INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 7: 437-442 (1992)

JIM WHO? RECALL OF NATIONAL LEADERS BY ELDERLY PEOPLE IN THREE COUNTRIES

DAVID AMES Senior Lecturer in Psychiatry of Old Age, University of Melbourne Department of Psychiatry, Royal Melbourne

Hospital, Parkville, Australia

DEBORAH ASHBY Lccturer in Medical Statistics, Department of Public Health, University of Liverpool, Liverpool, UK

LEON FLICKER Senior Lecturer in Geriatric Medicine, University of Melbourne, Mount Royal Hospital, Parkville, Australia

JOHN SNOWDON Associate Professor, Department of Psychiatry, Sydney University, Rozelle Hospital, Rozelle, N S W, Australia

CHRISTOPHER WEST Principle Experimental oficer, Department of Public Health, University of Liverpool, Liverpool, UK

AND

SIEGFRIED WEYERER Head, Psychogeriatric Research Unit, Central Institute of Mental Health, Mannheim, Germany

SUMMARY

The Organic Brain Syndrome scale (OBS) of the Brief Assessment Scale (BAS) was administered to 1202 elderly subjects in London, Mannheim, Sydney and Melbourne. Subjects’ knowledge of current and last national leaders was assessed, and two methods of scoring the OBS were compared. Taking into account the degree of cognitive impairment found using seven items of the OBS other than the national leader item, knowledge of current leader was much more consistent across countries than was knowledge of last leader. When subjects were allocated an error point for failing to know either current or last leader, dementia prevalence measured by the OBS was consistently 5-6% less than that found when they were allocated an error point for failing to know both leaders. Future studies using the BAS should publish prevalence data for both scoring methods in order to permit comparison between studies.

KEY W O R D S - R ~ ~ ~ ~ ~ , national leaders, survey, dementia, screening.

The Brief Assessment Scale (BAS) (MacDonald et al., 1982; Mann et al., 1989) is a screening instru- ment designed for the detection of cognitive impair- ment and depressive symptoms in elderly subjects. It is available in English and German versions and good inter-rater reliability between the two ver- sions was demonstrated in a bilingual population of elderly people in London (Mann et al., 1989). The BAS has been used to screen populations in receipt of residential, nursing home, hospital and day care care in the UK, Germany and Australia (MacDonald et al., 1982; Mann et al., 1984; Ames et al., 1988; Roohanna and Pitt, 1989; Snowdon and Mackintosh, 1989, Weyerer et al., 1990; Harri-

0885-6230/9 2/060437-O6$08.00 0 1992 by John Wiley & Sons, Ltd

son et al., 1990), and also has been used for research in other community settings (Lane and Snowdon, 1989; Welz et al., 1989; Harrison et al., 1990). The BAS consists of a Depression scale (DEP) and an Organic Brain Syndrome scale (OBS), both of which contain items derived from the Comprehen- sive Assessment and Referral Evaluation instru- ment (CARE) (Gurland et al., 1977). The OBS scale consists of eight items (see Appendix) and one error point is scored for an incorrect response to any item. For studies published to date subjects assessed with the BAS have been divided into three groups according to their OBS scores using earlier results obtained with the CARE as a basis for clas-

Received 19 July 1991 Accepted 13 January 1992

438 D. AMES ET AL.

sification. Those scoring 0-2 have been classed as free of cognitive impairment (probably not demented), those scoring 3-7 as mild to moderately impaired (probable mild to moderate dementia) and those scoring 8 as severely impaired (probable severe dementia). In some studies respondents who could not state any one of their age, date of birth, name of dwelling place or suburb at the start of the interview had their interviews discontinued and an OBS score of 8 assigned, because earlier work indicated that nearly all such individuals would score 8 on the complete scale and be incapable of giving coherent responses to the depression items (Mann et al., 1984). Occasional individuals who know either the name of their dwelling or its suburb but not its postal address have been questioned on all the items of the OBS and still received a score of 8.

