The Pleasant Events Schedule-AD: Psychometric Properties and Relationship to Depression and Cognition in Alzheimer's Disease Patients 1

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1 Copyright 1997 by The Cerontological Society of America The Cerontologist Vol.37, No. 1,40-45 The Pleasant Events Schedule-AD (PES-AD) has been described as a useful tool for identifying pleasant activities for Alzheimer's disease patients. The current investigation provides psychometric data on the PES-AD, introduces a shortened, 20-item version, and examines the relationship between pleasant events, cognitive functioning, and depression. Both versions of PES-AD had good reliability and were significantly correlated with each other and with other relevant measures. As hypothesized, both depression and decreased cognitive functioning were associated with reduced frequency of enjoyable activity, and the reduction was significantly greater in AD patients who were depressed than in those who were not depressed, regardless of cognitive level. Key Words: Dementia, Activities, Social learning theory The Pleasant Events Schedule-AD: Psychometric Properties and Relationship to Depression and Cognition in Alzheimer's Disease Patients 1 Rebecca G. Logsdon, PhD 2 and Linda Teri, PhD 2 The relationship between pleasant events and depression is an important aspect of behavioral theories of depression. Social learning theory provides a framework for describing this relationship. According to social learning theory, behavior is influenced by the continuing interaction between an individual and his or her environment (Bandura, 1977). Depression may result when an individual's environment provides a low rate of response-contingent positive reinforcers (Lewinsohn & Graf, 1973). In other words, too few pleasant (and too many unpleasant) events may act as a trigger for depressive mood, which results in decreased energy and motivation, which lead to fewer pleasant activities, creating a vicious cycle (Teri, Logsdon, Wagner & Uomoto, 1994). In Alzheimer's disease (AD), declining cognitive functioning may result in a gradual loss of the ability to perform activities that are rewarding, enjoyable, and meaningful. According to social learning theory, this may well be an important cause of increased levels of depression and other behavioral disturbances in individuals with AD (Mace, 1987; Teri et al., 1 This research was supported by NIA grants AG-05136, AG and NIMH grant MH Portions of this article were presented at the Annual Scientific Meeting of the Cerontological Society of America, November 1994, Atlanta, CA, and at the annual meeting of the American Psychological Association, August, 1995, New York, NY. Appreciation is extended to Sue McCurry, PhD and to the anonymous reviewers for feedback on an earlier version of the manuscript. Thanks also to Amy Schmidt, MSW, Mark Arnold, BS, and the staff of the Geriatric and Family Services Clinic for assistance with data collection and entry. 2 University of Washington School of Medicine. Address correspondence to Rebecca G. Logsdon, PhD, Department of Psychiatry and Behavioral Sciences, Box , University of Washington, Seattle, WA logsdon@u.washington.edu 1992; Zgola, 1987). Case studies by Teri and colleagues (Teri & Uomoto, 1991; Teri et al., 1994) provide preliminary support for a relationship between pleasant events and depression in AD, and suggest that an increase in pleasant events results in a reduction in depression, but additional research is needed to clarify this relationship. A measure of pleasant events, the Pleasant Events Schedule-AD (PES-AD; Teri & Logsdon, 1991) has been proposed as a useful clinical tool in assessing pleasant activities for Alzheimer's patients. The current investigation describes a method for scoring the PES-AD and provides psychometric data about the reliability and validity of the original 53-item PES-AD, and a shorter 20-item scale. To evaluate the relationship between pleasant events, depression, and cognitive functioning, depressed AD patients were compared to nondepressed AD patients on the PES-AD, the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960, 1967), and the Mini Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975). Since the cognitive decline that occurs in dementia eventually results in a decreased ability to plan and carry out activities, it is hypothesized that cognitive test scores will be positively correlated with PES-AD scores (patients who have better cognitive functioning will also have more pleasant events). Based on social learning theory and prior research with nondemented adults (Dobson & Joffe, 1986; Lewinsohn & Graf, 1973; Lewinsohn & MacPhillamy, 1974; Zeiss, Lewinsohn, & Munoz, 1979), it is further hypothesized that, regardless of cognitive level, depressed AD patients will identify fewer events as enjoyable, and report a lower frequency of pleasant events than 40 The Gerontologist

