Practice effects have been widely reported in healthy older adults, but these improvements due to repeat exposure to test materials have been more equivocal in individuals with mild cognitive impairment (MCI).
The current study examined short-term practice effects in MCI by repeating a brief battery of cognitive tests across one week in 59 older adults with amnestic MCI and 62 intact older adults.
Participants with amnestic MCI showed significantly greater improvements on two delayed recall measures (p < 0.01) compared to intact peers. All other practice effects were comparable between these two groups. Practice effects significantly improved scores in the MCI group so that 49% of them were reclassified as “intact” after one week, whereas the other 51% remained “stable” as MCI. Secondary analyses indicated the MCI-Intact group demonstrated larger practice effects on two memory measures than their peers (p < 0.01).
These results continue to inform us about the nature of memory deficits in MCI, and could have implications for the diagnosis and possible treatment of this amnestic condition.
mild cognitive impairment; practice effects; repeat testing
Recent studies have tried to determine which aspects of chronic illness heighten the risk for depression, with functional impairment receiving the most attention. There is growing evidence that functional impairment accounts for most of the association between chronic illness and depression. This study examines the relative contribution of cognitive function, physical function, and chronic illness to depression two years later in a nationwide sample of elders aged 70 and older.
This is a longitudinal community-based study of 5289 elders completing two waves of assessment in the Asset and Health Dynamics among the Oldest Old (AHEAD) study. Depression assessment included an abbreviated version of the CES-D and of the Composite International Diagnostic Interview (the CESD-8 and the CIDI-S). Cognitive function, physical function, and presence of chronic illness assessed at Wave 1 were examined as predictors of depression at Wave 2 while controlling for Wave 1 CESD-8 score.
In a full multivariate model, most baseline cognitive function, physical function, and chronic illness variables predicted depression as measured by the CESD-8 at Wave 2. The associations were markedly weaker between baseline variables and the Wave 2 CIDI-S. The Wave 1 CESD-8 score predicted all-cause mortality by Wave 2 (Z=3.13; P>|Z| = 0.002) even after controlling for key health and functioning variables.
Chronic illness, physical function, and cognitive function all independently predict depressive morbidity in late-life. The CIDI-S appeared less informative about these key relationships when compared to the CESD-8. The significance of depressive symptoms was demonstrated by their independent association with all-cause mortality at two-year follow-up.
depression; chronic illness; geriatric; functional impairment
Among patients with Alzheimer’s disease who have had a response to antipsychotic medication for psychosis or agitation–aggression, the risk of a recurrence of symptoms after discontinuation of the medication has not been established.
Patients with Alzheimer’s disease and psychosis or agitation–aggression received open-label treatment with risperidone for 16 weeks. Those who had a response to risperidone therapy were then randomly assigned, in a double-blind fashion, to one of three regimens: continued risperidone therapy for 32 weeks (group 1), risperidone therapy for 16 weeks followed by placebo for 16 weeks (group 2), or placebo for 32 weeks (group 3). The primary outcome was the time to relapse of psychosis or agitation.
A total of 180 patients received open-label risperidone (mean dose, 0.97 mg daily). The severity of psychosis and agitation were reduced, although there was a mild increase in extrapyramidal signs; 112 patients met the criteria for response to treatment, of whom 110 underwent randomization. In the first 16 weeks after randomization, the rate of relapse was higher in the group that received placebo than in the groups that received risperidone (60% [24 of 40 patients in group 3] vs. 33% [23 of 70 in groups 1 and 2]; P = 0.004; hazard ratio with placebo, 1.94; 95% confidence interval [CI], 1.09 to 3.45; P = 0.02). During the next 16 weeks, the rate of relapse was higher in the group that was switched from risperidone to placebo than in the group that continued to receive risperidone (48% [13 of 27 patients in group 2] vs. 15% [2 of 13 in group 1]; P = 0.02; hazard ratio, 4.88; 95% CI, 1.08 to 21.98; P = 0.02). The rates of adverse events and death after randomization did not differ significantly among the groups, although comparisons were based on small numbers of patients, especially during the final 16 weeks.
In patients with Alzheimer’s disease who had psychosis or agitation that had responded to risperidone therapy for 4 to 8 months, discontinuation of risperidone was associated with an increased risk of relapse.
To determine rates of psychotic symptoms and associated modifiable and non-modifiable factors among elderly long term nursing home residents without prior history of psychiatric illness.
A cross-sectional design using the Scale for the Assessment of Positive Symptoms (SAPS) to measure psychotic symptoms, the Folstein’s Mini-Mental State Exam (MMSE), and Mattis Dementia Rating Scale (DRS) to evaluate cognitive impairment. Frequency and rates of global psychotic symptoms and hallucinations, delusions, formal thought disorder, and bizarre behavior were calculated. Logistic regression was used to examine modifiable (e.g., medication use) and non-modifiable clinical characteristics (e.g., older age) associated with late-life psychosis.
There were 15.9% of subjects reporting delusions and 7.3% reporting hallucinations. History of stroke, poorer cognition, and receiving multiple medications showed significant association with late-life psychosis. Only stroke (OR = 9.12; 95% CI: 1.58-52.74) and receiving different classes of medications (benzodiazepines, neuroleptics, and antidepressants) (OR = 13.17; 95% CI: 2.10-85.82) remained significantly associated with psychosis after adjusting for Mattis DRS total score. Further analyses excluding subjects with MMSE scores of 24 or lower (n = 24) showed essentially the same results but subjects with better cognitive function suffered a less severe form of psychosis, essentially constituted by one symptom type (i.e., visual hallucinations).
