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1.  Stroke symptoms with absence of recognized stroke are associated with cognitive impairment and depressive symptoms in older adults with diabetes 
Self-reported stroke symptoms may represent unrecognized cerebrovascular events leading to poorer cognitive and mental health. We examined relationships between stroke symptoms, cognitive impairment, and depressive symptoms in a high-risk sample: 247 adults age ≥65 with diabetes. Stroke symptoms were assessed using the Questionnaire for Verifying Stroke-free Status, cognitive impairment was measured with the modified Telephone Interview for Cognitive Status, and depressive symptoms were measured using the 15-item Geriatric Depression Scale. In 206 participants without history of stroke/TIA, 27.7% reported stroke symptoms, with sudden loss of comprehension most frequently reported (11.7%). Having >1 vs. 0 stroke symptoms was associated with greater odds of cognitive impairment (OR=3.04, 95% CI, 1.15–8.05) and more depressive symptoms (b =2.60, p<.001) while controlling for age, race, gender, education, diabetes duration, diabetes severity, and cardiovascular comorbidities. Better recognition and treatment of cerebrovascular problems in older adults with diabetes may lead to improved cognition and mental health.
PMCID: PMC4823148  PMID: 26801916
Cognitive aging; Diabetes; Depression; Stroke
2.  Associations of Social Support and Self-Efficacy with Quality of Life in a Sample of Older Adults with Diabetes 
Older adults are disproportionately affected by diabetes, which is associated with increased prevalence of cardiovascular disease, decreased quality of life (QOL), and increased healthcare costs. The purpose of this study was to assess the relationships between social support, self-efficacy, and QOL in a sample of 187 older African Americans (AA) and Caucasians with diabetes. Greater satisfaction with social support related to diabetes, but not the amount of support received, was significantly correlated with QOL. In addition, persons with higher self-efficacy in managing diabetes had better QOL. In a covariate-adjusted regression model, self-efficacy remained a significant predictor of QOL. Findings suggest the potential importance of incorporating the self-efficacy concept within diabetes management and treatment in order to empower older adults living with diabetes to adhere to care. Further research is needed to determine whether improving self-efficacy among vulnerable older adult populations may positively influence QOL.
PMCID: PMC4753825  PMID: 26468654
Diabetes; older adults; quality of life; self-efficacy; social support
3.  An Examination of Lower Extremity Function and its Correlates in Older African American and White Men 
Ethnicity & Disease  null;25(3):271-278.
Maintaining functional status and reducing/eliminating health disparities in late life are key priorities. Older African Americans have been found to have worse lower extremity functioning than Whites, but little is known about potential differences in correlates between African American and White men. The goal of this investigation was to examine measures that could explain this racial difference and to identify race-specific correlates of lower extremity function.
Data were analyzed for a sample of community-dwelling men. Linear regression models examined demographics, medical conditions, health behaviors, and perceived discrimination and mental health as correlates of an objective measure of lower extremity function, the Short Physical Performance Battery (SPPB). Scores on the SPPB have a potential range of 0 to 12 with higher scores corresponding to better functioning.
The mean age of all men was 74.9 years (SD=6.5), and the sample was 50% African American and 53% rural. African American men had scores on the SPPB that were significantly lower than White men after adjusting for age, rural residence, marital status, education, and income difficulty (P<.01). Racial differences in cognitive functioning accounted for approximately 41% of the race effect on physical function. Additional models stratified by race revealed a pattern of similar correlates of the SPPB among African American and White men.
The results of this investigation can be helpful for researchers and clinicians to aid in identifying older men who are at-risk for poor lower extremity function and in planning targeted interventions to help reduce disparities.
PMCID: PMC4671416  PMID: 26673095
Health Disparities; African American Men; Lower Extremity Function
4.  Correlates of Depressive Symptoms in Older Adults with Diabetes 
Journal of Diabetes Research  2015;2016:8702730.
