Presenile dementia. Clinical aspects and evaluation of cerebrospinal fluid dynamics

Structural and functional characterization of the locus coeruleus in young and late middle-aged individuals

INTRODUCTION

The brainstem locus coeruleus (LC) influences a broad range of brain processes, including cognition. The so-called LC contrast is an accepted marker of the integrity of the LC that consists of a local hyperintensity on specific Magnetic Resonance Imaging (MRI) structural images. The small size of the LC has, however, rendered its functional characterization difficult in humans, including in aging. A full characterization of the structural and functional characteristics of the LC in healthy young and late middle-aged individuals is needed to determine the potential roles of the LC in different medical conditions. Here, we wanted to determine whether the activation of the LC in a mismatch negativity task changes in aging and whether the LC functional response was associated to the LC contrast.

METHODS

We used Ultra-High Field (UHF) 7-Tesla functional MRI (fMRI) to record brain response during an auditory oddball task in 53 healthy volunteers, including 34 younger (age: 22.15y ± 3.27; 29 women) and 19 late middle-aged (age: 61.05y ± 5.3; 14 women) individuals.

RESULTS

Whole-brain analyses confirmed brain responses in the typical cortical and subcortical regions previously associated with mismatch negativity. When focusing on the brainstem, we found a significant response in the rostral part of the LC probability mask generated based on individual LC images. Although bilateral, the activation was more extensive in the left LC. Individual LC activity was not significantly different between young and late middle-aged individuals. Importantly, while the LC contrast was higher in older individuals, the functional response of the LC was not significantly associated with its contrast.

DISCUSSION

These findings may suggest that the age-related alterations of the LC structural integrity may not be related to changes in its functional response. The results further suggest that LC responses may remain stable in healthy individuals aged 20 to 70.

Frailty: A Multidimensional Biopsychosocial Syndrome

The original conceptual landscape of frailty has evolved into a complex, multidimensional biopsychosocial syndrome. This has broadened the field to now include social and behavioral scientists and clinicians from a wide range of specialties. This article aims to provide an updated overview of this conceptual change by examining the emerging definitions of physical, cognitive, social, and psychological frailty; the tools used for diagnosis and assessment of these domains; the epidemiology of the domains; their pathogenesis, risk factors, and course; frameworks for prevention and treatment; and unresolved issues affecting the field.

Social Networks and Residential Status in Community-Dwelling Older Adults With Schizophrenia: Compensation by Reconfiguration?

OBJECTIVE

To address the paucity of data on the structure and content of social networks of older adults with schizophrenia (OAS).

METHODS

The OAS group comprised 249 persons aged 55 and older with early-onset schizophrenia living in supportive housing (SS; n = 151), independently (SI; n = 70), or with family (SF; n = 28). The community comparison (CC) group comprised 113 individuals. Social network analysis was used. Multinomial logistic regression with p ≤0.001 and p ≤0.05 was used for overall and pairwise comparisons, respectively.

RESULTS

Each OAS subgroup had more total, nonkin, and formal linkages than the CC group. The SS and SI subgroups had fewer kin linkages than the CC group. The CC group had more confidants than the SS subgroup, more reliable linkages than the SS and SI subgroups, and more sustenance linkages than each of the OAS subgroups. Nearly everyone in the CC, SI, and SF subgroups had a confidant, a reliable contact, and a sustenance linkage; 33% of the SS subgroup had no confidants. The SS subgroup displayed more psychiatric symptoms than the SI and SF subgroups. There were no differences in loneliness or relationship satisfaction between the CC and the schizophrenia subgroups.

CONCLUSION

Networks were expressed differentially across residential arrangements and differences may reflect dissimilarities in psychiatric functioning. OAS generally had ample levels of companionship and emotional and instrumental support, often comparable to their age peers. Whereas social networks typically decline at illness onset and may be predominantly family-focused, later life may be a time of network reconfiguration and reconstitution.

Rey-Osterrieth complex figure normative data for the psychiatric population

Objective: Appropriate normative data are crucial for competent neuropsychological assessment. Although individuals with psychiatric illness often perform more poorly than healthy adults on neuropsychological testing, data that reflect the psychiatric population are often lacking. We present a normative dataset and calculation tools for the Rey-Osterrieth Complex Figure Test (RCFT) derived from the psychiatric inpatient population. Method: A sample of 301 psychiatric inpatients completed the RCFT and the Test of Memory Malingering (TOMM) between 1999 and 2018. Participants were 59.5% male, 82.1% Caucasian, 13.3% black, and 4.6% identified as another racial demographic, largely consistent with recent Substance Abuse and Mental Health Services Administration (2018) data for inpatients in U.S. psychiatric facilities. Scores for RCFT Copy, Short-Delay Free Recall, Long-Delay Free Recall, Total Recognition, and Percent Retained were modeled via multiple regression with age and education as predictors. Base rates were computed for subscores comprising Total Recognition to aid clinical decision making. Results: Age and education served as significant individual predictors for all models except one model predicting percent retained across delay that included only age. Regression equations and regression standard errors were used to produce a score calculator using a commonly available spreadsheet software package. Healthy adult norms under-estimated performance in our sample, underscoring the importance of these normative data. Conclusions: These normative data for the RCFT represent a large cohort of psychiatric inpatients. For clinical practice and research, both the data and the tools provided are likely to be of particular usefulness among individuals with serious mental illness.

Psychological treatments for depression and anxiety in dementia and mild cognitive impairment

BACKGROUND

Experiencing anxiety and depression is very common in people living with dementia and mild cognitive impairment (MCI). There is uncertainty about the best treatment approach. Drug treatments may be ineffective and associated with adverse effects. Guidelines recommend psychological treatments. In this updated systematic review, we investigated the effectiveness of different psychological treatment approaches.

OBJECTIVES

Primary objective To assess the clinical effectiveness of psychological interventions in reducing depression and anxiety in people with dementia or MCI. Secondary objectives To determine whether psychological interventions improve individuals' quality of life, cognition, activities of daily living (ADL), and reduce behavioural and psychological symptoms of dementia, and whether they improve caregiver quality of life or reduce caregiver burden.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE, Embase, four other databases, and three trials registers on 18 February 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared a psychological intervention for depression or anxiety with treatment as usual (TAU) or another control intervention in people with dementia or MCI.

DATA COLLECTION AND ANALYSIS

A minimum of two authors worked independently to select trials, extract data, and assess studies for risk of bias. We classified the included psychological interventions as cognitive behavioural therapies (cognitive behavioural therapy (CBT), behavioural activation (BA), problem-solving therapy (PST)); 'third-wave' therapies (such as mindfulness-based cognitive therapy (MBCT)); supportive and counselling therapies; and interpersonal therapies. We compared each class of intervention with control. We expressed treatment effects as standardised mean differences or risk ratios. Where possible, we pooled data using a fixed-effects model. We used GRADE methods to assess the certainty of the evidence behind each result.

