JAGS
JANUARY 2015–VOL. 63, NO. 1
TELEVIDEO CLOCK DRAWING TEST TO REACH RURAL VETERANS: FEASIBILITY IN COMMUNITYBASED OUTPATIENT CLINICS IN THE DEPARTMENT OF VETERANS AFFAIRS To the Editor: Executive function includes higher-order cognitive processes such as planning, initiation, concurrent information processing, abstraction, and problem solving. Executive dysfunction, an early sign of dementia, is a common problem and often goes undiagnosed. Individuals with executive dysfunction experience tremendous difficulty keeping appointments, managing medications, and caring for themselves. On average, a typical elderly veteran has more than four medical problems and is taking six medications. With an aging veteran population, it is important to screen for executive dysfunction routinely, so it is important that the assessment be brief and easy to administer in busy primary care offices. The goal of the current study was to pilot the use of an executive function test over televideo to reach rural veterans. Arkansas is a rural state, with a majority of counties listed as rural or highly rural. A comprehensive activity-promotion telehealth clinic was developed to improve physical activity in rural veterans. It was desired to include a test as part of this clinic to exclude individuals with executive dysfunction because they might find it difficult to adhere to the program requirements, including wearing a pedometer and keeping a log of their steps. The Clock Drawing Test, consisting of CLOX1 and CLOX2, is a well-validated test of executive dysfunction.1 CLOX1 consists of a simple instruction to draw a clock with the hands at 1:45 on a blank sheet of paper. CLOX2 requires that the individuals copy a clock that the examiner draws without any additional instructions. The demonstration step adds a layer of complexity in performing this test over a video link. Both clocks are graded using the same rating rubric. Well-established cutoff points are available to diagnose executive dysfunction. The test typically takes less than 5 minutes to administer and score. The current study was designed to determine whether the Clock Drawing Test could be administered using telemedicine.
EQUIPMENT Videoconferencing systems were used at the host and remote sites using a hyperprotected dial-in, securityencrypted wireless system.
TEST ADMINISTRATION A trained examiner who was well versed in the test and routinely administers it at the host Veterans Affairs Medican Center administered the Clock Drawing Test. The veteran was at the remote site with a well-trained telehealth technician (THT). Standardized instructions were read for CLOX1. The THT provided the veteran with paper and pencil and remained easily accessible to solve any technical difficulties with the audiovisual equipment or connections but did not provide additional instruction or coaching to the veteran. For CLOX2, the
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205
host site examiner demonstrated how to draw the clock using a dry erase board over the video link. The veteran was then asked to copy the clock. The paper copies were then faxed to the examiner. The veteran was a 78-yearold, Caucasian man with type 2 diabetes mellitus, hypertension, chronic kidney disease, and depression.
TEST SCORING A geriatric psychiatrist (PRP) scored the test in conjunction with the examiner. No difficulty was noted in conducting the Clock Drawing Test administered over the video.
SATISFACTION The veteran denied having any problem understanding the instructions over the video link, and no extra prompting was necessary. He was able to see the demonstration of the clock drawing without any difficulty. The veteran expressed high satisfaction with this modality and thought that the videoconference made it more interesting. He commented that the provider was looking at him and interacting with him the entire time rather than appearing more engaged with the computer as had happened when he had seen a provider in person.
DISCUSSION The Department of Veterans Affairs (VA) has invested heavily with the aim of preparing itself to provide 21stcentury medical care by becoming a leader in telemedicine. Several telemedicine programs are currently ongoing at the VA, including teledermatology, teleretinal imaging, and telepsychiatry. There is growing evidence of the feasibility of performing neuropsychological tests using video conference, and satisfaction is high for tests that rely primarily on oral rather than written instructions.2 Research supports the equivalent interpretation of the administration of specific tests with consistent results with tests administered face to face.3,4 In some studies, it has been noted that the attention span and ability of the participant to remain engaged with the examiner is greater with telemedicine.5 Future application of this technology depends on expanded exploration of whether various medical and mental health professional services can be conducted using telehealth to meet the demand of an aging U.S. population. Prasad R. Padala, MD, MS Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas Lisa Nabholz, RN Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
206
LETTERS TO THE EDITOR
Kalpana P. Padala, MD, MS Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas Courtney Ghormley, PhD Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Dennis H. Sullivan, MD Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
ACKNOWLEDGMENTS Conflict of Interest: There are no financial or personal conflict of interest relevant to the submitted manuscript for any authors. Office of Rural Health, Department of Veterans Affairs P00493 (PI: Padala PR); Patient Centered Alternatives to Institutional Extended Care, VA Central Office Office of Geriatrics and Extended Care, Department of Veterans Affairs G598–4 (PI: Padala PR). Author Contributions: PRP: concept, recruiting and conducting study, manuscript preparation. LN: recruiting and conducting study, critical review of manuscript. KPP: concept, critical review of manuscript. CG, DHS: critical review of manuscript. Sponsor’s Role: The sponsor had no role in the design, methods, subject recruitment, data collections, analysis, or preparation of paper.