Investigators examined correlates of depressive symptoms within a sample of older adults with diabetes. Participants completed a structured telephone interview with measures including depressive symptoms, health conditions, cognitive function, and diabetes distress. Correlations and hierarchical linear regression models were utilized to examine bivariate and covariate-adjusted correlates of depressive symptoms. The sample included 246 community-dwelling adults with diabetes (≥65 years old). In bivariate analyses, African Americans, individuals with specific health issues (neuropathy, stroke, respiratory issues, arthritis, and cardiac issues), and those with higher levels of diabetes distress reported more depressive symptoms. Older age, higher education, more income, and better cognitive function were inversely associated with depressive symptoms. In the final covariate-adjusted regression model, stroke (B = .22, p < .001), cognitive function (B = −.14, p < .01), and higher levels of diabetes-related distress (B = .49, p < .001) each were uniquely associated with more depressive symptoms. Diabetes distress partially mediated the associations between cardiac issues and depressive symptoms and between cognitive function and depressive symptoms. Findings suggest that interventions targeted at helping older adults manage their diabetes-related distress and reducing the likelihood of experiencing additional health complications may reduce depressive symptoms within this population.
PMCID: PMC4670668  PMID: 26682235
5.  Comparison of In-Person and Telephone Administration of the Mini-Mental State Examination in the University of Alabama at Birmingham Study of Aging 
To validate the Mini-Mental State Examination (MMSE) telephone (MMSET) against the MMSE.
Homes of community-dwelling older adults.
African-American and non-Hispanic white adults aged 75 and older participating in the University of Alabama at Birmingham Study of Aging II, a longitudinal epidemiological study across the state of Alabama (N=419).
Cognition, measured using the MMSE, MMSET, and Six-Item Screener (SIS), and function, based on self-reported difficulty performing instrumental activities of daily living (IADLs). Correlation and agreement coefficients were used to examine concordance of the MMSE and MMSET; linear and logistic regressions were used to test associations with clinical outcomes of IADL difficulty and verified diagnoses of dementia.
The MMSET showed good internal consistency (Cronbach α=0.845), similar to the full MMSE, and strong correlation with the latter (Spearman ρ=0.694, p<.001). The MMSET explained a similar proportion of IADL difficulty as the full MMSE (coefficient of variation=0.201 and 0.189, respectively). The MMSET was also associated with verified dementia diagnoses (area under the receiver operating characteristic curve=0.73), which was similar to the full MMSE.
The MMSET is a brief, valid measure of cognition in older adults with psychometric properties similar to that of the full MMSE. Because it can be administered over the telephone, further use in epidemiological studies is promising.
PMCID: PMC4311874  PMID: 25283801
Mini-Mental State Examination; telephone administration; epidemiological studies; cognitive assessment
6.  Performance of the NINDS-CSN 5-Minute Protocol in a National Population-Based Sample 
In 2006, the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network (NINDS-CSN) Vascular Cognitive Impairment Harmonization Standards recommended a 5-Minute Protocol as a brief screening instrument for vascular cognitive impairment (VCI). We report demographically adjusted norms for the 5-Minute Protocol and its relation to other measures of cognitive function and cerebrovascular risk factors.
Cross-sectional analysis of 7,199 stroke-free adults in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study on the NINDS-CSN 5-Minute Protocol score.
Total scores on the 5-Minute Protocol were inversely correlated with age and positively correlated with years of education, and performance on the Six-Item Screener, Word List Learning, and Animal Fluency (all p-values<0.001). Higher cerebrovascular risk on the Framingham Stroke Risk Profile (FSRP) was associated with lower total 5-Minute Protocol scores (p<0.001). The 5-Minute Protocol also differentiated between participants with and without confirmed stroke and with and without stroke symptom histories (p<0.001).
