Consent for Research Involving Spanish- and English-Speaking Latinx Adults With Schizophrenia

BACKGROUND

Latinxs are vastly underrepresented in mental health research; one of many contributing factors may be complexities in the research consent process, including language preferences. We examined determinants of comprehension of research consent procedures and tested the effects of a preconsent research schema condition among 180 adults with schizophrenia (60 Latinx-English and 60 Latinx-Spanish preference, and 60 non-Latinx White).

STUDY DESIGN

Participants were randomly assigned (equal allocation) to an educational session regarding clinical research concepts and processes (schema condition) or to an attention control. Following a subsequent simulated consent procedure for a hypothetical drug trail, comprehension of consent disclosures was measured with 2 standard measures.

STUDY RESULTS

One-way ANOVAs showed significant medium effect size differences between ethnicity/language groups on both measures of comprehension (η2s = 0.066-0.070). The Latinx-Spanish group showed lower comprehension than non-Latinx White participants; differences between the 2 Latinx groups did not reach statistical significance. Group differences were not statistically significant after adjusting for differences in education, or on scores from structured measures of acculturation, health literacy, or research literacy. Two-way ANOVAs showed no significant main effects for consent procedure on either comprehension measure (Ps > .369; partial η2s < 0.006) and no significant group-by-consent interactions (Ps > .554; partial η2s < 0.008).

CONCLUSIONS

Although the preconsent procedure was not effective, the results suggest health and research literacy may be targets for reducing disparities in consent comprehension. The onus is on researchers to improve communication of consent information as an important step to addressing health care disparities.

Acculturation and clinical symptoms of schizophrenia among Latine adults in the United States

BACKGROUND

Research on acculturation and schizophrenia spectrum disorders has yielded inconsistent findings. This study aimed to clarify the influence of acculturation on symptomatology in Latine individuals with schizophrenia in the United States.

METHODS

The analysis involved cross-sectional data from Latine (n = 120) and non-Latine White (n = 60) adults with schizophrenia in San Diego, California. Participants completed the Short Acculturation Scale for Hispanics (SASH), Positive and Negative Symptom Scale, and Hamilton Depression Rating Scale in their preferred language. Univariate linear regressions were implemented to identify proxy measures as predictors of acculturation scores. Analyses of variance were conducted to analyze the relationship of SASH scores and proxy measures of acculturation to symptom severity.

RESULTS

Latine participants presented more symptom severity than non-Latine Whites. When categorized by acculturation status (Spanish-preferring, bicultural, and English-preferring), Spanish-preferring participants presented similar psychiatric symptoms to the non-Latine group and less severe symptoms than both other Latine groups. Analyses identified study language as the strongest proxy measure for the SASH. Latine participants assessed in English had significantly worse positive and depressive symptoms than those assessed in Spanish. Nativity status moderated the relationship between study language and symptomatology.

CONCLUSIONS

Findings support an association between acculturation and symptom severity among Latine individuals with schizophrenia. The use of proxy measures of acculturation may be useful in settings where time is constrained. Future research should continue to explore acculturation and symptomatology in Latine communities.

Compassion Meditation for Distressed Older Veterans: A Feasibility Study

OBJECTIVES

Older Veterans are at elevated risk for psychological distress and may encounter barriers to accessing mental health services. Compassion Meditation (CM) promotes positive emotions and outcomes among distressed individuals; thus, we conducted a preliminary feasibility study of CM among distressed older Veterans.

METHODS

Participants included 25 Veterans aged 55+ (M = 69.0, SD = 10.6) with anxiety and/or depressive symptoms, recruited from primary care, mostly male (76.0%), and White (60.0%). CM consisted of 10 groups, which were transitioned from in-person to telehealth due to COVID-19. Feasibility indices included rates of intervention initiation and completion, and attendance. Participants completed measures of symptom severity and well-being pre- and post-intervention.

RESULTS

Of 25 enrolled participants, 88.0% (n = 22) attended at least one session, and 52% (n = 13) completed the intervention (attended six or more sessions). Among intervention completers, the average number of sessions attended was 9.46. Seven Veterans withdrew from intervention due to difficulties engaging via telehealth.

CONCLUSIONS

These findings support the feasibility of CM training in older Veterans with psychological distress, though dropouts highlighted potential need for additional strategies to facilitate telehealth participation.

CLINICAL IMPLICATIONS

Older Veterans appear amenable to meditation-based practices, provided they are easy to access.

Perceived discrimination and nativity status: risk of cognitive impairment among Latin American older adults

OBJECTIVES

We examined the association between perceived discrimination and the risk of cognitive impairment with no dementia (CIND) and Alzheimer's disease and related dementias (ADRD) while considering the potential effects of nativity status.

DESIGN

A prospective analysis of discrimination and nativity status with dementia and cognitive impairment was conducted among Latinx adults aged 51 years and older who participated in the Health and Retirement Study.

SETTING

A national representative sample.

PARTICIPANTS

A sample of 1,175 Latinx adults aged 51 years and older.

MEASUREMENTS

Demographics, cognitive functioning, perceived discrimination, and nativity status (US-born vs. non-US born) were assessed. Traditional survival analysis methods (Fine and gray models) were used to account for the semi-competing risk of death with up to 10 years of follow-up.

RESULTS

According to our results, neither everyday discrimination nor nativity status on their own had a statistically significant association with CIND/ADRD; however, non-US-born Latinx adults who reported no discrimination had a 42% lower risk of CIND/ADRD (SHR = 0.58 [0.41, 0.83], p = .003) than US-born adults.

CONCLUSIONS

These results highlight the need for healthcare providers to assess for discrimination and provide support and resources for those experiencing discrimination. It also highlights the need for better policies that address discrimination and reduce health disparities.

B - 45 Differences in the Association between Social Activity and Neurocognition between Latino and Non-Hispanic White Older Adults with HIV

OBJECTIVE

Older Hispanics/Latinos/as/x (henceforth Latinos) are disproportionately affected by HIV-associated neurocognitive impairment compared to their non-Hispanic White counterparts. We examined social activity as a possible protective factor against worse neurocognitive outcomes for older people with HIV (PWH). Given cultural values regarding interpersonal relationships, we also examined whether the association between social activity and neurocognition was stronger for Latino than White PWH.

METHOD

Community-dwelling PWH (N = 114; 50% Latino [53% Spanish-speaking]; Overall group: Age: M = 58.03 SD = 5.75; Education: M = 13.29, SD = 3.39; 82% male; 58% AIDS; 95% on antiretroviral therapy; 4% detectable plasma RNA) completed neuropsychological and neuromedical evaluations. Global neurocognition was derived from demographically adjusted T-scores on a battery of 10 tests with separate norms for English and Spanish-speakers. A questionnaire assessed participants' engagement in 7 social activities over the past year. Covariates included physical activity, depressed mood, and HIV disease characteristics.

RESULTS

There were no ethnic differences in degree or nature of social activity. A linear regression model revealed a significant interaction between ethnicity and social activity on global neurocognitive T-scores, (β = 0.45, SE = 0.18, p = 0.02), such that increased engagement in social activities was associated with better global neurocognition in White PWH (β = 3.40, SE = 1.13, p < 0.01), but not Latino PWH (β = 0.57, SE = 1.00, p = 0.57).

CONCLUSIONS

Results indicate a possible protective influence of social activity on neurocognition in older White, but not Latino PWH, highlighting the importance of examining the generalizability of this relationship across ethnic/cultural groups. Future studies might examine the quality of social activities and their link with neurocognition in diverse older PWH.

Impact of educational attainment on time to cognitive decline among marginalized older adults: Cohort study of 20,311 adults

BACKGROUND

The effect of years of education on the maintenance of healthy cognitive functioning may differ by race and ethnicity given historical and ongoing inequities in educational quality.