2 nondepressed patients. And finally, since loss of interest in pleasant activities is a primary symptom of depression, it is hypothesized that depressed subjects will identify fewer items as enjoyable now, as compared to the past, while nondepressed subjects are expected to show no such decrease in items rated as enjoyable. Method Subjects Subjects were 42 AD outpatients, recruited from the research roster of the Geriatric & Family Services Clinic at the University of Washington Medical Center (described by Reifler, Larson, & Teri, 1987). The diagnosis of dementia was based on a thorough physical and neurological exam (including a complete blood count, serum chemistries, and thyroid functioning tests). When clinically indicated, brain imaging (MRI or CT scan) was obtained. Diagnostic information was also obtained in a detailed interview with the patient and caregiver, and in neuropsychological assessments of the patients. All patients had at least a 6-month history of cognitive problems, and had no treatable medical problems that were judged as contributing to their cognitive deficits. All met criteria for primary degenerative dementia as described in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition-revised {DSM-III-R; American Psychiatric Association, 1987) and National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS- ADRDA; McKhan et al., 1984) criteria for probable or possible AD. All patient-subjects lived in the community, with either a spouse (n = 31) or adult child (n = 11) who agreed to assist the patient and act as an informant. No subjects were currently taking antidepressants or other psychotropic medication (e.g., benzodiazepines or neuroleptics), and no subjects were suicidal, delusional, or hallucinating. Depression was evaluated by trained geriatric clinicians, based on extensive clinical interviews with the patient and caregiver. Nineteen patients met DSM-III- R (American Psychiatric Association, 1987) and research diagnostic criteria (RDC; Spitzer, Endicott, & Robins, 1978) for Major Depressive Disorder. Twentythree patients were judged to be not depressed. Demographic information is provided in Table 1. There were no significant differences between depressed and nondepressed subjects on any demographic variable, except (as expected) on HDRS scores. Measures Overall cognitive functioning was assessed using the Mini Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975). The MMSE is a brief cognitive screening measure that assesses orientation to time and place, attention, immediate and delayed memory, calculation, language, and constructional Variable Age Education Gender Male Female Mini Mental State Hamilton Depression Rating Scale Caregiver Relationship Spouse Adult Child *p< Table 1. Demographic Information Total Sample n = ± ± ± ± 7 31 (74%) 11 (26%) Depressed n = ± ± ± ± 5 17(89%) 2(11%) Not Depressed n = ± ± ± ± 4* 14(61%) 9 (39%) ability. The MMSE is widely used and has been demonstrated to have adequate test-retest reliability, concurrent validity, and sensitivity among older adults with and without diagnoses of dementia and depression. Scores range from 0 to 30; scores below 24 indicate probable cognitive impairment. Depression severity was assessed using the 17- item version of the Hamilton Depression Rating Scale (HDRS; Hamilton, 1960, 1967). The HDRS is derived from a semistructured interview, performed in this investigation by a geriatric clinician. Scores may range from 0 to 52, with scores higher than 14 indicative of clinically significant depressive symptomatology. The HDRS has been demonstrated to have adequate reliability and validity in AD patients, using caregivers as informants about patient depression (Teri & Wagner, 1991; Logsdon & Teri, 1995). The Pleasant Events Schedule-AD (PES-AD; Teri & Logsdon, 1991) is a 53-item checklist of events and activities for AD patients. The PES-AD was based on two earlier Pleasant Events Schedules, one developed by Lewinsohn and colleagues for use in a general adult population (PES; Lewinsohn & Talkington, 1979; MacPhillamy & Lewinsohn, 1982) and a modified version for older adults (PES-Elderly; Teri & Lewinsohn, 1982). The PES-AD was developed by eliminating; items from the PES-Elderly that were inappropriate for individuals with AD (e.g., getting a job advancement), modifying some items to make them more appropriate (e.g., "driving" was changed to "going for a ride in the car"), and adding items the authors have identified through clinical experience to be enjoyed by many individuals with AD (e.g., "looking at photo albums"). Activities were selected to cover two primary domains, passive-active and social-nonsocial. For example, "being outside" would be classified as a passive activity, while "exercising" is an active item. "Having meals with friends or family" is an example of a social item, and "watching TV" is a nonsocial item. All items were designed to be within the capabilities of mildly demented individuals, with some more cognitively taxing than others (e.g., "doing jigsaw puzzles, crosswords, and word games" as compared to "listening to music"). Vol. 37, No. 1,

