Recruiting Socially Disconnected Latinos Caring for a Person with Alzheimer's Disease and Related Dementias During the COVID-19 Pandemic: Lessons Learned

OBJECTIVES

The purpose of this article is to present conceptual and methodological challenges to recruitment strategies in enrolling socially disconnected middle-aged and older Latino caregivers of a loved one with Alzheimer's disease and related dementias (ADRD).

METHODS

Middle-aged and older Latino ADRD caregivers were recruited into two early stage, intervention development studies during the COVID-19 pandemic via online or in-person methods. Recruitment criteria included Latino ADRD caregivers over the age of 40 reporting elevated loneliness on the UCLA 3-item Loneliness Scale (LS) during screening.

RESULTS

Middle-aged, Latino caregivers were recruited predominantly from online methods whereas older caregivers were mostly recruited from in-person methods. We report challenges identifying socially disconnected Latino caregivers using the UCLA 3-item LS.

CONCLUSIONS

Our findings support previously reported disparities in recruitment by age and language and suggest further methodological considerations to assess social disconnection among Latino caregivers. We discuss recommendations to overcome these challenges in future research.

CLINICAL IMPLICATIONS

Socially disconnected Latino ADRD caregivers have an elevated risk for poor mental health outcomes. Successful recruitment of this population in clinical research will ensure the development of targeted and culturally sensitive interventions to improve the mental health and overall well-being of this marginalized group.

Effect of online tDCS to left somatomotor cortex on neuropsychiatric symptoms among older adults at risk for dementia

BACKGROUND

Neuropsychiatric symptoms (NPS) in mild cognitive impairment (MCI) cause distress to patients and caregivers, and accelerate progression to dementia. Transcranial direct current stimulation (tDCS) is a promising non-invasive treatment for NPS.

OBJECTIVE/HYPOTHESIS

This pilot study assessed behavioral and neural effects of a 4-week anodal tDCS intervention targeting left sensorimotor cortex (LSMC: left precentral/postcentral gyri) during visual attention (compared to online sham tDCS), in 40 older adults (24 females, mean age = 71) with MCI.

METHODS

A phase 0 double-blinded randomized control trial was conducted. NPS (patient-reported mood symptoms plus a caregiver-reported questionnaire) and fMRI were measured at baseline and immediately post-intervention.

RESULTS

Generalized Estimating Equations found no significant group by time interactions for either NPS measure. However, there was evidence of decreased patient-reported NPS (Wald's χ2 = 3.80, p = .051), decreased LSMC activation during visual attention (Wald's χ2 = 2.93, p = .087), and increased LSMC-amygdala resting-state functional connectivity (rsFC; Wald's χ2 = 3.13, p = .077) in intervention group from pre-to post-intervention. Decrease in LSMC activation (Wald's χ2 = 9.20, p = .002) and increase in LSMC-amygdala rsFC (Wald's χ2 = 4.72, p = .030) related to decreased patient-reported NPS. Increased positive valence across sessions was significantly associated with intervention-related NPS improvement (Wald's χ2 = 22.92, p < .001). There were no findings for caregiver-reported NPS. Effects were stronger for left postcentral compared to left precentral gyrus.

CONCLUSION

We found tentative evidence that tDCS applied to LSMC during visual attention in older adults with MCI improved NPS via changes in LSMC activation and LSMC-amygdala rsFC, suggesting improved emotion regulation. Patient-reported NPS was more sensitive to these changes than caregiver-reports, and effects were strongest for left postcentral gyrus. Follow-up studies should perform precise mechanistic investigation and efficacy testing.

A meta-analysis on neural changes of cognitive training for mental disorders in executive function tasks: increase or decrease brain activation?

BACKGROUND

Cognitive impairment is often found in patients with psychiatric disorders, and cognitive training (CT) has been shown to help these patients. To better understand the mechanisms of CT, many neuroimaging studies have investigated the neural changes associated with it. However, the results of those studies have been inconsistent, making it difficult to draw conclusions from the literature. Therefore, the objective of this meta-analysis was to identify consistent patterns in the literature of neural changes associated with CT for psychiatric disorders.