METHODS

We examined 20,311 Black, Latinx, and White adults aged 51-100 from the Health and Retirement Study (2008-2016). Telephone Interview for Cognitive Status-27 data was used to measure cognitive functioning. Generalized additive mixed models were stratified by race and ethnicity and educational attainment (≥12 vs. <12 years). Selected social determinants of health, all-cause mortality, time-varying health and healthcare utilization characteristics, and study wave were included as covariates.

RESULTS

On average, Black and Latinx adults scored lower at baseline compared to White adults regardless of educational attainment (p < 0.001), with a significant overlap in the distributions of scores. The rate of cognitive decline was non-linear for Black, Latinx, and White adults (p < 0.001), and a period of stability was witnessed for those with higher educational attainment irrespective of race and ethnicity. Compared to Black, Latinx, and White adults with lower educational attainment, higher-educated White adults received the greatest protection from cognitive decline (13 years; 64 vs. 51), followed by Latinx (12 years; 67 vs. 55), and Black adults (10 years; 61 vs. 51). Latinx adults experienced cognitive decline beginning at a later age.

CONCLUSIONS

The extent to which higher educational attainment protects adults from cognitive decline differs by race and ethnicity, such that higher-educated White adults received a greater benefit than higher-educated Black or Latinx adults.

Review of Major Social Determinants of Health in Schizophrenia-Spectrum Disorders: II. Assessments

BACKGROUND AND AIMS

Social determinants of health (SDoHs) impact the development and course of schizophrenia-spectrum psychotic disorders (SSPDs). Yet, we found no published scholarly reviews of psychometric properties and pragmatic utility of SDoH assessments among people with SSPDs. We aim to review those aspects of SDoH assessments.

STUDY DESIGN

PsychInfo, PubMed, and Google Scholar databases were examined to obtain data on reliability, validity, administration process, strengths, and limitations of the measures for SDoHs identified in a paired scoping review.

STUDY RESULTS

SDoHs were assessed using different approaches including self-reports, interviews, rating scales, and review of public databases. Of the major SDoHs, early-life adversities, social disconnection, racism, social fragmentation, and food insecurity had measures with satisfactory psychometric properties. Internal consistency reliabilities-evaluated in the general population for 13 measures of early-life adversities, social disconnection, racism, social fragmentation, and food insecurity-ranged from poor to excellent (0.68-0.96). The number of items varied from 1 to more than 100 and administration time ranged from less than 5 minutes to over an hour. Measures of urbanicity, low socioeconomic status, immigration status, homelessness/housing instability, and incarceration were based on public records or targeted sampling.

CONCLUSIONS

Although the reported assessments of SDoHs show promise, there is a need to develop and test brief but validated screening measures suitable for clinical application. Novel assessment tools, including objective assessments at individual and community levels utilizing new technology, and sophisticated psychometric evaluations for reliability, validity, and sensitivity to change with effective interventions are recommended, and suggestions for training curricula are offered.

Review of Major Social Determinants of Health in Schizophrenia-Spectrum Psychotic Disorders: I. Clinical Outcomes

BACKGROUND

Social determinants of health (SDoHs) are receiving growing attention and are particularly relevant to persons with schizophrenia-spectrum psychotic disorders (SSPDs), considering their heightened risk of comorbidities, cognitive and functional decline, and early mortality. Yet, we did not find any comprehensive review of multiple SDoHs in SSPD.

STUDY DESIGN

We conducted a scoping review of meta-analyses and systematic reviews of nine major SDoHs in SSPD.

STUDY RESULTS

Childhood abuse, parental psychopathology, parental communication problems, bullying, and urban settings with lower socioeconomic status were major risk factors for the greater incidence of SSPD and/or worse health. Social network size was inversely associated with overall psychopathology and negative symptoms. Experiences of racial/ethnic discrimination correlated with the prevalence of psychotic symptoms and experiences. Compared to native populations, the risk of psychosis was higher in immigrants, refugees, and asylees. Social fragmentation was associated with an increased prevalence of schizophrenia. Homeless populations had a 30-fold higher prevalence of schizophrenia than the general population. Seriously mentally ill people were 2.7 times more likely to report food insecurity than controls. The prevalence of non-affective psychosis in prisoners was 2.0%-6.5%, compared to 0.3% in the general population. Certain potentially positive factors like family and community resilience remain poorly studied.

CONCLUSIONS

SDoHs are associated with higher rates of and worse outcomes in SSPD. Well-designed longitudinal studies are needed to understand SDoHs' contribution to health in persons with SSPD, to develop interventions, and to implement changes in clinical care and public health policies that would reduce adverse health impacts of SDoHs. Positive SDoHs deserve greater attention.

Self-compassion, but not compassion toward others, is associated with better physical health: A cross-sectional study

Compassion is a modifiable construct that is associated with better physical health outcomes but, to our knowledge, has seldom been studied in people with schizophrenia (PwS) despite its applicability to counteract widespread depression in this community that might prevent positive health behaviors. We hypothesized that, compared to non-psychiatric comparison subjects (NCs), PwS would have lower compassion toward self (CTS), lower compassion toward others (CTO), and a positive association between compassion and health outcomes, such as physical wellbeing, comorbidities, and plasma hs-CRP. This cross-sectional study examined differences in physical health, CTS, and CTO in 189 PwS and 166 NCs. We used general linear models to analyze the relationship between compassion and health. As hypothesized, PwS had lower levels of CTS and CTO, worse physical well-being, more comorbidities, and higher levels of plasma hs-CRP than NCs. In the combined sample, higher CTS was significantly associated with better physical well-being and fewer comorbidities, while higher CTO was significantly associated with more comorbidities. In PwS alone, higher CTS was significantly associated with better physical well-being and lower levels of hs-CRP. CTS seemed to have a larger positive association with physical health than CTO, with depression acting as a potential mediator for CTS. Exploring effects of CTS interventions on physical health and health behaviors could be a promising next step.

Remotely Administered Resilience- and Wisdom-Focused Intervention to Reduce Perceived Stress and Loneliness: Pilot Controlled Clinical Trial in Older Adults

OBJECTIVE

Older adults are vulnerable to perceived stress and loneliness, exacerbated by the COVID-19 pandemic. We previously reported inverse relationships between loneliness/perceived stress and wisdom/resilience. There are few evidence-based tele-health interventions for older adults. We tested a new remotely-administered manualized resilience- and wisdom-focused behavioral intervention to reduce perceived stress and loneliness in older adults.

METHODS

This pilot controlled clinical trial used a multiple-phase-change single-case experimental design, with three successive 6-week phases: control, intervention, and follow-up periods. The intervention included six once-a-week one-hour sessions. Participants were 20 adults >65 years, without dementia.

RESULTS

All 20 participants completed every session. The study indicated feasibility and acceptability of the intervention. While the sample was too small for demonstrating efficacy, there was a reduction (small-to-medium effect size) in perceived stress and loneliness, and increase in resilience, happiness, and components of wisdom and positive perceptions of aging.

CONCLUSION

These preliminary data support feasibility, acceptability, and possible efficacy of a remotely-administered resilience- and wisdom-focused intervention in older adults to reduce stress and loneliness.

Abbreviated San Diego Wisdom Scale (SD-WISE-7) and Jeste-Thomas Wisdom Index (JTWI)

OBJECTIVES

Wisdom is a personality trait comprising seven components: self-reflection, pro-social behaviors, emotional regulation, acceptance of diverse perspectives, decisiveness, social advising, and spirituality. Wisdom, a potentially modifiable trait, is strongly associated with well-being. We have published a validated 28-item San Diego Wisdom Scale, the SD-WISE-28. Brief scales are necessary for use in large population-based studies and in clinical practice. The present study aimed to create an abbreviated 7-item version of the SD-WISE.

