One of the richest data sources available to study cognition and aging is the Health and Retirement Study (HRS). This nationally representative survey includes questions to help assess cognition, but many researchers may use this data without actually knowing the questions behind the variables—don’t be That Guy! (or Gal!) Listen to Dr. Lindsay Ryan, an HRS team member, coach Matt as he administers the Telephone Interview for Cognitive Status (TICS) to Donovan, who is surprisingly good at recalling types of birds.
Transcript
Matt Davis:
I teach Introductory Statistics to clinical students. And I often use research articles to demonstrate the concepts that we cover in class. Once I recall I was teaching Z-scores, which is basically a way of taking a distribution of values and translating it in a different system that can identify how far from the mean each observation lies. In an event, we were using a study that looked at the association between cataracts as a measure of oxidative stress and cognitive function. And I recall the researchers collected a ton of different measures on cognitive function. Some of these included the telephone interview for cognitive status, verbal memory, immediate and delayed paragraph recall using the east Boston memory test, verbal fluency, digit span backwards tests, etc. And I recall thinking, "Wow, this sounds pretty intensive", and I'd be really bad to feel these measures, but these are the tools that we use to assess cognitive function and how we go about identifying dementia and studies. I'm Matt Davis.
Donovan Maust:
And I'm Donovan Maust.
Matt Davis:
You're listening to Minding Memory, a podcast devoted to exploring research on Alzheimer's disease and other related dementias. Now we don't cover politics on this podcast, luckily, but cognitive assessment was brought up in the media a year or two ago when president Trump took a cognitive test. This was the whole person, woman, man camera TV thing. But in all seriousness, though, it was the first time I can recall the public was aware of what a clinical test for cognitive function actually was like. And to me, it sounds very similar to some of the tests that we use in studies. So Donovan, before we kind of jump in today, I was wondering if you can help us distinguish between how cognitive impairment is diagnosed in the clinical setting versus how we go about identifying it in studies.
Donovan Maust:
So that's a really complicated issue. I guess the first question is whether it's diagnosed in clinical settings at all. So hopefully, yes, it is considered and there is a cognitive assessment for older adults. And I guess how that diagnosis and assessment happens can vary a lot on the setting, the type of clinical setting, are you inpatient or outpatient? Are you seeing a primary care provider, or a neurologist, or a psychiatrist? So what we're really interested in thinking about specifically is dementia. And that's part of what we're talking about today. And so, when I think about dementia, there are a couple, there are a variety of criteria that folks say at the National Institutes of Health and the Alzheimer's Association have come up that people need to meet these criteria to get a diagnosis of dementia. And so, the most important thing is that it represents a decline in the person's cognition over time, that the decline can't be accounted for or explained by something like delirium or another type of a psychiatric illness.
So then what type of decline are we talking about? So it can be different. Most people think about a decline in memory, but actually to be diagnosed with dementia, it doesn't have to be in memory. It can be in like reasoning or more sort of complicated cognitive tasks. It can be in visual-spatial ability. So like drawing two interlocking pentagons, it can be in language, it can even be in personality or behavior.
So you basically need deterioration in at least two of these domains, one of which could be memory, but doesn't have to be memory. Usually people will get some lab work and neuroimaging as part of a workup of cognitive impairment. Although, honestly, that's more, these days is used to rule out other conditions than it is to say, "Oh, if we find this on your MRI, you definitely have dementia." That usually is not how the imaging or the lab work works. So it's a pretty complicated thing, actually, to get a diagnosis in a clinical setting. And, obviously, what we can get out of a survey, like what we're going to learn about today is more of just like a snapshot picture in time. And it's kind of our guesstimate at whether or not somebody has cognitive impairment or not.
Matt Davis:
Are the questionnaires specifically used in the clinical setting? Are they part of a standard workup? I mean, would every older adult get them or do you only get those questionnaires if you have some kind of sign that could be related to cognitive function?
