Association of Hearing Loss With Neuropsychiatric Symptoms in Older Adults With Cognitive Impairment

Neuropsychiatric symptoms (NPS) in persons with dementia (PWD) are common and can lead to poor outcomes, such as institutionalization and mortality, and may be exacerbated by sensory loss. Hearing loss is also highly prevalent among older adults, including PWD.ObjectiveThis study investigated the association between hearing loss and NPS among community- dwelling patients from a tertiary memory care center.Design, Setting, and ParticipantsParticipants of this cross-sectional study were patients followed at the Johns Hopkins Memory and Alzheimer's Treatment Center who underwent audiometric testing during routine clinical practice between October 2014 and January 2017.Outcome MeasurementsIncluded measures were scores on the Neuropsychiatric Inventory–Questionnaire and the Cornell Scale for Depression in Dementia.ResultsParticipants (n = 101) were on average 76 years old, mostly female and white, and had a mean Mini-Mental State Examination score of 23. We observed a positive association between audiometric hearing loss and the number of NPS (b = 0.7 per 10 dB; 95% confidence interval [CI]: 0.2, 1.1; t = 2.86; p = 0.01; df = 85), NPS severity (b = 1.3 per 10 dB; 95% CI: 0.4, 2.5; t = 2.13; p = 0.04; df = 80), and depressive symptom severity (b = 1.5 per 10 dB; 95% CI: 0.4, 2.5; t = 2.83; p = 0.01; df = 89) after adjustment for demographic and clinical characteristics. Additionally, the use of hearing aids was inversely associated with the number of NPS (b = ?2.09; 95% CI ?3.44, ?0.75; t = ?3.10; p = 0.003; df = 85), NPS severity (b = ?3.82; 95% CI ?7.19, ?0.45; t = ?2.26; p = 0.03; df = 80), and depressive symptom severity (b = ?2.94; 95% CI: ?5.93, 0.06; t = 1.70; p = 0.05; df = 89).ConclusionAmong patients at a memory clinic, increasing severity of hearing loss was associated with a greater number of NPS, more severe NPS, and more severe depressive symptoms, while hearing aid use was associated with fewer NPS, lower severity, and less severe depressive symptoms. Identifying and addressing hearing loss may be a promising, low-risk, non-pharmacological intervention in preventing and treating NPS.     

Literacy Independent Cognitive Assessment: Assessing Mild Cognitive Impairment in Older Adults with Low Literacy Skills

Objective

Comprehensive neuropsychological tests are important in the diagnosis and follow-up of patients with MCI; however, most were developed without consideration of illiteracy. We developed the Literacy Independent Cognitive Assessment (LICA) as a comprehensive neuropsychological assessment battery applicable to older adults who are either literate or illiterate. This study aimed to assess the reliability and validity of the LICA for diagnosis of MCI.

Methods

Normal controls (n=634) and patients with MCI (n=128) were recruited from 13 centers were included in this study. Participants were divided into illiterate or literate groups, based on their performance on a brief reading and writing test. The LICA, Korean Mini-Mental State Examination (K-MMSE), and Seoul Neuropsychological Screening Battery (SNSB) were administered.

Results

Total LICA scores distinguished MCI patients from controls (p<0.001). They were closely and positively correlated to the K-MMSE scores (r=0.632, p<0.001) but negatively correlated to clinical dementia rating (CDR) (r=-0.358, p<0.001) and CDR sum of boxes (r=-0.339, p<0.001). Area under the receiver operating characteristic curve for patients with MCI by total LICA score was 0.827 (0.783-0.870), superior to that presented by the K-MMSE. For the classification of MCI subtypes, inter-method reliability of LICA with the SNSB was good (κ 0.773; 0.679-0.867, p<0.001).

Conclusion

The results of this study show that the LICA may be reliably used to distinguish MCI patients from cognitively intact adults, to identify MCI subtypes and monitor progression toward dementia, regardless of illiteracy.     

Cognitive Functioning and Everyday Problem Solving in Older Adults

The relationship between cognitive functioning and a performance-based measure of everyday problem-solving, the Everyday Problems Test (EPT), thought to index instrumental activities of daily living (IADL), was examined in 291 community-dwelling non-demented older adults. Performance on the EPT was found to vary according to age, cognitive status, and education. Hierarchical regression analyses revealed that, after adjusting for demographic and health variables, measures of cognitive functioning accounted for 23.6% of the variance in EPT performance. In particular, measures of global cognitive status, cognitive decline, speed of processing, executive functioning, episodic memory, and verbal ability were significant predictors of EPT performance. These findings suggest that cognitive functioning along with demographic variables are important determinants of everyday problem-solving.     

