Are people with mild cognitive impairment aware of the benefits of errorless learning?

Mild cognitive impairment (MCI) has been described as a memory deficit in the absence of other cognitive dysfunction. It can be thought of as a pre-clinical dementia. Memory impairment in this group is not as severe as in early dementia and thus learning is still possible. We were interested to see if errorless learning, a widely used rehabilitation technique, was of benefit to people with MCI. Since it has been shown that successful rehabilitation is somewhat contingent on awareness of function, we were also interested to see if people with MCI were aware of the benefits of errorless learning. The present study employed an errorless learning procedure on 16 people with MCI and 16 older adult controls to learn two lists of 10 words in errorless and errorful learning conditions. We adopted a metacognitive approach measuring people's memory monitoring through judgements of learning (JOLs) a prediction of future memory performance. The results revealed errorless learning is an effective memory rehabilitation tool for people with MCI, with significant increases in recall performance for both groups relative to errorful learning. Most interestingly participants were aware of the benefits of errorless learning in their JOLs. MCI participants and controls both had significantly higher JOLs for words studied under errorless learning conditions. The learning performance in MCI and theories of metacognitive awareness are discussed.     

What explains variations in the clinical use of mild cognitive impairment (MCI) as a diagnostic category?

BACKGROUND: Mild cognitive impairment (MCI) is proposed to describe the transitional stage between normal cognitive aging and dementia. It has had significant impact in the field of dementia research, but it remains controversial whether or not it should be used as a diagnostic category in clinical practice. METHODS: Semi-structured interviews were carried out with international experts (N = 37) in the field of dementia research and practice. These interviews explored the advantages and difficulties of using MCI as a clinical diagnosis. RESULTS: There is wide variation in the clinical use of MCI. This variation depends on institutional factors and two types of cultural factors: (a) clinical culture, and (b) the "evidential culture" -- how research and guidelines figure in clinical practice. CONCLUSION: The study shows the importance of combining values-based practice with evidence-based practice in the early diagnosis of dementia.     

The neuropsychiatric profile of Parkinson’s disease subjects with and without mild cognitive impairment

Neuropsychiatric symptoms (NPS) are common clinical features of Parkinson’s disease (PD). However, NPS profiles in PD subjects with mild cognitive impairment (MCI) have scarcely been investigated. We aimed to describe the NPS profiles of non-demented PD subjects with and without MCI. A total of 410 non-demented PD subjects were included. Of these, 164 were cognitively normal PD subjects (PD-cn), 142 PD had amnestic MCI (PD-aMCI), and 104 had PD with non-amnestic MCI (PD-naMCI). NPS were evaluated in accordance with the Neuropsychiatric Inventory (NPI). PD-aMCI subjects revealed the highest NPS burden, followed by PD-naMCI and then PD-cn. Overall, the most common NPS in PD-MCI were in order: depression, sleep disturbance, anxiety and apathy. Irritability was significantly associated with PD-aMCI and PD-naMCI. Prospective studies are required to evaluate the significance, clinical correlates and prognostic role of NPS in subject with PD-MCI.     

Prevalence of sleep complaints and associated factors in community-dwelling older people in Brazil: the Bambuí Health and Ageing Study (BHAS)

BACKGROUND: Population-based studies of insomnia among older people residing in communities in developing countries are rare. The objectives of this population-based study were to determine the prevalence and factors associated with insomnia among older adults (60 years and over) living in a Brazilian town with 15,000 inhabitants (Bambuí MG). METHODS: All 1742 residents in this age group were selected for a structured interview and blood tests. From these, 1516 (87.0%) participated in the study. RESULTS: The prevalence of insomnia was 38.9%, being higher among women (45.3%) than among men (28.8%). The use of sleeping pills was reported by 380/1513 (25.1%) of the participants; 186 (49.0%) of these complained of insomnia, suggesting that their treatment should be reassessed. Factors independently associated with insomnia were: female sex (OR=1.78, 95% CI=1.41-2.24), dissatisfaction with free time arrangements (OR=1.88, 95% CI=1.28-2.77), self-rated health as reasonable or bad/very bad (OR=2.02, 95% CI=1.50-2.72 and OR=3.12, 95% CI=2.21-4.39, respectively), history of previous medical diagnosis of some chronic conditions (OR=1.38, 95% CI=1.10-1.73), inability to perform routine activities due to a health problem in the previous 2 weeks (OR=1.54, 95% CI=1.10-2.15), and staying in bed in the previous 2 weeks (OR=1.61, 95% CI=1.04-2.48). CONCLUSIONS: The prevalence of insomnia was high, indicating that this was a public health problem for older adults living in the study community. Our results emphasize the necessity for further investigations about insomnia among older people living in small communities in Brazil and other developing countries.     