Donovan Maust:
Right. So it totally depends, in theory, as part of what's called the Medicare Annual Wellness Checkup, there should be a cognitive assessment included as part of that. Usually what primary care providers are using needs to be really brief because they have so little time. And so what your primary care doctor say might give your 75-year-old parent would be a very different thing than the type of diagnostic workup you'd get if you were going to a memory center for a workup for whether or not you have dementia. And those assessments can actually take hours. So it really, really depends on what's the setting and what's the purpose of the screen or the testing that you're doing.
Matt Davis:
I'm just curious, again, focusing on the questionnaires to assess cognitive functioning, both in the clinic and some of the ones we talked about today in terms of research. We like to distinguish between subjective and objective measurements and studies. I'm just curious, would you consider a validated survey to assess cognitive function as more of an objective measurement or maybe even quasi-objective?
Donovan Maust:
No, I definitely see that as more objective. And it is really important because for example, for myself as a psychiatrist, oftentimes we'll see folks who come into the clinic, who are there with a complaint about their memory, but when you actually do a memory assessment, they might be doing fine. It might actually be that they're depressed or they're anxious. And so their depression or their anxiety is what's interfering with their memory, but when you actually test them objectively, their memory is fine. And so this type of data is really important to help understand clinically what's going on. The other thing which we'll get into, I think in another episode, perhaps, is that actually for family members, this can be really, really important where maybe actually a family member doesn't think there's any type of a cognitive problem. And then when their loved one has some of this testing, sometimes it happens in front of them. It can really actually be pretty eye-opening to help people understand if there is, in fact, some memory change or cognitive impairment, that's present that maybe they hadn't fully appreciated.
Matt Davis:
One of the places that many of us go to in terms of getting data on cognitive status and older adults is the health and retirement study. And the primary measure that's used in that study to assess cognitive function is known as the Telephone Interview for Cognitive Status. It's basically a set of questions that are scored and turned into a numeric value. And then later we can sort of use that numeric score in a number different ways to identify cognitive impairment. So researchers that use just the values of the variable and cognitive assessment sometimes can be a little detached from what's really going on. So in this episode, we thought we'd try administering the TICS to see how it really works and in doing so, get a look at what's behind the numbers.
Today we're joined by Dr. Lindsey Ryan. Lindsey is an Associate Research Scientist at the Institute for Social Research at the University of Michigan, what we call ISR for short. Her PhD is in Human Development and her own research investigates contextual influences on psychological wellbeing, physical health, and cognition related to aging. In her position at ISR, Lindsay oversees the administration of the Telephone Interview for Cognitive Status. She's kindly agreed to join us today to provide a little coaching to me as I tried administering the TICS to Donovan. Lindsay, thanks so much for joining us today.
Lindsay Ryan:
Happy to be here.
Matt Davis:
Before I try administering the TICS, can you tell us a little about the history of the use of the TICS in the health and retirement study?
Lindsay Ryan:
Sure. So, traditionally, most cognitive measures were developed for in-person testing, and in large national samples, it's very expensive and hard to do household visits, have people come in. And so the HRS, which is a very large nationally representative study, in their early waves, was done primarily over the phone, but they wanted to incorporate measures of cognition and cognitive status. And thankfully, about four years before the first wave of HRS, which was in 1992, there was a publication in 1988 that introduced the TICS measure that you were referencing earlier. And, again, this was developed to be basically kind of like a telephone version of the MMSE, which is another very standard frequently used measure of cognitive status.
Matt Davis:
And what does that stand for?
Lindsay Ryan:
The Mini-Mental State Exam. And so, the interest in having something that could be done over the phone really broadens the possibilities for other large-scale surveys to collect data.
And, in the early nineties, there was a lot of work with the TICS. People were excited about it. And there have been some adaptations from that original version. The original one, for example, they had immediate recall, immediate word recall, but not delayed. The modified version that came out in 1993 out of the delayed recall tweak some of the questions. So, when HRS wanted to incorporate a version of TICS, they took many of those modifications made in 1993, and then also did a few additional tweaks to make it appropriate for our survey context, really. And it's been in there almost from the beginning, in one way or the other, and has been one of the most utilized components of the study. I can go into more detail, but that's sort of the general history of why it was specifically picked for the HRS
Matt Davis:
And how is it administered in the field today? Currently?