Although the BAS was derived from the CARE, the scoring of one item has differed between the two instruments for historical reasons. In the CARE if respondents can name neither the current nor the last national leader (prime minister in the UK and Australia, president in the USA, chancel- lor in Germany) one error point is scored on the OBS scale, but if they can name one or the other no point is scored. Using the BAS, one point is scored on the OBS scale unless respondents can name both the current and last national leader. The CARE scoring is more lenient than the harsh rule adopted for the BAS. It is possible that the harsh BAS scoring may be a source of bias in published research with the BAS and may have led to some degree of overdiagnosis of dementia among popu- lations screened with the instrument.

Although a number of cognitive screens assess knowledge of a current national leader (Kahn et al., 1960; Hodkinson, 1973; Horn et al., 1989), there are problems in using such an item when results obtained at different times or in different countries are to be compared. Time in office varies widely between individual leaders of one country, and between countries such as the USA with its fixed presidential term and Italy where the rapid turn- over of prime ministers has prompted some researchers to use knowledge of the current pope as an item equivalent to knowledge of the national leader elsewhere. The public profile of individual leaders varies too, and there is evidence that at least some demented subjects find certain prime minis- ters intrinsically more memorable than others (Deary et al., 1985). The use of the BAS by a number of associated research groups in Australia,

Germany and the UK has produced data which permit us to compare knowledge of current and previous leaders between subjects with similar cog- nitive performance from three different countries. The screening of all residential homes in the London borough of Camden on two separate occasions allows us to explore the effect of time in and out of office upon recall of current and pre- vious British prime ministers. Our data also allow us to assess the effect of using two methods of scor- ing the ‘national leader’ item on the reported preva- lence of dementia in screened populations. Given the increasing popularity of the BAS as a research tool and the recent replacement of long-serving prime ministers in both Britain and Australia, this exploration of a possible source of inaccuracy is timely.

METHOD

Trained raters administered the BAS to subjects in London, Mannheim, Sydney and Melbourne. London subjects were residents of 12 residential homes for the elderly screened in 1982 and 1985/6 in order to study the prevalence of depression and dementia. Two-thirds of those resident in these homes in 1982 had gone by the time of the second survey, but 123 subjects were assessed for know- ledge of prime ministers on both occasions. Mann- heim subjects were inmates of 12 residential homes screened in 1988 for the purposes of a similar cross- sectional study of depression and dementia. Sydney subjects consisted of residents of hostels and nurs- ing homes and members of a randomly selected sample of elderly people living at home (Lane and Snowdon, 1989). In Melbourne the first 100 attenders at a memory clinic were examined with the BAS in 1988/9, and 99 completed the OBS scale. Because the Australian samples were smaller than the British and German ones, these data were merged to produce one Australian cohort of com- parable size to the European ones.

Inter-rater reliability between some members of the teams was assessed in 1986 and proved accep- table (Mann et al., 1989). All other raters were trained by a rater whose reliability was assessed for that publication. In London and Mannheim interviews were aborted if subjects failed to state at least one of the following correctly: their age, date of birth, the name of the institution in which they lived, or the suburb where they lived. In Mel- bourne and Sydney all items of the OBS were ad-

RECALL OF NATIONAL LEADERS 439

ministered regardless of response to the initial ques- tions. The responses to the national leader item were divided into five categories: (i) knows both current and last leader, (ii) knows current leader only, (iii) knows last leader only, (iv) knows neither leader, (v) item not administered. The number of subjects with each response was tabulated against the score (0-7) obtained on the other seven items of the BAS, which for the purpose of this article has been named the ROBS (rest of OBS) scale. Thus the ability of individuals with similar cognitive pro- files to recall current and previous national leaders could be compared between samples.

The proportion of residents classed as not demented (OBS score of 0-2), mild-moderately demented (OBS score of 3-7) and severely demented (OBS score of 8) was calculated for each of the four samples using two methods of scoring the OBS scale. The first (‘Harsh’) method scored the national leader item in the manner used for all published research to date, allotting one point unless the respondent knew the names of both the current and last leader. The second (‘Lenient’) method allotted one point on the OBS scale for the national leader item only if the respondent could name neither the current nor the last leader.