3 The resulting PES-AD has been used as part of a research treatment protocol for depressed AD patients (Teri, 1994; Teri et al., 1994). It is currently being used in a research program treating agitated AD patients and in a longitudinal investigation designed to reduce disability in AD patients. In clinical and educational settings where it has been used (e.g., the University of Washington Geriatric & Family Services Clinic and Alzheimer's Association support groups), caregivers report that the PES-AD is easy to complete, that it gives them ideas about activities that they had not thought of trying, and that it provides a positive approach to interacting with their family member. Items are rated according to their frequency () and availability () during the past month on a 3-point scale: not at all, a few times (1-6 times), and often (7 or more times). Items are also rated according to whether the patient now enjoys the activity () and whether the activity was enjoyed in the past (). To obtain an overall summary score of frequency of enjoyable activities, a cross product with (rated 0 or 1) x (rated 0, 1, or 2) is calculated for each item. Each item therefore receives a score of 0 = either does not enjoy or hasn't done in the past month, 1 = enjoys and has done a few times, and 2 = enjoys and has done often. The sum of these item scores () represents the frequency of pleasant activities during the past month. This score is similar to the ''obtained pleasure" rating of the original PES, developed by MacPhillamy & Lewinsohn (1974; 1982). Procedure All measures were obtained at the time of the patient's intake. Patients and caregivers were recruited for this investigation within one month of their evaluation. Caregivers were instructed to complete the PES-AD according to the standard instructions, involving their patient as much as possible by asking questions and discussing items with the patient. They were either mailed the checklist or it was given to them to take home and return the following week. If forms were not returned within a week, a follow-up telephone call was made. Return rate with this procedure was 100%. Results PES-AD Psychometrics Coefficient alpha and split-half reliabilities were calculated for each PES-AD subscale and for the EN- JOY (summary) scale and are listed in Table 2. Coefficient alpha values for the PES-AD (ranging from.86 to.95) are comparable to those reported by Teri and Lewinsohn (1982) for the Pleasant Events Schedule- Elderly, which ranged from.95 to.98. To assess validity of the scales, Pearson productmoment correlations between PES-AD, HDRS and MMSE scores were calculated. Results of this analysis are shown in Table 3. Both and scopes Scale PES-AD Short PES-AD Scale PES-AD Short PES-AD Table 2. Internal Consistency and Reliability of the PES-AD Scales Alpha Table 3. Correlations Between the PES-AD, Cognitive Status, and Depression MMSE ** * ** * HDRS' * * -.35* * * Depression Diagnosis' * -.35*.40* * -.39*.43* Split-Half PES-AD".91***.92***.92***.95***.95*** 'Pearson Product Moment Correlations. "Spearman Correlations. Correlations reported are for same scales of Short PES-AD and PES-AD. *p <.01; **p <.001; ***p < were significantly correlated with the MMSE (r =.57, p ^.001 and r =.45, p ^.01, respectively) and with the HDRS (r = -.41 for both scores, p ^.01). Spearman correlations between PES-AD scores and depression diagnosis were also significant for,, and (r =.39, -.35, and.40, respectively, p^.01). Thus, as hypothesized, subjects with higher MMSE scores (indicating better cognitive functioning) also scored higher on the PES-AD, and subjects with higher scores on the HDRS (indicating greater depression) scored lower on the PES-AD. Interestingly, neither nor scores alone were significantly correlated with HDRS or MMSE scores in this sample, indicating that frequency and availability of activity per se were not related to depression or to cognitive status. Frequency of activity that the patient enjoys was related to both. Demographic characteristics, including patient gender, age, duration of depression, and relationship to the caregiver were not significantly correlated with PES-AD, MMSE, or HDRS scores. 42 The Gerontologist

4 PES-AD: Short Form One of the goals of this investigation was to identify ways to minimize the amount of time and effort required of caregivers and patients to complete the scale. The goal was to keep items that were most useful and important, and to eliminate those that were redundant, not pleasant, or not related to the total score. Out of the original 53 items, 33 were eliminated. First, three items judged by the authors to be difficult to rate or not available to many patients were eliminated. These items were: being at the beach (not applicable in many parts of the country), thinking about something good in the future (not an observable behavior), and having a family member or friend tell me something that makes me proud (subjective judgement by caregiver). Second, eight items that were enjoyed by fewer than 30% of the subjects were eliminated. Next, inter-item and itemtotal correlations were evaluated, and 22 items with item-total correlations below.35 were eliminated. Item-total correlations and frequencies for items that were retained are shown in Table 4. The remaining items represent a balanced assortment of social and nonsocial, active and passive activities that are within the capabilities of most mildly to moderately demented patients. The resulting 20-item Short PES-AD scale was subjected to the same psychometric analysis as described for the long version. Internal consistencies and split-half reliabilities, in Table 2, show that the Short PES-AD is comparable to the full version. Spearman correlations with depression diagnosis and Pearson product moment correlations between the Short PES-AD and the full PES-AD, MMSE, and HDRS are shown in Table 3. As can be seen, Short Table 4. Item-Total Correlations and Frequencies for Short PES-AD Items Item-Total Items Correlation Frequency 3 1. Being outside 2. Shopping or buying things 3. Reading or listening to stories 4. Listening to music 5. Watching T.V. 6. Laughing 7. Having meals with friends or family 8. Making or eating