Chronic insomnia and cognitive functioning among older adults

Actigraphic Sleep Duration and Fragmentation in Older Women: Associations With Performance Across Cognitive Domains

Study Objectives

To determine the association of actigraphic sleep duration and fragmentation with cognition in community-dwelling older women.

Methods

We studied 782 women (mean age = 87.4) of varied cognitive status from the Study of Osteoporotic Fractures who completed wrist actigraphy and the Modified Mini-Mental State Examination (3MS), California Verbal Learning Test-II-Short Form, digit span, verbal fluency tests, and the Trailmaking Test, Part B (Trails B). Total sleep time (TST) and wake after sleep onset (WASO) tertiles were our primary predictors.

Results

There were few significant associations in adjusted analyses. Compared to women with intermediate TST (mean = 430.1 minutes), those with the longest (508.7 minutes) had significantly poorer performance on the 3MS and phonemic and semantic fluency. Compared to women with the least WASO (31.5 minutes), those in the middle tertile (61.5 minutes) had significantly poorer delayed recall and those in the middle tertile and highest tertile (126.2 minutes) had poorer total recall and semantic fluency. We observed significant adjusted associations of TST with impaired 3MS performance and of WASO with impaired delayed recall, semantic fluency, and digit span. After excluding participants with adjudicated dementia diagnoses or indeterminate cognitive status, some adjusted associations remained but decreased in magnitude, others became nonsignificant, and a new association emerged.

Conclusions

In community-dwelling older women, longer objectively measured sleep duration and greater sleep fragmentation are associated with poorer performance and impairment in only a subset of cognitive domains. Some of these associations may be driven by women with dementia in whom disturbed sleep and cognitive performance share an underlying neuropathological basis.

Priming recognition in good sleepers and in insomniacs

Insomniacs often report memory and concentration problems, but these complaints have not been consistently supported by performance measurements. Furthermore, while the majority of studies have addressed explicit memory, few have investigated the implicit domain, and very little is known concerning other types of implicit memory besides procedural memory, such as priming. Thus, the purpose of the study was to investigate priming effect for visual stimuli in insomniacs and good sleepers. Twenty-three insomniacs and 20 good sleepers performed a visual priming task in which they were asked to name new and old pictures presented at nine ascending levels of spatial filtering. Both neutral and sleep-related stimuli were used, as previous research evidenced an attentional bias for sleep-related stimuli. Visual priming effect was observed in both groups, suggesting that poor sleep quality does not affect this type of implicit memory. However, the identification process in insomniacs is influenced by the nature of the stimulus to identify: insomniacs recognized both new and old sleep-related stimuli at lower spatial frequencies compared with good sleepers. The tendency to selectively attend to sleep-related stimuli may influence top-down processes occurring during identification of filtering stimuli, by determining a pre-allocation of attentional resources and facilitating identification processes even when sensorial information is scant. Differences in the identification processes of sleep-related stimuli compared with neutral ones should be carefully taken into account as possible pre-clinical markers of insomnia in poor sleepers.

Enhancing Cognitive Functioning in Healthly Older Adults: a Systematic Review of the Clinical Significance of Commercially Available Computerized Cognitive Training in Preventing Cognitive Decline

Successfully assisting older adults to maintain or improve cognitive function, particularly when they are dealing with neurodegenerative disorders such as Alzheimer's disease (AD), remains a major challenge. Cognitive training may stimulate neuroplasticity thereby increasing cognitive and brain reserve. Commercial brain training programs are computerized, readily-available, easy-to-administer and adaptive but often lack supportive data and their clinical validation literature has not been previously reviewed. Therefore, in this review, we report the characteristics of commercially available brain training programs, critically assess the number and quality of studies evaluating the empirical evidence of these programs for promoting brain health in healthy older adults, and discuss underlying causal mechanisms. We searched PubMed, Google Scholar and each program's website for relevant studies reporting the effects of computerized cognitive training on cognitively healthy older adults. The evidence for each program was assessed via the number and quality (PEDro score) of studies, including Randomized Control Trials (RCTs). Programs with clinical studies were subsequently classified as possessing Level I, II or III evidence. Out of 18 identified programs, 7 programs were investigated in 26 studies including follow-ups. Two programs were identified as possessing Level I evidence, three programs demonstrated Level II evidence and an additional two programs demonstrated Level III evidence. Overall, studies showed generally high methodological quality (average PEDro score = 7.05). Although caution must be taken regarding any potential bias due to selective reporting, current evidence supports that at least some commercially available computerized brain training products can assist in promoting healthy brain aging.

Cognitive remediation to enhance mobility in older adults: the CREM study

Mobility disabilities represent the most prevalent disability among seniors. Emerging evidence indicates that executive functions play an important role in maintaining mobility. However, the use of cognitive remediation programs to enhance mobility has not been investigated in a full-scale randomized control trial. The CREM study is a single-blind randomized control trial to examine the effect of computerized cognitive remediation versus computer-based health education training on mobility in 420 seniors. The primary outcome is change in gait speed during normal walking and walking-while-talking conditions from baseline to postintervention. Secondary outcomes are change in mobility, mobility-related cognitive processes and neuroplasticity. Results of this study will fill an important gap in the efficacy and feasibility of cognitive remediation to improve mobility in seniors.

The Relationship between Sleep Complaints, Depression, and Executive Functions on Older Adults

Aim: In this manuscript, we report data on the association between executive functions screened by Frontal Assessment Battery, Five Digit Test and Digit Span with self-reported depressive symptoms and sleep complaints in non-demented older adults.

