Learning and serial effects on verbal memory in mild cognitive impairment

Modern Scores for Traditional Tests - Review of the Diagnostic Potential of Scores Derived from Word List Learning Tests in Mild Cognitive Impairment and Early Alzheimer's Disease

Episodic memory impairments are one of the early hallmarks in Alzheimer's Disease. In the clinical diagnosis and research, episodic memory impairment is typically assessed using word lists that are repeatedly presented to and recalled by the participant across several trials. Until recently, total learning scores, which consist of the total number of words that are recalled by participants, were almost exclusively used for diagnostic purposes. The present review aims at summarizing evidence on additional scores derived from the learning trials which have recently been investigated more frequently regarding their diagnostic potential. These scores reflect item acquisition, error frequencies, strategy use, intertrial fluctuations, and recall consistency. Evidence was summarized regarding the effects of clinical status on these scores. Preclinical, mild cognitive impairment and mild Alzheimer's Disease stages were associated with a pattern of reduced item acquisition, more errors, less strategy use, and reduced access of items, indicating slowed and erroneous encoding. Practical implications and limitations of the present research will be discussed.

Serial position effects and mild cognitive impairment: a comparison of measures and scoring approaches

INTRODUCTION

Serial position effects (SPEs) have shown promise as predictors of future cognitive decline and conversion from mild cognitive impairment (MCI) to Alzheimer's disease (AD), even when accounting for total learning and memory scores. However, conflicting results have been found in the literature, which may be at least partially related to the many ways in which SPEs are calculated. The current study aimed to address the discrepancies in the literature by examining whether one method of analyzing SPEs is more sensitive at distinguishing those with and without psychometrically defined MCI.

METHOD

86 older adult participants (57 healthy comparison, 29 MCI) completed the California Verbal Learning Test, Third Edition (CVLT3) and the Rey Auditory Verbal Learning Test (RAVLT), along with measures assessing multiple cognitive domains. Each participant completed two visits, between 3 and 9 days apart, with a different memory measure administered on each day. The standard scoring approach and the regional scoring approach to calculating SPEs were compared.

RESULTS

Results showed that, when significant differences were found, SPEs were always reduced in the MCI group compared to the healthy comparison group when using regional scoring; however, results were not as consistent when using standard scoring. Further, lower primacy than recency scores were only consistently seen in the MCI group when using the RAVLT but not the CVLT3. ROC analyses showed that only regional scoring of SPEs from delayed recall of the RAVLT and the CVLT3 accurately discriminated between those with and without MCI.

CONCLUSION

Regional scoring of SPEs may be more sensitive at identifying subtle cognitive decline compared to standard scoring. However, the specific measure that is used to analyze SPEs can impact the interpretation of findings.

Gender differences in the serial position among older adults

INTRODUCTION

There are gender disparities in age of diagnosis with Mild Cognitive Impairment (MCI) or dementia, which may be related to general female advantages in verbal memory across aging. Further examination of the serial position effect (SPE) may provide an avenue for earlier diagnosis of MCI/dementia among women.

METHOD

338 cognitively healthy adults aged 50⁺ (110 men; 228 women) were administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) List Learning task as part of dementia screening. We examined whether the SPE could be demonstrated on Trial 1 and delayed recall, and whether SPE patterns were consistent across genders, using mixed measure ANOVAs. Using regression, we also examined whether gender, SPE components, or their interactions predicted RBANS Delayed Memory Index (DMI) performance. Using cluster analyses, we identified a group with reduced primacy relative to recency on Trial 1 and a group without. We used ANOVA to examine whether clusters differed in DMI scores and whether this was moderated by gender.

RESULTS

We demonstrated the prototypical SPE on Trial 1. On delayed recall, we found reduced recency compared to primacy and middle performance. As expected, men exhibited worse performance on the DMI. However, gender did not interact with SPE. Primacy and middle, but not recency, performance on Trial 1 predicted DMI scores, as did the recency ratio. These relationships were not moderated by gender. Finally, participants with better primacy than recency on Trial 1 (N = 187) exhibited higher performance on DMI than participants with better recency than primacy (N = 151). Gender did not interact with cluster membership.

CONCLUSION

Our results have important clinical implications in assessment, where focusing on Trial 1 primacy performance and loss of recency between Trial 1 and delayed recall may help to address gender-related delays in age of diagnosis of MCI or dementia.

