Assessment of Mood States in Psychiatrically Disturbed Patients With Dementia Ralph H. B. Benedict, Ph.D. Marion Zucker Goldstein, M.D. Leonard R. Derogatis, Ph.D. Labile affect is a conlmon characteristic of elderly psychiatry patients, especially among patients in the early stages of prinzary progressive delnentia. The autbors sought to develop a method of assessing tbe full range of positive and negative moods in pSJJchiatl"ic patients with early denzentia and healthy elderly subjects. They modified the Derogatis Affects Balance Scale (DABS) to ease its adl1linistration in cognitively cOl1lpronlisedpatients and presented it to 51 geropsychiatry inpatients witb demerltia of either Alz!Jeil1ler's or vascular etiologj'. The modified DABS was found to discriminate depressed and nondepressed denzentia patiel1,ts and have acceptable test-retest reliability coefficients, despite extensive variation in scores. Analyses of construct and criterion-related validity were also consistent with previous DABS norl11ative studies. (American Journal of Geriatric Psychiatry 1996; 4:298-310) L ability of affect and mood swings are common clinical features of geriatric psychiatry patients suffering from progressive dementia. The adverse impact of these emotional phenomena has been documented by several authors. l -4 Included among Roth's5 early case descriptions were two geriatric psychiatry inpatients diagnosed with "arteriosclerotic psychosis," each ofwhom presented with labile affect and euphoria soon after admission to the hospital for a suicide attempt. It is now widely recognized that such episodes of uncharacteristic, fluctu.. ating mood can increase the burden of caregivers and lead to psychiatric hospitalization. The tendency for psychiatric patients with dementia to experience dramatic fluctuation in mood can also influence decisions made on behalf of patients Received August 8, 1995; revised January 3, 1996; accepted January 31, 1996. From the State University of Ne\vYork (SUNY) at Buffalo. Address correspondence to: Ralph H. B. Benedict, Ph.D., State University of Nc\v York (SUNY) at Buffalo, Dept. of Neurology, Erie County Medical Center, Suite 164, Buffulo, NY 14215. Copyright © 1996 American Association for Geriatric Psychiatry 298 VOLUME 4 • NUMBER 4 • FALL 1996 Benedict et at. with regard to postdischarge living arrangements and expenditures for care.6-8 Although dysphoria is the most frequently encountered affective symptom in psychiatry patients with dementia, some recent data suggest that positive mood states may be' equally important where the patient's psychosocial adjustment is concerned. For instance, in a pharmacologic trial designed to treat depression in dementia, Reifler et al. 9 observed that Alzheimer's disease patients responding to treatment were more cheerful, active, engaging, and in turn more cooperative with caretakers and better able to participate in family activities. Also, research with healthy adults has revealed significant correlations between a high frequency of positive mood states and increased socialization. 1o The implication of these findings is that it might be useful to monitor both positive and negative mood states in cognitively compromised psychiatric patients during hospitalization and to consider these data when making discharge plans. Intuitivel~ clinicians are apt to conceptualize negative and positive mood as opposite poles of a single psychological construct. It is logical to assume that if a patient evidences fewer symptoms of depression, he or she will also experience a higher frequency of positive moods, such as jo)', affection, and contentment. However, most factor analytic studies have supported a model that portrays positive and negative moods as separate, orthogonal constructs. II According to the structural, or "two-factor" model, positive moods reflect the subject'S general interest in or motivation for activi~ as might be illustrated by the following adjectives: active, excited, joyful, and warm. Negative moods (or affects) include dysphoria and its related mood adjectives, as well as feelings regarding general emotional distress, anxie~ fear, and hostilit}'. Although psychometric tests of emotional function are instrumental in the assessment of psych iTHE AMERICAN JOURNAL OF GEIUATIUC PSYCHIATRY atric outcomes, the commonly used depression self-rating scales 12- 14 neglect many of these positive and negative mood states. The Geriatric Depression Scale (GDS), for example t a reliable and valid instrument for detecting symptoms ofmajor affective disorder in geriatric patients with possible dementia,13,15,16 does not measure positive mood states, or negative moods other than guilt and dysphoria. Research related to questions concerning the influence ofpositive moods in dementia requires a reliable and valid instrument designed to