Lindsay Ryan:
So, the goal is to be administered in as standardized way as possible. We have hoards of interviewers across the country who do these tests either by phone or in person. Now there's about half the sample. Every wave gets it done in person, and they're called Computer-Assisted In-Person Interviews or Computer- Assisted Telephone Interviews. And there's a laptop with a special program, and we have it very highly scripted, which you have seen and we'll be illustrating later. The biggest difference now in administration is we have started incorporating a web mode to complete the HRS because some of our, particularly the younger respondents, those in mid-life, would like that as an option. And obviously you don't have the same controls when you don't have an interviewer there. If you want to do the word recall, you can't have an interviewer saying the words out loud. It has to be presented visually. They have to type in responses. So, we've made adaptations where possible, but really the introduction of the web mode has created some of the biggest changes.
Matt Davis:
So Lindsay has sent me the instructions that the HRS staff use when they administer the survey. Is there anything I should do before I take a crack at using this?
Lindsay Ryan:
So, main tips, we spend a lot of time training our interviewers. It's a week of training to be able to do this properly across the whole interview. And it's important not to give any direct positive or negative feedback because there's a lot of science showing that that can affect motivation. If you give them really positive feedback, they're going to possibly try harder. If you act like they're getting things incorrect or getting doing things wrong, they might be less motivated to continue trying their hardest. So, saying "thank you" when they're done with the responses is pretty sort of generic without giving away in your face or in your words how they're doing.
Matt Davis:
So when Donovan can only name a few animals, I shouldn't tell them that's really bad?
Lindsay Ryan:
Definitely not.
Donovan Maust:
Okay.
Matt Davis:
All right. Donovan, are you in character?
Donovan Maust:
I guess I'm in character. When Matt suggested that we do this, I told him that I have medical students. When I work with them at the hospital, I'll have them administer a cognitive test to me. I usually don't do very well because I'm distracted about patient care. So I'm going to really try and focus and do a better job this time. So let's see how we do.
Matt Davis:
It does seem like you probably have an advantage being familiar with it, but.
Donovan Maust:
I've actually never done the TICS, though. So I've done the MMSE or some of the other ones, but never the text. So I'm excited.
Matt Davis:
Okay. Let's do it. So I'm going to add a little something just to kind of get in character. So, Mr. Moss, thank you so much for participating in the Health and Retirement Study. Next, we're going to talk about things related to your memory. I'm going to ask you a couple of questions. Is that okay?
Donovan Maust:
Sure. Can my wife help me?
Matt Davis:
No. You're on your own.
Donovan Maust:
Oh, okay. All right.
Matt Davis:
Okay. Here it goes into the formal part of this. I'll read a set of 10 words and ask you to recall as many as you can. We have purposefully made the list long so it'll be difficult for anybody to recall all the words. Most people recall just a few. Please listen carefully as I read the set of words, because I can not repeat them. When I finish, I will ask you to recall aloud as many of the words as you can in any order. Is this clear?
Donovan Maust:
Yes. And I'm super nervous, but go ahead.
Matt Davis:
Okay. All right, here we go. Hotel, river, tree, skin, gold, market, paper, child, king, book.
Donovan Maust:
Hotel, river, tree, skin, gold, market, paper, book.
Matt Davis:
Okay. Now I'm going to ask you to think about the past week and the feelings that you have experienced. Please tell me if each of the following was true for you much of the time during the past week. So much of the time during the past week, you felt depressed. Would you say yes or no?
Donovan Maust: No.
Matt Davis:
Much of the time during the past week you felt that everything you did was an effort. Would you say yes or no?
Donovan Maust:
No.