REFERENCES 1. Royall DR, Cordes JA, Polk M. CLOX: An executive clock drawing task. J Neurol Neurosurg Psychiatry 1998;64:588–594. 2. Parikh M, Grosch MC, Graham LL et al. Consumer acceptability of brief video conference-based neuropsychological assessment in older individuals with and without cognitive impairment. Clin Neuropsychol 2013;27:808– 817. 3. Turner T, Horner M, VanKirk K et al. A pilot trial of neuropsychological evaluations conducted via telemedicine in the Veterans Health Administration. Telemed J E Health 2012;18:662–667. 4. Timpano F, Pirrotta F, Bonanno L et al. Videoconference-based Mini-Mental State Examination: A validation study. Telemed J E Health 2013;19: 931–937. 5. Barton C, Morris R, Rothlind J et al. Video-telemedicine in a memory disorders clinic: Evaluation and management of rural elders with cognitive impairment. Telemed J E Health 2011;17:789–793.
TESTOSTERONE LEVELS AND BONE MINERAL DENSITY IN HEALTHY ELDERLY MEN To the Editor: We read with interest the letter by Iucif and colleagues1 on the association between total testosterone
JANUARY 2015–VOL. 63, NO. 1
JAGS
(T) plasma levels and bone mineral density (BMD) in healthy elderly men. A study of the association between T plasma levels and several bone measurements in a larger cohort (n = 162) of healthy elderly men was recently published.2 Quantitative ultrasound (QUS) measurements at the calcaneous and the hand phalanges were made, as well as peripheral BMD (pBMD) in the hand phalanges. These techniques differ from central BMD measurements determined using dual-energy X-ray absorptiometry (DXA) that are considered the criterion standard for the diagnosis of osteoporosis but allow the assessment of bone tissue in populations that do not have access to central DXA. The results that Iucif and colleagues presented were obtained from a cohort of men aged 60 and older (similar to the second study cohort: mean age 74.2 5, range 65–88) with mean T plasma levels of 411 192 ng/dL (slightly higher than observed in the second study cohort: 365 171 ng/dL). Iucif and colleagues found a negative correlation between BMD and T levels in the proximal femur and lumbar spine. These results contradict a number of studies that have demonstrated positive associations between T levels and BMD measured centrally and that the authors did not discuss. In particular, a meta-analysis3 presented results from 1,083 subjects with a mean age of 64.5 and demonstrated that T improved BMD at least in the lumbar spine. The results of the current study also indicate that higher values of os calcis, phalangeal QUS, and pBMD at the phalanges were observed in healthy elderly adults with higher T plasma levels. There are studies that have not found a positive association between T levels and BMD,4,5 but these do not support the data that Iucif and colleagues present, and based on the data presented, there may have been some misinterpretations. First, care should be taken because results presented in Figure 1 of Iucif and colleagues are from a correlation study between T-score and T levels, but the authors conclude that these results represent a negative correlation between BMD and T levels. The T-score compares the individual’s BMD measured using central DXA with the average for young individuals and expresses the difference as a standard deviation score. Single T-score measurements should never be interpreted as indicating any magnitude of bone loss. Most of the subjects studied in the Iucif and colleagues cohort would be classified as clinically normal based on the equipment reference database. Crude BMD values correlated with T levels would more accurately support the conclusion presented in the letter. Second, the correlation study that Iucif and colleagues present seems not to be adjusted (bivariate correlation) using any confounding factor. In particular, because of the putative gradual decrease in T levels during aging, partial correlations should be adjusted at least for age to address a negative correlation between BMD and T levels in elderly adults. Other factors should also be included in the analysis (mainly adjustment by weight of the participants). Finally, because the authors are presenting data from T-scores obtained in men, they should recognize what reference database are they using to interpret their results correctly. The International Society for Clinical Densitometry Position Development Conference6 recently recommended the use of a uniform Caucasian (non-raceadjusted) female reference database to calculate T-scores for femoral neck; manufacturer databases could still be
JANUARY 2015–VOL. 63, NO. 1