assess the full spectrum of affect. To the best of our knowledge, there are no psychometric instruments designed to assess positive mood states that have been adequately tested in a sample of dementia patients. To overcome the limitations of depression self-rating scales, we decided to examine the potential utility of the Derogatis Mfects Balance Scale (DABS), 17,18 which was designed to measure the frequency of mood states in accordance with the two-factor model. The DABS measures eight aspects of mood (jo)', contentment, vigor, affection, anxiet)r, depression, guilt, hostility), which are grouped into the general constructs of positive and negative affects. The test is easy to administer and can be completed by most healthy adults in 5 to 10 minutes. Psychometric studies of the DABS have demonstrated that the test is reliable and valid in normal and general psychiatry populations. 17, 18 Also, the practical utility ofthe DABS has been demonstrated in several studies with a wide range of healthy volunteers, medically ill, and psychiatry patients. For instance, Rabins and colleagues 19 used the DABS to examine coping responses in a sample of caregivers of patients with Alzheimer's disease or cancer. Positive mood frequencies correlated significantly with number of social contacts, as well as measures of religious faith and family cohesiveness. In a study of psychosocial adjustment 299 Mood Assessment in Dementia in medical students,20 there were significant associations found bernreen adverse life events and lowered positive mood scores and increased negative mood scores. Hoehn-Saric and colleagues21 showed that patients with mixed anxiety disorder and depression had higher negative mood state scores than patients with anxiety disorder alone. Therefore, given the wealth of information it provides about a patient's affective experience, as well as its brevity and minimal respondent burden, the DABS could be a valuable tool for studying positive and negative mood states in patients suspected ofhaving progressive dementia. Unfortunatel~we have found that the DABS is difficult to use in psychological evaluations of even mildly cognitively compromised patients. Some patients become tangential when asked to indicate how often they experience a particular mood, and others tend to have difficulty interpreting the mood adjectives correctl~ In this stud~ we endeavored to remedy the procedural difficulties with the DABS so that the test could be used with geriatric, psychiatrically disturbed patients with mild-ta-moderate dementia. Toward this end, we developed a modified administration format for the DABS and presented it to geriatric psychiatry inpatients with dementia and age-matched normal control subjects. We now report our findings regarding the modified DABS's test-cetest reliability and validi~ METHODS Subjects Fifty-one patients, age 55 and over, with a diagnosis ofprimary progressive dementia, were studied. All were inpatients on a geriatric psychiatry unit of a university-affiliated hospital. In each case, the hospital admission had been precipitated 300 by an acute episode of altered mood and disruptive or dangerous behavior. Specifically; the patients manifested one or more of the following symptoms or behaviors: night wandering, wandering in traffic, violence, threat ofviolence, threat ofsuicide, or severe depression. Each patient underwent a comprehensive psychiatric examination performed by the second author, a boa,rd-certified geriatric psychiatrist. The first author, a clinical neuropsychologist, also examined each patient in order to establish the presence and quality of dementia. Together, the psychiatrist and neuropsychologist arrived at a consensus diagnosis based on the psychiatric. and neuropsychological examinations, the patient's medical and personal history; cranial neuroimaging, and laboratory studies. Patients meeting DSM..lV22 diagnostic criteria for dementia of the Alzheimer type (DAT) or vascular dementia (VaD) were included in the stud~ In most cases, the patients also met research criteria for either probable Alzheimer's disease 23 or Van,24 although there were insufficient data to establish a clear course of the dementia that would help in differentiating OAT and VaD in some cases. Therefore, several of the VaD patients were suspected ofhaving both cerebrovascular disease and Alzheimer s disease (Le., mixed disease). In all, there were 15 male and 36 female psychiatry patients with dementia, 42 of whom were white, with the remaining patients being Mrican American. A total of25 patients were diagnosed with DAT and 26 with VaD or mixed disease. The average age of the dementia sample was 74.8 ± 6.1 years, and the average educational level was 10.6 ± 2.9 years. Seventy-four healthy volunteers from the same metropolitan area as the patient sample were also examined. Some