RESULTS

Knowledge of current and last national leader was rated at 1325 interviews with 1202 subjects (123 London subjects were interviewed in both 1982 and 1985/6). In a further 261 interviews knowledge of national leaders was not assessed, usually because the interview was terminated due to failure on the initial OBS items. The Mannheim sample had the lowest rates of cognitive impairment. The second London sample had the highest rates. Table 1 shows recall of present and last national leader by subjects from the four samples tabulated against total score for the remaining seven OBS items (ROBS score). The number of subjects who knew the name of their current national leader may be calculated by adding those knowing h idhe r alone to the number knowing both leaders, while the number recalling the last leader may be calculated by adding the number who knew him alone to the number who knew both.

The two London samples show the effects of time in and out of office on national leader recall. In 1982 19%) of those screened recalled the name of Mr Callaghan, the last prime minister, but by 19851

6 he was remembered by only 9%, a decline which was not explained by the higher rate of cognitive impairment found in the second sample because the fall in recognition was seen at all levels of impairment. By contrast, the incumbent prime minister’s recognition rate was stable, falling from 63% in 1982 to 59% in 198516 despite a definite shift towards greater cognitive impairment in the population assessed. Among those who gave cor- rect responses to the other seven items of the OBS, knowledge of Mrs Thatcher’s name rose from 93% to 98% between surveys, while Mr Callaghan was recalled by 41% of these otherwise unimpaired sub- jects in 1982 but by only 25% in 1985/6.

Cross-national comparison of results indicated that all current leaders achieved recognition rates above 93% among those scoring 0/7 on the ROBS, but while Mr Kohl was known by 72% of those scoring 1,56% of those scoring 2, and 2 1% of those scoring 3-7, Mrs Thatcher was known by respecti- vely 87%, 79%, and 37% of comparable subjects after a similar period in office, and Mr Hawke by 86%, 82%, 36% after what was, on average a shorter period in power.

Table 2 compares the rates for no, mild-moder- ate and severe cognitive impairment using cut- points of 2/3 and 7/8 for the four samples when lenient and harsh methods of scoring the national leader item are employed. It shows a consistent shift of 5-6% of subjects from the mild-moderately impaired group into the unimpaired group when the lenient scoring method is used. The relative lack of effect upon the severely impaired group (OBS = 8) is due to the fact that many of these sub- jects were not rated for knowledge of national leaders after failing the initial OBS items, and among those who scored 7 or 8 after completing the whole scale, knowledge of either present or last leader was an uncommon event, occurring in only eight of 101 interviews.

DISCUSSION

The poor recall of Mr Callaghan’s name by mem- bers of both London samples contrasts powerfully with the excellent recall of his Australian and Ger- man contemporaries, Fraser and Schmidt, by their former subjects, supporting the hypothesis of Deary et al. (1985) that some leaders are intrinsi- cally more memorable than others. Mrs Thatcher and Mr Hawke were somewhat better known than

440 D. AMES ET AL.

Table 1-Recall of national leader by score obtained on remaining seven items of the OBS scale (ROBS) for subjects examined in three countries

Sydney1 London London Mannheim Melbourne

Setting(s)

Year of study Current leader Years in power Last leader Years in power

Total no. of subjects assessed with BAS

No. not rated for knowing national leaders (interviews aborted when initial items failed)

No. rated for knowing national leaders

Score on 7 items of OBS (ROBS) scalefor all subjects rated on national leaders items

0 Knew only current leader Knew both leaders Knew only last leader Knew neither leader

Total

1 Knew only current leader Knew both leaders Knew only last leader Knew neither leader

Total

2 Knew only current leader Knew both leaders Knew only last leader Knew neither leader

Total

3-7 Knew only current leader Knew both leaders Knew only last leader Knew neither leader

Total

All Knew only current leader Knew both leaders Knew only last leader Knew neither leader

Residential homes

1982 Thatcher 3 Callaghan 3

433

140

Residential homes Residential homes

1985/6 1988 Thatcher Kohl 6-7 6 Callaghan Schmidt 3 8

390 389

112 9

Hostels Nursing homes Community sample Memory clinic

1986-90 Hawke 3-7 Fraser 7

3 74

-

293 278 380 374

29 (52'/0) 23 (41%)

4 (7%) -

56

46 (61%) 16 (21%)

14(18%) -

76

25 (58%) 9 (21'Yn)