METHODS

We searched for cognitive training imaging studies in PubMed, Cochrane library, Scopus, and ProQuest electronic databases. We conducted an activation likelihood estimation (ALE) for coordinate-based meta-analysis of neuroimaging studies, conduct behavioral analysis of brain regions identified by ALE analysis, conduct behavioral analysis of brain regions identified by ALE analysis, and then created a functional meta-analytic connectivity model (fMACM) of the resulting regions.

RESULTS

Results showed that CT studies consistently reported increased activation in the left inferior frontal gyrus (IFG) and decreased activation in the left precuneus and cuneus from pre- to post- CT.

CONCLUSION

CT improves cognitive function by supporting language and memory function, and reducing neuronal resources associated with basic visual processing.

Relationships of Pain Treatment With Dementia and Functional Outcome in Medicare Home Health Care

Adequate pain management is important to post-acute care functional recovery, yet persons with Alzheimer’s disease and related dementias (ADRD) are often under-treated for pain. The objectives of this study were to examine in Medicare post-acute home health (HH) recipients with daily interfering pain 1) if analgesic use at home is related to functional outcome, and 2) if ADRD is related to the likelihood of analgesic use at home. We analyzed data from the Outcome and Assessment Information Set, Medicare claims, and electronic medical records of 6,039 Medicare beneficiaries ≥ 65 years who received care from a large HH agency in New York in 2019 and reported daily interfering pain. Analgesic use was identified in medication reconciliation of HH visits and categorized into any analgesics or opioid(s). ADRD was identified from ICD-10 codes and significant cognitive impairment. Functional outcome was measured as change in the composite score of Activity of Daily Living (ADL) limitations from HH admission to HH discharge. Use of any analgesics at home was associated with greater ADL improvement from HH admission to HH discharge (β= -0.20 [greater improvement by 0.2 ADLs], 95% Confidence Interval [CI]: -0.37, -0.04; p=0.017). Compared with patients without ADRD, those with ADRD were less likely to use any analgesics (Odds Ratio [OR] = 0.66, 95% CI: 0.49, 0.90, p=0.008) or opioids (OR=0.53, 95% CI: 0.47, 0.62, p<0.001) at home. Adequate pain management is essential to functional improvement in post-acute HH care. Patients with ADRD may be under-treated for pain in post-acute HH care.

Targeting autonomic flexibility to enhance cognitive training outcomes in older adults with mild cognitive impairment: study protocol for a randomized controlled trial

Importance

Cognitive training with components that can further enhance the transferred and long-term effects and slow the progress of dementia is needed for preventing dementia.

Objective

The goal of the study is to test whether improving autonomic nervous system (ANS) flexibility via a resonance frequency breathing (RFB) training will strengthen the effects of a visual speed of processing (VSOP) cognitive training on cognitive and brain function, and slow the progress of dementia in older adults with mild cognitive impairment (MCI).

Design

Stage II double-blinded randomized controlled trial. The study was prospectively registered at ClinicalTrials.gov, with registration approved on 21 August 2020 (No. NCT04522791).

Setting

Study-related appointments will be conducted on-site at University of Rochester Medical Center locations. Data collection will be conducted from August 2020 to February 2025.

Participants

Older adults with MCI (n = 114) will be randomly assigned to an 8-week combined intervention (RFB+VSOP), VSOP with guided imagery relaxation (IR) control, and a IR-only control, with periodical booster training sessions at follow-ups. Mechanistic and distal outcomes include ANS flexibility, measured by heart rate variability, and multiple markers of dementia progress. Data will be collected across a 14-month period.

Discussion

This will be among the first RCTs to examine in older persons with MCI a novel, combined intervention targeting ANS flexibility, an important contributor to overall environmental adaptation, with an ultimate goal for slowing neurodegeneration.

Trial registration

ClinicalTrials.gov NCT04522791. Registered on 21 August 2020

Protocol version: STUDY00004727; IRB protocol version 2, approved on 30 July 2020.