TELEVIDEO CLOCK DRAWING TEST TO REACH RURAL VETERANS: FEASIBILITY IN COMMUNITYBASED OUTPATIENT CLINICS IN THE DEPARTMENT OF VETERANS AFFAIRS To the Editor: Executive function includes higher-order cognitive processes such as planning, initiation, concurrent information processing, abstraction, and problem solving. Executive dysfunction, an early sign of dementia, is a common problem and often goes undiagnosed. Individuals with executive dysfunction experience tremendous difficulty keeping appointments, managing medications, and caring for themselves. On average, a typical elderly veteran has more than four medical problems and is taking six medications. With an aging veteran population, it is important to screen for executive dysfunction routinely, so it is important that the assessment be brief and easy to administer in busy primary care offices. The goal of the current study was to pilot the use of an executive function test over televideo to reach rural veterans. Arkansas is a rural state, with a majority of counties listed as rural or highly rural. A comprehensive activity-promotion telehealth clinic was developed to improve physical activity in rural veterans. It was desired to include a test as part of this clinic to exclude individuals with executive dysfunction because they might find it difficult to adhere to the program requirements, including wearing a pedometer and keeping a log of their steps. The Clock Drawing Test, consisting of CLOX1 and CLOX2, is a well-validated test of executive dysfunction.1 CLOX1 consists of a simple instruction to draw a clock with the hands at 1:45 on a blank sheet of paper. CLOX2 requires that the individuals copy a clock that the examiner draws without any additional instructions. The demonstration step adds a layer of complexity in performing this test over a video link. Both clocks are graded using the same rating rubric. Well-established cutoff points are available to diagnose executive dysfunction. The test typically takes less than 5 minutes to administer and score. The current study was designed to determine whether the Clock Drawing Test could be administered using telemedicine.
EQUIPMENT Videoconferencing systems were used at the host and remote sites using a hyperprotected dial-in, securityencrypted wireless system.
TEST ADMINISTRATION A trained examiner who was well versed in the test and routinely administers it at the host Veterans Affairs Medican Center administered the Clock Drawing Test. The veteran was at the remote site with a well-trained telehealth technician (THT). Standardized instructions were read for CLOX1. The THT provided the veteran with paper and pencil and remained easily accessible to solve any technical difficulties with the audiovisual equipment or connections but did not provide additional instruction or coaching to the veteran. For CLOX2, the
LETTERS TO THE EDITOR
205
host site examiner demonstrated how to draw the clock using a dry erase board over the video link. The veteran was then asked to copy the clock. The paper copies were then faxed to the examiner. The veteran was a 78-yearold, Caucasian man with type 2 diabetes mellitus, hypertension, chronic kidney disease, and depression.
TEST SCORING A geriatric psychiatrist (PRP) scored the test in conjunction with the examiner. No difficulty was noted in conducting the Clock Drawing Test administered over the video.
SATISFACTION The veteran denied having any problem understanding the instructions over the video link, and no extra prompting was necessary. He was able to see the demonstration of the clock drawing without any difficulty. The veteran expressed high satisfaction with this modality and thought that the videoconference made it more interesting. He commented that the provider was looking at him and interacting with him the entire time rather than appearing more engaged with the computer as had happened when he had seen a provider in person.
DISCUSSION The Department of Veterans Affairs (VA) has invested heavily with the aim of preparing itself to provide 21stcentury medical care by becoming a leader in telemedicine. Several telemedicine programs are currently ongoing at the VA, including teledermatology, teleretinal imaging, and telepsychiatry. There is growing evidence of the feasibility of performing neuropsychological tests using video conference, and satisfaction is high for tests that rely primarily on oral rather than written instructions.2 Research supports the equivalent interpretation of the administration of specific tests with consistent results with tests administered face to face.3,4 In some studies, it has been noted that the attention span and ability of the participant to remain engaged with the examiner is greater with telemedicine.5 Future application of this technology depends on expanded exploration of whether various medical and mental health professional services can be conducted using telehealth to meet the demand of an aging U.S. population. Prasad R. Padala, MD, MS Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, Arkansas Lisa Nabholz, RN Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
206
LETTERS TO THE EDITOR
Kalpana P. Padala, MD, MS Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas Courtney Ghormley, PhD Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Dennis H. Sullivan, MD Geriatric Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas Donald W. Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
ACKNOWLEDGMENTS Conflict of Interest: There are no financial or personal conflict of interest relevant to the submitted manuscript for any authors. Office of Rural Health, Department of Veterans Affairs P00493 (PI: Padala PR); Patient Centered Alternatives to Institutional Extended Care, VA Central Office Office of Geriatrics and Extended Care, Department of Veterans Affairs G598–4 (PI: Padala PR). Author Contributions: PRP: concept, recruiting and conducting study, manuscript preparation. LN: recruiting and conducting study, critical review of manuscript. KPP: concept, critical review of manuscript. CG, DHS: critical review of manuscript. Sponsor’s Role: The sponsor had no role in the design, methods, subject recruitment, data collections, analysis, or preparation of paper.