The Relationship Between Cognitive Reserve and Functional Ability is Mediated by Executive Functioning in Older Adults

It has been noted in the literature that cognitive reserve (CR) predicts future functional ability (FA), but the association between CR and current FA is rather limited. This investigation aimed to explicate this relationship, and hypothesized it would be mediated by executive functioning (EF). To best understand the relationship between CR and FA, we recruited and tested independent community-dwelling older adults (OAs). Bivariate correlations and hierarchical regressions were completed to determine the association between CR and FA. Both individual CR measures and a composite CR score were used. Mediation analyses were completed to examine our hypothesis that EF would mediate the CR and FA relationship. All measures of CR were positively related to and predictive of FA. Although the highest zero-order correlation across the independent CR proxies was between income and FA (r = .417), education accounted for the greatest amount of variance in FA, 8.3% after controlling for age and Mini-Mental State Examination performance. Furthermore, the CR composite had a higher correlation (r = .447) and accounted for more variance than any of the independent proxies. Complete mediation was found between a CR composite and FA via an internally consistent D-KEFS composite score (Cronbach’s α = .795). This suggests that as CR increases so does EF, which in turn improves FA. Thus, future investigations could determine the effect on FA in OAs by improving EF.     

Differences in Assessment of Everyday Preferences Between People With Cognitive Impairment and Their Care Partners: The Role of Neuropsychiatric Symptoms

ObjectiveAs cognitive impairment progresses, people with dementia increasingly rely on surrogate decision-makers for everyday activities. Yet, little is known about concordance on everyday preferences between persons with cognitive impairment and their care partners.MethodsThe sample included 69 dyads of persons with cognitive impairment (Clinical Dementia Rating Scale ≥0.5) and their care partners. We used the Preferences for Everyday Living Inventory (PELI) to assess preferences for activities and lifestyle choices among persons with cognitive impairment. The PELI was concurrently but separately administered to care partners, who answered as surrogate decision-makers. Factor analysis was used to ascertain factor structure of the PELI; reliability measures were computed within the sample. Paired sample t-tests were used to estimate differences in scores of corresponding PELI items for each factor. Multiple regression models were used to relate predictors, including neuropsychiatric symptoms, to agreement levels.ResultsFour factors were identified from the PELI: autonomous choice, social engagement, personal growth, and keeping a routine. Significant participant-care partner discrepancy was found in “social engagement” preferences (e.g., regular contact with family, meeting new people, volunteering). Geriatric Depression Scale-15 score and care partner sex were significantly associated with participant-care partner discrepancies in “social engagement” preferences.ConclusionThis study yields new insights regarding the most important preferences for persons with cognitive impairment and clarifies a path to optimizing surrogate decision-making around everyday preferences by highlighting areas of apparent disagreement and identifying potential predictors of discrepancy.     

Neuropsychiatric Symptoms as Risk Factors for Cognitive Decline in Clinically Normal Older Adults: The Cache County Study

IntroductionThere has been considerable progress in identifying early cognitive and biomarker predictors of Alzheimer's disease (AD). Neuropsychiatric symptoms (NPS) are common in AD and appear to predict progression after the onset of mild cognitive impairment or dementia.ObjectivesThe objective of the study is to examine the relationship between NPS in clinically normal older adults and subsequent cognitive decline in a population-based sample.MethodsThe Cache County Study on Memory in Aging consists of a population-based sample of 5,092 older adults. We identified 470 clinically normal adults who were followed for an average period of 5.73 years. NPS were evaluated at the baseline clinical assessment using the Neuropsychiatric Inventory (NPI). NPI domain scores were quantified as the product of frequency X severity in individual NPI domains, and then summed for the NPI-Total. Neuropsychological measures were collected at baseline and at each subsequent follow-up wave. Linear mixed-effects models assessed the association of NPI-Total, NPI-Depression, and NPI-Anxiety scores (obtained at baseline) on longitudinal change in neuropsychological performance, controlling for age, sex, and education.ResultsBaseline NPI-Total score was associated with a more rapid rate of decline in word list memory, praxis recall, and animal fluency. Baseline NPI-Depression was not associated with later decline on any of the cognitive tests, while baseline NPI-Anxiety was associated with decline in Symbol Digit Modality.ConclusionIn conclusion, among clinically normal older adults derived from this population-based study, total burden of NPS was associated with longitudinal cognitive decline. These results add to the evidence that NPS are risk factors for or clinical indicators of preclinical dementia syndrome. Our study was an exploratory study and we did not control for multiple comparisons.     