Memory evaluation with a new cued recall test in patients with mild cognitive impairment and Alzheimer’s disease

Abstract Free delayed recall is considered the memory measure with the greatest sensitivity for the early diagnosis of dementia. However, its specificity for dementia could be lower, as deficits other than those of pure memory might account for poor performance in this difficult and effortful task. Cued recall is supposed to allow a better distinction between poor memory due to concurrent factors and impairments related to the neurodegenerative process. The available cued recall tests suffer from a ceiling effect. This is a prospective, longitudinal study aiming to assess the utility of a new memory test based on cued recall that avoids the ceiling effect in the early diagnosis of Alzheimers disease (AD). Twenty-five patients with mild cognitive impairment (MCI), 22 probable AD patients (NINCDS-ADRDA) at a mild stage, 22 elderly patients with subjective memory complaints (SMC) and 38 normal age-matched controls took part in the study. The patients underwent a thorough cognitive evaluation and the recommended screening procedure for the diagnosis of dementia. All patients were re-examined 12–18 months later. A newly devised delayed cued recall test using semantic cues (The RI48 Test) was compared with three established memory tests: the Ten Word-List Recall from CERAD, the Doors and the Shapes Tests from The Doors and People Test Battery. Forty-four % of the MCI patients fulfilled criteria for probable AD at follow-up. The RI48 Test classified correctly 88% of the MCI and SMC participants and was the best predictor of the status of MCI and mild AD as well as the outcome of the MCI patients. Poor visual memory was the second best predictor of those MCI patients who evolved to AD. A cued recall test which avoids the ceiling effect is at least as good as the delayed free recall tests in the early detection of AD.     

Awareness of deficits in mild cognitive impairment and Alzheimer's disease: do MCI patients have impaired insight?

In this study we investigated impaired awareness of cognitive deficits in patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD). Very few studies have addressed this topic, and methodological inconsistencies make the comparison of previous studies difficult. From a prospective research program 36 consecutive patients with mild AD (MMSE above 19), 30 with amnesic MCI and 33 matched controls were examined. Using three methods for awareness assessment we found no significant differences in the level of awareness between MCI and AD. Both groups had impaired awareness and significant heterogeneity in the clinical presentation of awareness. The results demonstrate that subjective memory problems should not be a mandatory prerequisite in suspected dementia or MCI, which makes reports from informants together with thorough clinical interview and observation central when assessing suspected dementia disorders.     

Is expressed emotion related to estimates of ability made by older people with cognitive impairments and their partners?

Objectives: Discrepancies in ratings of ability are used to assess awareness in people with cognitive impairments, and previously have been found to be associated with comorbid depression and carer distress. This study explored how the degree of discrepancy between self-ratings of ability made by older people with a cognitive impairment and informant ratings made by their partners relates to aspects of their relationship quality. It was hypothesised that discrepancies between self- and partner ratings would be associated with partner's expressed emotion (EE), and replicate previous findings for associations with depression and carer distress.

Method: Forty-six people aged over 65 with mild cognitive impairment or early-stage dementia were recruited through NHS mental health services for older people. In a semi-structured interview, they and their partners gave separate ratings of cognitive abilities and instrumental activities of daily living (IADL). Partners also completed a 5-minute speech sample task to assess the type of EE. Depression in cognitively impaired participants and partner distress were also measured.

Results: High EE, depression and carer distress were associated with larger discrepancies in ratings of ability on the cognitive measure. EE was not associated with self-ratings or partner ratings of cognitive or IADL ability.

Conclusion: The findings suggest that where disagreement about the abilities of an older person with cognitive impairments is greater, the affective environment around that person is more likely to be characterised by criticism and/or emotional over-involvement. The implications of this for assessment, diagnosis, and helping couples adjust to cognitive deterioration are discussed.     

Free and cued selective reminding test predicts progression to Alzheimer’s disease in people with mild cognitive impairment

Introduction

To assess the diagnostic accuracy of the free and cued selective reminding test (FCSRT) for the development of Alzheimer’s disease (AD) in people with mild cognitive impairment (MCI).

Methods

We enrolled 187 consecutive MCI outpatients from a memory clinic that were evaluated at baseline and every 6 to 12 months through an extensive clinical and neuropsychological protocol. For each test, measures of diagnostic accuracy were obtained. To improve the overall specificity of the neuropsychological battery, we also used the diagnostic tests in parallel combination. The association between FCSRT indexes and AD was tested through proportional hazard regression models with other dementia subtypes as competing event. Laplace regression was used to model time-to-AD diagnosis as a function of FCSRT indexes.

