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1.  Cognition in patients with newly diagnosed brain metastasis: profiles and implications 
Journal of neuro-oncology  2014;120(1):179-185.
Cognitive impairment is a common symptom in patients with brain metastasis, and significant cognitive dysfunction is prevalent in a majority of patients who are still able to engage in basic self-care activities. In the current study, the neurocognitive performance of 32 patients with brain metastasis and 32 demographically-matched controls was examined using a battery of standardized neuropsychological tests, with the goal of comprehensively examining the cognitive functioning of newly diagnosed brain metastasis patients. The cognition of all patients was assessed within 1 week of beginning treatment for brain metastasis. Results indicated impairments in verbal memory, attention, executive functioning, and language in relation to healthy controls. Performance in relation to appropriate normative groups was also examined. Overall, cognitive deficits were prevalent and memory was the most common impairment. Given that cognitive dysfunction was present in this cohort of patients with largely minimal functional impairment, these results have implications for patients, caregivers and health care providers treating patients with brain metastasis.
PMCID: PMC4295820  PMID: 25035099
Cognition; Memory; Brain metastasis; Malignant brain tumor
2.  MRI Volume of the Medial Frontal Cortex Predicts Financial Capacity in Patients with Mild Alzheimer’s Disease 
Brain imaging and behavior  2013;7(3):10.1007/s11682-013-9226-3.
Persons with mild Alzheimer’s disease (AD) have significant deficits in financial abilities. This study examined the relationship between brain structure volumes, cognition, and financial capacity in patients with mild AD. Sixteen mild AD patients and 16 older adult comparisons completed the Financial Capacity Instrument (FCI), a psychometric measure of financial abilities, and also underwent magnetic resonance imaging (MRI) to obtain volumes of the bilateral hippocampi, angular gyri, precunei, and medial and dorsolateral frontal cortices. Mild AD patients performed significantly below comparisons on the FCI and had significantly smaller hippocampi. Among mild AD patients, FCI performance was moderately correlated with frontal (medial and dorsolateral frontal cortex) and posterior (angular gyri and precunei) cortical volumes. Stepwise regression demonstrated that medial frontal cortex volume predicted FCI score. The relationship between medial frontal cortex volume and overall FCI score was partially mediated by two measures of simple attention (DRS Attention, DRS Construction). The findings suggest that medial frontal cortex atrophy and associated declines in simple attention play an increasingly important role in declining financial skills in patients with mild AD.
PMCID: PMC3716854  PMID: 23504597
Alzheimer’s disease; financial capacity; magnetic resonance imaging; frontal cortex; precuneus; angular gyrus
3.  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
4.  MRI Volume of the Angular Gyri Predicts Financial Skill Deficits in Patients with Amnestic Mild Cognitive Impairment 
Persons with amnestic mild cognitive impairment (MCI) have demonstrated subtle impairments in IADLs including financial abilities, although the underlying brain changes related to these IADL impairments is poorly understood. The purpose of this investigation was to better understand how brain atrophy in MCI as measured by MRI volumetrics could impact IADLs such as financial abilities.
Controlled, matched sample, cross-sectional analysis regressing MRI volumetrics with financial performance measures.
University medical and research center.
Thirty-eight MCI patients and 28 older adult controls.
MRI volumetric measurement of the hippocampi, angular gyri, precunei, and medial frontal lobes. Participants also completed neuropsychological tests and the Financial Capacity Instrument (FCI).
We performed correlations between FCI scores and MRI volumes in the MCI group. Patients with MCI performed significantly below controls on the FCI and had significantly smaller hippocampi. Among MCI patients, performance on the FCI was moderately correlated with angular gyri and precunei volumes. Regression models demonstrated that angular gyri volumes were predictive of FCI scores. Tests of mediation showed that the relationship of angular gyri volume with FCI score was partially mediated by measures of arithmetic and possibly attention.