of the normal subjects were recruited through a university-based volunteer organization, and others responded to a newspaper advertisement and were paid for their part VOLUME 4 • NUMBER 4 • FALL 1996 Benedict et all ticipation. All of the normal control subjects were screened for the presence of neurological and psychiatric illness by telephone and face-ta-face intervie~ A1so t each control subject tested in the normal range on a short battery of neuropsychological tests (described below). All were over the age of 60 years (mean = 72.2 ± 5.9) and had completed an average of 14.3 ± 2.6 years of education. The racial composition of the control group was 73 white subjects and 1 black subject; there were 25 men and 49 women. Procedures The neuropsychology battel)) administered to both patients and control subjects, included the following tests: the Mini-Mental State Exam (MMSE)t 25 the Controlled Oral Word Association Test, with letter cues, 26 and category cues, 27 the 30..item short form of the Boston Naming Test,28 the Developmental Test of VisualMotor Integration,29 and the Trail Making Test. 30 Recently revised versions of the Hopkins Verbal Learning Test (HVLT_R)31 and the Brief Visuospatial Memory Test (BVMT-R)32 were also administered. Based on DSM..IV criteria, dementia was defined as impairment in memory (as in.. dicated by the HVLT-R and/or BVMT-R) plus impairment in at least one other domain of cognitive function. To screen for depression, we employed a IS-item short form of the GDS. Following the method of Parmalee et aI., 15,33 the GOS items were read to patients and volunteer subjects to ensure maximum compliance and understanding. When administered in this for.. mat, the GDS was found to be reliable and valid in a large sample of nursing home residents. Each patient was also rated by nursing staffand the first author on a short form of the Montgomery-Asberg Depression scale (MADS). 34 The standard administration of the DABS has been described elsewhere. 17,18 Subjects are asked to rank 40 mood adjec- tives (e.g., happ)) irritable, loving) in terms of the frequency of occurrence on a fivepoint scale ranging from 0 (not at all) to 4 (always). The test stimuli are presented visually in the format of a questionnaire. The frequency rankings are summed within each of the following eight general mood subscales: jo~ contentment t vigor, affection, anxie~ depression, guilt, and hostilit}'. Five summary scores are also calculated. The total positive affects (POS) and negative affects (NEG) scores are the respective sums of rankings for descriptors categorized under each general construct. The POS includes the moods jo~ contentment, vigort and affection. The NEG includes anxiety; depression, guilt, and hostili~ The range for each of these measures is 0 to 80. The affects..balance index (ABI) is calculated as POS - NEG / 20, representing the frequency ofpositive moods over that of negative moods. The ABI ranges from -4, which is the maximum negative valence, to +4, which is the maximum positive valence. The affects..expressiveness index (AEI) is the sum total of all mood rankings, regardless of valence, ranging from 0 to 160. Finall~ the posi.. tive-affects ratio (PAR), calculated as POS / AEI, is the proportion of total positive affective expression. For this study; the standard administration of the DABS was modified for use in a cognitively impaired subject sample. First t subjects were provided with a visual representation of the scale that was to be used for each adjective. The scale depicted each possible ranking, equally spaced from left to right across a 5 X SI/2-inch paper, as follows: 0 - never, 1 - rarel~ 2 sometimes, 3 - frequently, 4 - always. Once the subject understood the scale, each mood adjective was read by the examiner with the question: "Over the past several days, how often have you been feeling __?U It was common for patients to lapse into conversation, and when this occurred, the examiner repeated the question and directed the patient's atten- THE AMEIUCAN JOURNAL OF GERIATRIC PSYCHIATRY 301 Mood Assessment in Dementia tion to the ranking scale. The frequency, rather than the quali~ of each mood descriptor was emphasized. Subjects were frequently reminded that the test would progress more quickly if they would concentrate on the scale and simply indicate which descriptor best matched their experience over the past several days. For each subject, the examiner was permitted to pause and provide the meaning of any troublesome mood adjective or explain the meaning of the visual scale for frequency judgments. The patients were all examined in the neuropsychology clinic, in the same hospital as the geropsychiatry ward in which they were being treated. The examinations were usually done within 1 week of hospital admission. Normal control subjects \vere tested