Results

The area under the curve of the FCSRT indexes ranged from 0.69 (95% CI: 0.62–0.76) to 0.76 (95% CI: 0.70–0.82). The specificity peaked up to 100% when we combined the category fluency test with the delayed total recall index of the FCSRT. Participants who tested positive at the FCSRT, as compared with those with negative tests, presented a twofold to fivefold higher risk of developing AD (median follow-up time 2.5 years; p?<?0.001) and were diagnosed with AD 2–3 years earlier (p?<?0.001).

Discussion

The FCSRT assessment suite shows the best predictive performance in detecting AD in people with MCI. These findings might help to reliably and timely identify people at higher risk of AD that is crucial both for properly selecting participants to clinical trials and to fine tune an effective and patient-centered care.

     

Prevalence of mild cognitive impairment subtypes in patients attending a memory outpatient clinic—comparison of two modes of mild cognitive impairment classification. Results of the Vienna Conversion to Dementia Study

BackgroundEarly detection of dementia is becoming more and more important owing to the advent of pharmacologic treatment.ObjectiveThe goals of this study were to establish prevalence of mild cognitive impairment (MCI) subtypes in an outpatient memory clinic cohort using two different modes of MCI determination.DesignConsecutive patients complaining of cognitive problems who came to the memory outpatient clinic for assessment of a possible cognitive disorder were included in the study.SettingAcademic medical center.ParticipantsSix hundred eighty consecutive patients complaining about cognitive problems who came to the memory outpatient clinic for assessment of a possible cognitive disorder and fulfilled the inclusion criteria were included in the study. For 676 patients, sufficient data for MCI classification were available.ResultsCategorizing MCI patients into MCI subtypes according to the minimum mode of MCI classification revealed the following results: 106 patients (15.7%) were categorized as cognitively healthy, whereas 570 patients (84.3%) met the criteria for MCI. MCI patients were subtyped as amnestic mild cognitive impairment (aMCI) single domain (31 patients; 4.6%), aMCI multiple domain (226 patients; 33.4%), non-aMCI single domain (125 patients; 18.5%), and non-aMCI multiple domain (188 patients; 27.8%). Categorizing MCI patients into MCI subtypes according to the mean mode of MCI classification revealed the following results: 409 patients (60.5%) were categorized as cognitively healthy, whereas 267 patients (39.5%) met the criteria for MCI. MCI patients were subtyped as aMCI single domain (47 patients; 6.9%), aMCI multiple domain (57 patients; 8.5%), non-aMCI single domain (97 patients; 14.3%), and non-aMCI multiple domain (66 patients; 9.8%).ConclusionMCI diagnosis frequencies are substantially affected by the criteria used for estimation of MCI. The effect of modifying the presence of impairment on a single cognitive measure versus the presence of impairment on a mean composite score of a certain domain differed considerably, ranging from 39.5% to 84.3%, indicating the importance of the development of guidelines for operationalizing MCI.     

Complexity changes in preclinical Alzheimer’s disease: An MEG study of subjective cognitive decline and mild cognitive impairment

ObjectiveTo analyse magnetoencephalogram (MEG) signals with Lempel-Ziv Complexity (LZC) to identify the regions of the brain showing changes related to cognitive decline and Alzheimeŕs Disease (AD).MethodsLZC was used to study MEG signals in the source space from 99 participants (36 male, 63 female, average age: 71.82 ± 4.06) in three groups (33 subjects per group): healthy (control) older adults, older adults with subjective cognitive decline (SCD), and adults with mild cognitive impairment (MCI). Analyses were performed in broadband (2–45 Hz) and in classic narrow bands (theta (4–8 Hz), alpha (8–12 Hz), low beta (12–20 Hz), high beta (20–30 Hz), and, gamma (30–45 Hz)).ResultsLZC was significantly lower in subjects with MCI than in those with SCD. Moreover, subjects with MCI had significantly lower MEG complexity than controls and SCD subjects in the beta frequency band. Lower complexity was correlated with smaller hippocampal volumes.ConclusionsBrain complexity – measured with LZC – decreases in MCI patients when compared to SCD and healthy controls. This decrease is associated with a decrease in hippocampal volume, a key feature in AD progression.SignificanceThis is the first study to date characterising the changes of brain activity complexity showing the specific spatial pattern of the alterations as well as the morphological correlations throughout preclinical stages of AD.     