Impaired financial abilities in amnestic MCI correspond with volume of the angular gyri as mediated by arithmetic knowledge. The findings suggest that early neuropathology within the lateral parietal region in MCI leads to a breakdown of cognitive abilities that impact everyday financial skills. The findings have implications for diagnosis and clinical care of patients with MCI and AD.
PMCID: PMC3711192  PMID: 20374402
magnetic resonance imaging; mild cognitive impairment; financial capacity; angular gyrus; hippocampus; precuneus
5.  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
6.  Medical decision-making capacity in patients with malignant glioma 
Neurology  2009;73(24):2086-2092.
Patients with malignant glioma (MG) must make ongoing medical treatment decisions concerning a progressive disease that erodes cognition. We prospectively assessed medical decision-making capacity (MDC) in patients with MG using a standardized psychometric instrument.
Participants were 22 healthy controls and 26 patients with histologically verified MG. Group performance was compared on the Capacity to Consent to Treatment Instrument (CCTI), a psychometric measure of MDC incorporating 4 standards (choice, understanding, reasoning, and appreciation), and on neuropsychological and demographic variables. Capacity outcomes (capable, marginally capable, or incapable) on the CCTI standards were identified for the MG group. Within the MG group, scores on demographic, clinical, and neuropsychological variables were correlated with scores on each CCTI standard, and significant bivariate correlates were subsequently entered into exploratory stepwise regression analyses to identify multivariate cognitive predictors of the CCTI standards.
Patients with MG performed significantly below controls on consent standards of understanding and reasoning, and showed a trend on appreciation. Relative to controls, more than 50% of the patients with MG demonstrated capacity compromise (marginally capable or incapable outcomes) in MDC. In the MG group, cognitive measures of verbal acquisition/recall and, to a lesser extent, semantic fluency predicted performance on the appreciation, reasoning, and understanding standards. Karnofsky score was also associated with CCTI performance.
Soon after diagnosis, patients with malignant glioma (MG) have impaired capacity to make treatment decisions relative to controls. Medical decision-making capacity (MDC) impairment in MG seems to be primarily related to the effects of short-term verbal memory deficits. Ongoing assessment of MDC in patients with MG is strongly recommended.
= antiepileptic drug;
= Beck Depression Inventory;
= Capacity to Consent to Treatment Instrument;
= glioblastoma multiforme;
= Hopkins Verbal Learning Test;
= medical decision-making capacity;
= malignant glioma;
= University of Alabama at Birmingham.
PMCID: PMC2833103  PMID: 20018637
7.  Clinical Interview Assessment of Financial Capacity in Older Adults with Mild Cognitive Impairment and Alzheimer’s Disease 
To investigate financial capacity in patients with mild cognitive impairment (MCI) and Alzheimer’s disease (AD) using a clinician interview approach.
Tertiary care medical center.
Healthy older adults (N=75), patients with amnestic MCI (N=58), mild AD (N=97), and moderate AD (N=31).
The investigators and five study physicians developed a conceptually based, semi-structured clinical interview for evaluating seven core financial domains and overall financial capacity (Semi-Structured Clinical Interview for Financial Capacity; SCIFC). For each participant, a physician made capacity judgments (capable, marginally capable, or incapable) for each financial domain and for overall capacity.
Study physicians made a total of over 11,000 capacity judgments across the study sample (N=261). Very good inter-rater agreement was obtained for the SCIFC judgments. Increasing proportions of marginal and incapable judgment ratings were associated with increasing disease severity across the four study groups. For overall financial capacity, 95 percent of physician judgments for older controls were rated as capable, as compared to only 82% for patients with MCI, 26% for patients with mild AD, and 4% for patients with moderate AD.
Financial capacity in cognitively impaired older adults can be reliably evaluated by physicians using a relatively brief, semi-structured clinical interview. Financial capacity shows mild impairment in MCI, emerging global impairment in mild AD, and advanced global impairment in moderate AD. MCI patients and their families should proactively engage in financial and legal planning given these patients’ risk of developing AD and accelerated loss of financial abilities.