MAIN RESULTS

We included 29 studies with 2599 participants. They were all published between 1997 and 2020. There were 15 trials of cognitive behavioural therapies (4 CBT, 8 BA, 3 PST), 11 trials of supportive and counselling therapies, three trials of MBCT, and one of interpersonal therapy. The comparison groups received either usual care, attention-control education, or enhanced usual care incorporating an active control condition that was not a specific psychological treatment. There were 24 trials of people with a diagnosis of dementia, and five trials of people with MCI. Most studies were conducted in community settings. We considered none of the studies to be at low risk of bias in all domains.  Cognitive behavioural therapies (CBT, BA, PST) Cognitive behavioural therapies are probably slightly better than treatment as usual or active control conditions for reducing depressive symptoms (standardised mean difference (SMD) -0.23, 95% CI -0.37 to -0.10; 13 trials, 893 participants; moderate-certainty evidence). They may also increase rates of depression remission at the end of treatment (risk ratio (RR) 1.84, 95% CI 1.18 to 2.88; 2 studies, with one study contributing 2 independent comparisons, 146 participants; low-certainty evidence). We were very uncertain about the effect of cognitive behavioural therapies on anxiety at the end of treatment (SMD -0.03, 95% CI -0.36 to 0.30; 3 trials, 143 participants; very low-certainty evidence). Cognitive behavioural therapies probably improve patient quality of life (SMD 0.31, 95% CI 0.13 to 0.50; 7 trials, 459 participants; moderate-certainty evidence) and activities of daily living at end of treatment compared to treatment as usual or active control (SMD -0.25, 95% CI -0.40 to -0.09; 7 trials, 680 participants; moderate-certainty evidence). Supportive and counselling interventions Meta-analysis showed that supportive and counselling interventions may have little or no effect on depressive symptoms in people with dementia compared to usual care at end of treatment (SMD -0.05, 95% CI -0.18 to 0.07; 9 trials, 994 participants; low-certainty evidence). We were very uncertain about the effects of these treatments on anxiety, which was assessed only in one small pilot study. Other interventions There were very few data and very low-certainty evidence on MBCT and interpersonal therapy, so we were unable to draw any conclusions about the effectiveness of these interventions.

AUTHORS' CONCLUSIONS

CBT-based treatments added to usual care probably slightly reduce symptoms of depression for people with dementia and MCI and may increase rates of remission of depression. There may be important effect modifiers (degree of baseline depression, cognitive diagnosis, or content of the intervention). CBT-based treatments probably also have a small positive effect on quality of life and activities of daily living. Supportive and counselling interventions may not improve symptoms of depression in people with dementia. Effects of both types of treatment on anxiety symptoms are very uncertain. We are also uncertain about the effects of other types of psychological treatments, and about persistence of effects over time. To inform clinical guidelines, future studies should assess detailed components of these interventions and their implementation in different patient populations and in different settings.

Eye movement characteristics in male patients with deficit and non-deficit schizophrenia and their relationships with psychiatric symptoms and cognitive function

BACKGROUND

The cognitive impairment pattern of deficit schizophrenia (DS) is centered on an impaired attention function. Previous studies have suggested that the exploratory eye movement (EEM) tests reflect attention deficits in patients with schizophrenia. However, no study has investigated the characteristics of eye movement in DS in the Chinese Han population. This study aimed to investigate the pattern of eye movement characteristics in DS patients and to examine whether eye movement characteristic is associated with serious negative symptoms and cognitive decline in this schizophrenia subtype.

METHODS

A total of 86 male patients [37 DS and 49 non-deficit schizophrenia (NDS)] and 80 healthy controls (HC) participated in this study. Clinical symptoms were assessed using the Scale for the Assessment of Positive Symptoms (SAPS) and Scale for the Assessment of Negative Symptoms (SANS). Cognitive function was assessed using the Mattis Dementia Rating Scale (MDRS-2). Eye movement data of subjects were collected using an eye movement tracking analyzer.

RESULTS

There were significant differences in the overall eye movement data and cognitive test scores among the three groups (all P < 0.001). Both DS and NDS schizophrenia subgroups showed more severe eye movement and cognitive impairment compared with the control group. The number of eye fixations (NEF), total of eye scanning length (TESL), and cognitive function in DS patients were significantly lower than those in NDS patients. The discriminant analysis (D score) was higher than that of the control group (P < 0.001). In the DS group, the inattention factor of SANS was negatively correlated with the attention factor (r = - 0.545, P = 0.001) and structure factor of cognitive (r = - 0.389, P = 0.023), the affective flattening factor of SANS was negatively correlated with TESL (r = - 0.353, P = 0.041) and initiation/retention factor of cognitive (r = - 0.376,P = 0.028). TESL was found to positively correlate with the MDRS-2 total score (r = 0.427, P = 0.012), attention factor (r = 0.354, P = 0.040), and memory factor (r = 0.349, P = 0.043) in the DS group, whereas the mean of eye scanning length (MESL) positively correlated with cognitive impairments in the NDS group. The negative symptoms showed no significant correlation with cognition in the NDS group.

CONCLUSIONS

Total of eye scanning length may be a characteristic eye movement symptom in DS patients, which is associated with serious negative symptoms and cognitive impairment in this schizophrenia subtype.

An Integrative Literature Review on the Nomenclature and Definition of Dementia at a Young Age

Background:

There has been growing interest in young people living with dementia. Future research requires consensus on the terminology and operational definition of this group.

Objective:

The purpose of this integrative review was to explore and include all operational definitions used to define dementia at a young age.

Methods:

On August 14, 2020, the PubMed, Embase, Cinahl, and PsycInfo databases were searched for empirical and theoretical literature using Google. Various terms to describe and define ‘dementia’ and ‘at a young age’ were used to collect literature concerning terminology; age-related aspects, including cut-off ages and criteria; and etiologies of dementia at a young age.

Results:

The search yielded 6,891 empirical and 4,660 theoretical publications, resulting in the inclusion of 89 publications, including 36 publications containing an explicit discussion and 53 publications as confirmation. ‘Young-onset dementia’ was the most commonly used term of seven identified terms, in the last two decades. The age of 65 years at symptom onset was used most frequently when considering a total of six upper age limits and four criteria to define a cut-off age. Eight lower age limits and an option for subdivision based on age were included. We identified 251 different etiologies and 27 categories of etiologies.

Conclusion:

Despite relative consensus on the term young-onset dementia and an age at symptom onset being used as a cut-off criterion, much is still unclear concerning possible etiologies of dementia at a young age. In the current study, controversies were detected for discussion in an international consensus study.

The utility of self-rated health in older adults with schizophrenia

OBJECTIVES

Self-rated health is one of the most widely used measures in gerontology, but it has not been evaluated systematically in older adults with schizophrenia (OAS). Therefore, the aim of this study was to determine the utility of self-rated health in OAS by examining its influencing factors and contrasting these findings with a community comparison (CC) group.

METHOD

We compared 249 community-dwelling persons aged 55 years and older having a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, diagnosis of schizophrenia arising before age 45 years with a demographically similar group of 113 older adults in the general community. Using a modified version of Ocampo's model of self-rated health, we identified 12 predictor variables within 5 dimensions.

RESULTS

There were no significant differences in self-health ratings between the OAS and the CC groups. Six of the 12 variables in the model significantly correlated with self-rated health in both groups. In linear regression analysis, three variables were significantly associated with self-rated health in both groups: Center for Epidemiological Studies-Depression score, number of physical disorders, and perception of self-health versus others. Self-rated health assessment was not associated with positive or negative symptoms or lack of awareness of mental illness.

CONCLUSION

There was a striking similarity in the factors influencing self-rated health in the two groups. The findings were consistent with results of previous gerontological studies that self-rated health reflects elements of psychiatric and physical well-being, as well as perceptions of their age peers. Our results support the use of self-rated health as a legitimate clinical and research measure in OAS.

Associations among Braak stage, Parkinsonian gait, cognition, and functional status in autopsy-confirmed dementia with Lewy bodies

OBJECTIVE

Compromised functional abilities in older adults with dementia with Lewy bodies (DLB) represent a significant burden to families and frequently lead to institutionalization. Contributing factors to this compromise are poorly understood.