Methods: A total sample of 95 non-demented older adults performed Geriatric Depression Scale short version, Frontal Assessment Battery, Five Digit Test, Digit Span, and clinical interview. We split participants in groups stratified by age according to: young-old (60–69 years of age), old-old (70–79 years), and oldest-old (>80 years) and compared these three groups on the sociodemographic characteristics and executive functions performance. We carried out Poisson regression with robust error variance to verify sleep complaints and depression effects on executive functions performance. Gender, age, years of formal education, use of antidepressants and of benzodiazepines were considered as confounding variables, taking into account executive functions as dependent and sleep complaints and depression as independent variables.

Results: Controlling the effect of age, gender, years of formal education, use of benzodiazepines and of antidepressants there was a significant influence of depression in motor programming, inhibitory control, and working memory. Individuals without depression show motor programming scores 68.4% higher, inhibitory control scores 3 times greater and working memory scores also 3 times greater than individuals without depression. There was a significant influence of sleep complaints in phonemic fluency, motor programming, inhibitory control, and working memory. Individuals without sleep complaints show phonemic fluency scores 2 times greater than, motor programming scores 85.9% higher, inhibitory control scores 3 times greater and working memory scores also 3 times greater than individuals without sleep complaints.

Conclusions: Sleep complaints are associated with phonemic fluency, motor programming, inhibitory control, and working memory impairment. Depression symptoms presence are associated with motor programming and working memory performances. Depression and sleep complaints interaction would determine worse phonemic fluency, inhibitory control and working memory cognitive performance than these two conditions alone.

Deficits in attention performance are associated with insufficiency of slow-wave sleep in insomnia

OBJECTIVE

Cognitive impairment is associated with insomnia. However, there is a lack of evidence suggesting a link between insomnia and cognitive dysfunction in objective testing. The objectives of our current study were to assess the differences in components of attentional performance between primary insomnia patients and normal-sleeping controls and to examine potential predictors of attention impairment in patients with insomnia.

METHODS

We studied 36 patients (age 40.39 ± 12.36 years; 57.1% male) with insomnia and 25 normal-sleeping controls (age 39.88 ± 12.50 years; 52.9% male) who underwent one-night polysomnography followed by Multiple Sleep Latency Test (MSLT) and Attention Network Task (ANT). ANT reflected three attentional networks termed the alerting, orienting, and executive control networks.

RESULTS

After controlling for age, gender, body mass index, depression, anxiety, and education levels, patients with insomnia scored higher on the executive control variable of the ANT compared with normal-sleeping controls (96.75 ± 7.60 vs. 57.00 ± 10.49, p = 0.01). This higher score was independently associated with insufficiency of slow-wave sleep during nighttime sleep (β = -0.38, p = 0.04).

CONCLUSION

Our findings suggest that insomnia is associated with deficits in executive control of attention and that the underlying mechanism may be insufficiency of slow-wave sleep in chronic insomnia.

Age- and gender-specific associations between insomnia and falls in Boston Puerto Rican adults

PURPOSE

This study evaluated the age- and gender-specific associations between insomnia and falls in community-dwelling Puerto Rican adults, independently of multiple covariates.

METHODS

Cross-sectional data were collected from 954 Puerto Ricans, aged 46-79 years, in Boston, Massachusetts. In-person interviews were conducted to collect information on sociodemographics and lifestyle, mental status, medication use, comorbidities, sleep duration, insomnia symptoms, and falls and fractures. Blood and urine samples, and bone density measures were collected to assess C-reactive protein, serum interleukin-6, urinary cortisol, and bone mineral density.

RESULTS

Multivariate robust Poisson regressions suggested that adults with insomnia had a 32 % increased likelihood of having falls (PR 1.32, p < 0.05), after adjustment for multiple covariates. Age and gender modified the effect of insomnia on risk of falls. Insomnia was significantly associated with higher risk of falls in adults of 60 years or older (PR 1.49, p < 0.05) and in women (PR 1.36, p < 0.05), but not in adults younger than 60 years or in men. Insomnia was not associated with recurrent falls or fractures.

CONCLUSIONS

Age and gender need to be taken into account when considering treatment of insomnia in preventing geriatric falls. Well-designed evidence-based interventions to treat insomnia and improve sleep quality may reduce the risk of falls in this population.

The Concept of Missing Incidents in Persons with Dementia

Behavioral symptoms of dementia often present the greatest challenge for informal caregivers. One behavior, that is a constant concern for caregivers, is the person with dementia leaving a designated area such that their whereabouts become unknown to the caregiver or a missing incident. Based on an extensive literature review and published findings of their own research, members of the International Consortium on Wandering and Missing Incidents constructed a preliminary missing incidents model. Examining the evidence base, specific factors within each category of the model were further described, reviewed and modified until consensus was reached regarding the final model. The model begins to explain in particular the variety of antecedents that are related to missing incidents. The model presented in this paper is designed to be heuristic and may be used to stimulate discussion and the development of effective preventative and response strategies for missing incidents among persons with dementia.

Hippocampal activity mediates the relationship between circadian activity rhythms and memory in older adults

Older adults experience parallel changes in sleep, circadian rhythms, and episodic memory. These processes appear to be linked such that disruptions in sleep contribute to deficits in memory. Although more variability in circadian patterns is a common feature of aging and predicts pathology, little is known about how alterations in circadian activity rhythms within older adults influence new episodic learning. Following 10 days of recording sleep-wake patterns using actigraphy, healthy older adults underwent fMRI while performing an associative memory task. The results revealed better associative memory was related to more consistent circadian activity rhythms, independent of total sleep time, sleep efficiency, and level of physical activity. Moreover, hippocampal activity during successful memory retrieval events was positively correlated with associative memory accuracy and circadian activity rhythm (CAR) consistency. We demonstrated that the link between consistent rhythms and associative memory performance was mediated by hippocampal activity. These findings provide novel insight into how the circadian rhythm of sleep-wake cycles are associated with memory in older adults and encourage further examination of circadian activity rhythms as a biomarker of cognitive functioning.