The NINDS-CSN 5-Minute Protocol is a brief, easily administered screening measure that is sensitive to cerebrovascular risk and offers a valid method of screening for cognitive impairment in populations at risk for VCI.
PMCID: PMC4452126  PMID: 25166350
screening; cerebrovascular disorders; epidemiology; memory; semantic fluency; depression
7.  Cognitive Functioning in Adults Aging with HIV: A Cross-Sectional Analysis of Cognitive Subtypes and Influential Factors 
This cross-sectional study examined cognitive subtypes and influential factors in HIV-positive (HIV+) adults.
Two-step cluster analysis was conducted on a neurocognitive test battery in a sample (N = 78) of adults and older adults with HIV (Mage = 46.1). Next, cognitive, functional, and mental and physical health differences were compared between the HIV+ clusters and an HIV- reference group (N = 84; Mage = 47.9).
A two-cluster solution emerged, with a lower performing cluster exhibiting poorer performance across all domains except psychomotor speed, and a “normal” cluster displaying similar performance as the HIV- group. The most influential factors to classification in the lower performing cluster were older age and presence of stroke and hypertension. There were trends for longer duration of HIV-infection, higher unemployment rates, and greater prevalence of Hepatitis C co-infection in the lower performing cluster.
These findings suggest that there are not unique cognitive subtypes in HIV, but rather a subset of individuals who exhibit globally normal performance and those with below average performance. Older age and the related cardiovascular comorbidities of both aging and HIV medications may be key influential factors to variability in neurocognitive functioning in this population and thus should be considered in future studies. Implications for research and practice are provided.
PMCID: PMC4224145  PMID: 25386565
Cluster analysis; HIV/AIDS; older adults; Neurocognitive impairment
8.  Caregiving Strain and All-Cause Mortality: Evidence From the REGARDS Study 
Using a large, national sample, this study examined perceived caregiving strain and other caregiving factors in relation to all-cause mortality.
The REasons for Geographic and Racial Differences in Stroke (REGARDS) study is a population-based cohort of men and women aged 45 years and older. Approximately 12% (n = 3,710) reported that they were providing ongoing care to a family member with a chronic illness or disability. Proportional hazards models were used for this subsample to examine the effects of caregiving status measures on all-cause mortality over the subsequent 5-year period, both before and after covariate adjustment.
Caregivers who reported high caregiving strain had significantly higher adjusted mortality rates than both no strain (hazard ratio [HR] = 1.55, p = .02) and some strain (HR = 1.83, p = .001) caregivers. The mortality effects of caregiving strain were not found to differ by race, sex, or the type of caregiving relationship (i.e., spouse, parent, child, sibling, and other).
High perceived caregiving strain is associated with increased all-cause mortality after controlling for appropriate covariates. High caregiving strain constitutes a significant health concern and these caregivers should be targeted for appropriate interventions.
PMCID: PMC3674731  PMID: 23033358
Caregiving; Mortality; Strain.
9.  Effect of duration and age at exposure to the Stroke Belt on incident stroke in adulthood 
Neurology  2013;80(18):1655-1661.
To assess whether there are differences in the strength of association with incident stroke for specific periods of life in the Stroke Belt (SB).
The risk of stroke was studied in 24,544 black and white stroke-free participants, aged 45+, in the Reasons for Geographic and Racial Differences in Stroke study, a national population-based cohort enrolled 2003–2007. Incident stroke was defined as first occurrence of stroke over an average 5.8 years of follow-up. Residential histories (city/state) were obtained by questionnaire. SB exposure was quantified by combinations of SB birthplace and current residence and proportion of years in SB during discrete age categories (0–12, 13–18, 19–30, 31–45, last 20 years) and entire life. Proportional hazards models were used to establish association of incident stroke with indices of exposure to SB, adjusted for demographic, socioeconomic (SES), and stroke risk factors.