METHODS

Using data collected at a first study visit, multiple regression modeling was used to examine the associations between Braak staged Alzheimer disease (AD) pathology, Apolipoprotein E (ApoE) status, Parkinsonian gait, cognition, and functional status from a cohort of 102 cases with an autopsy-confirmed diagnosis of dementia stemming from combined Lewy body and AD pathology.

RESULTS

On average, 60% of functional activities were compromised per case. Worse functional status was associated with older age at first study visit, compromised cognitive status, and Parkinsonian gait after controlling for gender, mental status, and other covariates. Worse cognitive status predicted worse functional status in both the low and high Braak groups.

CONCLUSIONS

Older persons with DLB presenting with moderately compromised cognition and Parkinsonian gait should be expected to have impaired functional abilities. Providing these patients with supportive environments may help them to remain independent for longer periods of time.

Decreased Cerebrospinal Fluid Flow Is Associated With Cognitive Deficit in Elderly Patients

Background: Disruptions in cerebrospinal fluid (CSF) flow during aging could compromise protein clearance from the brain and contribute to the etiology of Alzheimer’s Disease (AD).

Objective: To determine whether CSF flow is associated with cognitive deficit in elderly patients (>70 years).

Methods: We studied 92 patients admitted to our geriatric unit for non-acute reasons using phase-contrast magnetic resonance imaging (PC-MRI) to calculate their ventricular and spinal CSF flow, and assessed their global cognitive status, memory, executive functions, and praxis. Multivariable regressions with backward selection (criterion p < 0.15) were performed to determine associations between cognitive tests and ventricular and spinal CSF flow, adjusting for depression, anxiety, and cardiovascular risk factors.

Results: The cohort comprised 71 women (77%) and 21 (33%) men, aged 84.1 ± 5.2 years (range, 73–96). Net ventricular CSF flow was 52 ± 40 μL/cc (range, 0–210), and net spinal CSF flow was 500 ± 295 μL/cc (range, 0–1420). Ventricular CSF flow was associated with the number of BEC96 figures recognized (β = 0.18, CI, 0.02–0.33; p = 0.025). Spinal CSF flow was associated with the WAIS Digit Span Backward test (β = 0.06, CI, 0.01–0.12; p = 0.034), and categoric verbal fluency (β = 0.53, CI, 0.07–0.98; p = 0.024) and semantic verbal fluency (β = 0.55, CI, 0.07–1.02; p = 0.024).

Conclusion: Patients with lower CSF flow had significantly worse memory, visuo-constructive capacities, and verbal fluency. Alterations in CSF flow could contribute to some of the cognitive deficit observed in patients with AD. Diagnosis and treatment of CSF flow alterations in geriatric patients with neurocognitive disorders could contribute to the prevention of their cognitive decline.

The Cretan Aging Cohort: Cohort Description and Burden of Dementia and Mild Cognitive Impairment

Our aim was to explore the burden of dementia in the Cretan Aging Cohort, comprised of 3140 persons aged ≥60 years (56.8% women, 5.8 ± 3.3 years formal education, 86.2% living in rural areas) who attended selected primary health-care facilities on the island of Crete, Greece. In the first study phase, a formal diagnosis of dementia had been reached in 4.0% of the participants. However, when selected 505 participants underwent thorough neuropsychiatric evaluation in the second phase of this study (344 with Mini-Mental State Examination [MMSE] <24 and 161 with MMSE ≥24), and results were extrapolated to the entire cohort, the prevalence of dementia and mild cognitive impairment was estimated at 10.8% (9.7%-11.9%) and 32.4% (30.8%-34.0%), respectively. Using both the field diagnostic data and the extrapolated data, the highest dementia prevalence (27.2%) was found in the 80- to 84-year-old group, who also showed the lowest educational level, apparently due to lack of schooling during World War II.

A Longitudinal Study of Illness Awareness in Older Adults With Schizophrenia

OBJECTIVE

Impaired insight is common in schizophrenia and may be affected by changes that occur with aging. There have been a few nonprospective investigations of insight in older adults with schizophrenia (OAS). This study examines the temporal fluctuations that occur with insight-defined as "awareness of mental illness" (dichotomized into presence or absence)-along with associated factors that influence illness awareness (IA) in OAS.

METHODS

The sample consisted of 103 persons derived from an initial sample of 250 community-dwelling persons aged 55 and over with early-onset schizophrenia spectrum disorder. Mean follow-up was 53 months. We examined 27 potential predictor variables of IA along with 5 covariates in bivariate analysis. The significant variables were then examined using multiple regression analyses.

RESULTS

23% of persons transitioned between presence and absence of IA, 62% had persistent IA, and 15% never had IA. At baseline, fewer negative symptoms (blunted affect), higher cognitive functioning (conceptualization), younger age, higher educational levels, and more physical disorders were associated significantly with higher rates of IA at follow-up. Baseline IA did not predict any variables at follow-up.

CONCLUSION

IA is often unstable in later life, with nearly one-fourth of persons showing fluctuations. Although younger age predicted IA over time, other factors associated with aging, such as cognitive functioning and physical disorders, had additional independent effects on IA. The impact of IA on clinical and functional variables attenuated over time, suggesting that for many OAS, IA may have a limited role in enhancing long-term outcomes.

Identification and Evaluation of Neuropsychological Tools Used in the Assessment of Alcohol-Related Cognitive Impairment: A Systematic Review

Background: Neuropsychological assessment is central to identifying and determining the extent of Alcohol-Related Cognitive Impairment (ARCI). The present systematic review aimed to synthesize and discuss the evidence appraising the neuropsychological tests used to assess ARCI in order to support clinicians and researchers in selecting appropriate tests for use with this population. Methods: We searched for studies investigating the psychometric, diagnostic and practical values of tools used in the screening, diagnosis, and assessment of Korsakoff's Syndrome (KS), Alcohol-Related Dementia (ARD), and those with a specific diagnosis of Alcohol-Related Brain Damage (ARBD). The following databases were searched in March 2016 and again in August 2018: MEDLINE, EMBASE, Psych-INFO, ProQuest Psychology, and Science Direct. Study quality was assessed using a checklist designed by the authors to evaluate the specific factors contributing to robust and clearly reported studies in this area. A total of 43 studies were included following the screening of 3646 studies by title and abstract and 360 at full-text. Meta-analysis was not appropriate due to heterogeneity in the tests and ARCI samples investigated in the studies reviewed. Instead, review findings were narratively synthesized and divided according to five domains of assessment: cognitive screening, memory, executive function, intelligence and test batteries, and premorbid ability. Effect sizes (d) were calculated to supplement findings. Results: Overall, several measures demonstrated sensitivity to the cognitive deficits associated with chronic alcoholism and an ability to differentiate between gradations of impairment. However, findings relating to the other psychometric qualities of the tests, including those important for the accurate assessment and monitoring of ARCI (e.g., test-retest reliability), were entirely absent or limited. Additionally, the synthesis of neuropsychological outcomes presented here supports the recent impetus for a move away from discrete diagnoses (e.g., KS, ARD) and the distinctions between them toward more broad and inclusive diagnostic conceptualizations of ARCI, thereby recognizing the heterogeneity in presentation. Conclusions: Based on the evidence reviewed, provisional recommendations for appropriate tests in each domain of assessment are presented, though further validation of most tests is warranted. Review findings can support efficient and evidenced-based test-selection and guide future research in this area.

A prospective analysis of the role of cognition in three models of aging and schizophrenia

OBJECTIVES

This study uses longitudinal data from a sample of older adults with schizophrenia spectrum disorder (OAS) to examine the role of cognition in 3 models of aging and schizophrenia-accelerated aging, paradoxical aging, and heterogeneity of course-and their clinical relevance.