Computer-based cognitive training for individuals with intellectual and developmental disabilities: pilot study

BACKGROUND

There is a growing focus in the United States on preserving cognitive functioning. However, individuals with intellectual and developmental disabilities (ID/DD) are not provided with opportunities to prevent cognitive decline. To investigate whether participants with ID/DD would improve in cognitive function after cognitive training, a cognitive training group (N = 11) was compared to 2 control groups, a computer games group (N = 11) and a waitlist group (N = 10) on performance on 15 cognitive functions.

FINDINGS

(1) Very high adherence rates (94%) of the sample and 100% of the cognitive training group indicate that when given adequate individual support, adults with ID/DD can successfully use a cognitive stimulation program. (2) No significant between- or within-group effects were observed for cognitive training when a stringent α, corrected for multiple comparisons, was used. (3) Trends of improvement in cognitive function were observed for the cognitive training group.

Insomnia symptoms and actigraph-estimated sleep characteristics in a nationally representative sample of older adults

BACKGROUND

Reports of insomnia symptoms are common among the elderly. However, little is known about the relationship between insomnia symptoms and objective assessments of sleep in the general population of older adults. We assessed concordance between insomnia symptoms and actigraphic sleep characteristics in a nationally representative sample of older Americans.

METHODS

In a national probability sample of 727 adults aged 62-91 years in 2010-2011 from the National Social Life, Health, and Aging Project, respondents were asked how often they (a) feel rested when they wake up, (b) have trouble falling asleep, (c) have trouble with waking up during the night, and (d) have trouble waking up too early and not being able to fall asleep again. Responses to these questions were compared to sleep characteristics estimated from three nights of actigraphy for the same individuals. Statistical analyses were adjusted for age, gender, race and ethnicity, income, assets, and education.

RESULTS

Feeling rested (Question (a), above) was not correlated with any actigraphy-estimated sleep characteristics. Questions (b)-(d) each had several significant correlations with the actigraphy metrics, but generally not with the specific objective sleep characteristics that each question intended to reference. In some cases, the associations were not in the expected direction.

CONCLUSIONS

Although three of four questions about insomnia symptoms were significantly associated with objectively estimated sleep characteristics, responses seem to be general indicators of sleep quality rather than reports of specific sleep characteristics.

Novel television-based cognitive training improves working memory and executive function

The main study objective was to investigate the effect of interactive television-based cognitive training on cognitive performance of 119 healthy older adults, aged 60–87 years. Participants were randomly allocated to a cognitive training group or to an active control group in a single-blind controlled two-group design. Before and after training interactive television cognitive performance was assessed on well validated tests of fluid, higher-order ability, and system usability was evaluated. The participants in the cognitive training group completed a television-based cognitive training programme, while the participants in the active control group completed a TV-based programme of personally benefiting activities. Significant improvements were observed in well validated working memory and executive function tasks in the cognitive training but not in the control group. None of the groups showed statistically significant improvement in life satisfaction score. Participants' reports of “adequate” to “high” system usability testify to the successful development and implementation of the interactive television-based system and compliant cognitive training contents. The study demonstrates that cognitive training delivered by means of an interactive television system can generate genuine cognitive benefits in users and these are measurable using well-validated cognitive tests. Thus, older adults who cannot use or afford a computer can easily use digital interactive television to benefit from advanced software applications designed to train cognition.

Is insomnia associated with cognitive impairments in breast cancer patients?

Insomnia and cognitive impairment are both highly prevalent in breast cancer patients. This study, conducted among women treated for non-metastatic breast cancer, aimed at assessing the relationship between insomnia and cognitive functioning, measured objectively and subjectively, and evaluating the moderating role of age, educational level and intellectual potential. Sixty-three women completed a neuropsychological battery, self-report scales of cognitive functioning, 2 weeks of a daily sleep diary, and a demographic and medical questionnaire. Significant differences between women with insomnia and good sleepers were found on verbal episodic memory and executive functioning, assessed objectively, and some aspects of subjective cognitive functioning. Moreover, older age and a higher education were associated with more severe cognitive impairments related to insomnia.

Associations between subjective sleep quality and brain volume in Gulf War veterans

STUDY OBJECTIVES

To investigate whether subjective sleep quality is associated with brain volume independent of comorbid psychiatric conditions.

DESIGN

Cross-sectional.

SETTING

Department of Veterans Affairs (VA) Medical Center.

PARTICIPANTS

One hundred forty-four Gulf War Veterans (mean age 45 years; range: 31-70 years; 14% female).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Total cortical, lobar gray matter, and hippocampal volumes were quantified from 1.5 Tesla magnetic resonance images using Freesurfer version 4.5. Subjective sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). Multiple linear regressions were used to determine the association of sleep quality with total and regional brain volumes. The global PSQI score was positively correlated with lifetime and current posttraumatic stress disorder (PTSD) and current depressive symptoms (P < 0.001) and was higher in veterans with Gulf War Illness, trauma exposure, and those using psychotropic medication (P ≤ 0.03). After adjusting for these comorbid variables, age, intracranial volume, and multiple comparisons, global PSQI was inversely associated with total cortical and frontal gray matter volume (adjusted P ≤ 0.03). Within the frontal lobe, total PSQI was inversely associated with the superior and middle frontal, orbitofrontal, anterior cingulate, and frontal pole volumes (adjusted P ≤ 0.02). Examination of the 3-factor structure of the PSQI revealed that the associations were driven by perceived sleep quality.

CONCLUSIONS

Poorer subjective sleep quality was associated with reduced total cortical and regional frontal lobe volumes independent of comorbid psychiatric conditions. Future work will be needed to examine if effective treatment of disturbed sleep leads to improved structural and functional integrity of the frontal lobes.