Pain treatment and functional improvement in home health care: Relationship with dementia

BACKGROUND

Pain management is important to post-acute functional recovery, yet older persons with Alzheimer's disease and related dementias (ADRD) are often undertreated for pain. The main objectives were (1) to examine the relationship between ADRD and analgesic use among Medicare home health care (HHC) recipients with daily interfering pain, and (2) to examine the impact of analgesic use on functional outcome in patients with and without ADRD.

METHODS

We analyzed longitudinal data from the Outcome and Assessment Information Set, Medicare HHC claims, and HHC electronic medical records during a 60-day HHC episode. The sample included 6048 Medicare beneficiaries ≥65 years receiving care from an HHC agency in New York in 2019 who reported daily interfering pain. Analgesic use was assessed during HHC medication reconciliation and included any analgesic, non-opioid analgesic, and opioid. ADRD was identified from ICD-10 codes (HHC claims) and cognitive impairment symptoms (Outcome and Assessment Information Set [OASIS]). Functional outcome was measured as change in the composite Activity of Daily Living (ADL) limitation score in the HHC episode.

RESULTS

ADRD was related to a lower likelihood of using any analgesic (odds ratio [OR] = 0.66, 95% confidence interval [CI]: 0.49, 0.90, p = 0.008) and opioids (OR = 0.54, 95% CI: 0.47, 0.62, p < 0.001), but not related to non-opioid analgesic use (OR = 0.94, 95% CI: 0.74, 1.18, p = 0.58). Stratified analyses showed that any analgesic use (β = -0.43, 95% CI: -0.73, -0.13, p = 0.004) and non-opioid analgesic use (β = -0.31, 95% CI: -0.56, -0.06, p = 0.016) were associated with greater ADL improvement in patients with ADRD, but not in patients without ADRD. Opioid use was not significantly related to ADL improvement regardless of ADRD status.

CONCLUSIONS

HHC patients with ADRD may be undertreated for pain, yet pain treatment is essential for functional improvement in HHC. HHC clinicians and policymakers should ensure adequate pain management for older persons with ADRD for improved functional outcomes.

Building National Capacity for Dementia Caregiving Research: The NIA Edward R. Roybal Centers

The NIA Edward R. Roybal Centers for Translational Research in the Behavioral and Social Sciences of Aging aim to translate and integrate basic behavioral and social research findings into principle-driven interventions aimed at innovatively improving both the lives of older people and the capacity of institutions to adapt to societal aging. Newly funded Centers focus on interventions to promote caregiving mastery, integrate the use of technology in care support to improve assessments and interventions in care provision, develop behavioral interventions to reduce isolation and promote social connectedness in caregivers, promote health in racial/ethnic minorities, and apply insights from data science and behavioral economics to improve palliative care delivery and long-term support facilities for persons with dementia and their caregivers. Center leaders will present an overview of their cutting-edge, early-stage research projects based on the NIH Stage model conceptual framework and discuss implications for improving care of caregivers and patients.

Dysregulation of inflammation, neurobiology, and cognitive function in PTSD: an integrative review

Compelling evidence from animal and human research suggest a strong link between inflammation and posttraumatic stress disorder (PTSD). Furthermore, recent findings support compromised neurocognitive function as a key feature of PTSD, particularly with deficits in attention and processing speed, executive function, and memory. These cognitive domains are supported by brain structures and neural pathways that are disrupted in PTSD and which are implicated in fear learning and extinction processes. The disruption of these supporting structures potentially results from their interaction with inflammation. Thus, the converging evidence supports a model of inflammatory dysregulation and cognitive dysfunction as combined mechanisms underpinning PTSD symptomatology. In this review, we summarize evidence of dysregulated inflammation in PTSD and further explore how the neurobiological underpinnings of PTSD, in the context of fear learning and extinction acquisition and recall, may interact with inflammation. We then present evidence for cognitive dysfunction in PTSD, highlighting findings from human work. Potential therapeutic approaches utilizing novel pharmacological and behavioral interventions that target inflammation and cognition also are discussed.