METHODS

The sample consisted of 103 community-dwelling persons aged 55 and over (mean=61years) with early-onset schizophrenia. Mean follow-up was 52.5months (range: 12-116months); 55% were men; 55% were white. We identified 21 potential predictor variables and used the Dementia Rating Scale (DRS) to assess cognition.

RESULTS

There were no significant differences in the DRS at baseline (T1) and follow-up (T2). However, 20%, 22% and 58% of persons exhibited >0.5 effect size increase or decrease, or no change in their DRS scores, respectively; 19% were rapid decliners (>-2.11pts/year) and 19% were rapid improvers (>+2.11pts/year). In multivariable analysis, there were 3 predictors of higher DRS (T2): DRS (T1), decline in anxiety score, and race (white).

CONCLUSIONS

The heterogeneity model best characterized the trajectory of cognition in later life. The accelerated aging model did not represent typical cognitive trajectories since most individuals were stable or improved. The heterogeneous trajectories made it difficult to generalize about cognition's role in the paradoxical aging model. Despite the paucity of predictors, our findings suggested that it may be clinically productive to enlist remediation strategies that target anxiety and cognition, and direct more attention to non-white OAS.

A Longitudinal Analysis of Quality of Life and Associated Factors in Older Adults with Schizophrenia Spectrum Disorder

OBJECTIVES

Self-perceived quality of life (QOL) is an important outcome indicator in schizophrenia and a predictor of symptomatic and functional improvement. This study provides the first large scale longitudinal study of the fluctuations, predictors, and impact of QOL in older adults with schizophrenia spectrum disorder (SSD).

METHODS

The sample consisted of 104 community-dwelling persons with SSD aged 55 and over (mean age: 61years) who developed the disorder prior to age 45. Mean follow-up was 52.5 months (range 12-116 months); 55% were men; 55% were white. We identified 22 potential predictor variables and used the Quality of Life Index (QLI) to assess QOL.

RESULTS

There were no significant group differences in the QLI at baseline and follow-up. However, 33%, 24% and 43% of persons exhibited > 0.5 effect size increase or decrease, or no change, respectively. In multivariable analysis, there were 5 baseline predictors of QLI at follow-up: QLI, Center for Epidemiological Studies-Depression Scale (CES-D) scores, religiousness, perceived well-being versus others/past self, and time from initial interview. Baseline QLI predicted 5 variables at follow-up: the Positive and Negative Syndrome Scale (PANSS) anxiety score, PANSS positive score, CES-D score, insight, and perceived well-being versus others/past self.

CONCLUSION

In many persons with SSD, QOL is not static in later life and one third improved their QOL. Effectively treating depressive symptoms and encouraging religious participation may improve QOL. QOL had two pivotal roles: As a relatively independent dynamic outcome measure and as a critical variable affecting clinical outcomes such as anxiety, depressive and positive symptoms.

Improvement of Advanced Parkinson's Disease Manifestations with Deep Brain Stimulation of the Subthalamic Nucleus: A Single Institution Experience

We present our experience at the University of Illinois at Chicago (UIC) in deep brain stimulation (DBS) of the subthalamic nucleus (STN), describing our surgical technique, and reporting our clinical results, and morbidities. Twenty patients with advanced Parkinson’s disease (PD) who underwent bilateral STN-DBS were studied. Patients were assessed preoperatively and followed up for one year using the Unified Parkinson’s Disease Rating Scale (UPDRS) in “on” and “off” medication and “on” and “off” stimulation conditions. At one-year follow-up, we calculated significant improvement in all the motor aspects of PD (UPDRS III) and in activities of daily living (UPDRS II) in the “off” medication state. The “off” medication UPDRS improved by 49.3%, tremors improved by 81.6%, rigidity improved by 50.0%, and bradykinesia improved by 39.3%. The “off” medication UPDRS II scores improved by 73.8%. The Levodopa equivalent daily dose was reduced by 54.1%. The UPDRS IVa score (dyskinesia) was reduced by 65.1%. The UPDRS IVb score (motor fluctuation) was reduced by 48.6%. Deep brain stimulation of the STN improves the cardinal motor manifestations of the idiopathic PD. It also improves activities of daily living, and reduces medication-induced complications.

Comparing Cognitive Profiles of Licensed Drivers with Mild Alzheimer's Disease and Mild Dementia with Lewy Bodies

Purpose. Alzheimer's disease (AD) and dementia with Lewy Bodies (DLB) constitute two of the most common forms of dementia in North America. Driving is a primary means of mobility among older adults and the risk of dementia increases with advanced age. The purpose of this paper is to describe the cognitive profile of licensed drivers with mild AD and mild DLB. Method. Licensed drivers with mild AD, mild DLB, and healthy controls completed neuropsychological tests measuring general cognition, attention, visuospatial/perception, language, and cognitive fluctuations. Results. The results showed differences between healthy controls and demented participants on almost all neuropsychological measures. Participants with early DLB were found to perform significantly worse on some measures of attention and visuospatial functioning in comparison with early AD. Discussion. Future research should examine the relationship between neuropsychological measures and driving outcomes among individuals with mild AD and mild DLB.

The record of independent living

This paper describes the Record of Independent Living, a new measure of activities of daily living specifically designed for the evaluation of elderly patients experiencing cognitive decline.

Passive behaviors in Alzheimer' disease: A descriptive analysis

Fifteen empirical studies investigating passive behaviors (PB) in Alzheimer's disease (AD) were examined. Results indicated that PB are distinct from depression; they tend to increase over the course of the disease; and they can be related to cognitive status and personality changes. Absence of theoretical frameworks, lack of an instrument specifically designed to measure PB in AD, and no clearly established operational concept capable of describing and unifying behaviors into a syndrome of passivity represent problem areas for researchers. Future research to determine whether PB are a “default” mechanism brought on by AD itself or the result of a need to isolate or withdraw in order to cope with multiple stressors is indicated. Antecedent behaviors, those associated with passivity itself as well as caregiver responses and interventions also warrant investigation.

Does cognitive self-consciousness link older adults' cognitive functioning to obsessive-compulsive symptoms?

To elucidate how obsessional symptoms might develop or intensify in late-life, we tested a risk model. We posited that cognitive self-consciousness (CSC), a tendency to be aware of and monitor thinking, would increase reactivity to aging-related cognitive changes and mediate the relationship between cognitive functioning and obsessive-compulsive disorder (OCD) symptoms. Older adults (Mage = 76.7 years) completed the Dementia Rating Scale-2 (DRS-2), a CSC measure, and an OCD symptom measure up to four times over 18 months. A model that included DRS-2 age and education adjusted total score as the indicator of cognitive functioning fit the data well, and CSC score change mediated the relationship between initial cognitive functioning and changes in OCD symptoms. In tests of a model that included DRS-2 Initiation/Perseveration (I/P) and Conceptualization subscale scores, the model again fit the data well. Conceptualization scores, but not I/P scores, were related to later OCD symptoms, and change in CSC scores again mediated the relationship. Lower scores on initial cognitive functioning measures predicted increases in CSC scores over time, which in turn predicted increases in OCD symptoms over the 18 months of the study. Implications for understanding late-life obsessional problems are discussed.