Association between Sleep Disturbances and Leisure Activities in the Elderly: A Comparison between Men and Women

It has been suggested that physical or social activity is associated with fewer sleep disturbances among elderly people. Women report more sleep disturbances than men, which could indicate a variation in activity patterns between the genders. The aim of this study was to investigate associations between sleep disturbances and leisure activities in men and women (n = 945) aged ≥60 years in a Swedish population. Sleep disturbances were measured using eight dichotomous questions and seventeen variables, covering a wide range of leisure activities. Few leisure activities were found to be associated with sleep disturbances and their importance decreased when the models were adjusted for confounders and gender interactions. After clustering the leisure activities and investigating individual activities, sociointellectual activities were shown to be significant for sleep. However, following adjustment for confounders and gender interactions, home maintenance was the only activity significant for sleep. Being a female increased the effect of home maintenance. Besides those leisure activities, poor/fair self-rated health (OR 7.50, CI: 4.27–11.81) and being female (OR 4.86, CI: 2.75–8.61) were found to have the highest association with poor sleep. Leisure activities pursued by elderly people should focus on activities of a sociointellectual nature, especially among women, to promote sleep.

Longitudinal course of insomnia: age-related differences in subjective sleepiness and vigilance performance in a population-based sample

OBJECTIVE

The present study utilized a population-based sample investigating the following aims: (1) compare the longitudinal course of insomnia in middle-aged and older adults and (2) examine age-related differences on subjective complaint and objective performance in middle-aged and older adults based on the course of insomnia.

METHODS

1657 middle-aged adults (48.16% male, mean age=55.35±4.03years) and 405 older adults (48.40% male, mean age=70.13±3.88years) from the Korean Genome and Epidemiology Study (KoGES) were classified into 4 groups - no insomnia (NI), single episode insomnia (SEI), remitted persistent insomnia (PI-R), and ongoing persistent insomnia (PI-O) based on their course of insomnia over 5 time points spaced two years apart. Their performance on the psychomotor vigilance task (PVT) and subjective daytime sleepiness were compared across different insomnia groups, and the results were compared between middle-aged adults and older adults.

RESULTS

Analysis of covariance indicated that subjective daytime sleepiness was significantly different across the insomnia groups in middle-aged adults based on insomnia group (P=<.0001), but, did not affect objective vigilance performance. In contrast, older adults displayed significantly different PVT response time, but not daytime sleepiness, based on insomnia group (P=0.03).

CONCLUSION

Insomnia impacts psychomotor performance and subjective sleepiness differently, based on age group. There may be underlying processes associated with the aging that amplifies the impact of insomnia on vigilance performance, yet lessens perceived sleepiness in older adults.

Preliminary evidence for the feasibility of at-home online cognitive training with older adults

Increased levels of cognitive activity may improve general cognitive function in older adults and potentially increase cognitive reserve, protecting against the onset of dementia associated with syndromes like Alzheimer's disease. To test the efficacy of cognitive training administered online, 18 participants (11 cognitively healthy; 7 mild cognitive impairment) were recruited from a clinical population of older adults to complete an online training intervention (CogniFit™). Before and after training, participants completed a separate battery of assessment measures, including measures of quality of life and competency at everyday activities, as well as a series of tests assessing cognitive function. Participants generally adhered to the online training protocol and completed a computerized assessment battery pre- and post-training. However, participants with mild cognitive impairment (MCI) were somewhat less likely to adhere to the protocol, suggesting that more direct contact is needed with this population in intervention research. Furthermore, participants demonstrated significant improvement on a measure of working memory and also in processing speed across several assessments, though these data are tentative, as no control data exist. These results, along with the generally good adherence observed, suggest that online cognitive training is feasible for this population and a potentially valuable tool for the wider dissemination of cognitive training.

Insomnia with Short Sleep Duration: Nosological, Diagnostic, and Treatment Implications

The diagnosis of insomnia is based solely on subjective complaints. This has contributed to the low reliability and validity of the current nosology of insomnia as well as to its lack of firm association with clinically relevant outcomes such as cardiometabolic and neurocognitive morbidity. We review evidence that insomnia with objective short sleep duration is associated with physiological hyperarousal, higher risk for hypertension, diabetes, neurocognitive impairment, and mortality as well as with a persistent course. It also appears that objective short sleep duration in poor sleepers is a biological marker of genetic predisposition to chronic insomnia. In contrast, insomnia with objective normal sleep duration is associated with cognitive-emotional and cortical arousal and sleep misperception but not with signs of physiological hyperarousal or medical complications. Thus, short sleep duration in insomnia may be a reliable marker of the biological severity and medical impact of the disorder. We propose that (a) objective measures of sleep be included in the diagnosis of insomnia and its subtypes, (b) objective measures of sleep obtained in the home environment of the patient would become part of the routine assessment and diagnosis of insomnia in a clinician's office setting, and (c) insomnia with short sleep duration may respond better to biological treatments, whereas insomnia with normal sleep duration may respond primarily to psychological therapies.

Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder

Until recently, the association of chronic insomnia with significant medical morbidity was not established and its diagnosis was based solely on subjective complaints. We present evidence that insomnia with objective short sleep duration is the most biologically severe phenotype of the disorder, as it is associated with cognitive-emotional and cortical arousal, activation of both limbs of the stress system, and a higher risk for hypertension, impaired heart rate variability, diabetes, neurocognitive impairment, and mortality. Also, it appears that objective short sleep duration is a biological marker of genetic predisposition to chronic insomnia. In contrast, insomnia with objective normal sleep duration is associated with cognitive-emotional and cortical arousal and sleep misperception but not with signs of activation of both limbs of the stress system or medical complications. Furthermore, the first phenotype is associated with unremitting course, whereas the latter is more likely to remit. We propose that short sleep duration in insomnia is a reliable marker of the biological severity and medical impact of the disorder. Objective measures of sleep obtained in the home environment of the patient would become part of the routine assessment of insomnia patients in a clinician's office setting. We speculate that insomnia with objective short sleep duration has primarily biological roots and may respond better to biological treatments, whereas insomnia with objective normal sleep duration has primarily psychological roots and may respond better to psychological interventions alone.