Changes in visual memory in mild cognitive impairment: a longitudinal study with CANTAB

BACKGROUND

Mild cognitive impairment (MCI), as a stage in the cognitive continuum between normal ageing and dementia, is mainly characterized by memory impairment. The aims of this study were to examine CANTAB measures of temporal changes of visual memory in MCI and to evaluate the usefulness of the baseline scores for predicting changes in cognitive status.

METHODS

The study included 201 participants aged over 50 years with subjective cognitive complaints. Visual memory was assessed with four CANTAB tests [paired associates learning (PAL), delayed matching to sample (DMS), pattern recognition memory (PRM) and spatial span (SSP)] administered at baseline and on two further occasions, with a follow-up interval of 18-24 months. Participants were divided into three groups according to the change in their cognitive status: participants with subjective cognitive complaints who remained stable, MCI participants who remained stable (MCI-Stable) and MCI participants whose cognitive deterioration continued (MCI-Worsened). Linear mixed models were used to model longitudinal changes, with evaluation time as a fixed variable, and multinomial regression models were used to predict changes in cognitive status.

RESULTS

Isolated significant effects were obtained for age and group with all CANTAB tests used. Interactions between evaluation time and group were identified in the PAL and DMS tests, indicating different temporal patterns depending on the changes in cognitive status. Regression models also indicated that CANTAB scores were good predictors of changes in cognitive status.

CONCLUSIONS

Decline in visual memory measured by PAL and DMS tests can successfully distinguish different types of MCI, and considered together PAL, DMS, PRM and SSP can predict changes in cognitive status.

Following H.N. over 21 years: recency change and reduced retention predict later impairment in memory, and recency ratio may combine both effects

The study follows an intellectually superior patient from initial subjective memory complaints to MCI and dementia over 21 years. Primary memory measures, process- and reliable change-measures from 12 assessments with the California Verbal Learning Test (CVLT) were analyzed as well as experimental measures of retrieval and Recency-Ratio (Rr) combining traditional recency measures with selective retrieval impairments of recency items.Recency change preceded normatively impaired memory by four years, and retention percentage by two years. Rr indicated risk for MCI conversion 13 years prior to receiving that diagnosis, and is an interesting measure for early detection of dementia in CVLT.

Determining affected memory domains in patients with amnestic mild cognitive impairment using computerized and interactive tests

This study explores different episodic memory domains, namely object, temporal and spatial memory, affected in patients with a clinical diagnosis of single domain amnestic mild cognitive impairment (aMCI). 15 aMCI patients and 25 healthy controls were recruited and tested. Object, spatial, and temporal memory were tested using computerized tasks and again in interactive, real-world tasks. Controls outperformed patients on the object computerized task and showed a trend toward significance for the computerized spatial and temporal tasks, but there was no difference in spatial and temporal memory when using the interactive tasks, indicating the employment of compensatory mechanisms in patients to overcome some of the memory impairments associated with aMCI. These findings highlight that aMCI patients might delay seeking help due to compensatory mechanisms which mask their deficits in real-world situations.

Longitudinal Patterns of the Tip-of-the-Tongue Phenomenon in People With Subjective Cognitive Complaints and Mild Cognitive Impairment

Background

The Tip-of-the-Tongue (ToTs) state is considered a universal phenomenon and is a frequent cognitive complaint in old age. Previous cross-sectional studies have found that ToT measures successfully discriminate between cognitively unimpaired adults and adults with Mild Cognitive Impairment (MCI). The aim of this study was to identify longitudinal patterns of ToTs in individuals with subjective complaints and with MCI regarding progress of their cognitive status.

Method

The study included 193 participants with subjective cognitive complaints (SCC) and 56 participants with MCI who completed a baseline and two follow-up assessments, with an interval of about 18 months between each assessment. Participants were classified into three groups by considering cognitive stability or deterioration from the baseline diagnosis: SCC-stable, MCI-stable and MCI-worsened. Participants performed a ToT task involving recognition and naming of famous people depicted in 50 photographs. Generalized Linear Mixed Models (GLMM) were used to model longitudinal changes in familiarity, feeling of knowing, semantic access, phonological access and verbal fluency.

Results

Phonological access differentiated MCI patients, stable and worsened, from adults with SCCs at all evaluation times. Phonological access declined over time in the three groups, without significant interactions between groups and time.

