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Clinical Manifestations.

Zeling He1, John Hanfelt1, Felicia C Goldstein2

  • 1Emory University Rollins School of Public Health, Atlanta, GA, USA.

Alzheimer'S & Dementia : the Journal of the Alzheimer'S Association
|December 26, 2025
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Summary
This summary is machine-generated.

Instrumental activities of daily living (IADL) scales can be biased by race and informant factors. Adjusting for differential item functioning (DIF) improves accuracy in diagnosing cognitive impairment in older adults.

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Area of Science:

  • Gerontology
  • Neuroscience
  • Psychometrics

Background:

  • Instrumental activities of daily living (IADL) scales are vital for diagnosing mild cognitive impairment (MCI) versus dementia in older adults.
  • IADL rating scales can be subject to differential item functioning (DIF), introducing biases based on demographic or contextual factors.
  • Addressing DIF is critical for equitable access to clinical trials and FDA-approved treatments for cognitive impairment.

Purpose of the Study:

  • To evaluate differential item functioning (DIF) in the Functional Activities Questionnaire (FAQ), an informant-based IADL scale.
  • To assess the impact of participant race and informant characteristics on IADL ratings.
  • To determine if DIF adjustment can mitigate biases and improve the accuracy of IADL assessments in older adults with MCI.

Main Methods:

  • Utilized the Likelihood-based Investigation of Differential Item Functioning (LIDIF) model on data from 7,958 participants with MCI from the National Alzheimer's Coordinating Center Uniform Data Set.
  • Simultaneously adjusted for multiple covariates including participant age, sex, education, race, and informant sex and cohabitation status.
  • Estimated DIF-adjusted IADL levels using posterior means to mitigate rating biases.

Main Results:

  • Significant DIF effects were identified across all 10 FAQ items, with race and informant characteristics being key sources of bias.
  • Black participants were rated as less impaired than white participants, particularly at higher impairment levels, even after covariate adjustment.
  • Informant cohabitation status influenced ratings; non-cohabitating informants reported less functional impairment. DIF adjustment reduced racial disparities and floor effects, identifying more individuals with impairment.

Conclusions:

  • Accounting for demographic and informant characteristics in FAQ assessments is crucial.
  • Adjusting for DIF enhances the accuracy and fairness of IADL assessments.
  • Improved IADL assessment supports equitable clinical decision-making and appropriate recognition of functional impairment across diverse populations.