The Role of Cognition and Depression in Predicting Functional Outcome in Geriatric Medical Rehabilitation Patients

The roles depression and cognition play in activities of daily living (ADL) and ambulation recovery in geriatric patients were investigated. Subjects consisted of 423 medical rehabilitation inpatients between the ages of 60 and 99. Depression and cognition as measured by standard tests at admission were found to be significantly related to performance on ADLs and ambulation at admission and discharge. Furthermore, measures of depression and cognition accounted for 7% of unique discharge ADL variance above and beyond that accounted for by admission level of ADL functioning, demographic variables, and number of existing medical conditions. Level of depression and quality of cognitive abilities did not, however, predict ambulation recovery in a regression model. Overall, depression and cognition appear to play a significant role in functional recovery. Treatment strategies for multidisciplinary team members are provided.

Deficits in Attention and Visual Processing but not Global Cognition Predict Simulated Driving Errors in Drivers Diagnosed With Mild Alzheimer's Disease

This study sought to predict driving performance of drivers with Alzheimer's disease (AD) using measures of attention, visual processing, and global cognition. Simulated driving performance of individuals with mild AD (n = 20) was contrasted with performance of a group of healthy controls (n = 21). Performance on measures of global cognitive function and specific tests of attention and visual processing were examined in relation to simulated driving performance. Strong associations were observed between measures of attention, notably the Test of Everyday Attention (sustained attention; r = -.651, P = .002) and the Useful Field of View (r = .563, P = .010), and driving performance among drivers with mild AD. The Visual Object and Space Perception Test-object was significantly correlated with the occurrence of crashes (r = .652, P = .002). Tests of global cognition did not correlate with simulated driving outcomes. The results suggest that professionals exercise caution when extrapolating driving performance based on global cognitive indicators.

Outcome measures for Parkinson's disease dementia: a systematic review

BACKGROUND

Parkinson's disease dementia (PDD) is a major cause of morbidity and mortality in Parkinson's disease (PD), which severely affects patient functioning and quality of life and increases the risk for nursing home admission. Unfortunately, current treatment options for PDD are limited and have only marginal therapeutic effects. As novel treatments are developed, there will be a need to assess their efficacy in well-designed randomized controlled trials. However, there is no consensus on the optimal outcome measures for use in PDD clinical trials.

METHODS

A systematic review of PDD clinical trials and empiric studies of outcome measures used in PDD was performed. Outcome measures were divided into five categories: 1) cognitive; 2) behavioral and mood; 3) activities of daily living and quality of life; 4) global; and 5) caregiver burden.

FINDINGS

A total of 20 PDD pharmacologic clinical trials were identified. These trials incorporated a broad array of outcome measures, which were used inconsistently across trials. We summarize the psychometric properties and other relevant data on outcome measures used, including their diagnostic utility, inter-rater reliability, test-retest reliability, responsiveness, clinically meaningful change, and availability of alternate forms.

CONCLUSIONS

We have identified the best-evidenced PDD outcome measures in each domain. Further research is needed to assess the validity, reliability, and clinically meaningful change of these measures in PDD to inform the design of future clinical trials and enhance the ability of clinicians, researchers and policy-makers to interpret study results. In addition, the development of outcome measures specific to PDD may be warranted.

Longitudinal study of remission among older adults with schizophrenia spectrum disorder

OBJECTIVE

Although studies have found that as many as half of older community-dwelling adults with schizophrenia were in symptomatic remission, these findings had been based on cross-sectional data. This study examines longitudinal changes in symptom remission rates and predictors of remission.

METHODS

The original sample consisted of 250 persons with schizophrenia spectrum disorders aged 55 and over living in New York City who developed the disorder before age 45. Data on 104 follow-up interviews are presented. Mean follow-up was 54 months (range: 12-116 months); mean age was 61 years, 55% were male, and 55% were white. A modified version of the Remission in Schizophrenia Working Group criteria was used for determining remission status.

RESULTS

There was a nonsignificant decline in the percentage attaining remission (49% baseline, 40% follow-up); 25% were in remission at both assessments, 35% were not in remission at either assessment, 25% went from remission to nonremission, and 16% went from nonremission to remission. Four significant baseline predictors of remission were found at follow-up: higher community integration, greater number of entitlements, fewer psychotropic medications, and lower frequency of psychiatric services. Baseline remission status predicted having more total contacts at follow-up.

CONCLUSION

Older adulthood is not necessarily a quiescent period, and there is considerable fluctuation in remission status. Two social variables-community integration and entitlements-predicted remission on follow-up, thus suggesting social interventions may be especially useful strategies for this population.

Impairment of brainstem implicit learning paradigms differentiates multiple system atrophy (MSA) from idiopathic Parkinson syndrome

OBJECTIVES

Learning as measured by eyeblink classical conditioning is preserved in patients with idiopathic Parkinson's disease, but severely affected in patients with progressive supranuclear palsy. We here sought to clarify whether procedural learning is impaired in multiple system atrophy (MSA), and whether it may be helpful for the differentiation of parkinsonian syndromes.

DESIGN

We investigated learning using (1) eyeblink classical conditioning with a delay (interstimulus interval 0 ms) and a trace (600 ms) paradigm and (2) a serial reaction time task.

SETTING

Participants were recruited from academic research centres.

PARTICIPANTS

11 patients with MSA and 11 healthy controls.

RESULTS

Implicit learning in eyeblink classical conditioning (acquisition of conditioned responses) as well as the serial reaction time task measures of implicit learning (reaction time change) are impaired in patients with MSA as compared with controls, whereas explicit learning as measured by the sequence recall of the serial reaction time task is relatively preserved.

ANALYSIS

We hypothesise that the learning deficits of patients with MSA are due to lesions of cerebellar and connected brainstem areas.

CONCLUSIONS

A retrospective synopsis of these novel data on patients with MSA and groups of patients with idiopathic Parkinson's disease and progressive supranuclear palsy studied earlier suggest that eyeblink classical conditioning may contribute to the early differentiation of atypical Parkinson syndromes from idiopathic Parkinson's disease. This hypothesis should be tested in a prospective trial.

Do negative affect characteristics and subjective memory concerns increase risk for late life anxiety?

To better understand the development and exacerbation of late-life anxiety, we tested a risk model positing that trait negative affect (NA) characteristics would interact with cognitive functioning, thereby increasing some older adults' risk for increased anxiety symptoms. The moderator-mediator model consisted of measures of NA, cognitive functioning, and their interaction, as predictors of later Hamilton Anxiety Rating Scale scores (HARS) via a mediational process, subjective memory concerns (SMCs). Older adults (aged 65-years and over; M(age)=76.7 years, SD=6.90 years) completed evaluations four times over approximately 18 months. A latent growth curve model including Anxiety Sensitivity Index total score (ASI), Mattis Dementia Rating Scale-2 (DRS) total raw score, the ASI×DRS interaction, a SMC measure as mediator, HARS intercept (scores at times 3 and 4), and HARS slope provided good fit. The ASI×DRS-2 interaction at Time 1 predicted HARS slope score (β=-.34, p<.05). When ASI score was high, stronger cognitive functioning was associated with fewer anxiety symptoms. The indirect effect of ASI score predicting HARS score 18-months later through the SMC mediator was statistically significant (β=.08, p<.05). Results suggest that the cognitive functioning changes associated with aging might contribute to the development of anxiety symptoms in older adults with specific NA traits. Implications for predicting and preventing late life anxiety disorders are discussed.

Systematic review of neuropsychological outcomes in dementia from cognition-based psychological interventions

BACKGROUND/AIMS

Although there is increasing evidence for the effectiveness of cognition-based psychological interventions in dementia, little is known about which neuropsychological domains are more amenable to change.

METHOD

A systematic search identified randomised controlled trials grouped according to intervention type (cognitive training/cognitive stimulation). Methodological quality was evaluated.