METHOD

Participants included 2093 people, aged 20-82 years, recruited and surveyed through the online crowdsourcing platform Amazon Mechanical Turk. The participants' mean age was 46 years, with 55% women. Participants completed the SD-WISE-28 as well as validation scales for various positive and negative constructs. Psychometric analyses (factor analysis and item response theory) were used to select one item from each of the seven SD-WISE-28 subscales.

RESULTS

We selected a combination of items that produced acceptable unidimensional model fit and good reliability (ω = 0.74). Item statistics suggested that all seven items were strong indicators of wisdom, although the association was weakest for spirituality. Analyses indicated that the 28-item and 7-item SD-WISE are both very highly correlated (r = 0.92) and produce a nearly identical pattern of correlations with demographic and validity variables.

CONCLUSION

The SD-WISE-7, and its derived Jeste-Thomas Wisdom Index (JTWI) score, balances reliability and brevity for research applications.

Pilot Study of Compassion Meditation Training to Improve Well-being Among Older Adults

OBJECTIVES

Compassion meditation (CM) training has demonstrated potential in improving well-being and psychosocial functioning. However, most prior studies of CM training have focused on younger adults. The generalizability of the effectiveness of CM training with older adults requires further study. This pilot study was intended to inform future randomized controlled studies of CM training in older adults.

METHODS

Participants included 24 older adults who attended a 10-week group CM training. Exploratory outcome measures were administered prior to, during, and after the intervention. Participants also completed logs of mood and meditation practice, and provided descriptive comments in response to open-ended questions administered at the end of treatment.

RESULTS

High treatment completion rates (87.5%) and reported adherence (85.7% of assigned meditation) were observed. Descriptive feedback from participants indicated older adults are interested in and capable of learning and applying new concepts and skills in support of their well-being. Pre- to post-intervention changes were explored with a variety of self-report measures. Weekly journals suggested increased feelings of love, closeness, or trust, and decreased feelings of stress, nervousness, or being overwhelmed.

CONCLUSIONS

These findings provide preliminary support for the feasibility of CM training in community-dwelling older adults, and suggest the need for future efficacy and effectiveness clinical trials.

CLINICAL IMPLICATIONS

CM training offers potential benefits for improving well-being among older adults, and, as an example of a strengths-based approach, can be tailored to the specific needs of older adults.

Stakeholders' Perspectives regarding Participation in Neuromodulation-Based Dementia Intervention Research

This study evaluated stakeholders' perspectives regarding participation in two hypothetical neuromodulation trials focused on individuals with Alzheimer's disease and related disorders (ADRDs). Stakeholders (i.e., individuals at risk for ADRDs [n = 56], individuals with experience as a caregiver for someone with a cognitive disorder [n = 60], and comparison respondents [n = 124]) were recruited via MTurk. Primary outcomes were willingness to enroll (or enroll one's loved one), feeling lucky to have the opportunity to enroll, and feeling obligated to enroll in two protocols (transcranial magnetic stimulation, TMS; deep brain stimulation, DBS). Relative to the Comparison group, the At Risk group endorsed higher levels of "feeling lucky" regarding both research protocols, and higher willingness to participate in the TMS protocol. These findings provide tentative reassurance regarding the nature of decision making regarding neurotechnology-based research on ADRDs. Further work is needed to evaluate the full range of potential influences on research participation.

Reductions in sleep quality and circadian activity rhythmicity predict longitudinal changes in objective and subjective cognitive functioning in women treated for breast cancer

PURPOSE

To examine long-term cognitive effects of chemotherapy and identify predictors among women with breast cancer (WBC).

PATIENTS AND METHODS

Sixty-nine WBC scheduled to receive chemotherapy, and 64 matched-controls with no cancer, participated. Objective and subjective cognition, total sleep time, nap time, circadian activity rhythms (CAR), sleep quality, fatigue, and depression were measured pre-chemotherapy (Baseline), end of cycle 4 (Cycle-4), and one-year post-chemotherapy (1-Year).

RESULTS

WBC showed no change in objective cognitive measures from Baseline to Cycle-4 but significantly improved from both time points to 1-Year. Matched-controls showed an increase in test performance at all time points. WBC had significantly higher self-reported cognitive dysfunction at Cycle-4 and 1-Year compared to baseline and compared to matched-controls. Worse neuropsychological functioning was predicted by less robust CARs (i.e., inconsistent 24 h pattern), worse sleep quality, longer naps, and worse cognitive complaints. Worse subjective cognition was predicted by lower sleep quality and higher fatigue and depressed mood.

CONCLUSION

Objective testing showed increases in performance scores from pre- and post-chemotherapy to one year later in WBC, but matched-controls showed an increase in test performance from baseline to Cycle-4 and from Cycle-4 to 1-Year, likely due to a practice effect. The fact that WBC showed no practice effects may reflect a form of learning deficit. Compared with the matched-controls, WBC reported significant worsened cognitive function. In WBC, worse objective and subjective cognitive functioning were predicted by worse sleep and sleep-related behaviors (naps and CAR). Interventions that target sleep, circadian rhythms, and fatigue may benefit cognitive function in WBC.

Increased Prevalence of Metabolic Syndrome in Veterans with PTSD Untreated with Antipsychotic Medications

Post-Traumatic Stress Disorder (PTSD) is not solely a psychiatric disorder; it also includes significant medical morbidity. Although there is evidence of increased risk of metabolic syndrome (MetS) in PTSD, the interpretation of previous studies is confounded by inclusion of people on antipsychotic medications, which independently cause increased MetS. In this study we investigated whether Veterans with PTSD not treated with antipsychotic medications (n=115) demonstrate increased MetS compared to an age-comparable group of people from the U.S. National Health and Nutrition Examination Survey (NHNES; n=1005). Using standardized criteria (abnormal values in 3 out of the 5 domains of obesity, hypertension, high density lipoprotein, triglyceride and fasting glucose concentrations) we compared the prevalence of MetS across groups. Relative to the NHNES group, a significantly higher proportion of the Veteran PTSD group met criteria for MetS (26.9% vs. 41.7%) with a higher proportion of abnormal values in four out of five MetS domains (excepting glucose). Our results suggest that the elevation of MetS associated with PTSD cannot be fully explained by iatrogenic effects of antipsychotic medication. We suggest that extra attention be devoted to the clinical management of metabolic risk factors for morbidity in patients with PTSD.

Physical and Mental Health Characteristics of 2,962 Adults With Subjective Cognitive Complaints

We investigated subjective cognitive complaints (SCCs), as well as physical and mental health factors, in adults and older adults. U.S. residents (N = 2,962) were recruited via the Amazon Mechanical Turk platform and completed a 90-item survey. Overall, 493/1930 (25.5%) of younger adults and 278/1032 (26.9%) of older adults endorsed SCCs. Analyses revealed worse physical and mental health characteristics in the SCC+ compared to the SCC- group, with primarily medium (Cohen's d = 0.50) to large (0.80) effect sizes. Age did not moderate relationships between SCCs and physical/mental health. Results suggest that SCCs are associated with a diverse set of negative health characteristics such as poor sleep and high body mass index, and lower levels of positive factors, including happiness and wisdom. Effect sizes of psychological correlates were at least as large as those of physical correlates, indicating that mental health is critical to consider when evaluating SCCs.

Qualitative study of loneliness in a senior housing community: the importance of wisdom and other coping strategies

OBJECTIVE

Older adults are at a high risk for loneliness, which impacts their health, well-being, and longevity. While related to social isolation, loneliness is a distinct, internally experienced, distressing feeling. The present qualitative study sought to identify characteristics of loneliness in older adults living independently within a senior housing community, which is typically designed to reduce social isolation.