in the neuropsychology clinic, at home, or in a testing room designated at a local senior citizens' recreation center. Regardless of the exam location, neuropsychological testing was always conducted in a room that was free of distraction. Thirteen patients and 21 control subjects were seen for a follow-up neuropsychological examination that included the DABS and the neuropsychology test bat.. teJ.1r. The average test-retest interval was 27.6 ± 19.7 days for patients and 50.1 ± 34.4 days for control subjects. Participation in the follow-up examination was vol.. untary for both groups. Patients were seen while in the hospital, during a 2-5·day period before discharge. Control subjects were tested in the same environment both times. Statistical Analyses The first goal of the study was to replicate previous findings of the DABS with regard to its reliability and validity in normal geriatric subjects. Test-retest reliability was assessed by means of Pearson ,. reliability coefficients. An extension of the construct validity of the DABS was then 302 attempted by means of principal-components analysis with varimax rotation. These same procedures were also performed in the patient sample. RESULTS Group Differences The dementia and control groups were matched on age, but disparate in level ofeducation (t(I) = 7.54;P < 0.0001). Therefore, we used one-way analyses of covariance (ANCOVAs)t with education entered as a covariate, to compare the group means on the DABS. Table 1 presents mean scores on age, education, MMSE, and DABS measures, with the dementia group separated according to normal « 5) vs. abnormal ~ 5) GOS score. I5 ,33 In Figure 1, the nlcan scores for each subgroup are plotted in T-score equivalents (mean = 50 ± 10) based on preViously published normative tables for adults (that are not balanced for age).17 Figure 1 demonstrates that the DABS scores obtained in the normal elderly group conform quite nicely to the normative database previously published by Derogatis and colleagues. 17,18 As in previous normative studies with the DABS, healthy control subjects reported positive mood states much more frequently than negative moods. As a concrete example, the average ranking in the joy category (e.g., happ~ glad) was 2.9, which corresponds roughly to the descriptor "frequcntl~" On the other hand, the average ranking in the depression category (e.g., sad, miserable) was 0.7, or urarel~" Hence, like younger subjects, elderly individuals tend to experience positive moods at a higher frequency than negative moods, re· suIting in a positive ABI. Note that normal elderly group means fall within 0.5 SO of the norm for the test. This finding suggests that scores from the modified DABS used here can be interpreted using the existing VOLUME 4 • NUMBER 4 • FALL 1996 Benedict et ale TABLE 1. Group means ± standard deviations (and ranges) for demographic variables and measures derived from tbe Derogatis Affects Balance Scale (DABS) Dementia Patients Nondepressed Depressed (II = 22) (II 29) = Age, years Education, years Mini-Mental Scate Exam 74.8 ± 5.7 (65-84) 10.7 ± 3.3 (6-20) 22.0 ± 4.5 (7-28)3 74.7 ± 6.5 (55-85) 10.5 ± 2.6 (6-18) 22.4 ± 3.8 (16-28)3 Control Subjects (II = 74) 72.2 ± 5.9 (64-88) 14.3 ± 2.6 (8-20) 28.3 ± 1.4 (25-30) (MMSE) Derogatis Affects Bahlncc Scale (DABS) joy 13.7 ± Contentment 13.3 ± Vigor 9.7 ± Affection 13.0 ± Anxiety 7.6 ± Depression 5.4 ± Guilt 3.6 ± I-Iostility 6.3 ± Positive Affects Total (POS) 49.7 ± Negative Affccts Total (NEG) 22.8 ± Affects Balance Index (ABI) 1.4 ± Affects Expressiveness Index 72.6 ± Positive Affects Ratio (PAR) 0.69 ± 4.9 (3-20)b 4.2 (6-20)Olb 4.3 (0-18)3 5.0 (4-20) 3.6 (0-14)b 4.1 (O_12)ab 2.9 (O-9)b 4.3 (O-l~i) 13.6 (27_73)ab 11.4 (1-41)b 1.1 (-0.3 - 3.5):'b 13.1 (56-98) 0.15 (OA6-0.98)b 8.1 7.9 6.8 10.0 11.9 12.6 10.1 9.3 32.8 43.9 -0.56 76.7 0,41 ± 5.4 0-17 3 ± 4.8 (0-18)3 ± 4.3 (0-15)3 ± 6.0 (0-20)3 ± 4.8 (2-20)3 ± 5.4 (3-20)3 ± 5.0 (0-19)3 ± 5.6 (1-20)3 ± 18.2 (O~9)a ± 17.0 (16-76);1 ± 1.4 (-3.4 - 2.0)a ± 20.5 (17-118) ± 0.21 (0-0.72);\ 14.6 14.7 13.3 14.3 6.5 3.3 3.9 4.9 56.8 18.6 1.9 75.4 0.76 ± 2,4 8-20 ± 2.5 (8-20) ± 2.8 (5-19) ± 2.9 (7-20) ± 2.6 (0-12) ± 2.6 (0-9) ± 2.6 (0-9) ± 2.7 (0-10) ± 8.9 (28-79) ± 8.2 (0-31) ± 0.7 (-0.15 - 3.5) ± 10.7 (48-102) ± 0.10 (0.47-1.0) Onc·\vay ANOVA comparing group means for age \vcre not significant. ANOVA comparing group means for years of education \vcre significant (F(2 122) = 28.2; P < 0.0001). Nc\vman-Keuls comparisons revealed significant differences bct\vcen control subjects and each dementia subsample. uANCOVA, controlling for level of education t reveals a significant difference bct\vccn the patient subsample and control subjects, using an alpha criterion of 0.01. bANCOVA, controlling for level of education, reveals a significant difference bet\veen depressed and nondcprcsscd dementia