snacks 9. Helping around the house 10. Being with family 11. Wearing favorite clothes 12. Listening to the sounds of nature 13. Getting or sending letters, cards 14. Going on outings 15. Having coffee, tea, etc. with friends 16. Being complimented 17. Exercising (walking, dancing, etc.) 18. Going for a ride in the car 19. Grooming (wearing make up, shaving) 20. Recalling and discussing past events "Frequency = percent of subjects who enjoyed the activity and engaged in it at least once during the prior month. PES-AD correlations with other measures were comparable to correlations obtained with the full PES- AD, indicating good validity, and the correlations between comparable subscales of the short and full versions of the PES-AD ranged from.91 to.95, indicating excellent agreement between the two scales. Pleasant Events, Cognition, and Depression To examine the relationship between pleasant events and depression in AD patients, an analysis of covariance was performed to determine whether depressed and nondepressed subjects differed on any subscales or scales of the PES-AD and the Short PES- AD. MMSE scores were entered as a covariate and results of this analysis are shown in Table 5. Consistent with the correlational analysis, the covariate, MMSE, was not significant for,, or, but was significant for [PES-AD: f(1,39) = 20.3, p <.0001; Short PES-AD: F(1,39) = 13.4, p<.001] and [PES-AD: F(1,39) = 9.8,p<.01; Short PES-AD: F(1,39) = 8.0, p <.01 ]. As hypothesized, subjects with higher cognitive functioning enjoyed more activities, and participated in more enjoyable activities during the prior month. Similarly, the depressed and nondepressed subjects did not differ significantly on or. They did, however differ on the number of items endorsed as being enjoyable, on subscale scores [PES-AD: F(1,39) = 10.0, p <.01; Short PES-AD: F(1,39) = 11.1, p <.01] and [PES-AD: F(1,39) = 6.1, p <.01; Short PES-AD: F(1,39) = 8.4, p <.01], and on summary score, [PES-AD: F(1,39) = 8.9, p <.01; Short PES-AD: F(1,39) = 11.3, p <.01]. These differences were in the hypothesized direction, with depressed subjects reporting fewer activities as now enjoyable, and engaging in fewer enjoyable activities in the past month than nondepressed subjects, at all levels of cognitive functioning. In order to test the hypothesis that depressed subjects would show a loss of interest in pleasant activities, the relationship between the number of items endorsed as pleasant now () as compared with the number of items endorsed as pleasant in the past () was examined. To determine whether subjects enjoyed more, fewer, or the same number of activities now as in the past, an INTEREST score for each subject was calculated as ( - ). Using this formula, a score of zero indicates that the subject enjoys the same number of activities now as in the past. A positive score indicates that the subject enjoys more activities now than in the past, while a negative score indicates that the subject enjoys fewer activities now than in the past, thus has lost interest in some activities that were previously enjoyable. INTEREST scores were examined in the same way as other scores, first in a correlational analysis, then in an analysis of covariance comparing depressed and nondepressed subjects. IN- TEREST was significantly correlated with MMSE (r =., p ^.001), HDRS (r = -.37, p =.005), and depression diagnosis (r =.52, p <.0001), but not with any demographic characteristics. MMSE was again entered as a covariate in the analysis of variance, and was significant [F(1,39) = 13.9, p <.001], with higher cog- Vol.37, No. 1,

5 Table 5. Comparison of PES-AD Scores in Depressed and Non-depressed Subjects, with MMSE Score as Covariate Scale Depressed n = 19 Means + SD Nondepressed n = 23 Covariate MMSE F Values Main Effect Depression Diagnosis Total Variance Explained PES-AD FREC? * " * Short PES-AD C C d " C.9 it it it db : t it : t : t : t ± ± ± ± ± ± ± ± ± ± ± *** * ** * * 6.1* 8.9* * 8.4* 11.3* *** 5.4* 10.4*** *** 7.1* 10.7*** Note: Higher scores indicate higher levels of activity on all scales. "Items are rated 0 to 2; total scores can range from 0 to 106. b ltems are rated 0 or 1; total scorescan range from 0 to 53. c ltems are rated from 0 to 2; total scores can range from 0 to 40. d ltems are rated 0 or 1; total scores can range from 0 to 20. *p <.01; **p <.001; ***p < nitive functioning related to less loss of interest. The INTEREST score was significantly lower in the depressed subjects than in the nondepressed subjects [F(1,39) = 17.78; p <.001], confirming the hypothesis that depression is significantly related to greater loss of interest in pleasant activities in AD subjects, regardless of their level of cognitive functioning. Discussion Results of this investigation indicate that the PES- AD provides a useful measure for assessing pleasant events in AD patients. Further, a short version of the PES-AD that is reduced from 53 to 20 items correlated well with the longer version. In addition, the subscale assessing availability () did not appear to differ in any important way from the frequency () subscale; therefore it is recommended that it be omitted from the Short PES-AD to further reduce caregiver time and effort in completing the form. In some settings, particularly in research or clinical settings where pleasant events and activities are a secondary rather than a primary concern, the short version may be more useful