METHOD

Semi-structured qualitative interviews regarding the experience of loneliness, risk factors, and ways to combat it were conducted with 30 older adults, ages 65-92 years. The interviews were audiotaped, transcribed, and coded using a grounded theory analytic approach based on coding, consensus, co-occurrence, and comparison.

RESULTS

Three main themes with multiple subthemes are described: (A) Risk and Protective factors for loneliness: age-associated losses, lack of social skills or abilities, and protective personality traits; (B) Experience of loneliness: Sadness and lack of meaning as well as Lack of motivation; and (C) Coping strategies to prevent or overcome loneliness: acceptance of aging, compassion, seeking companionship, and environment enables socialization.

DISCUSSION

Despite living within a communal setting designed to reduce social isolation, many older adults described feeling lonely in stark negative terms, attributing it to aging-associated losses or lack of social skills and abilities. However, interviewees also reported positive personal qualities and actions to prevent or cope with loneliness, several of which mirrored specific components of wisdom. The results support the reported inverse relationship between loneliness and wisdom and suggest a potential role for wisdom-enhancing interventions to reduce and prevent loneliness in older populations.

A randomized trial of physical activity for cognitive functioning in breast cancer survivors: Rationale and study design of I Can! Improving Cognition After Cancer

INTRODUCTION

Difficulties with cognition are extremely common among breast cancer survivors and can significantly impact quality of life, daily functioning, and ability to return to work. One promising intervention is increasing physical activity, as it has been effective in improving cognition in non-cancer populations. Few physical activity intervention trials with cognition outcomes have included cancer survivors. This project builds upon our previous work indicating that increased physical activity can improve objectively measured processing speed and self-reported cognition among breast cancer survivors.

METHODS

The I Can! study will examine whether a physical activity intervention improves cognition among 250 post-treatment breast cancer survivors (Stages I-III, <5 years post-treatment) who are reporting cognitive difficulties. This 2-arm randomized controlled trial comparing a 6-month physical activity intervention (Exercise Group) to a health & wellness attention-comparison condition (Health & Wellness Group) will examine intervention effects on cognition (at 3 and 6 months) and maintenance of effects at 12 months. The primary aim is to investigate the impact of exercise on objectively measured processing speed and self-reported cognition. Secondary aims are to investigate maintenance of cognitive changes and examine candidate biological mechanisms and psychological mediators.

CONCLUSION

The I Can! study will contribute to the scientific, public health, and survivorship intervention literature by providing new information on the impact of physical activity for cognitive impairment in breast cancer survivors. Findings from this study will inform guidelines for physical activity to improve the lives of millions of breast cancer survivors.

Women and Men Differ in Relative Strengths in Wisdom Profiles: A Study of 659 Adults Across the Lifespan

Wisdom is a multi-component trait that is important for mental health and well-being. In this study, we sought to understand gender differences in relative strengths in wisdom. A total of 659 individuals aged 27-103 years completed surveys including the 3-Dimensional Wisdom Scale (3D-WS) and the San Diego Wisdom Scale (SD-WISE). Analyses assessed gender differences in wisdom and gender's moderating effect on the relationship between wisdom and associated constructs including depression, loneliness, well-being, optimism, and resilience. Women scored higher on average on the 3D-WS but not on the SD-WISE. Women scored higher on compassion-related domains and on SD-WISE Self-Reflection. Men scored higher on cognitive-related domains and on SD-WISE Emotion Regulation. There was no impact of gender on the relationships between wisdom and associated constructs. Women and men have different relative strengths in wisdom, likely driven by sociocultural and biological factors. Tailoring wisdom interventions to individuals based on their profiles is an important next step.

Is spirituality a component of wisdom? Study of 1,786 adults using expanded San Diego Wisdom Scale (Jeste-Thomas Wisdom Index)

OBJECTIVE

Wisdom has gained increasing interest among researchers as a personality trait relevant to well-being and mental health. We previously reported development of a new 24-item San Diego Wisdom Scale (SD-WISE), with good to excellent psychometric properties, comprised of six subscales: pro-social behaviors, emotional regulation, self-reflection (insight), tolerance for divergent values (acceptance of uncertainty), decisiveness, and social advising. There is controversy about whether spirituality is a marker of wisdom. The present cross-sectional study sought to address that question by developing a new SD-WISE subscale of spirituality and examining its associations with various relevant measures.

METHODS

Data were collected from a national-level sample of 1,786 community-dwelling adults age 20-82 years, as part of an Amazon M-Turk cohort. Participants completed the 24-item SD-WISE along with several subscales of a commonly used Brief Multidimensional Measure of Religiousness/Spirituality, along with validated scales for well-being, resilience, happiness, depression, anxiety, loneliness, and social network.

RESULTS

Using latent variable models, we developed a Spirituality subscale, which demonstrated acceptable psychometric properties including a unidimensional factor structure and good reliability. Spirituality correlated positively with age and was higher in women than in men. The expanded 28-item, 7-subscale SD-WISE total score (called the Jeste-Thomas Wisdom Index or JTWI) demonstrated acceptable psychometric properties. The Spirituality subscale was positively correlated with good mental health and well-being, and negatively correlated with poor mental health. However, compared to other components of wisdom, the Spirituality factor showed weaker (i.e., small-to-medium vs. medium-to-large) association with the SD-WISE higher-order Wisdom factor (JTWI).

CONCLUSION

Similar to other components as well as overall wisdom, spirituality is significantly associated with better mental health and well-being, and may add to the predictive utility of the total wisdom score. Spirituality is, however, a weaker contributor to overall wisdom than components like pro-social behaviors and emotional regulation. Longitudinal studies of larger and more diverse samples are needed to explore mediation effects of these constructs on well-being and health.

Predictors of Loneliness by Age Decade: Study of Psychological and Environmental Factors in 2,843 Community-Dwelling Americans Aged 20-69 Years

OBJECTIVE

Loneliness is a prevalent and serious public health problem due to its effects on health, well-being, and longevity. Understanding correlates of loneliness is critical for guiding efforts toward the development of evidence-based strategies for prevention and intervention. Considering that patterns of association between age and loneliness vary, the present study sought to examine age-related differences in risk and protective factors for loneliness.

METHODS

Correlates of loneliness were examined through a large web-based survey of 2,843 participants (aged 20-69 years) from across the United States from April 10, 2019, through May 10, 2019. Participants completed the 4-item UCLA Loneliness Scale, San Diego Wisdom Scale (with the following subscales measuring components of wisdom: Prosocial Behaviors, Emotional Regulation, Self-Reflection, Acceptance of Divergent Values, Decisiveness, and Social Advising), and other scales measuring psychosocial variables. Multivariate regression analyses were conducted to identify the best model of loneliness and examine potential age-related differences.

RESULTS

Age demonstrated a nonlinear quadratic relationship with loneliness (Wald statistic = 5.48, P = .019); levels were highest in the 20s and lowest in the 60s with another peak in the mid-40s. Across all decades, loneliness was associated with not having a spouse or partner (P < .001), sleep disturbance (P < .02), lower prosocial behaviors (P < .001), and smaller social network (P < .001). Lower social self-efficacy (P < .001) and higher anxiety (P < .005) were associated with worse loneliness in all age decades, except the 60s. Loneliness was uniquely associated with decisiveness in the 50s (P = .012) and with education (P = .046) and memory complaints (P = .013) in the 60s.

CONCLUSIONS

Our findings identify several potentially modifiable targets related to loneliness, including several aspects of wisdom and social self-efficacy. Differential predictors at different decades suggest a need for a personalized and nuanced prioritizing of prevention and intervention targets.

Aging and Trauma: Post Traumatic Stress Disorder Among Korean War Veterans

Having experienced posttraumatic stress disorder 30 years prior to its recognition as a formal disorder, Korean War veterans are now an aging population that requires unique clinical management.