subsamplcs, using an alpha criterion of 0.01. Note: t normative base, and that the influence of age on DABS scores is minimaL The ANCOVAs in Table 1 comparing the subgroup means were significant for each DABS measure except the Affects Expressiveness Index (AEI). Thus, although large differences were apparent with respect to the valance of mood frequency ratings, the subgroups tended to use the descriptors "always" or "not at all" with equal frequen~ Table 1 indicates that the dementiaonly subgroup obtained mostly normal DABS scores, although there were statistically significant differences on the subscales for contentment, vigor, and depression, as well as POS and ABI. However, as is readily apparent in Figure 1, the effect sizes between the dementia-only patients and control subjects were quite THE AMEIUCAN JOURNAL OF GERIATIUC PSYCHIATRY small relative to the dementia-depressed subgroup. The most noteworthy difference between dementia-only and control subjects was found on the vigor subscale. The vigor subscale includes items such as "energetic," Uactive,U and "lively;U and it is understandable that the frequency of these mood states would decline in individuals with cognitive dysfunction as a result of limitations imposed on activities of daily living. In contrast, dementia patients with abnormal GDS scores were found to have abnormal scores on all DABS measures except AEI. As can be seen in Figure 1, lower scores on positive affects and substantial elevations on the negative subscales characterized this subgroup. Mean subscale scores fell from 1.5 to 3.6 standard deviations (5Ds) outside of the average range. 303 Mood Assessment in Dementia FIGURE 1. T scores of the Derogatis Affects Balance. Scale (DABS) for denlcntia patients and normal elderly control subjccts. Score 80 - - - - - - - - - - - - - - - - - - - - - , ~-------....., ~ :: Control subiects ::::::::::::::::::~::::::::........'- -:_g_:~_:_~_: ~_:_~ _~_~e _~_~ _s _..e.d. ~ 50 .. ·._ . 40 30-.~••••••••••••••••••••• _ ••••••••• 20 >0 .., c ~ OJ E "E QJ 'E 0 U Note: .... 0 c :> ~ m 0 £ -« ~ Q) 'x c: < t: 0 •iii VI -g ·5 C) .~ ~ a. eu C a.. .~ iii < "0 tn CD Z The Tscore scale has a mean of 50 and a standard deviation of 10. ABI = Affects Balance Index. These intergroup differences could be the result of both dementia and depression. However, on the majority of subscales t as well as POS, NEG, ABI, and PARt the depressed subgroup means were also significantly different from dementia-only patients. Therefore, even within a demen.. tia-depression sample, the DABS appears to be sensitive to diminished positive affectivity and increased negative affectivi~ In brief, whereas the expected group means on the DABS were found in healthy elderly control subjects, the dementia patients, as a group, evidenced significantly reduced positive mood rankings and elevated rankings on negative mood states. The variances associated with these pa.. tieut sample means were also quite high compared with control subjects, suggest.. ing a higher degree of variability in mood' frequency ratings. When the demen304 0 J: Q) > '.t= 'Vi 0 tia-depression sample was separated by normal vs. abnormal GDS score, nondepressed subjects obtained scores approxi.. mating the normal range, whereas those with depression evidenced abnormal frequencies of positive and negative mood states. Test-Retest Stability of the DABS in Normal and Dementia Samples In evaluating the psychometric aspects of the DABS, our first task was to assess its temporal stability in both dementia patients and healthy control subjects. This was accomplished via test-retest Pearson r correlation coefficients calculated for each of the DABS summary scores, as well as t-test comparisons of group means at Test 1 and Test 2. Beginning with the control group VOLUME 4 • NUMBER 4 • FALL 1996 Benedict et al. TABLE 2. Test-retest means ± standard deviations and reUability coefficients for the Derogatis Affects Balance Scale (DABS) Normal Control Subjects (II Positive Mfects Total (POS) Negative Mfects Total (NEG) Mfects Balance Index (ABI) Affects Expressiveness Index Positive Affects Ratio (PAR) Dementia Group (II = 13) Positive Affects Total (POS) Negative Meets Total (NEG) Affects Balance Index (ABI) Meets Expressiveness Index Positive Mfeets Ratio (PAR) = 21) Test 1 56.9 ± 18.4 ± 1.9 ± 74.3 ± 0.76 ± 8.6 7.3 0.6 10.8 0.09 Test 1 41.5 ± 21.2 38.8 ± 21.7 0.1 ± 2.1 ± 10.8 0.52 ± 0.26 80.4 Test 2 53.6 ± 16.1 ± 1.9 ± 69.6 ± 0.77 ± 10.7 8.2 0.8 9.0 0.11 Test 2 45.1 28.1 0.8 73.2 ± 16.6 ± ± ± 0.63 ± 20.1 1.8 8.6 0.25 ReUabillty Coefficient 0.81*** 0.77*** 0.87*** 0.70*** 0.81*** Reliability Coefficient 0.62* 0.71·* 0.68** 0.40 0.71** Note: All test-retest mean score comparisons by t..test, using an alpha criterion of 0.01, were not statistically significant. *p < 0.05; **p < 0.01; ***p < 0.001; all