In the demographic and SES models, risk of stroke was significantly associated with proportion of life in the SB and with all other exposure periods except birth, ages 31–45, and current residence. The strongest association was for the proportion of the entire life in SB. After adjustment for risk factors, the risk of stroke remained significantly associated only with proportion of residence in SB in adolescence (hazard ratio 1.17, 95% confidence interval 1.00–1.37).
Childhood emerged as the most important period of vulnerability to SB residence as a predictor of future stroke. Improvement in childhood health circumstances should be considered as part of long-term health improvement strategies in the SB.
PMCID: PMC3716470  PMID: 23616168
10.  Indicators of Childhood Quality of Education in Relation to Cognitive Function in Older Adulthood 
The association between years of education and cognitive function in older adults has been studied extensively, but the role of quality of education is unknown. We examined indicators of childhood educational quality as predictors of cognitive performance and decline in later life.
Participants included 433 older adults (52% African American) who reported living in Alabama during childhood and completed in-home assessments of cognitive function at baseline and 4 years later. Reports of residence during school years were matched to county-level data from the 1935 Alabama Department of Education report for school funding (per student), student–teacher ratio, and school year length. A composite measure of global cognitive function was utilized in analyses. Multilevel mixed effects models accounted for clustering of educational data within counties in examining the association between cognitive function and the educational quality indices.
Higher student–teacher ratio was associated with worse cognitive function and greater school year length was associated with better cognitive function. These associations remained statistically significant in models adjusted for education level, age, race, gender, income, reading ability, vascular risk factors, and health behaviors. The observed associations were stronger in those with lower levels of education (≤12 years), but none of the education quality measures were related to 4-year change in cognitive function.
Educational factors other than years of schooling may influence cognitive performance in later life. Understanding the role of education in cognitive aging has substantial implications for prevention efforts as well as accurate identification of older adults with cognitive impairment.
PMCID: PMC3598357  PMID: 22546959
Cognitive aging; Education; Health disparities
12.  ACTIVE Cognitive Training and Rates of Incident Dementia 
Systematic cognitive training produces long-term improvement in cognitive function and less difficulty in performing activities of daily living. We examined whether cognitive training was associated with reduced rate of incident dementia. Participants were from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study (n=2,802). Incident dementia was defined using a combination of interview- and performance-based methods. Survival analysis was used to determine if ACTIVE treatment affected the rate of incident dementia during 5 years of follow-up. A total of 189 participants met criteria for incident dementia. Baseline factors predictive of incident dementia were older age, male gender, African American race, fewer years of education, relationship other than married, no alcohol use, worse MMSE< worse SF-36 physical functioning, higher depressive symptomatology, diabetes, and stroke (all p<.05). A multivariable model with significant predictors of incident dementia and training group revealed that cognitive training was not associated with a lower rate of incident dementia. Cognitive training did not affect rates of incident dementia after 5 years of follow-up. Longer follow-up or enhanced training may be needed to fully explore the preventive capacity of cognitive training in forestalling onset of dementia.
PMCID: PMC3384749  PMID: 22400989
Cognitive training; Intervention; Aging; Dementia; Prevention; Cognition
13.  Identification of Mild Cognitive Impairment in ACTIVE: Algorithmic Classification and Stability 
Rates of mild cognitive impairment (MCI) have varied substantially, depending on the criteria used and the samples surveyed. The present investigation used a psychometric algorithm for identifying MCI and its’ stability to determine if low cognitive functioning was related to poorer longitudinal outcomes. The Advanced Cognitive Training of Independent and Vital Elders (ACTIVE) study is a multi-site longitudinal investigation of long-term effects of cognitive training with older adults. ACTIVE exclusion criteria eliminated participants at highest risk for dementia (i.e., MMSE<23). Using composite normative for sample- and training- corrected psychometric data, 8.07% of the sample had amnestic impairment, while 25.09% had a non-amnestic impairment at baseline. Poorer baseline functional scores were observed in those with impairment at the first visit, including a higher rate of attrition, depressive symptoms, and self-reported physical functioning. Participants were then classified based upon the stability of their classification. Those who were stably impaired over the five-year interval had the worst functional outcomes (e.g., IADL performance), and inconsistency in classification over time also appeared to be associated increased risk. These findings suggest that there is prognostic value in assessing and tracking cognition to assist in identifying the critical baseline features associated with poorer outcomes.