Personalized cognitive training in unipolar and bipolar disorder: a study of cognitive functioning

Patients with unipolar depressive disorder and in the depressive phase of bipolar disorder often manifest psychological distress and cognitive deficits, notably in executive control. We used computerized cognitive training in an attempt to reduce psychological affliction, improve everyday coping, and cognitive function. We asked one group of patients (intervention group) to engage in cognitive training three times a week, for 20 min each time, for eight consecutive weeks. A second group of patients (control group) received standard care only. Before the onset of training we administered to all patients self-report questionnaires of mood, mental and psychological health, and everyday coping. We also assessed executive control using a broad computerized neurocognitive battery of tests which yielded, among others, scores in Working Memory, Shifting, Inhibition, Visuomotor Vigilance, Divided Attention, Memory Span, and a Global Executive Function score. All questionnaires and tests were re-administered to the patients who adhered to the study at the end of training. When we compared the groups (between-group comparisons) on the amount of change that had taken place from baseline to post-training, we found significantly reduced depression level for the intervention group. This group also displayed significant improvements in Shifting, Divided Attention, and in the Global executive control score. Further exploration of the data showed that the cognitive improvement did not predict the improvements in mood. Single-group data (within-group comparisons) show that patients in the intervention group were reporting fewer cognitive failures, fewer dysexecutive incidents, and less difficulty in everyday coping. This group had also improved significantly on the six executive control tests and on the Global executive control score. By contrast, the control group improved only on the reports of cognitive failure and on working memory.

Cognitive training improves sleep quality and cognitive function among older adults with insomnia

Study Objectives

To investigate the effect of an eight-week, home-based, personalized, computerized cognitive training program on sleep quality and cognitive performance among older adults with insomnia.

Design

Participants (n = 51) were randomly allocated to a cognitive training group (n = 34) or to an active control group (n = 17). The participants in the cognitive training group completed an eight-week, home-based, personalized, computerized cognitive training program, while the participants in the active control group completed an eight-week, home-based program involving computerized tasks that do not engage high-level cognitive functioning. Before and after training, all participants' sleep was monitored for one week by an actigraph and their cognitive performance was evaluated.

Setting

Community setting: residential sleep/performance testing facility.

Participants

Fifty-one older adults with insomnia (aged 65–85).

Interventions

Eight weeks of computerized cognitive training for older adults with insomnia.

Results

Mixed models for repeated measures analysis showed between-group improvements for the cognitive training group on both sleep quality (sleep onset latency and sleep efficiency) and cognitive performance (avoiding distractions, working memory, visual memory, general memory and naming). Hierarchical linear regressions analysis in the cognitive training group indicated that improved visual scanning is associated with earlier advent of sleep, while improved naming is associated with the reduction in wake after sleep onset and with the reduction in number of awakenings. Likewise the results indicate that improved “avoiding distractions” is associated with an increase in the duration of sleep. Moreover, the results indicate that in the active control group cognitive decline observed in working memory is associated with an increase in the time required to fall asleep.

Conclusions

New learning is instrumental in promoting initiation and maintenance of sleep in older adults with insomnia. Lasting and personalized cognitive training is particularly indicated to generate the type of learning necessary for combined cognitive and sleep enhancements in this population.

Trial Registration

ClinicalTrials.gov NCT00901641

Does combined cognitive training and physical activity training enhance cognitive abilities more than either alone? A four-condition randomized controlled trial among healthy older adults

Cognitive training and aerobic training are known to improve cognitive functions. To examine the separate and combined effects of such training on cognitive performance, four groups of healthy older adults embarked on a 4 months cognitive and/or mild aerobic training. A first group [n = 33, mean age = 80 (66-90)] engaged in cognitive training, a second [n = 29, mean age = 81 (65-89)] in mild aerobic training, a third [n = 29, mean age = 79 (70-93)] in the combination of both, and a fourth [n = 31, mean age = 79 (71-92)] control group engaged in book-reading activity. The outcome was a well-validated multi-domain computerized cognitive evaluation for older adults. The results indicate that, when compared to older adults who did not engage in cognitive training (the mild aerobic and control groups) older adults who engaged in cognitive training (separate or combined training groups) showed significant improvement in cognitive performance on Hand-Eye Coordination, Global Visual Memory (GVM; working memory and long-term memory), Speed of Information Processing, Visual Scanning, and Naming. Indeed, individuals who did not engage in cognitive training showed no such improvements. Those results suggest that cognitive training is effective in improving cognitive performance and that it (and not mild aerobic training) is driving the improvement in the combined condition. Results are discussed in terms of the special circumstances of aerobic and cognitive training for older adults who are above 80 years of age.

