more accurately measure the effects of potential therapies.

Alzheimer Disease↗
PubMedDate not supplied

Executive cognitive impairment: a novel perspective on dementia.

In 1994 the American Psychiatric Association added impairment of executive control functions (ECF) to its list of cognitive domains that should be considered in the assessment of dementia. This recommendation has not been widely implemented. None the less, there is growing evidence that ECF impairment is common, strongly associated with disability and functional decline, and not well detected by traditional dementia screening tests. This article reviews the implications of ECF for the epidemiology of dementia. The total number of dementia cases may be much greater than previously thought and we are likely to be selectively missing cases with reversible causes of ECF impairment.

Adolescent↗
PubMedDate not supplied

Severe dysosmia is specifically associated with Alzheimer-like memory deficits in nondemented elderly retirees.

OBJECTIVES: To determine whether or not (1) impaired olfactory function is associated with impaired memory on neuropsychological testing in healthy retirees, and if so then (2) whether memory impairment is most consistent with a mesiotemporal rather than frontal system disorder. METHODS: 173 independent residents of a continuing care retirement community were studied. Subjects completed the University of Pennsylvania Smell Identification Test (UPSIT) and a battery of both general and specific cognitive measures that included the Mini-Mental State Examination (MMSE) and the Executive Interview (EXIT25). Subjects were examined twice over 3 years. RESULTS: UPSIT performance was normal in 21% and in the 'anosmic' range in 25% of subjects. Anosmic UPSIT performance was associated with significantly worse performance on all cognitive tests. However, only short-term verbal memory was independently associated with UPSIT-defined anosmia. This association remained significant after adjusting for the other cognitive and sociodemographic variables. The memory deficits of anosmic subjects were qualitatively consistent with a cortical type (type 1) dementing illness such as Alzheimer's disease (AD). Over time, UPSIT-defined 'anosmic' cases suffered significantly greater declines on both the MMSE and the EXIT25, independently of baseline age, gender and MMSE score. CONCLUSIONS: Impaired odor identification in individuals without overt dementia is associated with an AD-like memory impairment and an increased rate of cognitive decline. The comorbid association of these deficits is consistent with the known hierarchical spread of preclinical AD pathology and may be a specific indicator of future clinical AD dementia.

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