PMCID: PMC3573882  PMID: 23095218
cognitive impairment; research classification; cognitive aging; longitudinal follow-up
14.  Work-Related Stress May Increase the Risk of Vascular Dementia 
We examined job control, job demands, social support at work, and job strain (ratio of demands to control) in relation to risk of any dementia, Alzheimer’s disease (AD), and vascular dementia (VaD).
A cohort study.
The population-based Study of Dementia in Swedish Twins.
A total of 257 dementia cases (167 AD, 46 VaD) and 9,849 non-demented individuals.
Dementia diagnoses were based on telephone screening for cognitive impairment followed by in-person clinical work-up. An established job exposure matrix was matched to main occupation categories to measure work characteristics.
In generalized estimating equations (adjusted for the inclusion of complete twin pairs), lower job control was associated with greater risk of any dementia (odds ratio [OR]=1.17, 95% confidence interval [95%CI] 1.04-1.31) and VaD specifically (OR=1.39, 95% CI 1.07-1.81). Lower social support at work was associated with increased risk of dementia (OR=1.15, 95% CI 1.03-1.28), AD (OR=1.14, 95% CI 1.00-1.31), and VaD (OR=1.28, 95% CI=1.02-1.60). Greater job strain was associated with increased risk of VaD only (OR=1.28, 95% CI 1.02-1.60), especially in combination with low social support (OR=1.35, 95% CI 1.11-1.64). Age, gender, education, and cardiovascular disease were controlled. Results were not explained by work complexity or manual work. No differences in work-related stress scores were observed in the 54 twin pairs discordant for dementia, although only two pairs included a twin with VaD.
Work-related stress including low job control and low social support at work may increase the risk of dementia, particularly VaD. Modification to work environment that includes attention to social context and provision of meaningful roles for the workers may contribute to the efforts to promote cognitive health.
PMCID: PMC3258308  PMID: 22175444
Work-related stress; job strain; dementia; vascular dementia
15.  Modeling Change in Memory Performance and Memory Perceptions: Findings from the ACTIVE Study 
Psychology and aging  2011;26(3):518-524.
Within the context of the ACTIVE study, the current investigation explored the relationships between objective memory and two components of subjective memory (frequency of forgetting and use of external aids) over a five-year period. Relationships were assessed using parallel process latent growth curve models. Results indicated that changes in objective memory were associated with changes in perceived frequency of forgetting, but not with use of external aids (calendars, reminder notes) over time. Findings suggest that memory complaints may accurately reflect decline in objective memory performance, but that these memory changes are not necessarily related to compensatory behaviors.
PMCID: PMC3168728  PMID: 21463064
objective memory; subjective memory; latent growth curves; later adulthood
Annals of neurology  2011;70(2):229-236.
To determine whether incidence of impaired cognitive screening status is higher in the southern Stroke Belt region of the United States than in the remaining U.S.
A national cohort of adults ≥ age 45 was recruited by the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study from 2003–2007. Participants’ global cognitive status was assessed annually by telephone with the Six-item Screener (SIS) and every two years with fluency and recall tasks. Participants who reported no stroke history and who were cognitively intact at enrollment (SIS > 4 of 6) were included (N = 23,913, including 56% women, 38% African Americans and 62% European Americans, 56% Stroke Belt residents and 44% from the remaining contiguous United States and the District of Columbia). Regional differences in incident cognitive impairment (SIS score ≤ 4) were adjusted for age, sex, race, education, and time between first and last assessments.