Mediators of a Physical Activity Intervention on Cognition in Breast Cancer Survivors: Evidence From a Randomized Controlled Trial

Background

Emerging research suggests that increasing physical activity can help improve cognition among breast cancer survivors. However, little is known about the mechanism through which physical activity impacts cancer survivors’ cognition.

Objective

The objective of this secondary analysis examined physical and psychological function potentially linking physical activity with changes in cognition among breast cancer survivors in a randomized controlled trial where the exercise arm had greater improvements in cognition than the control arm.

Methods

A total of 87 sedentary breast cancer survivors were randomized to a 12-week physical activity intervention (n=43) or control condition (n=44). Objectively measured processing speed (National Institutes of Health Toolbox Oral Symbol Digit), self-reported cognition (patient-reported outcomes measurement information system [PROMIS] cognitive abilities), PROMIS measures of physical and psychological function (depression, anxiety, fatigue, and physical functioning), and plasma biomarkers (brain-derived neurotrophic factor, homeostatic model assessment 2 of insulin resistance, and C-reactive protein [CRP]) were collected at baseline and 12 weeks. Linear mixed-effects models tested intervention effects on changes in physical and psychological function variables and biomarkers. Bootstrapping was used to assess mediation. Exploratory analyses examined self-reported cognitive abilities and processing speed as mediators of the intervention effect on physical functioning.

Results

Participants in the exercise arm had significantly greater improvements in physical functioning (beta=1.23; 95% CI 2.42 to 0.03; P=.049) and reductions in anxiety (beta=−1.50; 95% CI −0.07 to −2.94; P=.04) than those in the control arm. Anxiety significantly mediated the intervention effect on cognitive abilities (bootstrap 95% CI −1.96 to −0.06), whereas physical functioning did not (bootstrap 95% CI −1.12 to 0.10). Neither anxiety (bootstrap 95% CI −1.18 to 0.74) nor physical functioning (bootstrap 95% CI −2.34 to 0.15) mediated the intervention effect on processing speed. Of the biomarkers, only CRP had greater changes in the exercise arm than the control arm (beta=.253; 95% CI −0.04 to 0.57; P=.09), but CRP was not associated with cognition; therefore, none of the biomarker measures mediated the intervention effect on cognition. Neither cognitive abilities (bootstrap 95% CI −0.06 to 0.68) nor processing speed (bootstrap 95% CI −0.15 to 0.63) mediated the intervention effect on physical function.

Conclusions

Physical activity interventions may improve self-reported cognition by decreasing anxiety. If supported by larger studies, reducing anxiety may be an important target for improving self-reported cognition among cancer survivors.

Trial Registration

ClinicalTrials.gov NCT02332876; https://clinicaltrials.gov/ct2/show/NCT02332876

Sleep Disturbances and Inflammatory Biomarkers in Schizophrenia: Focus on Sex Differences

OBJECTIVES

Persons with schizophrenia, and women in particular, are at high risk for sleep disturbances and inflammatory activation. The sleep-inflammation link has been reported to be stronger in women within the general population. This study sought to examine the sleep-inflammation link in persons with schizophrenia and its relationship with demographic, clinical and cognitive variables.

DESIGN

Cross-sectional case-control study.

PARTICIPANTS

Community-dwelling outpatients with schizophrenia (N=144, 46% women) and non-psychiatric comparison (NC) participants (N=134, 52% women), age 26-65 years.

MEASUREMENTS

Reported sleep disturbances (sleep quality and duration), and mental and physical health were assessed. Cognitive assessments included executive functioning (Delis-Kaplan Executive Function System) and global cognitive functioning (Telephone Interview for Cognitive Status - modified.) Inflammatory biomarkers included pro-inflammatory cytokines [high sensitivity C-Reactive Protein (hs-CRP), Interleukin (IL)-6, Tumor Necrosis Factor-α (TNF-α)] and an anti-inflammatory cytokine (IL-10).

RESULTS

The schizophrenia group had longer sleep duration, worse sleep quality, and increased levels of hs-CRP, IL-6, and TNF-α compared to NCs. Women with schizophrenia were less likely to have good sleep quality and had elevated levels of hs-CRP and IL-6 compared to men with schizophrenia. In the schizophrenia group, worse sleep quality and global cognitive functioning were associated with higher hs-CRP and IL-6 levels. Female sex and younger age were also associated with higher hs-CRP levels.

CONCLUSIONS

Sleep disturbances and increased inflammation, which were common in schizophrenia, were associated in persons with schizophrenia. Moreover, women with schizophrenia had worse sleep quality and inflammation than men. Further examination of the sleep-inflammation links, their contribution to clinical outcomes, and sex-specific factors is warranted.

A new scale for assessing wisdom based on common domains and a neurobiological model: The San Diego Wisdom Scale (SD-WISE)

Wisdom is an ancient concept that has gained new interest among clinical researchers as a complex trait relevant to well-being and healthy aging. As the empirical data regarding wisdom have grown, several measures have been used to assess an individual's level of wisdom. However, none of these measures has been based on a construct of wisdom with neurobiological underpinnings. We sought to develop a new scale, the San Diego Wisdom Scale (SD-WISE), which builds upon recent gains in the understanding of psychological and neurobiological models of the trait. Data were collected from 524 community-dwelling adults age 25-104 years as part of a structured multi-cohort study of adult lifespan. Participants were administered the SD-WISE along with two existing measures of wisdom that have been shown to have good psychometric properties. Factor analyses confirmed the hypothesized measurement model. SD-WISE total scores were reliable, demonstrated convergent and discriminant validity, and correlated, as hypothesized, negatively with emotional distress, but positively with well-being. However, the magnitudes of these associations were small, suggesting that the SD-WISE is not just a global measure of mental state. The results support the reliability and validity of SD-WISE scores. Study limitations are discussed. The SD-WISE, with good psychometric properties, a brief administration time, and a measurement model that is consistent with commonly cited content domains of wisdom based on a putative neurobiological model, may be useful in clinical practice as well as in bio-psycho-social research, especially investigations into the neurobiology of wisdom and experimental interventions to enhance wisdom.

Overview of measurement-based positive psychiatry

BACKGROUND

Psychiatry has traditionally focused on studying psychopathology and treating mental illnesses to relieve symptoms and prevent relapse. Positive psychiatry seeks to expand the scope of psychiatry to broader aspects of mental health and well-being among individuals with or without mental illnesses. Positive psychosocial factors such as well-being, resilience, optimism, wisdom, and social support are central to positive psychiatry.

AIM

To summarize the emerging science of positive psychiatry, emphasizing the use of measures of positive characteristics and outcomes relevant to mental health.

METHODS

Overview of recent research in positive psychiatry, focusing on measurements.

RESULTS

Positive psychosocial factors are associated with better mental and physical health in diverse populations. Among individuals with serious mental illnesses, levels of these factors vary considerably, but positive psychiatry interventions can improve well-being and rates of recovery in at least subsets of the patients. A number of measures of positive factors and outcomes are available; most of them are based on self-reports, which have advantages as well as limitations.

CONCLUSIONS

Positive psychiatry has the potential to improve the health and well-being of individuals with or without mental illnesses. Further research is needed to provide clinicians and investigators with a full tool-box of validated measures for positive psychosocial factors and outcomes. These measures should be subjected to rigorous psychometric evaluation across populations to help clarify mechanisms underlying positive factors, evaluate their longitudinal trajectories, and examine the impact of interventions on health and well-being over the lifespan in different clinical groups.