significance levels for Pearson r. data shown in Table 2, it can be seen that the follow-up examination means fell con· sistently within 0.5 SD of the Test 1 score on all DABS measures. Using an alpha criterion ofP < 0.01, none ofthe paired..sample t..tests were statistically significant. The test-retest reliability coefficients were also well within acceptable psychometric limits. The test-retest interval in the patient group was smaller (28 vs. 50 days) than in the control group, but the fact that the patients were heterogeneous with respect to psychiatric symptoms and undergoing change in psychiatric symptoms resulted in a more conservative test of the DABS's reliability. Again, t-test comparisons of group means were not statistically significant on any of the five measures. The test-retest correlations, however, were considerably more modest. The reliability coefficient was only 0.40 for AEI, indicating that this measure is not reliable in a dementia sample. On the other hand, the reliability coefficients were more acceptable on DABS measures reflecting mood valence, ranging from 0.62 to 0.71. These coefficients may be considered adequate, given the wide range of medications that were used for treatment of this sample, the various psychiatric symptoms present THE AMEIUCAN JOURNAL OF GERIATRIC PSYCHIATRY on admission, and the fact that some individual patients were likely improving psychiatrically; whereas others were not. Validity In order to further examine the construct validity ofthe DABS, the eight mood subscale scores were submitted to a principal-components analysis with varimax rotation. The two-factor solution obtained from the control group, accounting for 69% of the variance in the matrix, is presented in Table 3. The two factors are easily interpreted. Factor 1, which accounted for 43% of the variance, is the Positive Mfects factor. Factor 2, the Negative Affects factor, accounted for an additional 26% of the variance. The factors are strikingly or.. thogonal, with a complete absence ofsplit loadings (Le., very low correlations between mood states and factors on which they do not load significantly). This is also the same factor solution obtained in previous research with the DABS using a younger normal sample. 17,18 A very similar two-factor solution was obtained from the dementia group DABS scores, this time accounting for 73% of the variance in the matrix (Factor 1 accounted 305 Mood Assessment in Dementia for 55% of the variance, and Factor 2 accounted for 18% of the variance). There was one split loading, found on the depression scale. Thus, the mood state, depression, appears to share variance with both the positive and negative factors. The remaining seven mood variables, howTABLE 3. ever, are uniquely positive or negative. In the final analysis, Pearson r correlations were calculated to gauge the relationship between affective constructs measured by the DABS and the depression inventories. This analysis was limited to the patient sample because of the re- Factor analysis matrices for normal control subjects and dementia patients Factor 1 Factor 2 0.91919 0.87525 0.76851 0.82644 0.13049 -0.24836 -0.07951 -0.18808 -0.19685 -0.15880 -0.13300 0.10673 0.73627 0.77891 0.80022 0.78794 0.84967 0.80593 0.78103 0.83249 -0.07155 -0.41615 -0.28400 -0.15298 -0.33429 -0.10472 -0.10749 0.86720 0.80049 0.84585 0.73905 Control Subjects JoY Contentment Vigor Mfection Anxiety Depression Guilt Hostility Dementia Patients Joy Contentment Vigor Mfection Anxiety Depression Guilt Hostility -0.36775 Note: Values are the resulting factor matrices after varimax rotation. Italicized coefficients are those that are more than twice the value of the associated coefficient from the opposing factor. TABLE 4. Correlations (r) between the Derogatis Affects Balance Scale (DABS) and criterion measures in the dementia sample Geriatric Depression Scale (GDS) Entire Sample MMSE > 24 MMSE < 20 (N = 51) (II = 16) (II = 13) DABS Positive Total (POS) Negative Total (NEG) Affects Balance Index (ABI) Mfccts Expressiveness Index Positive Affects Ratio (PAR) DABS Positive Total (POS) Negative Total (NEG) Mfects Balance Index (ABI) Affects Expressiveness Index Positive Affects Ratio (PAR) Note: 306 MMSE -0.62 -0.80 -0.50 0.69 0.80 0.62 -0.75 -0.82 -0.63 0.07 0.28 0.06 -0.74 -0.82 -0.56 Montgomery-Asberg Depression Scale (MADS) Entire Sample MMSE> 24 MMSE < 20 -0.65 0.58 -0.70 0.08 -0.73 -0.82 0.85 -0.85 0.38 -0.85 -0.74 0.49 -0.70 0.41 -0.63 = Mini-Mental State Exam. VOLUME 4 • NUMBER 4 • FAll 1996 Benedict et all stricted range of GDS and MADS scores among control subjects. Obviousl~ associations between tests such as the GDS and MADS, which are designed to measure signs and symptoms ofmajor affective disorder, and the DABS would be difficult to uncover in a sample of subjects who are free of depression. Table 