PMCID: PMC2714907  PMID: 19453308
financial capacity; competency; clinical assessment; mild cognitive impairment; Alzheimer’s disease
8.  Contributions of volumetrics of the hippocampus and thalamus to verbal memory in temporal lobe epilepsy patients 
Brain and cognition  2008;69(1):65-72.
Recent theories have posited that the hippocampus and thalamus serve distinct, yet related, roles in episodic memory. Whereas the hippocampus has been implicated in long-term memory encoding and storage, the thalamus, as a whole, has been implicated in the selection of items for subsequent encoding and the use of retrieval strategies. However, dissociating the memory impairment that occurs following thalamic injury as distinguished from that following hippocampal injury has proven difficult. This study examined relationships between MRI volumetric measures of the hippocampus and thalamus and their contributions to prose and rote verbal memory functioning in 18 patients with intractable temporal lobe epilepsy (TLE). Results revealed that bilateral hippocampal and thalamic volume independently predicted delayed prose verbal memory functioning. However, bilateral hippocampal, but not thalamic, volume predicted delayed rote verbal memory functioning. Follow-up analyses indicated that bilateral thalamic volume independently predicted immediate prose, but not immediate rote, verbal recall, whereas bilateral hippocampal volume was not associated with any of these immediate memory measures. These findings underscore the cognitive significance of thalamic atrophy in chronic TLE, demonstrating that hippocampal and thalamic volume make quantitatively, and perhaps qualitatively, distinct contributions to episodic memory functioning in TLE patients. They are also consistent with theories proposing that the hippocampus supports long-term memory encoding and storage, whereas the thalamus is implicated in the executive aspects of episodic memory.
PMCID: PMC2796537  PMID: 18599175
Hippocampus; Thalamus; Verbal memory; MRI volumetrics; Temporal lobe epilepsy
9.  Family Functioning and Low Vision: A Systematic Review 
This review highlights the literature on the function and adjustment process of family members of persons with adult-onset vision loss. The majority of the literature has focused on the unique role that the family plays in providing both instrumental and emotional support to adults with low vision. In contrast, the impact of low vision on the psychosocial adjustment of the family has been largely understudied. The review concludes with a discussion of the implications for clinical practice, along with directions for future research on the family within the context of low vision rehabilitation.
PMCID: PMC2798155  PMID: 20046836
10.  Medical Decision-Making Capacity in Cognitively Impaired Parkinson's Disease Patients Without Dementia 
Little is currently known about the higher order functional skills of patients with Parkinson disease and cognitive impairment. Medical decision-making capacity (MDC) was assessed in patients with Parkinson's disease (PD) with cognitive impairment and dementia. Participants were 16 patients with PD and cognitive impairment without dementia (PD-CIND), 16 patients with PD dementia (PDD), and 22 healthy older adults. All participants were administered the Capacity to Consent to Treatment Instrument (CCTI), a standardized capacity instrument assessing MDC under five different consent standards. Parametric and non-parametric statistical analyses were utilized to examine capacity performance on the consent standards. In addition, capacity outcomes (capable, marginally capable, or incapable outcomes) on the standards were identified for the two patient groups. Relative to controls, PD-CIND patients demonstrated significant impairment on the understanding treatment consent standard, clinically the most stringent CCTI standard. Relative to controls and PD-CIND patients, patients with PDD patients were impaired on the three clinical standards of understanding, reasoning, and appreciation. The findings suggest that impairment in decisional capacity is already present in cognitively impaired PD patients without dementia, and increases as these patients develop dementia. Clinicians and researchers should carefully assess decisional capacity in all PD patients with cognitive impairment.
PMCID: PMC2579319  PMID: 18759361
consent capacity; medical decision-making; cognitive impairment without dementia; functional change; Parkinson's disease

Results 1-10 (10)