Matt Davis:
Your sleep was restless.
Donovan Maust:
No.
Matt Davis:
You were happy?
Donovan Maust:
Yes.
Matt Davis:
You felt lonely.
Donovan Maust:
No.
Matt Davis:
You enjoyed your life.
Donovan Maust:
Yes.
Matt Davis:
You felt sad.
Donovan Maust:
No.
Matt Davis:
You could not get going.
Donovan Maust:
No.
Matt Davis:
Okay. For this next question, please try to count backward as quickly as you can, from the number that I will give you. I will tell you when to stop, please start with 20.
Donovan Maust:
20, 19, 18, 17, 16, 15, 14, 13, 12, 11, 10, 9, 8.
Matt Davis:
You may stop now. Thank you. Now, let's try some subtraction of numbers. 100 minus seven equals what?
Donovan Maust:
93.
Matt Davis:
And seven from that?
Donovan Maust:
86, 79, 72, 65.
Matt Davis:
Okay. You're going too fast for me. It's a test to retest phenomenon.
Donovan Maust:
Okay.
Matt Davis:
A little while ago, I read you a list of words and you repeated the ones you could remember.
Donovan Maust:
Oh no.
Matt Davis:
Please tell me any of the words that you can remember now.
Donovan Maust:
Oh, jeez. Tree, hotel, human, skin. That's it.
Davis:
All right, here we go. We're interested in how memory actually works. We find that even people with very good memories seem to forget things from time to time. The next questions are a little different, but are often asked on studies about memory. Please tell me today's date. What month is it?
Donovan Maust:
It is May.
Matt Davis:
And the day?
Donovan Maust:
Friday.
Matt Davis:
Day of the month?
Donovan Maust:
The 14th.
Matt Davis:
And the year?
Donovan Maust:
2021.
Matt Davis:
Okay. Now I'm going to ask you for the names of some people in things. What do people usually use to cut paper?
Donovan Maust:
Scissors.
Matt Davis:
What do you call the kind of prickly plant that grows in the desert?
Donovan Maust:
Cactus.
Matt Davis:
Who is the president of the United States right now?
Donovan Maust:
Biden.
Matt Davis:
Who is the vice-president?
Donovan Maust:
Harris.
Matt Davis:
Okay. That brings us to the last part of this. Now I want to see how many different animals you can name. You will have 60 seconds. When I say "begin", say the animal names as fast as you can. Are you ready?
Donovan Maust:
Sure.
Matt Davis:
Begin.
Donovan Maust:
Dog, cat, rabbit, deer, crane, cardinal, zebra, hippopotamus, giraffe, elephant, gorilla, monkey, chimpanzee, orangutan, turtle, snake, eel, scorpion, spider. I should have stuck with particular habitat. Let's go like cheetah, tiger, lion, rhino, flamingo, stork, eagle, vulture, condor, goose, duck, hummingbird, woodpecker. I'll stop. I think I passed the cutoff.
Matt Davis:
Okay. And that's 55 seconds. So close enough.
Donovan Maust:
Okay.
Matt Davis:
And scene. So, Lindsay, how did we do, and more importantly, how's Donovan's cognitive functioning?
Lindsay Ryan:
I will say that was an impressive number of animals, and I was following along and I didn't notice any repeats, which is very good. I would say, Matt, you did a really good job enunciating. Your pacing was pretty good. It takes some practice to do the word list presentation at the accurate pacing. So was slightly off, but again, you actually did very well.
Donovan Maust:
So was Matt a little bit too fast or too slow? What's the pacing supposed to be?
Lindsay Ryan:
It's supposed to be about one word every two seconds.
Donovan Maust:
Okay.
Lindsay Ryan:
So I would say you were a little bit fast, particularly towards the end, but.
Matt Davis:
My students say that I talk too fast, so I'm not surprised.
Lindsay Ryan:
I have that problem as well. But yeah, the one thing I did notice that was interesting is that when you were doing your delayed word recall, there was one intrusion, one word that wasn't on the original list. And it's only because I have the list memorized that I noticed "human" as a word that wasn't originally read.