4 summarizes the results of the correlational analysis. A5 was expected, there was no relationship between the AEI and either of the depression scales. Correlations between the POS, NEG, ABI, and PAR measures from the DABS and the depression scale scores were in the expected direction and consistent across depression scales. Overall, magnitude of correlations was moderate, ranging from 0.58 (NEG and MADS) to-0.75 (ABlandGDS). To investigate the role of dementia in these correlations, we compared the validity coefficients of 13 patients with MMSE scores under 20 to validity coefficients obtained from 16 patients with MMSE scores above 24. The correlations for these mild- and severe-dementia subgroups are also presented in Table 4. It can be seen that for POS, NEG, ABI, and PAR, the validity coefficients are smaller for the subgroup with severe dementia. For the GDS, the largest mild- vs. severe-dementia discrepancy in correlations was -0.80 vs. -0.50 on the POS measure. When the MADS is considered, the largest mild- vs. severe-dementia difference is .0.85 vs. 0.49, on the NEG measure. When individual mood subscales were examined in the severe-dementia subgroup, GDS validity coefficients were less than 0.5 on the contentment, vigor, affection, and anxiety subscales. The MADS validity coefficients were less than 0.5 on the anxiet}', depression, guilt, and hostility subscales. DISCUSSION Despite the wide range of extreme mood states and psychiatric symptoms that oc- cur in primary progressive dementia, the formal psychometric assessment of positive mood states has received little attention in the literature. Specific psychiatric symptoms, such as depression and paranoia have been well documented in patients with dementia, but little is known about the influence of the full spectrum of positive and negative moods on shortor long-term psychosocial outcomes. In order to facilitate research on this topic, we attempted to determine whether a commonly used psychometric test of affects balance could be used in a sample of dementia inpatients recently admitted for an acute episode of emotional and/or behavioral disturbance. Overall, we conclude that the modified administration format of the DABS yields reliable and valid data regarding fluctuating mood states in both normal elderly subjects and geriatric psychiatry patients with mild-tomoderate degrees of dementia. The data obtained from the geriatric control sample was consistent with previous DABS normative studies supporting its use in elderly subjects. The mean subscale scores obtained from our healthy 'geriatric subjects were all within 0.5 SDs of the mean score obtained from the original standardization sample. 17,18 There.. fore, the current method of obtaining T-score eqUivalents appears to be valid for geriatric subjects, as well. In 21 normal elderly subjects taking the DABS on two separate occasions separated by a 50-day interval, test-retest correlations were well within the acceptable range. The con.. struct validity of the DABS was also replicated in this elderly sample. The last solution, depicting two well-defined orthogonal constructs representing positive and negative affects, is consistent with previous research using the DABS, as well as the structural, two-factor model of mood. It This stud~ therefore, extends previous normative research with the DABS to the geriatric population. In dementia-depression inpatients, THE AMERICAN JOURNAL OF GERIATRIC PSYCHIATRY 307 Mood Assessment in Dementia the psychometric properties of the DABS were found to be more questionable, althought on the whole, the results support its use in patients with mild-ta-moderate dementia. Group comparisons revealed abnormal scores in this sample of 51 dementia-depression patients. As expected, patients reported a much lower frequency of positive mood states and a higher frequency of negative mood states than did age-matched control subjects. Of course, these group differences could be caused by dementia and/or affective symptoma.. tolo~ Yet, when the dementia group was divided according to GDS score, only those patients with depression were markedly abnormal on the DABS. These subgroup differences cannot be explained by the degree of dementia because the subgroups had equivalent MMSE scores. The ability of the DABS to discriminate dementia patients with and without depression suggests that the test would be useful in clinical samples. As for the reliability of the DABS among dementia-depression patients, most of the test-retest correlations were in the acceptable range t which is remarkable, given that many of the patients were in an acute state of confusion, agitation, and/or psychosis when tested the first time. However, these data are from a very small sample of patients (n = 13), and so these findings should be regarded as prelimina~ The construct