9 (21%) 43

30 (25%) 6 (5%) 1 (1%)

81 (60%) 118

29 (73') 10 (25%) -

1 (3%) 40

31 (67%) 9 (20%)

6 (1 3%) -

46

25 (74%) 2 (6%) -

7 (21%) 34

56 (350/0) 3 (2%) 2 (1%)

97 (61%) 158

41 (33Yo) 77 (62%)

1 (1%) 5 (4%)

124

28 (28%) 44 (44%)

8 (8%) 20 (20%)

100

15 (26%) I7 (30%) 5 (9%)

20 (35%) 57

14 (14Yo) 7 (7%) 2 (2%)

76 (77%) 99

29 (19'/0) 1 17 (78%)

2 (1%) 2 (1%)

150

33 (46%) 28 (39%)

1 (lYn) 9(13%)

71

22 (50%) 14 (32Yo) -

8 (18%) 44

32 (29%) 8 (7Yo) 5 (5%)

64 (59'Yo) 109

130 (44%) 141 (51%) 98 (26Yu) I16 (31%) 54 (1 8%) 24 (9%) 145 (38%) 167 (45%)

108 (370/) 11 1 (40%) 121 (32%) 83 (22%) 1 (OY") 2 (1%) 16 (4%) 8 (2%)

~~

Note: All percentages rounded to nearest whole number.

Mr Kohl. Both were charismatic and highly visible leaders who appeared to arouse strong emotions within their electorates, and one might hypothesize that knowledge of Mr Kohl's name might have been

considerably higher if the data had been collected after German reunification.

The rescoring of the national leader item had a very consistent effect upon prevalence rates for

RECALL OF NATIONAL LEADERS 44 1

Table 2--Dementta status of subjects screened with the OBS scale of the BAS using two different scoring methods for the ‘national leader’ item

Sydney/ London London Mannheim Melbourne

OBS seorddivnentra status 0-2 (‘no dementia’)

Harsh Lenient

144 (33%) 88 (23%) 241 (62%) 235 (63%) 169 (39%) 11 3 (2%’0) 261 (67%) 251 (69%)

3-7 (‘mild- moderate dementia’) Harsh 155 (36%) 190 (49%) 132 (34%) 1 18 (32%) Lenient 130 (300/0) 166 (43%) 1 12 (29%) 98 (26%)

8 (‘severe dementia’) Harsh Lenient

134 (3 1%) 1 12 (29%) 16 (4%) 21 (6%) I34 (31%) 11 2 (29%) 16 (4%) 19 (5%)

Total 433 390 389 374

Note: Lenient scoring allocated one OBS error point when subjects knew neither current nor last national leader. Harsh scoring allocated onc error point when subjects did not know current and last national leader.

mild-moderate cognitive impairment in all four samples. The finding of a consistent effect on preva- lence rates using the lenient method of scoring is an important result which indicates that published data on mild-moderate dementia rates reported in studies using the BAS should be adjusted down- wards by 6%) to achieve comparability with rates which would be found using the CARE schedule.

Two recommendations concerning the use of the OBS scale of the BAS stem from our work. First, as is the case with all screening instruments, there is no substitute for validating the instrument on the target population in a pilot study prior to the start of the main investigation, and this should always be done when possible. Second, researchers reporting prevalence rates for no, mild-moderate and severe dementia on the basis of scores obtained with the OBS scale of the BAS should state the method of scoring employed, and present their results using both the Harsh and Lenient scoring systems for knowledge of national leaders, in order to permit comparison with other published work. Cross-national differences in results will be mini- mized by adopting the lenient method of scoring the national leader item, but a difference in promi- nence of national leaders may lead to some varia- tion in results. The future development of screening instruments for use in more than one country will need to take account of these factors, but our results indicate that they need not present a major barrier to future cross-national comparisons.

ACKNOWLEDGEMENTS

The authors wish to thank Anthony Mann and Nori Graham for allowing the use of data gathered in 1982, the subjects who participated, the inter- viewers who administered the schedules, the auth- orities who permitted the administration of questionnaires, the National Unit for Psychiatric Research and Development (UK) which funded Dr Ames’ salary from 1985 to 1987, and the German Ministry of Research and Technology which sup- ported the Mannheim study.