RESULTS

Of the 129 studies identified, 18 met the inclusion criteria; 11 were 'Cognitive Training' and 7 'Cognitive Stimulation'. For Cognitive Training, it was not possible to conclude which (if any) domains are most amenable to change. For Cognitive Stimulation, there was good evidence for general cognitive enhancement, more specifically in language and memory.

CONCLUSIONS

Further in-depth trials are needed to determine neuropsychological processes more clearly.

Prevalence of negative symptoms and associated factors in older adults with schizophrenia spectrum disorder

OBJECTIVE

To examine the prevalence of negative symptoms and associated factors in older adults with schizophrenia spectrum disorder living in the community.

METHODS

The sample consisted of a multiracial sample of 198 persons aged 55 and more with a schizophrenia spectrum disorder that developed the disorder before the age of 45; 39% and 61% lived independently and in supported community residences, respectively. George's Social Antecedent Model of Psychopathology was used to examine 16 predictor variables of negative symptoms, based on scores of 4 or more on any of the PANSS negative symptom items.

RESULTS

Forty percent of the sample met the criteria for the presence of negative symptoms, and this decreased to 19% when potential secondary symptoms were excluded. In bivariate analysis, 10 variables were found to be significantly associated with the presence of negative symptoms, but when the model was tested in logistic regression analysis, only 3 variables retained significance: greater positive symptom scores (odds ratio [OR] = 1.26), lower cognitive scores (OR = 0.96), and fewer confidantes (OR = 0.80).

CONCLUSION

Negative symptoms do not dominate the clinical picture in later life, and levels of negative symptoms appear to be no higher than in younger schizophrenia populations. The relative paucity of significant variables and their modest effect sizes suggest that treatment for negative symptoms in later life will depend largely on strategies directed specifically at the negative symptoms.

Interpersonal conflict strategies and their impact on positive symptom remission in persons aged 55 and older with schizophrenia spectrum disorders

BACKGROUND

Although interpersonal interactions are thought to affect psychopathology in schizophrenia, there is a paucity of data about how older adults with schizophrenia manage interpersonal conflicts. This paper examines interpersonal conflict strategies and their impact on positive symptom remission in older adults with schizophrenia spectrum disorders.

METHODS

The schizophrenia group consisted of 198 persons aged 55 years and over living in the community who developed schizophrenia before age 45. A community comparison group (n = 113) was recruited using randomly selected block-groups. Straus' Conflict Tactics Scale (CTS) was used to assess the ways that respondents handled interpersonal conflicts.

RESULTS

Seven conflict management subscales were created based on a principal component analysis with equamax rotation of items from the CTS. The order of the frequency of the tactics that was used was similar for both the schizophrenia and community groups. Calm and Pray tactics were the most commonly used, and the Violent and Aggressive tactics were rarely utilized. In two separate logistic regression analysis, after controlling for confounding variables, positive symptom remission was found to be associated significantly with both the Calm and Pray subscales.

CONCLUSIONS

The findings suggest that older persons with schizophrenia approximate normal distribution patterns of conflict management strategies and the most commonly used strategies are associated with positive symptom remission.

Influence of socio-demographic characteristics on DRS-2 performance in Spanish-speaking older adults

The present study compared the performance of English- and Spanish-speaking healthy controls (HCs) on the Spanish translation of the Dementia Rating Scale-Second edition (ST-DRS-2) and examined the classification accuracy of the ST-DRS-2 and Mini-Mental State Examination (MMSE) with an age- and education-matched clinical sample. In contrast to previous findings with English-speakers, a stronger relationship was observed between ST-DRS-2 Total scores and education than with age, and despite being matched on both of these variables, English-speaking HCs significantly out-performed their Spanish-speaking counterparts on the ST-DRS-2. The greatest between-group difference was found on the Memory subscale, wherein the majority of errors committed by Spanish-speaking HCs were significantly related to level of acculturation. ST-DRS-2 Total and Memory subscale scores produced greater classification accuracy than the MMSE; however, ST-DRS-2 Total scores yielded the greatest corresponding rates of sensitivity and specificity. Normative data are provided and recommended to improve the ST-DRS-2's diagnostic accuracy with Spanish-speakers.

Clinical validity of the Mattis Dementia Rating Scale-2 in Parkinson disease with MCI and dementia

The utility of the Mattis Dementia Rating Scale 2 (MDRS-2) in screening for dementia in Parkinson disease (PD) is well documented. However, little is known about its sensitivity to mild cognitive impairment in PD (PD-MCI). This study sought to document the validity of the MDRS-2 for diagnoses of PD-MCI and dementia in PD (PDD). Twenty-two healthy controls (HCs), 22 PD-MCI, and 16 PDD were compared on each MDRS-2 subscales and MDRS-2 total standard scores. Patients with PDD performed significantly worse than the other groups (all Ps < .05) on the MDRS-2 total and on all subscales, except attention. PD-MCI had significant lower scores than HCs on the MDRS-2 total and on initiation/perseveration and memory subscales. The optimal cutoff score for PD-MCI diagnosis was ≤ 140/144 and ≤ 132/144 for PDD. These findings suggest that MDRS-2 is a useful tool to identify dementia but that there might be a ceiling effect in the MDRS-2 cutoff score to diagnose MCI in PD.

Post-mortem findings in 10 patients with presumed normal-pressure hydrocephalus and review of the literature

AIMS

Neuropathological features of idiopathic normal-pressure hydrocephalus (iNPH) are poorly characterized. Brain biopsy during life may help in the differential diagnosis of dementia, but post-mortem validation of biopsy findings is scarce. Here we review and report brain biopsy and post-mortem neuropathological findings in patients with presumed NPH.

METHODS

We evaluated 10 patients initially investigated by intraventricular pressure monitoring and a frontal cortical biopsy for histological and immunohistochemical assessment as a diagnostic procedure for presumed NPH.

RESULTS

Out of the 10 patients, eight were shunted and seven benefited. Until death, six had developed severe and two mild cognitive impairment. One was cognitively unimpaired, and one was mentally retarded. Three subjects displayed amyloid-β (Aβ) aggregates in their frontal cortical biopsy obtained at the initial procedure. One of these patients developed Alzheimer's disease during a follow-up time of nearly 10 years. One patient with cognitive impairment and NPH suffered from corticobasal degeneration. In six patients various vascular lesions were seen at the final neuropathological investigation. Five of them were cognitively impaired, and in four vascular lesions were seen sufficient in extent to be considered as causative regarding their symptoms.

CONCLUSIONS

The frequent finding of vascular pathology in NPH is intriguing, suggesting that vascular alterations might be causative of cognitive impairment in a notable number of patients with NPH and dementia. Brain biopsy can be used to detect Aβ aggregates, but neuropathological characteristics of iNPH as a distinct disease still need to be discovered.

Mattis Dementia Rating Scale 2: screening for MCI and dementia

Identifying patients at higher risk of developing dementia is important. The usefulness of the Mattis Dementia Rating scale-Second Edition (MDRS-2) to detect and differentiate between patients with amnestic mild cognitive impairment (A-MCI), Parkinson's disease and MCI (PD-MCI), PD with dementia (PDD), and Alzheimer's disease (AD) was investigated. In all, 22 healthy controls (HC), 22 A-MCI, 22 PD-MCI, 16 PDD, and 22 AD patients were evaluated using an extensive neuropsychological battery, including the MDRS-2. The MDRS-2 total standardized score detected all groups of patients. The dementia groups performed worse than HC on the 5 MDRS-2 subscales. Alzheimer's disease patients scored higher than PDD on MDRS-2 conceptualization and lower on memory. Healthy controls were better than PD-MCI on MDRS-2 initiation/perseveration and memory and better than A-MCI on memory. No difference was found between the MCI groups. The MDRS-2 is a suitable short scale for MCI and dementia screening but is not specific enough to differentiate between A-MCI and PD-MCI.