Acute Affective Reactivity and Quality of Life in Older Adults with Amnestic Mild Cognitive Impairment: A Functional MRI Study

OBJECTIVES

Poor quality of life (QoL) is a major concern among older adults with amnestic mild cognitive impairment (MCI). Maladaptive affective regulation and its relevant frontal dysfunction that are often observed in older adults with MCI may provide an insight into the understanding of their QoL.

METHODS

In this case-controlled study, participants (MCI patients, N = 18; healthy comparisons [HC], N = 21) completed cognitive tasks, and underwent resting-state functional magnetic resonance imaging (rs-fMRI) immediately before and after the tasks. The amplitude of low-frequency fluctuations (ALFF) of rs-fMRI signals was calculated to examine the brain's spontaneous activity. The change in valence from the Self-Assessment Manikin indexed affective reactivity. QoL was assessed using Quality of Life-AD measure. Multiple mediator model was used to examine the mediating effect of frontal regions' ALFF reactivity between the affective reactivity and QoL.

RESULTS

The MCI group had significantly worse QoL and more negative affective reactivity than HC group. Less negative affective reactivity was significantly associated with better QoL in MCI not HC. ALFF in the anterior cingulate cortex, medial prefrontal cortex (MPFC), and superior frontal gyrus (SFG) increased significantly less after cognitive tasks in MCI than HC. For the entire sample, greater increases of ALFF in MPFC and SFG were significantly associated with better QoL, and SFG alone significantly mediated the association between affective reactivity and QoL.

CONCLUSIONS

Enhancing SFG activation, especially among those with MCI, may provide a therapeutic target for addressing the negative impact of maladaptive affective regulation on QoL.

Amygdala functional connectivity is associated with locus of control in the context of cognitive aging

Locus of control (LOC) measures the extent to which individuals perceive control over their lives. Those with a more "internal" LOC feel self-sufficient and able to determine important aspects of their own future, while those with a more "external" LOC feel that their lives are governed by events beyond their control. Reduced internal LOC and increased external LOC have been found in cognitive disorders, but the neural substrates of these control perceptions are yet unknown. In the present study, we explored the relationship between amygdala functional connectivity and LOC in 18 amnestic mild cognitive impairment (MCI) and age-, sex-, and education-matched, 22 cognitively healthy controls (HC). Participants completed cognitive challenge tasks (Stroop Word Color task and Dual 1-back) for 20min, and underwent resting-state functional magnetic resonance imaging immediately before and after the tasks. We found significantly lower internal LOC and higher external LOC in the MCI group than the HC group. Compared to HC, MCI group showed significantly stronger positive associations between internal LOC and baseline right amygdala connections (including right middle frontal gyrus and anterior cingulate cortex), and stronger negative associations between internal LOC and change of these right amygdala connections. Across all participants, external LOC explained the relationships between associations of another set of right amygdala connections (including middle cingulate cortex and right superior frontal gyrus), both at baseline and for change, and performance in the cognitive challenge tasks. Our findings indicate that the right amygdala networks might be critical in understanding the neural mechanisms underlying LOC's role in cognitive aging.

Frequency of mentally stimulating activities modifies the relationship between cardiovascular reactivity and executive function in old age

OBJECTIVES

Recent evidence suggests that younger and middle-age adults who show greater cardiovascular reactivity (CVR) to acute mental stress demonstrate better reasoning and memory skills. The purpose of this study was to examine whether older adults would exhibit a similar positive association between CVR and executive function and whether regular engagement in mentally stimulating activities (MSA) would moderate this association.

DESIGN

Secondary cross-sectional analysis.

SETTING

Three clinical research centers in the Midwest and on the West Coast and East Coast.

PARTICIPANTS

A total of 487 older adults participating in an ongoing national survey.

MEASUREMENTS

Heart rate (HR) and low-frequency (LF) and high-frequency (HF) domains of heart rate variability (HRV) were measured at baseline and in response to standard mental stress tasks (Stroop color word task and mental arithmetic). Executive function was measured separately from the stress tasks by using five neuropsychological tests. MSA was measured by self-reported frequency of six common MSA.