REFERENCES

Ames, D., Ashby, D., Mann, A. H. and Graham, N. (1988) Psychiatric illness in elderly residents of Part 111 homes in one London borough: Prognosis and review. Age Ageing 17,249-256.

Deary, I. J., Wessely, S. and Farrell, M. (1985) Dementia and Mrs Thatcher. Brit. Med. J . 291, 1768.

Gurland, B., Kuriansky, J., Sharpe, L. et al. (1977) The comprehensive assessment and referral evaluation (CARE)-rationale, development and reliability. Znt. J. Hum. Dev. 8 , 9 4 2 .

Harrison, R., Savla, N. and Kafetz, K. (1990) Dementia, depression and physical disability in a London bor- ough: A survey of elderly people in and out of residen- tial care and implications for future developments. Age Ageing 19,97-103.

442 D. AMES ET AL.

Hodkinson, H. M. (1973) Mental impairment in the elderly. J. Roy. Coll. Phys. Lond. 7, 305-3 17.

Horn, L., Cohen, C. I. and Teresi, J. (1989) The EASI: A self-administered screening test for cognitive impair- ment in the elderly. J . Am. Geriatr. Soc. 37,848-855.

Khan, R., Goldfarb, A., Pollack, M. and Peck, A. (1960) Brief objective measures for the determination of men- tal status in the aged. Am. J. Psychiat. 117, 326328.

Lane, F. and Snowdon, J. (1989) Memory and dementia: A longitudinal survey of suburban elderly. In Clinical and Abnormal Psychology (P. Loribond and P. Wilson, Eds). Elsevier, Amsterdam.

Macdonald, A., Mann, A., Jenkins, R., Richard, L., Godlove, C . and Rodwell, G. (1982) An attempt to determine the impact of four types of care upon the elderly in London by the study of matched groups. Psychol. Med. 12, 193-200.

Mann, A., Graham, N. and Ashby, D. (1984) Psychiatric illness in residential homes for the elderly: A survey in one London borough. Age Ageing 13,257-265.

Mann, A., Ames, D., Graham, N. et al. (1989) The relia- bility of the brief assessment schedule. Int. J. Geriatr. Psychiat. 4,221-225.

Roohanna, R. and Pitt, B. (1989) Psychiatric morbidity in patients admitted to geriatric wards. In The Fourth Congress of the International Psychogeriatric Associa- tion: Program and Abstracts. IPA, Tokyo, p. 11 8.

SAS Institute (1986) SUGI Supplemental Library Users Guide, Version 5. SAS Institute, Cary, North Carolina.

Snowdon, J . and Mackintosh, S. (1989) Depression and dementia in three Sydney hostels. Austral. J. Ageing 8,2628.

Welz, R., Lindner, M., Klose, M. and Pohlmeier, H. (1989) Psychische Storungen und korperliche Erkran- kungen im Alter. Fundamenta Psychaitrica 3,223-228.

Weyerer, S., Geiger-Kabisch, C., Kroper, C., Denzinger,

R. and Platz, S. (1990) Die Erfassung von Demenz und Depression mit Hilfe des Brief Assessment Inter- views (BAI): Ergebnisse einer Reliabilitats- und Validi- tatsstudie bei Altenheimbewohnern in Mannheim. Zeitschr. Gerontol. 23,205-2 10.

APPENDIX

Brief Assessment Scale Organic Brain Syndrome Scale scoring rules

There are eight items in the OBS scale and each has a possible score of 0 (correct response) or 1 (error). Thus the scale has a possible scoring range from 0 to 8. The eight items are listed below

Item ~ Score

I . Does not know agelgives incorrect age 2. Does not know date of birth/gives incorrect date of birth 3. Does not know correct postal addredgives incorrect

address 4. Cannot recall interviewer's name 5. Does not know both current and last national leader' 6. Does not know current month/gives incorrect month 7. Does not know current yeadgives incorrect year 8. Makes error(s) when asked to touch right ear with

right hand, right ear with left hand and left ear with right hand

* Under the lenient scoring method used by the CARE schedule an error point is allotted only when neither current nor last national leader is known.