Discussion

This study provides the first longitudinal evidence of differences in ToT measures for adults with MCI. The findings indicate that phonological access measures successfully differentiated between the diagnostic groups. However, slopes remain irrespective of the diagnostic group and progression toward more advance stages of cognitive impairment.

Design process and preliminary psychometric study of a video game to detect cognitive impairment in senior adults

INTRODUCTION

Assessment of episodic memory has been traditionally used to evaluate potential cognitive impairments in senior adults. Typically, episodic memory evaluation is based on personal interviews and pen-and-paper tests. This article presents the design, development and a preliminary validation of a novel digital game to assess episodic memory intended to overcome the limitations of traditional methods, such as the cost of its administration, its intrusive character, the lack of early detection capabilities, the lack of ecological validity, the learning effect and the existence of confounding factors.

MATERIALS AND METHODS

Our proposal is based on the gamification of the California Verbal Learning Test (CVLT) and it has been designed to comply with the psychometric characteristics of reliability and validity. Two qualitative focus groups and a first pilot experiment were carried out to validate the proposal.

RESULTS

A more ecological, non-intrusive and better administrable tool to perform cognitive assessment was developed. Initial evidence from the focus groups and pilot experiment confirmed the developed game's usability and offered promising results insofar its psychometric validity is concerned. Moreover, the potential of this game for the cognitive classification of senior adults was confirmed, and administration time is dramatically reduced with respect to pen-and-paper tests.

LIMITATIONS

Additional research is needed to improve the resolution of the game for the identification of specific cognitive impairments, as well as to achieve a complete validation of the psychometric properties of the digital game.

CONCLUSION

Initial evidence show that serious games can be used as an instrument to assess the cognitive status of senior adults, and even to predict the onset of mild cognitive impairments or Alzheimer's disease.

[Analysis of intrusion errors in free recall]

Extra-list intrusion errors during five trials of the eight-word list-learning task of the Amsterdam Dementia Screening Test (ADST) were investigated in 823 consecutive psychogeriatric patients (87.1% suffering from major neurocognitive disorder). Almost half of the participants (45.9%) produced one or more intrusion errors on the verbal recall test. Correct responses were lower when subjects made intrusion errors, but learning slopes did not differ between subjects who committed intrusion errors and those who did not so. Bivariate regression analyses revealed that participants who committed intrusion errors were more deficient on measures of eight-word recognition memory, delayed visual recognition and tests of executive control (the Behavioral Dyscontrol Scale and the ADST-Graphical Sequences as measures of response inhibition). Using hierarchical multiple regression, only free recall and delayed visual recognition retained an independent effect in the association with intrusion errors, such that deficient scores on tests of episodic memory were sufficient to explain the occurrence of intrusion errors. Measures of inhibitory control did not add significantly to the explanation of intrusion errors in free recall, which makes insufficient strength of memory traces rather than a primary deficit in inhibition the preferred account for intrusion errors in free recall.

The effects of age on the learning and forgetting of primacy, middle, and recency components of a multi-trial word list

The serial position effect reveals that recall of a supraspan list of words follows a predictable pattern, whereby words at the beginning (primacy) and end (recency) of a list are recalled more easily than words in the middle. This effect has typically been studied using single list-learning trials, but in neuropsychology, multi-trial list-learning tests are more commonly used. The current study examined trends in learning for primacy, middle, and recency effects across multiple trials in younger and older age cohorts. Participants were 158 volunteers, including 79 adults aged 17-36 ("younger" group) and 79 adults aged 54-89 years ("older" group). Each participant completed four learning trials and one delayed (5-10 min) recall trial from the Memory Assessment Scales. Scores were divided into primacy (first four words), middle (middle four words), and recency (final four words) scores for all trials. For list acquisition, mixed effects modeling examined the main effects of and interactions between learning slope (logarithmic), age group, and serial position. Rate of learning increased logarithmically over four trials and varied by serial position, with growth of middle and recency word acquisition increasing more rapidly than recall of primacy words; this interaction did not differ by age group. Delayed retention differed according to age group and serial position; both older and younger adults demonstrated similar retention for primacy words, but older adults showed reduced retention for middle and recency words. Although older adults acquired less information across learning trials, the reason for this reduced acquisition was related to initial learning, not to rate of learning over time. Older compared to younger adults were less efficient at transferring middle and recency words from short-term to long-term memory.