Use of Informants to Identify Mild Cognitive Impairment in Older Adults

Extensive research supports the use of informant ratings in diagnosing dementia. In comparison, far fewer studies have examined the use of informant ratings in identifying mild cognitive impairment (MCI), a state that occurs as healthy older adults make the gradual transition to dementia. A review of available studies that have examined discrepancies between MCI patient and informant reports has for the most part demonstrated that informant ratings reveal greater loss of everyday functional ability and cognitive competency. Additionally, current findings support a significantly greater association of informant ratings with objective measures of patient cognitive performance and characteristics of underlying dementing processes. Structured measures used to examine the diagnostic efficacy of informant ratings in identifying cases of MCI are reviewed. Two recently developed instruments seem especially promising, but further validation efforts will be required before they can be considered to meet standards for clinical use.     

Longitudinal Changes in Neuropsychiatric Symptoms: Impact of Discrepancy in Everyday Preferences Between Persons With Cognitive Impairment and Their Care Partners

ObjectivesNeuropsychiatric symptoms (NPS) of dementia are common and may be driven by inability of persons with cognitive impairment (CI) to communicate needs. We addressed the relevance of this unmet-needs model to burden of NPS among persons with milder CI.MethodsThe sample included 48 dyads of persons with CI and their care partners. NPS were measured at baseline and follow-up (mean 486 days +/-107 SD). Mixed random and fixed effects longitudinal models were used to evaluate impact of discrepancies between persons with CI and their care partners in everyday preferences (baseline) on changes in NPS over time.ResultsHigher levels of underestimation of “social engagement” preferences of persons with CI by care partners were associated with a higher average burden of NPS across all follow-up.ConclusionsThis study suggests that unmet-needs may be a useful construct for understanding etiology for NPS across the spectrum of severity of cognitive impairment.     

Associations of Pulmonary Function with Dementia and Depression in an Older Korean Population

Objective

Previous studies reported an association between pulmonary function and cognitive function. However, not much has been investigated in this regard concerning dementia in a community population, taking depression into account. We aimed to examine the associations of pulmonary function with dementia and depression in a community-dwelling elderly population.

Methods

A total of 1,038 participants were evaluated for dementia and depression using the Korean version of the Geriatric Mental State Schedule B3 (GMS B3-K), the Community Screening Interview for Dementia-Korean version (CSID-K) and a modified 10-item Word List Learning from the Consortium to Establish a Registry of Alzheimer''s Disease (CERAD). Pulmonary function was measured as forced expiratory volume in 1 s (FEV₁) from a forced expiratory maneuver.

Results

Prevalence rates of dementia and depression were 11.0% and 10.4%, respectively. Individuals who were diagnosed with dementia manifested a lower mean FEV₁, as compared to those without dementia after adjusting for potential confounders, including disability and depression [OR=1.34 (1.05-1.72)]. Following gender-stratified analysis, the association was only statistically significant in women [OR=1.40 (1.04-1.89)]. The association between depression and mean FEV₁ was less significant compared to dementia [OR=1.32 (1.10-1.58)]. However, the association was no longer significant after adjusting for age and years of education. No association was significant in the gender-stratified analysis.

Conclusion

Decreased pulmonary function was associated with dementia status only in an older female Korean population. Pulmonary function and depression were not significantly associated in either gender.     