A widening longevity gap between people with schizophrenia and general population: A literature review and call for action

Individuals with schizophrenia have higher mortality rates than the population at large. General mortality rates have declined in developed countries since the early 1970s, extending average lifespan by nearly a decade. This review of eight longitudinal studies of mortality in schizophrenia found that the mean standardized mortality ratio (SMR, a measure of mortality rate in schizophrenia compared to the general population) increased 37%, from 2.2 in the pre-1970s studies to 3.0 in the post-1970s reports. Major changes in societal stigma, healthcare, and economic policy are urgently warranted to ensure that this vulnerable segment of the population participates in the longevity revolution.

Loneliness in schizophrenia: Construct clarification, measurement, and clinical relevance

Loneliness is a highly prevalent experience in schizophrenia. Theoretical models developed in the general population propose that loneliness is tantamount to a feeling of being unsafe, is accompanied by enhanced environmental threat perception, and leads to poor physical, emotional, and cognitive functioning. Previous research has reported that loneliness is associated with poorer physical and emotional health in schizophrenia; however, few studies have directly compared loneliness and its correlates in persons with schizophrenia and non-psychiatric comparison subjects. The purpose of the current study was to evaluate similarities and differences in the construct of loneliness, the equivalency of the measurement of this construct, and similarities and differences in the pattern of external correlates of loneliness between schizophrenia and non-psychiatric comparison groups. The third version of the University of California, Los Angeles Loneliness Scale (UCLA-3) was administered to 116 individuals with schizophrenia or schizoaffective disorder and 106 non-psychiatric comparison subjects. Additional clinical and positive psychological measures were collected, as well as demographic characteristics of the two groups. Multiple groups confirmatory factor analysis revealed that the UCLA-3 was best characterized by a bifactor model in which all items loaded on a general loneliness dimension as well as one of two orthogonal method factors reflecting item wording in both groups. Furthermore, the UCLA-3 exhibited invariant measurement of these latent constructs across groups. Mean levels of loneliness were nearly a standard deviation higher in the schizophrenia group. Nonetheless, the overall pattern and strength of correlates were largely similar across groups, with loneliness being positively associated with depression, anxiety, and perceived stress, and negatively correlated with mental well-being, happiness, and resilience. Subtle differences in correlates of age, optimism, and satisfaction with life were found. Overall, loneliness appears to be distinct from other schizophrenia-related deficits and operates similarly across schizophrenia and NC groups, suggesting that theoretical models of loneliness developed in the general population may generalize to schizophrenia.

Positive mental health in schizophrenia and healthy comparison groups: relationships with overall health and biomarkers

OBJECTIVE

Positive psychological factors (PPFs) have been reported to have a significant impact on health in the general population. However, little is known about the relationship of these factors with mental and physical health in schizophrenia.

METHOD

One hundred and thirty-five outpatients with schizophrenia and 127 healthy comparison subjects (HCs), aged 26-65 years, were evaluated with scales of resilience, optimism, happiness, and perceived stress. Measures of mental and physical health were also obtained. Regression analyses examined associations of a PPF composite with health variables.

RESULTS

Relative to the HCs, the schizophrenia group had lower levels of PPFs. However, there was considerable heterogeneity, with over one-third of schizophrenia participants having values within the 'normative' range. The PPF composite was positively related to mental and physical health variables and with biomarkers of inflammation and insulin resistance. The relationship between PPFs and mental health was particularly strong for individuals with schizophrenia.

CONCLUSION

A sizable minority of adults with chronic schizophrenia have levels of resilience, optimism, happiness, and perceived stress similar to HCs. Psychosocial interventions to enhance PPFs should be tested in patients with serious mental illnesses, with the goal of improving their mental health (beyond controlling symptoms of psychosis) and their physical health.

Supported Decision Making in Serious Mental Illness

OBJECTIVE

Making decisions is central to the exercise of control over one's well-being. Many individuals with serious mental illness (SMI) experience limitations in their decision-making capacity. These individuals have often been placed under legal guardianship and substitute decision makers have been appointed to make decisions on their behalf. More recently, supported decision making (SDM) has emerged as a possible alternative in some cases. SDM involves recruitment of trusted supports to enhance an individual's capacity in the decision-making process, enabling him or her to retain autonomy in life decisions. This overview examines issues associated with decision-making capacity in SMI, frameworks of substitute decision making and SDM, and emerging empirical research on SDM.

METHOD

This is an overview of the medical and legal literature on decision making capacity and supported decision making for persons with SMI.

RESULTS

Many but not all individuals with SMI exhibit decrements in decision-making capacity and skill, in part due to cognitive impairment. There are no published data on rates of substitute decision making/guardianship or SDM for SMI. Only three empirical studies have explored SDM in this population. These studies suggest that SDM is viewed as an acceptable and potentially superior alternative to substitute decision making for patients and their caretakers.

CONCLUSIONS

SDM is a promising alternative to substitute decision making for persons with SMI. Further empirical research is needed to clarify candidates for SDM, decisions in need of support, selection of supporters, guidelines for the SDM process, integration of SDM with emerging technological platforms, and outcomes of SDM. Recommendations for implementation of and research on SDM for SMI are provided.

Randomized controlled trial of increasing physical activity on objectively measured and self-reported cognitive functioning among breast cancer survivors: The memory & motion study

BACKGROUND

Increasing physical activity can improve cognition in healthy and cognitively impaired adults; however, the benefits for cancer survivors are unknown. The current study examined a 12-week physical activity intervention, compared with a control condition, on objective and self-reported cognition among breast cancer survivors.

METHODS

Sedentary breast cancer survivors were randomized to an exercise arm (n = 43) or a control arm (n = 44). At baseline and at 12 weeks, objective cognition was measured with the National Institutes of Health Cognitive Toolbox, and self-reported cognition using the Patient-Reported Outcomes Measurement Information System scales. Linear mixed-effects regression models tested intervention effects for changes in cognition scores.

RESULTS

On average, participants (n = 87) were aged 57 years (standard deviation, 10.4 years) and were 2.5 years (standard deviation, 1.3 years) post surgery. Scores on the Oral Symbol Digit subscale (a measure of processing speed) evidenced differential improvement in the exercise arm versus the control arm (b = 2.01; P < .05). The between-group differences in improvement on self-reported cognition were not statistically significant but were suggestive of potential group differences. Time since surgery moderated the correlation, and participants who were ≤2 years post surgery had a significantly greater improvement in Oral Symbol Digit score (exercise vs control (b = 4.00; P < .01), but no significant improvement was observed in patients who were >2 years postsurgery (b = -1.19; P = .40). A significant dose response was observed with greater increased physical activity associated with objective and self-reported cognition in the exercise arm.

CONCLUSIONS

The exercise intervention significantly improved processing speed, but only among those who had been diagnosed with breast cancer within the past 2 years. Slowed processing speed can have substantial implications for independent functioning, supporting the potential importance of early implementation of an exercise intervention among patients with breast cancer. Cancer 2018;124:192-202. © 2017 American Cancer Society.

Childhood Adversity and Schizophrenia: The Protective Role of Resilience in Mental and Physical Health and Metabolic Markers

OBJECTIVE

To determine the impact of childhood adversity and current (adulthood) resilience on mental and physical health and markers of metabolic function among adults with schizophrenia and nonpsychiatric comparison participants (NCs).

METHODS

We conducted a cross-sectional study of 114 participants with schizophrenia (DSM-IV-TR criteria) and 101 NCs aged 26-65 years during 2012-2017. Sociodemographic, clinical, and laboratory measures were examined. Childhood Trauma Questionnaire was used to retrospectively assess emotional abuse/neglect, physical abuse/neglect, and sexual abuse experienced during childhood. Connor-Davidson Resilience Scale was employed to measure resilience.

