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BMC Med Res Methodol. 2018 Jul 3;18(1):69. doi: 10.1186/s12874-018-0530-x.

Correction for retest effects across repeated measures of cognitive functioning: a longitudinal cohort study of postoperative delirium.

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Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA, 02131, USA.
Harvard Medical School, Boston, MA, USA.
Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Boston, MA, USA.
Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, 1200 Centre St, Boston, MA, 02131, USA.
Harvard Medical School, Boston, MA, USA.
Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Department of Psychiatry and Human Behavior and Neurology, Brown University Warren Alpert Medical School, Providence, RI, USA.



Few studies have compared methods to correct for retest effects or practice effects in settings where an acute event could influence test performance, such as major surgery. Our goal in this study was to evaluate the use of different methods to correct for the effects of practice or retest on repeated test administration in the context of an observational study of older adults undergoing elective surgery.


In a cohort of older surgical patients (N = 560) and a non-surgical comparison group (N = 118), we compared changes on repeated cognitive testing using a summary measure of general cognitive performance (GCP) between patients who developed post-operative delirium and those who did not. Surgical patients were evaluated pre-operatively and at 1, 2, 6, 12, and 18 months following surgery. Inferences from linear mixed effects models using four approaches were compared: 1) no retest correction, 2) mean-difference correction, 3) predicted-difference correction, and 4) model-based correction.


Using Approaches 1 or 4, which use uncorrected data, both surgical groups appeared to improve or remain stable after surgery. In contrast, Approaches 2 and 3, which dissociate retest and surgery effects by using retest-adjusted GCP scores, revealed an acute decline in performance in both surgical groups followed by a recovery to baseline. Relative differences between delirium groups were generally consistent across all approaches: the delirium group showed greater short- and longer-term decline compared to the group without delirium, although differences were attenuated after 2 months. Standard errors and model fit were also highly consistent across approaches.


All four approaches would lead to nearly identical inferences regarding relative mean differences between groups experiencing a key post-operative outcome (delirium) but produced qualitatively different impressions of absolute performance differences following surgery. Each of the four retest correction approaches analyzed in this study has strengths and weakness that should be evaluated in the context of future studies. Retest correction is critical for interpretation of absolute cognitive performance measured over time and, consequently, for advancing our understanding of the effects of exposures such as surgery, hospitalization, acute illness, and delirium.


Cognitive decline; Delirium; Post-operative; Practice; Repeated measures; Retest; Surgery

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