Orthostatic hypotension and subjective sleep quality in older people

Poor sleep quality and orthostatic hypotension are common complaints in an older population, and both are related to factors such as polypharmacy and depression. However, it is not known whether there is a direct association between the two. Our objective is to investigate a potential association between orthostatic blood pressure response and subjective sleep quality in older people. A within-subjects, cross-sectional design embedded in a larger longitudinal study design. Participants were recruited from the community to visit the TRIL clinic at St James's Hospital, where they underwent a structured medical and psychosocial assessment. A total of 505 community dwelling adults aged 60+ (321 females, mean age 72.44) were participated in this study. Orthostatic blood pressure responses were recorded during an active stand using Finometer equipment, and health-related factors such as pain ratings, co-morbidities, polypharmacy, timed up and go, Mini-Mental State Examination score, body mass index, as well as depression, anxiety, age and gender, were also recorded. Self-reported sleep quality was also assessed using the Pittsburgh Sleep Quality Index. The results showed that timed up and go, polypharmacy, depression, anxiety, gender and delayed recovery of blood pressure at orthostasis were associated with subjective poor sleep quality. There is an association between subjective sleep quality and delayed recovery of blood pressure at orthostasis, independent of mental health or polypharmacy effects, in older adults. This link may have implications for the management of sleep disorders in older people.

Working memory performance of older adults with insomnia

Older individuals suffering insomnia typically report declines in their cognitive performance beyond what they consider to be normal changes due to the aging process. Recent neuro-imaging studies have demonstrated frontal lobe hypo-activation among insomniac populations when compared with healthy, good sleepers. However, research is yet to confirm whether frontal lobe hypo-activation translates into objective declines when performing tasks hypothesized to draw upon this brain region. This study aimed to investigate whether older insomnia sufferers demonstrate significantly impaired performance on a challenging working memory task when compared with age-matched good sleepers. Forty-nine older individuals (mean age = 69.43 years, SD = 4.83) suffering from sleep maintenance insomnia were compared with 49 age-matched good sleepers. Cognitive performance was assessed using the Double Span Memory Task, a computer-based working memory task that requires participants to indicate the names and/or spatial locations of increasingly longer sequences of visually presented objects. After controlling for general intelligence, the individuals suffering from insomnia did not perform differently when compared with the good sleepers on either the simpler or more cognitively demanding components of the task. Older individuals with insomnia did not display an observable impairment of working memory in this study relative to good sleepers. Despite the mixed results from previous research, this study adds weight to the absence of objective impairment in insomniacs, at least while performing short-term demanding cognitive tasks.

Development of the Insomnia Screening Scale based on ICSD-II

OBJECTIVE

Although various instruments have been developed to evaluate insomniac symptoms in individuals, none of them are based on the International Classification of Sleep Disorder, 2nd (ICSD-II). The purpose of this study is to develop a new scaling system, the Insomnia Screening Scale (ISS) to fit the new diagnostic criteria.

METHODS

Study 1 was conducted to formulate the new items of the insomnia screening scale (ISS), which were divided into four major subscales, and establish the reliability and validity of the ISS in clinical insomniac subjects. Study 2 tested the external validity of the ISS, which was used in a community survey, and investigated the relationship between ISS and daytime function, especially working memory.

RESULTS

The final version of the ISS has good internal consistency (α = 0.87-0.98), and explains 64% of the variance. The insomnia group had poor working memory performance on the cognitive tasks.

CONCLUSIONS

The ICSD-II based ISS is a reliable and valid instrument for evaluating an individual's insomniac symptoms. The major difference between the ISS and the previous instruments is that the ISS not only assess the subjective insomniac and daytime symptoms but also examines the sleep environment and sleep opportunities of the participants.

Association of sleep quality and dementia among long-lived Chinese older adults

In this study, we examined the existence of relationship between sleep quality and dementia in subjects aged 90 years and above. The sample included 216 men and 444 women. Dementia and sleep quality were measured with 30-item mini-mental state examination (MMSE) and the Pittsburgh sleep quality index, respectively. Subjects with dementia had higher sleep quality score (7.83 ± 2.15 vs. 5.22 ± 2.49; P < 0.0001), longer sleep latency (50.97 ± 21.33 vs. 37.61 ± 12.53; P < 0.0001), and a lower sleep efficiency percentage (73.95 ± 8.783 vs. 81.32 ± 10.21; P < 0.0001) and more likely to report poor sleep quality (25.42 vs.17.13 %; P = 0.035). Subjects with poor sleep quality had significantly lower MMSE scores (P = 0.007) and higher prevalence of dementia (P = 0.042). Multiple logistic regressions were performed by adjusting clinical factors that are thought to be associated with dementia or sleep quality. We found that poor sleep quality was a risk factor for dementia (unadjusted odds ratio (OR) 1.719, 95 % confidence interval (CI) 1.138-2.597; adjusted OR 1.759, 95 % CI 1.012-3.057). There was no significant difference in MMSE scores (11.25 ± 3.40, 16.26 ± 5.14, and 15.43 ± 5.51; P = 0.105) among participants with daily average sleep durations of <5, 5-9, and >9 h, respectively. Among Chinese nonagenarians and centenarians, dementia was correlated with poor sleep quality, longer sleep latency, and lower sleep efficiency percentage.

Sleep onset/maintenance difficulties and cognitive function in nondemented older adults: the role of cognitive reserve

This study examined the relationship between cognitive function and sleep onset/maintenance difficulties (SO/MD) in nondemented older adults. We hypothesized that SO/MD negatively impacts cognition and that older adults with lower education would be especially vulnerable to its effects. The sample comprised 549 older adults from the Einstein Aging Study (EAS), a community-based cohort. Participants completed neuropsychological assessment and a sleep questionnaire. Univariate ANCOVAs were performed with cognitive performance as a dependent variable, SO/MD (present or absent) and education (lower: ≤ 12 years; higher: >12 years) as between-subjects factors, and age, ethnicity, gender, depression, and cardiovascular comorbidies as covariates. Participants were an average age of 79.7 ± 5.0 years (range = 71-97 years). Fifty-seven percent (n = 314) of the sample met criteria for SO/MD. Among participants with SO/MD, those with lower education performed more poorly on a test of category fluency than participants with higher education (means: 35.2 vs. 41.0; p < .001); among older adults without SO/MD, educational attainment had no measurable effect on cognition (SO/MD × education interaction (F(1,536) = 14.5; p = .00)). Consistent with the cognitive reserve hypothesis, older adults with lower education appear selectively vulnerable to the negative effects of sleep onset/maintenance difficulties on tests of verbal fluency.