than the full PES-AD, since it takes much less time to complete. In settings where pleasant events are a primary focus, such as in adult day centers or activity programs, the longer version may be preferable, since it provides a wider range of potential activities from which to select. The current investigation provides new information about the relationship between pleasant activities, cognitive functioning, and depression in AD patients. Caregivers reported comparable frequencies of overall activity for depressed and nondepressed patients at all levels of cognitive functioning. This finding may appear counterintuitive, since low activity levels have been observed clinically in both depressed individuals and in cognitively impaired individuals. However, it is consistent with a crosssectional study in which subjects over the age of 50 were found to engage in comparable levels of activity regardless of depression diagnosis, although depressed subjects reported fewer of the activities as enjoyable (Lewinsohn & MacPhillamy, 1974). As hypothesized, important differences were found in the number of activities that were rated as enjoyable, and in the frequency of enjoyable activities during the prior month. Fewer activities were reported to be enjoyed by individuals diagnosed as depressed than by individuals who were not depressed, regardless of cognitive level. This supports the hypothesis that depression amplifies the reduction in enjoyable activities in AD patients regardless of their level of cognitive functioning. This finding is consistent with studies of the impact of depression on activities of daily living, where depression has been found to be associated with increased functional impairment in AD, independent of cognitive level (Fitz & Teri, 1994; Pearson, Teri, Reifler, & Raskind, 1989). Results of this investigation also confirm the hypothesis that loss of interest in pleasant activities is greater in depressed than in nondepressed AD patients, regardless of their level of cognitive functioning. As discussed earlier, fewer activities were identified as now enjoyable () and more activities were identified as enjoyable in the past () for patients who were depressed than for patients who were not depressed. Thus, a behavioral treatment program for depression may be most effective when it both increases the frequency of activities that the patient currently identifies as enjoyable, and introduces a problem-solving component to increase the number of activities that the patient enjoys. Such an approach has met with some success and is being further studied (Teri, 1994). 44 The Gerontologist

6 It should be noted that subjects in this study were community-residing AD patients who lived with a spouse or adult child caregiver who was very involved in the day-to-day activities of the patient. These factors may have mitigated a decline in overall activity level. Results may or may not generalize to patients not represented in this sample, such as severely impaired or institutionalized AD patients, or patients whose caregivers are less involved with their day-to-day activity. In addition, subjects were primarily middle-class Caucasians with at least a high school education. Further research is needed to determine whether the PES-AD is equally useful with individuals in different living situations, or of different ethnic, cultural, and educational backgrounds. It will also be useful for future research to evaluate the extent to which mildly demented patients can complete the measure about themselves, and the extent to which their assessments agree with their caregivers' ratings. The shortened version of the PES- AD makes such an investigation more realistic. Although memory impairment may make it difficult for patients to rate frequency of activities during the past month, they may very well be able to indicate which activities they enjoy now. In summary, both the long and short forms of the PES-AD are useful tools for the assessment of pleasant events in individuals with AD. They yield an assessment of the frequency and perceived enjoyability of a number of activities appropriate for mildly to moderately demented community-residing patients. Both forms of the PES-AD provide the clinician or care provider with a method for identifying activities that the patient enjoys. The long version is obviously more comprehensive; the short version is quicker to complete. Clinical literature and structured programs for AD patients emphasize the importance of keeping patients active and involved in a variety of tasks, with the goals of maximizing cognitive functioning, maintaining interpersonal skills, and improving patient mood. The information gained from the PES-AD will be useful in planning daily activity schedules for individuals either at home or in care facilities (e.g., Adult Activity Centers). In terms of future research, the PES-AD provides an assessment of an essential domain of care: the number and frequency of pleasant events. What kinds of activities do AD patients find pleasant at various stages of the disease? What activities are most reasonable for caregivers to incorporate into their daily routines? How does increasing pleasant events impact the patient's mood, functional status, or quality of life? How do various treatments affect the number of pleasant events, and the patient's ability to participate in them? 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