RESULTS

Persons with schizophrenia reported more severe childhood trauma, lower resilience, and worse mental and physical health and had worse metabolic biomarker levels than NCs. Trauma severity correlated with worse depression in the NCs (r = 0.34), but not in the schizophrenia group (r = 0.02). In both groups, trauma severity was associated with worse physical well-being, higher fasting insulin levels, and greater insulin resistance (P ≤ .02). Notably, resilience appeared to counteract effects of trauma and diagnosis on mental and physical health. The schizophrenia subgroup with high resilience and severe trauma reported mental and physical well-being and had glycosylated hemoglobin levels and insulin resistance scores that were comparable to those of NCs with low resilience and severe trauma.

CONCLUSIONS

To our knowledge, this is the first study to quantitatively assess effects of both childhood trauma and resilience in schizophrenia on health, notably metabolic function. Interventions to bolster resilience in the general population and in people with schizophrenia may improve outcomes for those with a history of childhood adversity.

Multimedia Aided Consent for Alzheimer's Disease Research

OBJECTIVES

Optimizing the research consent process simultaneously fosters respect for autonomy and protection of those with diminished capacity for autonomy. This study evaluated the effectiveness of an enhanced research consent procedure, employing multimedia disclosure and corrective feedback, in improving decisional capacity among 114 people with mild-to-moderate Alzheimer's disease (AD) and 134 non-psychiatric comparison (NC) subjects.

METHODS

Participants were randomized to consent type (routine versus enhanced) and protocol type (lower versus higher risk). Outcomes included a 5-item questionnaire assessing immediate comprehension, MacArthur Competence Assessment Tool for Clinical Research assessing four components of decision-making capacity, and categorical decisional capacity (based on a cut-score established in reference to expert judgments for a subset of participants).

RESULTS

There was no significant effect of the enhanced consent procedure, relative to routine consent, on immediate comprehension or decisional capacity.

CONCLUSIONS

Multimedia tools do not appear to be the solution to better consent for AD research.

CLINICAL IMPLICATIONS

Given the ethical primacy of informed consent and issues of justice for impaired populations who might be harmed by an absence of research-based treatment advances, continued search for ways to more meaningfully engage people with AD in the consent or assent process is warranted.

Reduction in surgical fog with a warm humidified gas management protocol significantly shortens procedure time in pediatric robot-assisted laparoscopic procedures

INTRODUCTION

The adoption of robot-assisted laparoscopic (RAL) procedures in the field of urology has occurred rapidly, but is, to date, without pediatric-specific instrumentation. Surgical fog is a significant barrier to safe and efficient laparoscopy. This appears to be a significant challenge when adapting three-dimensional 8.5-mm scopes to use in pediatric RAL surgery. The objective of the present study was to compare matched controls from a prospectively collected database to procedures that were performed utilizing special equipment and a protocol to minimize surgical fog in pediatric RAL procedures.

METHODS

A prospectively collected database of all patients who underwent RAL pediatric urology procedures was used to compare: procedure, age, sex, American Society of Anesthesiologists score, weight, console time, number of times the camera was removed to clean the lens during a procedure, length of hospital stay, and morphine equivalents required in the postoperative period. A uniquely developed protocol was used, it consisted of humidified (95% relative humidity) and warmed CO₂ gas (95 °F) insufflation via Insuflow® on a working trocar, with active smoke evacuation via PneuVIEW®XE on the opposite working trocar with a gas pass through of 3.5-5 l/min. The outcomes were compared with matched controls (Summary Fig).

RESULTS

The novel gas protocol was utilized in 13 procedures (five pyeloplasties, two revision pyeloplasties, three ureteroureterostomies (UU), three nephrectomies) and compared with 13 procedures (six pyeloplasties, one revision pyeloplasty, three UU, three nephrectomies) prior to the protocol development. There was no statistical difference in age (P = 0.78), sex (P = 0.11), ASA score (P = 1.00) or weight (P = 0.69). There were no open conversions, ≥Grade 2 Clavien complications, or readmissions within 30 days in either group.

CONCLUSIONS

This novel gas protocol yielded a statistically significant reduction in procedure time, by decreasing the number of times the camera was required to be pulled during the case by more than five occurrences, and saved approximately 35 min on average per case.

When Does Therapeutic Misconception Affect Surrogates' or Subjects' Decision Making about Whether to Participate in Dementia Research?

"Therapeutic misconception" (TM) refers to inappropriate assumptions and beliefs on the part of research participants regarding key distinctions between the purpose, methods, intended benefits, and potential disadvantages of research compared to those of clinical care. Despite an extensive literature describing TM across varied types of research and populations, minimal work has addressed TM in the context of dementia research. This is a serious gap, for several reasons: people with dementia are at significant risk of diminished capacity; surrogate decision makers are typically asked to provide consent on behalf of the person with dementia; and available treatments for dementia are quite limited. More research is needed on the prevalence, nature, and impact of TM in the context of clinical dementia research.

Assessment of Healthcare Decision-making Capacity

It is often necessary for neuropsychologists, clinical psychologists, and other healthcare professionals to assess an individual's capacity to consent to treatment related to healthcare. This task can be challenging and requires a delicate balance of both respect for individuals' autonomy, as well as the protection of individuals with diminished capacity to make an autonomous decision. The purpose of the present review is to provide an overview of the conceptual model of decisional capacity as well as a brief summary of some of the currently available instruments designed to help evaluate medical decision making. In addition, current empirical literature on the relationship between neuropsychological abilities and decision-making capacity is discussed and a brief set of recommendations is provided to further aid clinicians or consultants when they are required to complete the ethically important but difficult task of making determinations about healthcare decision-making capacity.

Paradoxical Trend for Improvement in Mental Health With Aging: A Community-Based Study of 1,546 Adults Aged 21-100 Years

OBJECTIVE

Studies of aging usually focus on trajectories of physical and cognitive function, with far less emphasis on overall mental health, despite its impact on general health and mortality. This study examined linear and nonlinear trends of physical, cognitive, and mental health over the entire adult lifespan.

METHODS

Cross-sectional data were obtained from 1,546 individuals aged 21-100 years, selected using random digit dialing for the Successful AGing Evaluation (SAGE) study, a structured multicohort investigation that included telephone interviews and in-home surveys of community-based adults without dementia. Data were collected from 1/26/2010 to 10/07/2011 targeting participants aged 50-100 years and from 6/25/2012 to 7/15/2013 targeting participants aged 21-100 years with an emphasis on adding younger individuals. Data included self-report measures of physical health, measures of both positive and negative attributes of mental health, and a phone interview-based measure of cognition.

RESULTS

Comparison of age cohorts using polynomial regression suggested a possible accelerated deterioration in physical and cognitive functioning, averaging 1.5 to 2 standard deviations over the adult lifespan. In contrast, there appeared to be a linear improvement of about 1 standard deviation in various attributes of mental health over the same life period.

CONCLUSIONS

These cross-sectional findings suggest the possibility of a linear improvement in mental health beginning in young adulthood rather than a U-shaped curve reported in some prior studies. Lifespan research combining psychosocial and biological markers may improve our understanding of resilience to mental disability in older age and lead to broad-based interventions promoting mental health in all age groups.

Determinants of Capacity to Consent to Research on Alzheimer's disease

OBJECTIVE

Investigators conducting Alzheimer's disease (AD) research need to consider participants' capacity to consent. Cognitive functioning is a significant predictor of decisional capacity, but there is a dearth of information on the influence of neuropsychiatric symptoms in AD on decisional capacity. We examined the rates of decisional capacity associated with two types of research protocols, and the association of capacity with neuropsychiatric symptoms and other participant characteristics.

METHODS

We comprehensively evaluated decisional capacity among 64 patients with mild-to-moderate AD and 70 healthy comparison (HC) subjects randomized to consider either a medium risk or higher risk hypothetical research protocol. Additional measures included sociodemographics, cognitive deficits, and neuropsychiatric symptoms.