Memory Scanning and Structured Learning in Alzheimer's Disease and Parkinson' Disease

Cette étude examine deux différents groupes de patients dans le but d'analyser la vitesse d'exploration de la mémoire à court terme. Il s'agit done de ceux qui sont atteints d'un parkinson (PD) (principalement pathologie sous-corticale) et de ceux qui semblent souffrir d'une démence de type Alzheimer (DAT) (principalement pathologie corticale). Une comparaison a été établie entre les patients non-déments (PD) (âge M = 58.3), les patients légèrement déments (DAT) (âge M = 67.0) et les sujets contrôlés normaux (NC) (âge M = 58.9) dans le but de déterminer si l'exploration ralentie crée une différence entre une pathologie corticale et sous-corticale. Parmi les trois groupes, les différences relevées au niveau de la tâche d'exploration de la mémoire n'étaient pas significatives. Cependant, certains patients atteints d'un parkinson semblaient effectuer cet exercice d'exploration plus lentement. Ceci pourrait être dû à l'âge, à la durée de la maladie, ou à une interaction entre ces deux facteurs. La plupart des patients DAT ont dû recevoir des directives très précises et détaillées avant de pouvoir effectuer la tâche voulant qu'ils reconnaissent certains objets, ceci en dépit des résultats indiquant une vitesse d'exploration normale, et plusieurs ont été incapables de l'exécuter, même après avoir reçu des directives supplémentaires.

Successful aging in older adults with schizophrenia: prevalence and associated factors

OBJECTIVE

This study contrasts the prevalence of successful aging in older adults with schizophrenia with their age peers in the community and examines variables associated with successful aging in the schizophrenia group.

METHODS

The schizophrenia group consisted of 198 community-dwelling persons aged 55 years and older who developed schizophrenia before the age of 45 years. A community comparison group (N = 113) was recruited using randomly selected block groups. The three objective criteria proposed by Rowe and Kahn were operationalized using a six-item summed score. The association of 16 predictor variables with the successful aging score in the schizophrenia group was examined.

RESULTS

The community group had significantly higher successful aging scores than the schizophrenia group (4.3 versus 3.0; t = 8.36, df = 309, p <0.001). Nineteen percent of the community group met all six criteria on the successful aging score versus 2% of the schizophrenia group. In regression analysis, only two variables-fewer negative symptoms and a higher quality of life index-were associated with the successful aging score within the schizophrenia group.

CONCLUSION

Older adults with schizophrenia rarely achieve successful aging and do so much less commonly than their age peers. Only two significant variables were associated with successful aging neither of which are easily remediable. The elements that comprise the components of successful aging, especially physical health, may be better targets for intervention.

Disability in late-life major depression: patterns of self-reported task abilities, task habits, and observed task performance

This article describes patterns of concordance/discordance between self-reported abilities ("can do") and habits ("does do") and observed task performance of daily living tasks in three groups of older adults: late life depression with mild cognitive impairment (n=53), late life depression without mild cognitive impairment (n=64), and non-depressed, cognitively normal controls (n=31). Self-reported data were gathered by interview in participants' homes, followed by observation of task performance. Significant differences in the patterns of response were found between controls and respondents with both late life depression and mild cognitive impairment for the cognitive instrumental activities, and between the two depressed groups and controls for the physical instrumental activities. For both sets of activities, controls exhibited the greatest overestimation of task performance. No differences were found among the groups for the less complex functional mobility and personal care tasks. However, for the more complex instrumental activities, concordance was close to, or less than, chance. The findings led us to conclude that when performance testing is not feasible, self-reports of functional status that focus on habits may be more accurate than those that focus on abilities.

The diagnostic accuracy of dementia-screening instruments with an administration time of 10 to 45 minutes for use in secondary care: a systematic review

Early screening for dementia is crucial for identifying reversible causes as well as managing, counseling, and other therapeutic interventions. Many reviews have compared the suitability of very brief screening instruments for use in primary care, but reviews on more extensive instruments in secondary care are scarce. In addition, results on diagnostic accuracy are often biased due to methodological shortcomings, differences in the spectrum of patients or reporting. This systematic review reports the diagnostic accuracy of dementia-screening instruments with an administration time of 10 to 45 minutes, validated in secondary care, restricted to mild dementia and validation studies of ''high quality.'' Characteristics such as cognitive domains and reliability figures are also highlighted.

Cognitive impairment in older adults without dementia: clinical and pathologic outcomes in a community-based sample

This study examines clinical and neuropathologic characteristics of 37 participants in a community-based dementia series who had cognitive complaints at enrollment but did not meet dementia criteria. Participants had neuropsychological testing, were followed until death, and underwent autopsy. Twenty-four participants progressed to dementia, and their baseline characteristics were analyzed. Of the 24, 13 met criteria for neuropathologic Alzheimer disease (AD). The 13 participants who progressed to neuropathologic AD (mean intake age 78.5 +/- 7.7, mean enrollment 6.4 +/- 2.1 years) performed worse than the 11 who progressed to neuropathologic non-AD dementias (mean intake age 79.0 +/- 6.0, mean enrollment 6.0 +/- 3.2 years) on baseline Wechsler Memory Scale (WMS) delayed logical memory (3.4 +/- 2.9 vs 6.3 +/- 3.9, P = .05) and delayed visual reproduction (1.4 +/- 2.1 vs 3.1 +/- 2.7, P = .02). These observations are consistent with the view that nondemented patients with underlying AD may be more likely to present with memory than nonmemory cognitive impairment.

Clinical and experimental approaches to varieties of memory

Memory is described as a complex aspect of cognitive functioning. Memory is dependent upon input from the sensory modalities; it relies upon the passage of time; and it requires intervening processes for initial acquisition and subsequent access. Based upon questions posed concerning the relationship between clinical and experimental advances in memory and memory disorders, an example is given to illustrate the influence of research upon techniques for diagnosis and rehabilitation. Suggestions are provided about how to approach answering other related questions in neuropsychology. An integrated program is suggested with the aim of bringing together findings from neuroanatomy, neurochemistry, and neurobehavior. Emphasis is placed upon integrating results of research based upon human and nonhuman models of disordered memory and other cognitive functions. Neuroanatomical systems important for performing delayed-reaction tasks are reviewed, as are results of delayed response and delayed alternation testing in several human populations with neurological dysfunction suggestive of frontal lobe damage.

Longitudinal cognitive performance in older adults with cardiovascular disease: evidence for improvement in heart failure

BACKGROUND

Cardiovascular disease (CVD) and particularly heart failure (HF) have been associated with cognitive impairment in cross-sectional studies, but it is unclear how cognitive impairment progresses over time in older adults with these conditions.

OBJECTIVE

The aim of this study was to prospectively examine cognitive function in patients with HF versus other forms of CVD.

METHOD

Seventy-five older adults (aged 53-84 years) with CVD underwent Doppler echocardiogram to evaluate cardiac status and 2 administrations of the Dementia Rating Scale (DRS), a test of global cognitive functioning, 12 months apart.