validity of the DABS was supported in the analyses using dementia-depression patients. In the principalcomponents analysis, the distinction between individual DABS subscales was somewhat less clear than in control subjects, but the final varimax solution was very similar to that of the control group. It is possible that with increasing levels of dementia, the two factors that underlie frequency ratings are less independent and more analogous to a single, unidimensional, positive/negative scale. Also, the cognitive dysfunction associated with 308 increasingdegrees ofdementia might sim.. ply interfere with the test-taking skills of patients. For instance, it is conceivable that some patients with severe dementia would have difficulty understanding certain mood adjectives, or be unable to recall accurately the frequency with which they have experienced certain moods. Supporting this conclusion were the discrepancies among validity coefficients favoring those obtained from patients with MMSE scores greater than 24, compared with those with MMSE scores lower than 20. We might add that, based on our clinical observations, it is our general impression that the DABS yields extreme ratings, or is simply not tolerated by patients who have severe dementia (MMSE scores less than 17). Overall then, although our data support the reliability and validity of the modified administration of the DABS in patients with mild-to-moderate Alzheimer's or vascular dementia, the DABS should be interpreted cautiously or not be used in evaluations ofpatients with severe dementia. One should bear in mind that our findings are based on an adapted version ofthe DABS, and not the standard administration described by Derogatis. 17 Our interview format, coupled with the visual scale to assist in patient rankings, was felt to be instrumental in our ability to obtain valid results in patients with mild dementia. We had previously found that when the DABS was administered as a standard self-report instrument t patients often responded randomly or were confused by certain mood adjectives, such as the terms "warm" or "vigor." Orally presenting each mood adjective helped to facilitate questions regarding unclear items or confusion with the rating scale. Given that the modified version of the DABS requires only slightly more time than the standard version (we have found that the test can be completed by a patient with moderate dementia in 15 to 25 minutes), we recommend its use in all geriatric subjects" VOLUME 4 • NUMBER 4 • FALL 1996 Benedict et at. Finally; instruments such as the modified DABS, which can assess the full spectrum of mood balance changes in dementia, may facilitate research designed to determine the predictive value ofmood states. An interesting question for future study is whether mood changes are related to behavioral problems, such as night wandering, screaming, threats of violence, and other behaviors that are so distressing to caregivers. One might hypothesize that in the early stages of progressive dementia, positive mood states may facilitate psychosocial adaptation. The patient with mild dementia, even if aroused and activity-seeking, has a preserved capacity for guiding behavior in a logical, goal-directed fashion. On the other hand, for the psychiatrically disturbed patient in the middle or late stages of DAT or VaD, elevated positive moods could underlie a general state ofincreased arousal, which, when combined with cognitive dysfunction, leads to a sequence of misdirected abnormal and disturbing be- haviors. Such a patient would likely have difficulty adjusting to a milieu with few structured activities and limited staff resources. We might further predict that high levels of negative affects t in particular, hostili~ would predict poor psychosocial outcomes in dementia-depression patients regardless of the degree of dementia. If certain mood states are predictive of psychosocial outcomes in patients at risk for disruptive behaviors, psychiatric interventions could be designed to decrease the frequency ofthese troublesome mood states before patients are discharged. The reliable and valid assessment of positive as well as negative moods and the balance between them will provide a means for investigating these and related questions. A copy ofthe visual analog scale used in the study and further information pertaining to the modified, interview-based format ofthe DABS is available from Dr. Benedict on request. References I.Alexopoulos GS, Abrams RC: Depression in Alzheimer's disease. Psychiatr Clin Noeth Am 1991; 14:327-340 2. Burns A: Affective symptoms in Alzheimer's dis· easc. International Journal of Geriatric Psychia· try 1991; 6:371-376 3. Burns A: Psychiatric phenomena in dementia of the Alzheimer type. Int Psychogeriatr 1992; 4:43-54 4. 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