1,937 participants (8.1%) declined to an SIS score ≤ 4 at their most recent assessment, over a mean of 4.1 (± 1.6) years. Residents of the Stroke Belt had greater adjusted odds of incident cognitive impairment than non-Belt residents (OR = 1.18; 95% CI 1.07 – 1.30). All demographic factors and time independently predicted impairment.
Regional disparities in cognitive decline mirror regional disparities in stroke mortality, suggesting shared risk factors for these adverse outcomes. Efforts to promote cerebrovascular and cognitive health should be directed to the Stroke Belt.
PMCID: PMC3152671  PMID: 21618586
17.  The Relationship Between Cognitive Function and Life Space: The Potential Role of Personal Control Beliefs 
Psychology and Aging  2011;27(2):364-374.
We examined the relationship of cognitive and functional measures with life space (a measure of spatial mobility examining extent of movement within a person’s environment) in older adults, and investigated the potential moderating role of personal control beliefs. Internal control beliefs reflect feelings of competence and personal agency, while attributions of external control imply a more dependent or passive point of view. Participants were 2,737 adults from the ACTIVE study, with a mean age of 74 years. Females comprised 76% of the sample, with good minority representation (27% African American). In multiple regression models controlling for demographic factors, cognitive domains of memory, reasoning, and processing speed were significantly associated with life space (p<.001 for each), and reasoning ability appeared most predictive (B=.117). Measures of everyday function also showed significant associations with life space, independent from the traditional cognitive measures. Interactions between cognitive function and control beliefs were tested, and external control beliefs moderated the relationship between memory and life space, with the combination of high objective memory and low external control beliefs yielding the highest life space (t=−2.07; p=.039). In conclusion, older adults with better cognitive function have a larger overall life space. Performance-based measures of everyday function may also be useful in assessing the functional outcome of life space. Additionally, subjective external control beliefs may moderate the relationship between objective cognitive function and life space. Future studies examining the relationships between these factors longitudinally appear worthwhile to further elucidate the interrelationships of cognitive function, control beliefs, and life space.
PMCID: PMC3302939  PMID: 21875217
aging; cognition; control beliefs; life space
18.  The Impact of Feedback on Self-rated Driving Ability and Driving Self-regulation Among Older Adults 
The Gerontologist  2010;51(3):367-378.
In 129 community-dwelling older adults, feedback regarding qualification for an insurance discount (based on a visual speed of processing test; Useful Field of View) was examined as a prospective predictor of change in self-reported driving ability, driving avoidance, and driving exposure over 3 months, along with physical, visual, health, and cognitive variables. Multiple regression models indicated that after controlling for baseline scores on the outcome measures, failure to qualify was a significant predictor of increased avoidance over 3 months (p = .02) but not change in self-rated driving ability or exposure. Female gender (p = .03) was a significant predictor of subsequent lower self-rated driving ability. Overall, the findings of this study provide support for the role of feedback in the self-monitoring of older adults’ driving behavior through avoidance of challenging driving situations but not through driving exposure or self-rated driving ability.
PMCID: PMC3095650  PMID: 21071621
Older drivers; Driving ability; Self-regulation; Self-rated driving; Driving exposure; Driving avoidance
19.  Cognitive and Everyday Functioning in Older and Younger Adults with and without HIV 
Clinical gerontologist  2011;34(5):413-426.
The purpose of this study was to: (1) examine cognitive performance differences in older and younger adults with and without HIV, and (2) determine if such differences were related to a laboratory measure of instrumental activities of daily living (IADLs). Ninety-eight HIV-positive (69 younger, 29 older) and 103 HIV-negative (84 younger, 19 older) adults were evaluated on a number of cognitive measures. Controlling for a number of confounders, age by HIV status interactions were found on two cognitive measures, indicating poorer cognitive performance for those aging with HIV. Poorer performance on these cognitive measures corresponded with poorer performance on the Timed Instrumental Activities of Daily Living (TIADL) test. These findings suggest that as adults age with HIV, they may be at risk for cognitive declines that would impair their ability to engage in activities important for maintaining independent living.