The pattern of cortical atrophy in Parkinson’s disease with mild cognitive impairment according to the timing of cognitive dysfunction

The density of Lewy bodies or the concurrent β-amyloid pathology would act as modulators in the relative timing of dementia during the course of Parkinson’s disease. Depending on the temporal relationship between the onset of parkinsonism and that of cognitive impairment, patients with Parkinson’s disease with mild cognitive impairment were divided into two groups of earlier (<1 year) and later (≥1 year) cognitive decline, and cortical atrophy patterns and correlation of gray matter and timing of cognitive decline were analyzed using voxel-based morphometry. The morphometric analysis showed that patients with earlier cognitive decline demonstrated greater cortical atrophy in the inferior parietal and orbitofrontal areas than did those with later cognitive decline. Additionally, the anatomical bases of the timing of their cognitive decline differed in terms of correlation patterns. These data suggest that the pathological burden in Parkinson’s disease with mild cognitive impairment may be more severe in patients with earlier cognitive decline than in those with later cognitive decline, and that the neural basis corresponding to the timing of cognitive decline may differ in these patients.     

Do white matter changes contribute to the subsequent development of dementia in patients with mild cognitive impairment? A longitudinal study

OBJECTIVE: White matter lesions on brain CT or MRI are a frequent finding in patients with Alzheimer's disease. However, little is known about the prognostic significance of these changes in cognitively impaired individuals who are at risk for subsequent development of dementia. This study aims at investigating the potential impact of white matter lucencies (WML) on brain CT on the course of mild cognitive impairment. PATIENTS AND METHODS: Twenty-seven patients (mean age 72, SD 4.03) with mild cognitive impairment (MCI) and no signs of cerebrovascular disease were prospectively examined. At their initial presentation, all patients underwent a structured interview for the diagnosis of dementia (SIDAM) and a brain CT. Linear measures of atrophy and visual ratings of white matter changes were performed. At follow-up (mean interval 29 months), these patients were re-examined with the SIDAM. Eight patients had developed dementia and met clinical criteria for Alzheimer's disease (crossover group). RESULTS: Evaluation of the initial CT scans revealed significantly more frequent and extended white matter abnormalities and a higher degree of temporal lobe atrophy in the crossover group as compared to the cognitively stable group. In the crossover group, high WML severity initially was associated with a lesser degree of temporal lobe atrophy and higher global cognitive performance. CONCLUSION: We conclude that WML play a role in the dementia process and that they might accelerate cognitive decline in individuals with mild cognitive impairment. WML should be included in prospective studies of MCI as potential predictor variables.     

The practical management of cognitive impairment and psychosis in the older Parkinson’s disease patient

Parkinson’s disease (PD) has been described as an age-related disease. Ageing significantly increases the risk of psychosis and dementia. Older patients often have a complex mixture of delirium, psychosis, dementia, gait and balance problems and other comorbidities which can cause significant management problems. There are concerns about the safety and tolerability of the treatments for psychosis and dementia. Delirium is common in older Parkinson’s patients and must be assessed and managed carefully. The aetiology of psychosis in Parkinson’s is complex and often associated with the development of cognitive impairment. Initial adjustments of Parkinson’s drugs should be considered if symptoms are intrusive. Where drug therapy is required, evidence suggests that quetiapine may be a safe initial option. There is no contraindication to the use of clozapine in older patients, with the required blood monitoring. Dementia is almost inevitable with very advanced disease and increasing age, and is associated with a marked cholinergic deficit in the brain. Cholinesterase inhibitors may be more effective in PD than in Alzheimer’s disease and appear relatively safe with appropriate monitoring of the pulse. There is much less evidence for the use of memantine. There is no current evidence for the use of specific non-pharmacological therapies in the management of psychosis or dementia in PD. Due to the associated gait and balance problems, older Parkinson’s patients benefit from comprehensive multi-disciplinary assessment.     

Disturbed sleep patterns in elders with mild cognitive impairment: the role of memory decline and ApoE ɛ4 genotype

Sleep disturbances are prevalent in patients with Alzheimer' disease (AD), being one of the most troubling symptoms during the progression of disease. However, little research has been made to determine if impaired sleep patterns appear years before AD diagnosis. This study tries to shed light on this issue by performing polysomnographic recordings in healthy elders and patients with mild cognitive impairment (MCI). We further investigated whether changes in sleep patterns parallel memory decline as well as its relationship with the Apolipoprotein E (ApoE) ?4 genotype. Results showed a significant shortening of rapid eye movement (REM) sleep together with increased fragmentations of slow-wave sleep in MCI patients relative to healthy elders. Interestingly, we further showed that reduction of REM sleep in MCI patients with ApoE ?4 was more noticeable than in ?4 non-carriers. Contrary to our initial hypothesis, changes in sleep patterns were not correlated with memory performance in MCI patients. Instead, increased REM sleep accompanied enhanced immediate recall in MCI ?4 non-carriers. Taken together, these results suggest that sleep disruptions are evident years before diagnosis of AD, which may have implications for early detection of dementia and/or therapeutic management of sleep complaints in MCI patients.