RESULTS

Twenty AD patients (31.3%) and 67 HCs (95.7%) were deemed capable; 44 AD patients (68.8%) and 3 HCs (4.3%) incapable of consent. Age, education, and severity of cognitive deficits were associated with incapable status; there were no significant associations with severity of neuropsychiatric symptoms or protocol risk level.

CONCLUSIONS

Findings highlight the importance of understanding of capacity and its assessment among people with AD, rather than treating AD diagnosis as synonymous with impaired capacity. As novel treatments move from bench to bedside, methods of assessing and addressing capacity impairment must similarly advance.

CLINICAL IMPLICATIONS

In assessing research consent capacity, use structured assessments with population specific cut scores interpreted in the context of the person's background including education, culture, and language. Individuals should be encouraged to execute research proxy documents when able.

Obstructive Sleep Apnea and Cognition in Parkinson's disease

OBJECTIVE

Obstructive sleep apnea (OSA) is very common in Parkinson's disease (PD). OSA is known to affect patients' cognition. The present study assessed whether PD patients with OSA (PD + OSA) score lower on cognitive measures than those without OSA (PD - OSA). In addition, this study evaluated whether treating the OSA with continuous positive airway pressure (CPAP) in PD + OSA patients results in an improved cognitive functioning.

METHODS

Eighty-six patients with PD underwent an overnight polysomnography screen for OSA and were administered the Mini-Mental Status Exam (MMSE) and the Montreal Cognitive Assessment (MoCA). This resulted in 38 patients with PD + OSA who were randomly assigned to receive either therapeutic CPAP for 6 weeks (n = 19) or placebo CPAP for three weeks followed by therapeutic CPAP for three weeks (n = 19). Intervention participants completed a neurocognitive battery at baseline and 3- and 6-week time-points.

RESULTS

Patients with PD + OSA scored significantly lower than PD - OSA on the MMSE and MoCA after controlling for age, education, and PD severity. OSA was a significant predictor of cognition (MMSE p <0.01; MoCA p = 0.028).There were no significant changes between groups in cognition when comparing three weeks of therapeutic CPAP with 3 weeks of placebo CPAP. Comparisons between pre-treatment and 3-week post-therapeutic CPAP for the entire sample also revealed no significant changes on overall neuropsychological (NP) scores.

CONCLUSIONS

Findings suggest that PD patients with OSA show worse cognitive functioning on cognitive screening measures than those without OSA. However, OSA treatment after three or six weeks of CPAP may not result in overall cognitive improvement in patients with PD.

Improving the understanding of the link between cognition and functional capacity in schizophrenia and bipolar disorder

OBJECTIVE

Deficits in cognitive functioning are related to functional disability in people with serious mental illness. Measures of functional capacity are commonly used as a proxy for functional disabilities for cognitive remediation programs, and robust linear relationships between functional capacity and cognitive deficits are frequently observed. This study aimed to determine whether a curvilinear relationship better approximates the association between cognitive functioning and functional capacity.

METHOD

Two independent samples were studied. Study 1: participants with schizophrenia (n=435) and bipolar disorder (n=390) aged 18-83 completed a neuropsychological battery and a performance-based measure of functional capacity. Study 2: 205 participants with schizophrenia (age range=39-72) completed a brief neuropsychological screening battery and a performance-based measure of functional capacity. For both studies, linear and quadratic curve estimations were conducted with cognitive performance predicting functional capacity scores.

RESULTS

Significant linear and quadratic trends were observed for both studies. Study 1: in both the schizophrenia and bipolar participants, when cognitive composite z-scores were >0 (indicating normal to above normal performance), cognition was not related to functional capacity. Study 2: when neuropsychological screening battery z-scores were >-1 (indicating low average to average performance), cognition was not related to functional capacity.

CONCLUSIONS

These results illustrate that in cognitively normal adults with serious mental illness, the relationship between cognitive function and functional capacity is relatively weak. These findings may aid clinicians and researchers determine who may optimally benefit from cognitive remediation programs, with greater benefits possibly being achieved for individuals with cognitive deficits relative to individuals with normal cognition.

Associations of high sensitivity C-reactive protein levels in schizophrenia and comparison groups

Schizophrenia is characterized by physical (mainly metabolic and cardiovascular) comorbidity and shortened lifespan. High sensitivity C-reactive protein (hs-CRP), an inflammatory marker of hepatic origin linked to metabolic and cardiovascular diseases and mortality in the general population, has been reported to be elevated in people with schizophrenia. However, the relationship of hs-CRP to psychiatric and medical risk factors, after controlling for potentially confounding variables such as smoking, is not well established in schizophrenia. We assessed hs-CRP levels along with various demographic, psychiatric, and metabolic measures in 88 clinically stable outpatients with schizophrenia or schizoaffective disorder and 71 age epoch-matched comparison subjects with no history of a major psychiatric illness. hs-CRP levels were significantly higher in individuals with schizophrenia than in comparison subjects. Higher hs-CRP levels in the schizophrenia group were associated with female gender, more severe negative symptoms, greater medical comorbidity, and worse metabolic risk factors including BMI, fasting glucose, and hemoglobin A1c levels. hs-CRP was not related to age, race, education, smoking status, antipsychotic dosage, or cognitive impairment. Longitudinal studies are needed to investigate the relationship between hs-CRP and long-term health outcomes including metabolic syndrome, cardiovascular disease, and mortality in schizophrenia.

Impact of increasing physical activity on cognitive functioning in breast cancer survivors: Rationale and study design of Memory & Motion

INTRODUCTION

Many breast cancer survivors experience problems with cognitive functioning that can persist years after treatment. Increasing physical activity has been shown to improve cognitive functioning in healthy and cognitively impaired adults, but has not yet been tested in cancer survivors. The primary aim of this randomized controlled trial is to examine the effects of a 3-month physical activity intervention compared to a waitlist Control arm on neuropsychological outcomes and subjective cognitive concerns in breast cancer survivors.

METHODS

Eighty sedentary breast cancer survivors, self-reporting difficulties with cognition, will be randomized into an Exercise arm or Control arm. The Exercise arm includes an activity tracker (i.e., a Fitbit), phone calls, plus tailored and non-tailored email content. The Control arm will receive emails on women's health topics on the same schedule as the Exercise arm. Assessments conducted at baseline and 3 months include: neuropsychological testing, cognitive concerns and other aspects of quality of life, and 7 days of a hip-worn accelerometer. Participants will also provide fasting blood draws to assess brain-derived neurotropic factor, Insulin-like growth factor 1, insulin resistance, and C-reactive protein. Primary and secondary outcomes are changes in neuropsychological testing and cognitive concerns. Biomarkers will be examined to further understand the underlying relationship between physical activity and cognition.

CONCLUSION

The Memory & Motion study is designed to test whether increasing physical activity can improve cognitive functioning in breast cancer survivors. Results from this study could be used to guide development of interventions to improve cognitive functioning in breast cancer survivors.

Telepsychiatry for Neurocognitive Testing in Older Rural Latino Adults

As the population of older Latinos in the U.S. increases, availability of culturally adapted geriatric psychiatry services is becoming a growing concern. This issue is exacerbated for rural Latino populations. In this study, we assessed whether neurocognitive assessment via telepsychiatry (TP) using a Spanish-language battery would be comparable to in-person (IP) testing using the same battery in a sample of Spanish-speaking older adults in a rural setting. Patients (N = 22) received IP and TP testing 2 weeks apart. The order of IP and TP test administrations in individual subjects was determined randomly. Comparison of scores indicated that there were no significant differences between IP and TP test performance though both groups scored non-significantly higher at the second visit. This study demonstrates feasibility and utility of neurocognitive testing in Spanish using TP among older rural Latinos.