The impact of sleep quality on cognitive functioning in Parkinson's disease

In healthy individuals and those with insomnia, poor sleep quality is associated with decrements in performance on tests of cognition, especially executive function. Sleep disturbances and cognitive deficits are both prevalent in Parkinson's disease (PD). Sleep problems occur in over 75% of patients, with sleep fragmentation and decreased sleep efficiency being the most common sleep complaints, but their relation to cognition is unknown. We examined the association between sleep quality and cognition in PD. In 35 non-demented individuals with PD and 18 normal control adults (NC), sleep was measured using 24-hr wrist actigraphy over 7 days. Cognitive domains tested included attention and executive function, memory and psychomotor function. In both groups, poor sleep was associated with worse performance on tests of attention/executive function but not memory or psychomotor function. In the PD group, attention/executive function was predicted by sleep efficiency, whereas memory and psychomotor function were not predicted by sleep quality. Psychomotor and memory function were predicted by motor symptom severity. This study is the first to demonstrate that sleep quality in PD is significantly correlated with cognition and that it differentially impacts attention and executive function, thereby furthering our understanding of the link between sleep and cognition.

A Holistic approach to assess older adults' wellness using e-health technologies

OBJECTIVES

To date, methodologies are lacking that address a holistic assessment of wellness in older adults. Technology applications may provide a platform for such an assessment, but have not been validated. We set out to demonstrate whether e-health applications could support the assessment of older adults' wellness in community-dwelling older adults.

MATERIALS AND METHODS

Twenty-seven residents of independent retirement community were followed over 8 weeks. Subjects engaged in the use of diverse technologies to assess cognitive performance, physiological and functional variables, as well as psychometric components of wellness. Data were integrated from various e-health sources into one study database. Correlations were assessed between different parameters, and hierarchical cluster analysis was used to explore the validity of the wellness model.

RESULTS

We found strong associations across multiple parameters of wellness within the conceptual model, including cognitive, functional, and physical. However, spirituality did not correlate with any other parameter studied in contrast to prior studies of older adults. Participants expressed overall positive attitudes toward the e-health tools and the holistic approach to the assessment of wellness, without expressing any privacy concerns.

CONCLUSIONS

Parameters were highly correlated across multiple domains of wellness. Important clusters were noted to be formed across cognitive and physiological domains, giving further evidence of need for an integrated approach to the assessment of wellness. This finding warrants further replication in larger and more diverse samples of older adults to standardize and deploy these technologies across population groups.

Hippocampal M1 receptor function associated with spatial learning and memory in aged female rhesus macaques

Of the acetylcholine muscarinic receptors, the type 1 (M1) and type 2 (M2) receptors are expressed at the highest levels in the prefrontal cortex (PFC) and hippocampus, brain regions important for cognition. As equivocal findings of age-related changes of M1 and M2 in the nonhuman primate brain have been reported, we first assessed age-related changes in M1 and M2 in the PFC and hippocampus using saturation binding assays. Maximum M1 receptor binding, but not affinity of M1 receptor binding, decreased with age. In contrast, the affinity of M2 receptor binding, but not maximum M2 receptor binding, increased with age. To determine if in the elderly cognitive performance is associated with M1 or M2 function, we assessed muscarinic function in elderly female rhesus macaques in vivo using a scopolamine challenge pharmacological magnetic resonance imaging and in vitro using saturation binding assays. Based on their performance in a spatial maze, the animals were classified as good spatial performers (GSP) or poor spatial performers (PSP). In the hippocampus, but not PFC, the GSP group showed a greater change in T(2)*-weighted signal intensity after scopolamine challenge than the PSP group. The maximum M1 receptor binding and receptor binding affinity was greater in the GSP than the PSP group, but no group difference was found in M2 receptor binding. Parameters of circadian activity positively correlated with the difference in T(2)*-weighted signal intensity before and after the challenge, the maximum M1 receptor binding, and the M1 receptor binding affinity. Thus, while in rhesus macaques, there are age-related decreases in M1 and M2 receptor binding, in aged females, hippocampal M1, but not M2, receptor function is associated with spatial learning and memory and circadian activity.

Short or long sleep duration is associated with memory impairment in older Chinese: the Guangzhou Biobank Cohort Study

STUDY OBJECTIVES

To examine the association between sleep-related factors and memory impairment.

DESIGN

Cross-sectional study

SETTING

Community-based study in Guangzhou, China.

PARTICIPANTS

28,670 older Chinese (20,776 women and 7,894 men) aged 50 to 85 years.

MEASUREMENTS AND RESULTS

Demographic and socioeconomic data, sleep-related factors, and cognitive function were collected by face-to-face interview. Potential confounders, such as employment and occupational status, smoking, alcohol and tea use, physical activity, self-rated health, anthropometry, blood pressure, and fasting plasma glucose and lipids were measured. After adjusting for multiple potential confounders, an inverted U-shaped association between sleep duration and delayed word recall test (DWRT) score, a validated measure of memory impairment, was found, with 7 to 8 h of habitual sleep duration showing the highest score (P-values for trend from 3 to 7 h and from 7 to ≥ 10 h were all ≤ 0.001). Compared to sleep duration of 7 h, the adjusted odds ratio for memory impairment from the sleep duration of 3 to 4 or ≥ 10 h was 1.29 (95% confidence interval 1.07-1.56) and 1.52 (1.25-1.86), respectively. Subjects with daily napping, morning tiredness, or insomnia had significantly lower DWRT scores than those without (P ranged from < 0.001 to 0.01).