PMCID: PMC3342698  PMID: 22563140
HIV; AIDS; Aging; Neuropsychology; Cognition; IADLs
20.  Work-Related Exposure to Extremely Low-Frequency Magnetic Fields and Dementia: Results from the Population-Based Study of Dementia in Swedish Twins 
We examined the association between extremely low-frequency magnetic fields (EMF) and the risk of dementia and Alzheimer’s disease using all 9,508 individuals from the Study of Dementia in Swedish Twins (HARMONY) with valid occupational and diagnostic data.
Dementia diagnoses were based on telephone screening followed by in-person clinical workup. Main lifetime occupation was coded according to an established EMF exposure matrix. Covariates were age, gender, education, vascular risk factors, and complexity of work. Based on previous research, data were also analyzed separately for cases with disease onset by age 75 years versus later, men versus women, and those with manual versus nonmanual main occupation. We used generalized estimating equations with the entire sample (to adjust for the inclusion of complete twin pairs) and conditional logistic regression with complete twin pairs only.
Level of EMF exposure was not significantly associated with dementia or Alzheimer’s disease. However, in stratified analyses, medium and high levels of EMF exposure were associated with increased dementia risk compared with low level in cases with onset by age 75 years (odds ratio: 1.94, 95% confidence interval: 1.07–3.65 for medium, odds ratio: 2.01, 95% confidence interval: 1.10–3.65 for high) and in participants with manual occupations (odds ratio: 1.81, 95% confidence interval: 1.06–3.09 for medium, odds ratio: 1.75, 95% confidence interval: 1.00–3.05 for high). Results with 42 twin pairs discordant for dementia did not reach statistical significance.
Occupational EMF exposure appears relevant primarily to dementia with an earlier onset and among former manual workers.
PMCID: PMC2954236  PMID: 20622138
Dementia; Magnetic fields; Occupation; Alzheimer’s disease
21.  Normative Performance on an Executive Clock Drawing Task (CLOX) in a Community-Dwelling Sample of Older Adults 
The CLOX is a clock drawing test used to screen for cognitive impairment in older adults, but there is limited normative data for this measure. This study presents normative data for the CLOX derived from a diverse sample of 585 community-dwelling older adults with complete cognitive data at baseline and 4-year follow-up. Participants with evidence of baseline impairment or substantial 4-year decline on the Mini-Mental State Examination were excluded from the normative sample. Spontaneous clock drawing (CLOX1) and copy (CLOX2) performances were stratified by age group and reading ability from the Wide Range Achievement Test, 3rd edition (WRAT-3). Lowest mean CLOX scores were observed for the oldest age group (75+ years old) with the lowest WRAT-3 reading scores. For all groups, average scores were higher for CLOX2 than CLOX1. These normative data may be helpful to clinicians and researchers for interpreting CLOX performance in older adults with diverse levels of reading ability.
PMCID: PMC2957959  PMID: 20601672
Normative data; Clock drawing test; Reading ability; Older adults; Aging
22.  Changes in Mobility Among Older Adults with Psychometrically Defined Mild Cognitive Impairment 
Studies have found that adults with possible mild cognitive impairment (MCI) exhibit decrements in everyday functioning (e.g., Wadley, V. G., Crowe, M., Marsiske, M., Cook, S. E., Unverzagt, F. W., Rosenberg, A. L., et al. (2007). Changes in everyday function among individuals with psychometrically defined mild cognitive impairment. Journal of the American Geriatrics Society, 55, 1192–1198). However, it is not known whether driving mobility and life space mobility are reduced in such individuals. The current study examined 5-year trajectories of mobility change in older adults (N = 2,355) with psychometrically defined MCI from the Advanced Cognitive Training for Independent and Vital Elderly trial. Mixed effect models evaluated group differences for the following mobility outcomes: driving space, life space, driving frequency, and driving difficulty. Relative to cognitively normal participants, participants with possible MCI showed reduced baseline mobility for all outcomes as well as faster rates of decline for driving frequency and difficulty. These results suggest that mobility declines could be features of MCI, and changes in mobility may be particularly important for researchers and clinicians to monitor in this population.