Donovan Maust:
Was skin a word?
Lindsay Ryan:
Yes.
Donovan Maust:
I think maybe somehow that connection turned into human.
Lindsay Ryan:
Sure. And you said "skin", I think shortly after "human" as well. But very good job.
Donovan Maust:
Thank you. I'm glad I passed.
Matt Davis:
So, for listeners, that word list is sort of the immediate assessment and the delayed assessment. And I've seen in other data sets, sometimes they'll do the immediate thing multiple times, but you guys do it once.
Lindsay Ryan:
Yeah. So, which is another battery of these sorts of tests they have, they call wordless learning, they do a presentation of one word list, three different orders. And usually the immediate score is that first presentation. Then you do another two times. So, in theory, you should have a higher delayed recall when you get multiple presentations. Part of HRS is that it's a very, very long interview. We don't have a lot of time to do that sort of presentation. We do it in some of the sub studies, but not in the main core.
Matt Davis:
So, just like in broad strokes, the questions that I just asked Donovan and that the things I had him do, how are those kind of turned into that numeric score?
Lindsay Ryan:
Right. So, not counting the animal naming at the end, which isn't officially a part of TICS. The overall score is out of 35 total points. Now there's a subsection of those questions at the end, starting with the date, naming the date all the way through vice-president that they're only asked of respondents on their baseline interview. And then they're asked every wave of those 65 and over, because those are types of measures that you don't expect to decline until people are much older. And so, for the whole sample, the total possible would be out of 27 points. So for word recall, you have 10 possible words. You have 10 possible points. You either remember the word or you don't. For serial sevens, when he was doing the subtraction, there should be five trials, which he did very quickly. That was impressive. And again, you get a point for every possible correct response. I think the trickiest one is backward counting. If you do it correctly on the first try, you get two points. If it takes you a second try, you only get one, but otherwise it's very straightforward scoring.
Donovan Maust:
So in the beginning there were a number of questions that seem to be getting at my mood. Is that a part of the TICS?
Lindsay Ryan:
That is not a part of the TICS, it's an adaptation of the CSD, Depressive Symptom Scale. And from the very beginning of HRS, that was chosen to be part of the time filler between the immediate and delayed. And it's important to note because you mentioned this earlier, actually, depression can mask can, can make someone's cognitive status look worse than it is. And so, there is a slight risk that we're priming people to be a little bit more negative by asking these questions. But on the plus side, everybody does the same way. So at least it's consistently administrated that way. And again, it was done that way from the beginning, so we haven't deviated to make sure that the longitudinal data is consistent.
Matt Davis:
I also kind of love how it speaks to the time efficient, time pressure of HRS, where you're trying to cram so much data collection into as brief period of time, have it super packed. And so you make use of that wait time to collect other important information.
Lindsay Ryan:
Yeah. I mean, every question is in there for a very specific reason.
Matt Davis:
Precious time.
Lindsay Ryan:
Yes. I mean, the first interview can be up to three hours long with all the things that... There are more questions in the baseline interview that don't get asked again unless something changes. But yeah, every minute is precious.
Matt Davis:
It makes so much more sense that you were talking about sort of the speed at which it has to be delivered out. I didn't really think about that in terms of the timing between the immediate and delayed, but now it kind of makes sense.
Lindsay Ryan:
We do have timing measures. So if you want to be really precise, you can adjust for possible interviewer differences in immediate and delayed. It's something that's available in the data. Not everybody cares at that level of detail, but we do provide that.
Matt Davis:
Wow. And in terms of the scoring, just to be clear, there aren't any kind of bonus points, because I think president Trump, that he got bonus points for something.
Donovan Maust:
And by the way, I didn't realize it until we were looking at the TICS today that I was like, well, he had quite an advantage for a couple of those questions where the president and vice-president was.