RESULTS

Higher HR reactivity was associated with better executive function after controlling for demographic and health characteristics and baseline HR, and the interaction between HR reactivity and MSA was significant for executive function. Higher LF-HRV reactivity was also associated with executive function, but subsequent analyses indicated that frequency of MSA was the strongest predictor of executive function in models that included LF-HRV or HF-HRV.

CONCLUSIONS

Higher HR reactivity to acute psychological stress is related to better executive function in older adults. For those with lower HR reactivity, engaging frequently in MSA produced compensatory benefits for executive function.

Associations between depressive symptoms and memory deficits vary as a function of insulin-like growth factor (IGF-1) levels in healthy older adults

OBJECTIVES

Accumulating evidence suggests an adverse association between depressive symptoms and cognition, but a positive association between insulin-like growth factor (IGF)-1 and cognition. The present study examined the influence of IGF-1 in the relationship between depressive symptoms and learning and memory.

METHODS

A cross-sectional study of 94 healthy fit older adults. Blood was collected and plasma IGF-1 was measured. Depressive symptoms were assessed with the Geriatric Depression Scale (GDS), and learning and memory were assessed using the Rey Auditory Verbal Learning Test (AVLT).

RESULTS

Among older adults with lower IGF-1 levels, higher depressive symptoms scores were associated with lower AVLT delayed recall and recognition. Older adults with higher IF-1 levels showed no associations between depressive symptoms and memory.

CONCLUSIONS

The association between depressive symptoms and cognition is stronger among older adults with lower levels of circulating IGF-1. Further validation studies on groups with depression or different stages of cognitive impairment are needed. IGF-1 may be a novel intervention target for slowing cognitive decline in older adults with depressive symptoms.

Pain and wound healing in surgical patients

BACKGROUND

Human and animal laboratory studies have shown that stress delays healing of standardized punch biopsy wounds.

PURPOSE

This 5-week prospective study of 17 women who underwent elective gastric bypass surgery addressed the association between postsurgical pain intensity and subsequent healing of a standard 2.0-mm punch biopsy wound.

METHODS

Participants were assessed 1 week before surgery, within 3 hr before surgery, 1 to 3 days postsurgery, and at weekly intervals for 4 weeks following surgery.

RESULTS

Patient ratings of greater acute postsurgical pain, averaged over Days 1 and 2 postsurgery, and greater persistent postsurgical pain, averaged over 4 weekly postsurgery pain ratings, were significantly associated with subsequent delayed healing of the punch biopsy wound. Presence of depressive symptoms on the day of surgery, pre-existing persistent pain, and medical complications following initial discharge from the hospital were not related to wound healing. Depressive symptoms on the day of surgery and pre-existing persistent pain did predict persistent postsurgical pain intensity.

CONCLUSIONS

These findings extend the previous laboratory models of wound healing to a surgical population, providing the first evidence that pain plays an important role in postsurgery wound healing, a key variable in postsurgical recovery.

Self presentation and cardiovascular reactivity

This research was concerned with two issues: first, whether cardiovascular response patterns to a social stressor (i.e. self-presentation under evaluative circumstances) differ as a function of one's ability to control the impression one makes on others; second, whether cognitive appraisals are necessary or sufficient for the cardiovascular components of emotional arousal. Forty-two male subjects (Ss), monitored for cardiac impedance and blood pressure, were shown a previously recorded videotape of themselves in which each S verbally described personal aspects about himself. Ss in an Active condition were allowed to mark segments of the tape they wanted to re-shoot before the tape was evaluated by reviewers. Ss in a Passive condition viewed their tape but could not indicate whether to revise it. Control conditions allowed assessment of the activity entailed in tape marking and of evaluation per se. Self-reports of stress, threat, and coping ability regarding the upcoming task were taken. Blood pressure elevations occurred equally in both experimental conditions, but apparently through different underlying mechanisms. The Active condition produced myocardial responses (increased ejection fraction), while the Passive condition produced a vascular response (increased total peripheral resistance). However, while cardiovascular reactivity patterns did differ as a function of the opportunity to control the impression one could make on evaluative others, they did not differ as a function of having appraised the task as a challenge or as a threat. Consideration also is given to the conditions necessary for cognitive appraisal to occur and to influence reactivity.