CONCLUSIONS

Short or long sleep duration was an important sleep-related factor independently associated with memory impairment and may be a useful marker for increased risk of cognitive impairment in older people.

Using informatics to capture older adults' wellness

PURPOSE

The aim of this paper is to demonstrate how informatics applications can support the assessment and visualization of older adults' wellness. A theoretical framework is presented that informs the design of a technology enhanced screening platform for wellness. We highlight an ongoing pilot demonstration in an assisted living facility where a community room has been converted into a living laboratory for the use of diverse technologies (including a telehealth component to capture vital signs and customized questionnaires, a gait analysis component and cognitive assessment software) to assess the multiple aspects of wellness of older adults.

METHODS

A demonstration project was introduced in an independent retirement community to validate our theoretical framework of informatics and wellness assessment for older adults. Subjects are being recruited to attend a community room and engage in the use of diverse technologies to assess cognitive performance, physiological and gait variables as well as psychometrics pertaining to social and spiritual components of wellness for a period of eight weeks. Data are integrated from various sources into one study database and different visualization approaches are pursued to efficiently display potential correlations between different parameters and capture overall trends of wellness.

RESULTS

Preliminary findings indicate that older adults are willing to participate in technology-enhanced interventions and embrace different information technology applications given appropriate and customized training and hardware and software features that address potential functional limitations and inexperience with computers.

CONCLUSION

Informatics can advance health care for older adults and support a holistic assessment of older adults' wellness. The described framework can support decision making, link formal and informal caregiving networks and identify early trends and patterns that if addressed could reduce adverse health events.

Spatial Memory Performance Associated with Measures of Immune Function in Elderly Female Rhesus Macaques

We recently reported that in aged female rhesus macaques, spatial learning and memory correlates with circadian sleep-wake measures and hippocampal muscarinic type 1 (M(1)) receptor binding. To investigate if spatial memory also correlates with measures of immune function, we now assessed the magnitude of the adaptive immune response to vaccination in the same old female rhesus macaques. Cognitively characterized animals were classified as good spatial performers (GSP) or poor spatial performers (PSP) based on performance in the Spatial Foodport maze. The GSP group had higher frequency of CD8, but not CD4, interferon-γ (IFN-γ) producing cells following vaccination compared to the PSP group, suggesting a stronger CD8 T cell response in the GSP group. In addition, the number of CD-8 IFN-γ positive cells correlated with measures of sleep quality. Interestingly, the PSP group had a significantly higher antibody titer compared to the GSP group, and antibody titer negatively correlated with day-time activity. Thus, in aged female rhesus macaques, superior cognitive performance is correlated with a more robust CD8 T cell response but a reduced antibody response to vaccination.

Computer-based, personalized cognitive training versus classical computer games: a randomized double-blind prospective trial of cognitive stimulation

BACKGROUND

Many studies have suggested that cognitive training can result in cognitive gains in healthy older adults. We investigated whether personalized computerized cognitive training provides greater benefits than those obtained by playing conventional computer games.

METHODS

This was a randomized double-blind interventional study. Self-referred healthy older adults (n = 155, 68 ± 7 years old) were assigned to either a personalized, computerized cognitive training or to a computer games group. Cognitive performance was assessed at baseline and after 3 months by a neuropsychological assessment battery. Differences in cognitive performance scores between and within groups were evaluated using mixed effects models in 2 approaches: adherence only (AO; n = 121) and intention to treat (ITT; n = 155).

RESULTS

Both groups improved in cognitive performance. The improvement in the personalized cognitive training group was significant (p < 0.03, AO and ITT approaches) in all 8 cognitive domains. However, in the computer games group it was significant (p < 0.05) in only 4 (AO) or 6 domains (ITT). In the AO analysis, personalized cognitive training was significantly more effective than playing games in improving visuospatial working memory (p = 0.0001), visuospatial learning (p = 0.0012) and focused attention (p = 0.0019).

CONCLUSIONS

Personalized, computerized cognitive training appears to be more effective than computer games in improving cognitive performance in healthy older adults. Further studies are needed to evaluate the ecological validity of these findings.

The societal costs of insomnia

OBJECTIVE

Insomnia can be broadly defined as difficulty initiating or maintaining sleep, or sleep that is not refreshing or of poor quality with negative effect on daytime function. Insomnia can be a primary condition or comorbid to an underlying disorder. Subjective measures of insomnia used in population studies, usually based on complaints of unsatisfactory sleep, put the prevalence at about 10%. Insomnia is more common in the elderly and in women, and is often associated with medical and psychiatric disorders. This review examines the measures used to assess quality of sleep (QOS) and daytime functioning and the impact of insomnia on society using these measures.

METHODS

Literature searches were performed to identify all studies of insomnia (primary and comorbid) in adults (aged 18-64 years) and the elderly (aged ≥ 65 years) with baseline and/or outcomes relating to QOS or daytime functioning. The impact of poor QOS on quality of life (QOL), psychomotor and cognitive skills, health care resource utilization, and other societal effects was examined.

RESULTS

Although definitions and measurement scales used to assess sleep quality vary widely, it is clear that the societal consequences of insomnia are substantial and include impaired QOL and increased health care utilization. The impact of poor QOS and impaired daytime functioning common in insomnia can lead to indirect effects such as lower work productivity, increased sick leave, and a higher rate of motor vehicle crashes.

CONCLUSIONS

Insomnia is associated with substantial direct and indirect costs to society. It is almost impossible to separate the costs associated with primary and comorbid insomnia. More studies are required which control for the severity of any primary disorder to accurately evaluate the costs of comorbid insomnia. Development of standardized diagnostic and assessment scales will enable more accurate quantification of the true societal burden of insomnia and will contribute to greater understanding of this disorder.