RESULTS

Although DRS performance did not statistically differ between groups at either administration, a significant between-group difference in the rate of cognitive change emerged (lambda = 0.87; F = 10.50; P = .002; omega 2 = 0.11). Follow-up analyses revealed that patients with HF improved significantly on global DRS performance, whereas patients with other forms of CVD remained stable. More specifically, patients with HF showed improvement on subscales of attention, initiation/perseveration, and conceptualization. Exploratory analyses indicated that higher diastolic blood pressure at baseline was associated with improved DRS performance in patients with HF (r = 0.38; P = .02).

CONCLUSIONS

Patients with HF exhibited modest cognitive improvements during 12 months, particularly in attention and executive functioning. Higher diastolic blood pressure at baseline was associated with improvement. These results suggest that cognitive impairment in patients with HF may be modifiable and that improved blood pressure control may be an important contributor to improved function. Further prospective studies are needed to replicate results and determine underlying mechanisms.

Outcome among community dwelling older adults with schizophrenia: results using five conceptual models

There have been few studies examining the outcome of schizophrenia in later life. Using five conceptual models, we test two hypotheses with respect to range of outcomes among older schizophrenia outpatients and how they compare to their age peers in the community. We operationalized five outcome measures from the following conceptual models: Remission, adapting criteria of Andreasen et al. (The American Journal of Psychiatry, 162:441-449, 2005); Recovery, adapting the criteria by Liberman et al. (International Review of Psychiatry, 14:256-272, 2002); Community Integration using the model of Wong and Solomon (Mental Health Services Research, 4:13-28, 2002); Subjective and Objective Successful Aging using the model of Rowe and Kahn (Science, 237:143-149, 1987). The schizophrenia (S) group consisted of 198 community-dwelling persons aged 55 and over who developed schizophrenia before age 45 and a community comparison (CC) group (N = 113). Remission and recovery criteria were met by 49 and 17% of the S group, respectively. There were significant differences between the S and CC groups in the distribution of community integration and successful aging scales: 41% of the CC group met at least 10 of 12 criteria versus 23% of the S group on the Community Integration Scale; 19% of the CC group met all six criteria vs. 2% of the S group on the Objective Successful Aging Scale; 27% of the CC group vs. 13% of the S group met all six criteria on the Subjective Successful Aging Scale. Correlations among the five outcome measures ranged from r = .19 to .48 (median value: r = .26 or 7% shared variance). There is wide variability in outcome in later life depending on which measure is used. Rather than one universal indicator, each measure offers a different perspective that can provide useful guidelines for researchers, clinicians, and policy makers.

Subjective reasons for adherence to psychotropic medication and associated factors among older adults with schizophrenia

RATIONALE

There are limited data examining subjective influences on medication adherence among older persons with schizophrenia. The subjective reasons for adherence to antipsychotic medication and associated clinical and psychosocial factors in this population are examined.

METHODS

The sample consisted of 198 community dwelling persons aged >or=55 who developed schizophrenia before age 45. Using the Rating of Medication Influences Scale (ROMI), a principal component factor analysis with varimax rotation yielded three subscales: Medication Affinity and Prevention, Influence of Others, and Impact of Authority. These subscales were dichotomized into high and low based on a median split. We also created an ordinal High Adherence measure based on the summed scores of each person's three dichotomized ROMI subscales. A modified Health Belief Model was used to examine the association between 18 predictor variables and the ROMI subscales and the adherence scale.

RESULTS

The mean subscale rankings were Medication Affinity and Prevention > Impact of Authority > Influence of Others. In logistic regression, lower education, more side effects, higher depression scores, and more mental health services were associated with higher scores on Influence of Others subscale. More side effects and more entitlements were associated with higher scores on the Medication Affinity and Prevention subscale. The Impact of Authority subscale had no significant associations. More side effects and higher depression scores were associated with higher scores on High Adherence measure.

CONCLUSION

We identified a three-dimensional model for explaining the subjective reasons for medication adherence in older persons with schizophrenia. Our findings suggest that cognitive approaches and use of authority figures may be useful for promoting adherence in older adults. Independent variables associated with these subscales may provide guidance for improving adherence in this population.

Review of normative data for common screening measures used to evaluate cognitive functioning in elderly individuals

When conducting neuropsychological evaluations of the elderly, it is important to compare patients' test scores to appropriate normative data to maximize diagnostic and descriptive accuracy. Many sets of normative data are now available for screening measures that assess cognitive functioning in the elderly. This article systematically reviewed available norms for 6 widely used screening measures of cognitive functioning in elderly patients. Details regarding the sample characteristics and data collection methods are provided for each set of norms, thereby providing a useful reference for clinicians.

Distinct cognitive profiles and rates of decline on the Mattis Dementia Rating Scale in autopsy-confirmed frontotemporal dementia and Alzheimer's disease

Neuropsychological studies have shown that patients with Frontotemporal dementia (FTD) perform worse than patients with Alzheimer's disease (AD) on tests of conceptualization and verbal fluency, but better on tests of memory and visuospatial functions. However, it is not known if these distinct cognitive profiles are robust enough to be detected using a relatively brief dementia screening instrument such as the Mattis Dementia Rating Scale (MDRS). To address this issue, the MDRS subscale profiles of patients with autopsy-confirmed FTD (n = 17) or AD (n = 34) were compared. Results showed distinct cognitive profiles in which FTD patients performed worse than AD patients on the Initiation/Perseveration and Conceptualization subscales while performing better on the Memory and Construction subscales. The distinct subscale profiles correctly classified 85% of AD patients and 76% of FTD patients. Profiles were maintained in a subset of mildly-to-moderately demented patients (MDRS > or = 105) and correctly classified 89% of these patients. In addition, FTD patients (mean = 30.0 points/year) declined faster than AD patients (mean = 14.8 points/year) on MDRS total and specific subscale scores. These results suggest that the MDRS may be a useful adjunct to other clinical measures for distinguishing FTD from AD and tracking the progression of the disorder.

Depression in older adults with schizophrenia spectrum disorders: prevalence and associated factors

RATIONALE

Although depression is common in older adults with schizophrenia, it has not been well studied. The authors examine those factors that are related to depression in a multiracial urban sample of older persons with schizophrenia.

METHODS

The schizophrenia group consisted of 198 persons aged 55 or older who lived in the community and developed schizophrenia before age 45. Persons with substantial cognitive impairment were excluded from the study. A community comparison group (N = 113) was recruited using randomly selected census tract data. The authors adapted George's Social Antecedent Model of Depression, which consists of six categories comprising 16 independent variables, and used a dichotomous dependent variable based on a Center for Epidemiologic Studies Depression Scale cutoff score of > or = 16.

RESULTS

The schizophrenia group had significantly more persons with clinical depression than the community comparison group (32% versus 11%, respectively; chi(2) = 28.23, df = 1, p = 0.001). Bivariate analysis revealed that eight of the 16 variables were significantly related to clinical depression in the schizophrenia group. In logistic regression, six variables retained significance: physical illness (odds ratio [OR] = 1.60, 95% confidence interval [CI], 1.17-2.18), quality of life (OR = 0.84, 95% CI, 0.76-0.93), presence of positive symptoms (OR = 1.12, 95% CI, 1.02-1.21), proportion of confidants (OR = 0.03, 95% CI, 0.01-0.39), copes by using medications (OR = 2.12, 95% CI, 1.08-4.13), and copes with conflicts by keeping calm (OR = 1.34, 95% CI, 1.03-1.74).

CONCLUSION

Consistent with earlier studies of schizophrenia in older persons, the authors found physical health, positive symptoms, and several nonclinical variables to be associated with depression. Potential points for intervention include strengthening social supports, improving physical well-being, more aggressive treatment of positive symptoms, and increasing the recognition and treatment of depression.