PMCID: PMC2853603  PMID: 20147739
Driving; Life space; Mild cognitive impairment; Mobility; Older adults
23.  Diabetes and Cognitive Decline: Investigating the Potential Influence of Factors Related to Health Disparities 
Journal of aging and health  2010;22(3):292-306.
We investigated whether factors related to health disparities – race, rural residence, education, perceived racial discrimination, vascular disease, and health care access and utilization – may moderate the association between diabetes and cognitive decline.
Participants were 624 community-dwelling older adults (49% African American, 49% rural) who completed in-home Mini-Mental State Examination at baseline and four-year follow-up.
Diabetes at baseline predicted cognitive decline over four years in regression models adjusted for a number of possible confounds. Only perceived discrimination and health utilization showed significant interaction effects with diabetes. Among African Americans who reported experiencing racial discrimination, there was a stronger relationship between diabetes and cognitive decline. Among participants who reported absence of visiting a physician within the past six months, the association between diabetes and cognitive decline was substantially larger.
Findings suggest that factors related to health disparities may influence cognitive outcomes among older adults with diabetes.
PMCID: PMC2837792  PMID: 20103688
diabetes; cognitive decline; older adults; health disparities
24.  Subjective cognitive function and decline among older adults with psychometrically defined amnestic MCI 
To examine the relationship between subjective cognitive function and subsequent cognitive decline among individuals with psychometrically defined amnestic mild cognitive impairment (MCI), and to determine whether the presence of depressive symptoms modifies this relationship.
Fifty-five individuals met psychometric criteria for amnestic mild cognitive impairment (MCI). Cognitive decline was measured using the Mini-Mental State Examination (MMSE), which was administered at baseline and at follow-up two years later. Subjective cognitive function was examined using two different one-item memory complaints, as well as a scale focused on current level of cognitive function relative to past function and a scale focused on forgetting in specific everyday situations.
In multiple regression analyses, the one-item complaint of change in memory at baseline predicted future cognitive decline. There was a significant interaction effect whereby this association was stronger in participants who endorsed fewer symptoms of depression.
Individuals showing memory deficits consistent with amnestic MCI have at least some insight regarding cognitive decline and the extent to which subjective cognitive function is useful in predicting future decline may depend on what particular questions are asked as well as presence of depressive symptoms.
PMCID: PMC2905787  PMID: 16955448
subjective cognitive function; mild cognitive impairment; depression; cognitive decline
25.  Mild Cognitive Impairment and Everyday Function: An Investigation of Driving Performance 
Mild Cognitive Impairment (MCI) involves subtle functional losses that may include decrements in driving skills. We compared 46 participants with MCI to 59 cognitively normal controls on a driving evaluation conducted by a driving rehabilitation specialist who was blinded to participants’ MCI classification. Participants with MCI demonstrated significantly lower performance than controls on ratings of global and discrete driving maneuvers, but these differences were not at the level of frank impairments. Rather, performance was simply less than optimal, which to a lesser degree was also characteristic of a subset of the cognitively normal control group. The finding of significantly lower global driving ratings, coupled with the increased incidence of dementia among people with MCI and the known impact of dementia on driving safety, suggests the need for increased vigilance among clinicians, family members, and individuals with MCI for initially benign changes in driving that may become increasingly problematic over time.
PMCID: PMC2832580  PMID: 19196629
Mild Cognitive Impairment; Functional Ability; Instrumental Activities of Daily Living; Driving

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