Alexithymia and Executive Function in Younger and Older Adults

Objective: Alexithymia is associated with adverse mental and physical health outcomes. Determining neuropsychological factors associated with alexithymia may aid in elucidating its underlying mechanisms and identifying treatment targets. Accumulating evidence indicates that executive dysfunction may co-occur with alexithymia in younger adults (YA). However, research on this link in older adults (OA), who may be at greater risk for alexithymia, is scant. This study determined associations between alexithymia and executive function (EF) in healthy younger and OA. Alexithymia was predicted to be associated with poorer EF in both age-groups. Method: Younger (n = 65, aged 18–30; 46% female) and OA (n = 44, aged 61–92; 73% female) completed the 20-item Toronto Alexithymia Scale, three EF tasks (Verbal Fluency, Design Fluency, and Trail Making), measures of memory and verbal IQ, and a self-report measure of depressive symptoms. Three EF composites were created to assess verbal EF, visuospatial EF, and global EF. Results: Greater alexithymia and difficulty describing feelings were associated with poorer verbal EF in OA (p = .02 and p = .005, respectively) but not in YA (ps > .05). The other neuropsychological measures were not significantly associated with alexithymia in regression analyses. Conclusions: Findings are consistent with previous research identifying links between EF and alexithymia. The association between alexithymia and verbal EF may be due to shared prefrontal circuitry involved in emotion regulation. Results provide insight into possible origins of emotion self-awareness deficits in OA.     

A New Approach to the Characterization of Subtle Errors in Everyday Action: Implications for Mild Cognitive Impairment

Mild functional difficulties have been associated with early cognitive decline in older adults and increased risk for conversion to dementia in mild cognitive impairment, but our understanding of this decline has been limited by a dearth of objective methods. This study evaluated the reliability and validity of a new system to code subtle errors on an established performance-based measure of everyday action and described preliminary findings within the context of a theoretical model of action disruption. Here 45 older adults completed the Naturalistic Action Test (NAT) and neuropsychological measures. NAT performance was coded for overt errors, and subtle action difficulties were scored using a novel coding system. An inter-rater reliability coefficient was calculated. Validity of the coding system was assessed using a repeated-measures ANOVA with NAT task (simple versus complex) and error type (overt versus subtle) as within-group factors. Correlation/regression analyses were conducted among overt NAT errors, subtle NAT errors, and neuropsychological variables. The coding of subtle action errors was reliable and valid, and episodic memory breakdown predicted subtle action disruption. Results suggest that the NAT can be useful in objectively assessing subtle functional decline. Treatments targeting episodic memory may be most effective in addressing early functional impairment in older age.     

Cognitive Exercise and Its Role in Cognitive Function in Older Adults

Converging lines of research indicate that complex mental activity is associated with reduced dementia risk. Thus, intense interest exists in whether different forms of cognitive exercise can help protect against cognitive decline and dementia. However, there is considerable confusion in terminology that is hindering progress in the field. We therefore introduce a concrete definition of cognitive training (CT) and make this the focus of our article. Clinical research that has evaluated CT in normal aging, mild cognitive impairment, and dementia is then critically reviewed. Despite many methodological shortcomings, the overall findings indicate that multidomain CT has the potential to improve cognitive function in healthy older adults and slow decline in affected individuals. Finally, practical issues, including the strengths and weaknesses of commercial products, are explored, and recommendations for further research and clinical implementation are made.     

Everyday functional ability across different phases of bipolar disorder

Bipolar Disorder (BD) is a chronic illness characterized by significant neurocognitive impairment and functional deficits. Functional status is typically assessed with self-report or observer ratings restricted by poor participant insight and subjective judgment, while application of performance-based measures has been limited. We assessed functional ability in manic, depressed, and euthymic BD individuals using the UCSD Performance-Based Skills Assessment (UPSA-2), which simulates real-world tasks such as medication management. UPSA-2 was administered to 17 manic or hypomanic BD, 14 depressed BD, 23 euthymic BD, and 28 healthy comparison (HC) participants matched for age, education, and IQ. Psychopathology was quantified with the Young Mania Rating Scale (YMRS), Hamilton Depression Rating Scale (HDRS), and the Positive and Negative Syndrome Scale (PANSS); executive functioning was assessed with the Wisconsin Card Sorting Task (WCST). All BD groups exhibited functional ability deficits on the UPSA-2 and impaired performance on the WCST compared to HC. UPSA-2 scores were lower in manic/hypomanic subjects relative to other BD participants and mania symptoms correlated with functional impairment. Poor WCST performance was also associated with worse UPSA-2 function. In summary, BD functional deficits occur across different phases of the disorder and may be impacted by symptom severity and associated with executive dysfunction.