REFERENCES 1. Royall DR, Cordes JA, Polk M. CLOX: An executive clock drawing task. J Neurol Neurosurg Psychiatry 1998;64:588–594. 2. Parikh M, Grosch MC, Graham LL et al. Consumer acceptability of brief video conference-based neuropsychological assessment in older individuals with and without cognitive impairment. Clin Neuropsychol 2013;27:808– 817. 3. Turner T, Horner M, VanKirk K et al. A pilot trial of neuropsychological evaluations conducted via telemedicine in the Veterans Health Administration. Telemed J E Health 2012;18:662–667. 4. Timpano F, Pirrotta F, Bonanno L et al. Videoconference-based Mini-Mental State Examination: A validation study. Telemed J E Health 2013;19: 931–937. 5. Barton C, Morris R, Rothlind J et al. Video-telemedicine in a memory disorders clinic: Evaluation and management of rural elders with cognitive impairment. Telemed J E Health 2011;17:789–793.
TESTOSTERONE LEVELS AND BONE MINERAL DENSITY IN HEALTHY ELDERLY MEN To the Editor: We read with interest the letter by Iucif and colleagues1 on the association between total testosterone
JANUARY 2015–VOL. 63, NO. 1
JAGS
(T) plasma levels and bone mineral density (BMD) in healthy elderly men. A study of the association between T plasma levels and several bone measurements in a larger cohort (n = 162) of healthy elderly men was recently published.2 Quantitative ultrasound (QUS) measurements at the calcaneous and the hand phalanges were made, as well as peripheral BMD (pBMD) in the hand phalanges. These techniques differ from central BMD measurements determined using dual-energy X-ray absorptiometry (DXA) that are considered the criterion standard for the diagnosis of osteoporosis but allow the assessment of bone tissue in populations that do not have access to central DXA. The results that Iucif and colleagues presented were obtained from a cohort of men aged 60 and older (similar to the second study cohort: mean age 74.2 5, range 65–88) with mean T plasma levels of 411 192 ng/dL (slightly higher than observed in the second study cohort: 365 171 ng/dL). Iucif and colleagues found a negative correlation between BMD and T levels in the proximal femur and lumbar spine. These results contradict a number of studies that have demonstrated positive associations between T levels and BMD measured centrally and that the authors did not discuss. In particular, a meta-analysis3 presented results from 1,083 subjects with a mean age of 64.5 and demonstrated that T improved BMD at least in the lumbar spine. The results of the current study also indicate that higher values of os calcis, phalangeal QUS, and pBMD at the phalanges were observed in healthy elderly adults with higher T plasma levels. There are studies that have not found a positive association between T levels and BMD,4,5 but these do not support the data that Iucif and colleagues present, and based on the data presented, there may have been some misinterpretations. First, care should be taken because results presented in Figure 1 of Iucif and colleagues are from a correlation study between T-score and T levels, but the authors conclude that these results represent a negative correlation between BMD and T levels. The T-score compares the individual’s BMD measured using central DXA with the average for young individuals and expresses the difference as a standard deviation score. Single T-score measurements should never be interpreted as indicating any magnitude of bone loss. Most of the subjects studied in the Iucif and colleagues cohort would be classified as clinically normal based on the equipment reference database. Crude BMD values correlated with T levels would more accurately support the conclusion presented in the letter. Second, the correlation study that Iucif and colleagues present seems not to be adjusted (bivariate correlation) using any confounding factor. In particular, because of the putative gradual decrease in T levels during aging, partial correlations should be adjusted at least for age to address a negative correlation between BMD and T levels in elderly adults. Other factors should also be included in the analysis (mainly adjustment by weight of the participants). Finally, because the authors are presenting data from T-scores obtained in men, they should recognize what reference database are they using to interpret their results correctly. The International Society for Clinical Densitometry Position Development Conference6 recently recommended the use of a uniform Caucasian (non-raceadjusted) female reference database to calculate T-scores for femoral neck; manufacturer databases could still be