Lindsay Ryan:
Yeah. So I'm pretty sure the test he did was what's called the MOCA, which is another version of this that was developed in Canada. I don't know of actual bonus scoring. So that's not how I was trained, but no, with an hour version, you cannot get bonus points. Sadly.
Matt Davis:
So, my last question is kind of an open-ended one. I was just wondering, in your time working on the health and retirement study, you must have seen like a lot of different things, especially with training people in different implementations. Is there any sort of interesting anecdotes you'd want to share with us regarding the TICS?
Lindsay Ryan:
Well, I laughed at the beginning when you asked if your spouse can help because I don't do the actual interviews, but I've heard from interviewers who say they can hear a grown child, or a spouse in the background. "Market. You forgot market on the word list." And it is real. And when we're doing it over the phone, we don't have much control over the environment.
Matt Davis:
Yeah. And in the clinic, you always have to say, "Now your daughter or your wife can't help you on this." They have to do it on their own. So.
Lindsay Ryan:
A few years ago, I don't even remember how it happened, but one of our participants wanted to write a little editorial about her experience in this big national study and wanted to interview somebody on the project, and I am the one she talked to. And she told me she was in her mid-sixties, that she's been in the study for 10, 15 years. And so, every two years she knows what's coming because it's very consistent. And the week leading up to her interview, she actually creates her own word lists, some tests herself in the hopes. Because she's like, "Now that I'm getting older, I'm nervous that I'm not going to do very well. So I quiz myself." I thought, "Oh dear". This is why we have practice effects in longitudinal data on cognition. It's a perfect example.
Matt Davis:
I think I could see my parents training themselves for something like this as well. So,
Lindsay Ryan:
A lot of individual differences and who would be worried about that or not. And then I guess, because he did animal naming, one of my favorite things to mention is that you're allowed to do all sorts of subtypes of animals. I noticed you were going in depth on birds. [00:27:30] That's all fine.
Matt Davis:
I was surprised by the bird responses, you were really specific.
Donovan Maust:
I was thinking of what I've been seeing outside in the spring.
Lindsay Ryan:
Some people do breeds of dogs, different lizards. It's interesting. But we don't allow fictional creatures like dragons or unicorns, but we do a lot of cross-national work and some countries, they actually do accept that. I'm pretty sure in China they'll take dragon, in Ireland, where there's all sorts of different mythology [00:28:00] and beliefs, they are more accepting of certain types of creatures that wouldn't be considered correct in the US.
Donovan Maust:
Loch Ness monster if you're in Scotland or something.
Lindsay Ryan:
Yes.
Matt Davis:
That's amazing. I mean, do you not count insects?
Lindsay Ryan:
Oh no. Insects counts.
Donovan Maust:
I did. I was getting into some insects and I was like, "Wait, no, this isn't an animal. So maybe I need to go back to"-
Lindsay Ryan:
It's not a plant. So it would count.
Matt Davis:
That would be a fascinating study to kind of compare, culturally, the different animals that are listed on the animal recall. There's a study for you,
Donovan Maust:
Well, this has been fun. I want to thank our guests, Dr. Ryan and Donovan for being such a good sport. And, as always, thanks to all of you who listened in.
If you enjoyed our discussion today, please consider subscribing to our podcast. Other episodes can be found on Apple podcasts, Spotify, and SoundCloud, as well as directly from us at CAPRA. [00:29:00] med.umich.edu, where a full transcript of this episode is also available. On our website, you'll also find links to our seminar series and the data products we've created for dementia research. Music and engineering for this podcast was provided by Dan Langa more information available at www.danlanga.com. Minding Memory is part of the Michigan Medicine Podcast Network. Find more shows at uofmhealth.org/podcast. Support for this podcast comes from The National Institute on Aging at the National Institutes of Health, as well as the Institute for Healthcare Policy and Innovation at the University of Michigan. The views expressed in this podcast not necessarily represent the views of the NIH or the University of Michigan. Thanks for joining us. And we'll be back through.
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