Rates of late-life psychosis in this sample of nursing home residents without previous psychiatric history were high. Simultaneous use of medications including antidepressants, sedatives, and stimulants may be a clinically relevant modifiable factor to be targeted in prevention studies. Severity and type of psychosis is dependent on the severity of cognitive impairment.
psychosis; late-life; aging psychiatry; polypharmacy; stroke; cognitive impairment; prescription medications
This study was designed to determine the relationships between PET-based quantitative measures of cerebral blood flow and cerebrovascular reserve and neuropsychological functioning in elderly individuals with atherosclerotic vascular disease. It was hypothesized that cerebrovascular function would be significantly associated with neuropsychological functioning. Results showed that both baseline global cerebral blood flow and cerebrovascular reserve were significantly associated with global neuropsychological functioning, when controlling for age and sex. Cerebrovascular reserve was additionally associated with performance on measures of memory and attention. Additional research is needed to determine whether measures of cerebral blood flow can be used to predict cognitive decline.
Practice effects on cognitive tests have been shown to further characterize patients with amnestic Mild Cognitive Impairment (aMCI), and may provide predictive information about cognitive change across time. We tested the hypothesis that a loss of practice effects would portend a worse prognosis in aMCI.
Longitudinal, observational design following participants across one year.
Three groups of older adults: 1. cognitively intact (n=57), 2. aMCI with large practice effects across one week (MCI+PE, n=25), and 3. aMCI with minimal practice effects across one week (MCI−PE, n=26).
After controlling for age and baseline cognitive differences, the MCI−PE group performed significantly worse than the other groups after one year on measures of immediate memory, delayed memory, language, and overall cognition.
Although these results need to be replicated in larger samples, the loss of short-term practice effects portends a worse prognosis in patients with aMCI.
Mild Cognitive Impairment; practice effects; dementia
This study evaluated brain volumes in healthy older subjects without dementia who presented with memory complaints. The objective was to examine cortical volumes in relation to cognitive performance among patients who do not have dementia, but who do have mild cognitive deficits.
Fifteen participants were evaluated (mean age = 71.8 ± 6.2). Brain structure was measured via high-resolution magnetic resonance imaging to quantify gray and white matter volumes. Volumetric measures were assessed relative to cognitive function in separate regression models controlling for total cerebral volume. Reported here are measures of global cognitive performance using the Mattis Dementia Rating Scale (DRS) in relation to volumetric measures.
Baseline MMSE scores ranged from 27 to 30 (mean = 29.3; SD = 0.9). After controlling for total cerebral volume, we observed that lower white matter volume in the temporal lobe [F(1,14) = 5.72, p = 0.03] was associated with lower performance on the Mattis Dementia Rating Scale (DRS).
Structural imaging may help provide useful clinical information in the context of mild cognitive decline. Currently, the diagnosis of dementia relies on longitudinal measures of cognition. Future studies will help determine whether the addition of brain imaging may enhance diagnostic certainty as well as predict long-term outcome.
Cognition; Imaging; Aging; Memory
Assisted living (AL) is an increasingly popular long-term care alternative for older adults with dementia, making this setting an important focus for both clinical practice and research among psychiatric nurses.
This article describes results from a pilot study focusing on residents' cognitive and emotional status as well as psychotropic drug use. Findings are compared to reports from larger studies in the literature.
A descriptive, correlational design was used to collect data from 17 residents in two dementia-specific AL facilities.
Thirty-one psychiatric diagnoses were identified for 17 participants. Anxiety and depression symptoms were endorsed by more than 50% of participants, and 88% were prescribed psychotropic medications.
AL residents may experience problems with cognition and emotional symptoms such as anxiety and depression, creating important roles for psychiatric nurses in staff education, promotion of nonpharmacologic interventions, and monitoring of psychotropic medication use in this growing population.
assisted living; dementia; behavioral symptoms; psychotropic mediation
Assisted living (AL) is an increasingly popular long-term care option for older adults with dementia. Recent reports suggest that as many as 68% of AL residents have dementia, and that frequency of both behavioral symptoms and psychotropic medications are high. This pilot project explored the feasibility of research methods for use in AL facilities. Findings suggest that most AL residents with dementia have moderate to severe dementia, and the majority are taking one or more psychotropic medication. Descriptive and qualitative findings related to health records, caregiver perceptions of behavioral symptoms, and practicality of assessment methods undertaken are described and implications for psychiatric nursing practice and research are reviewed.
The process of conducting nursing research can be far more complicated than what is described in nursing textbooks, particularly when the investigation is conducted in a new and unfamiliar care setting. This article describes a number of unexpected events and outcomes associated with implementing what was considered, at the onset, a well-designed research study under the leadership of experienced investigators. Lessons learned, which are believed to be valuable to both neophyte and seasoned researchers, are reviewed.
Assessing cognitive change in older adults is a common use of neuropsychological services, and neuropsychologists have utilized several strategies to determine if a change is “real,” “reliable,” and “meaningful.” Although standardized regression-based (SRB) prediction formulas may be useful in determining change, SRBs have not been widely applied to older adults. The current study sought to develop SRB formulas on a group of 127 community-dwelling older adults for several widely used neuropsychological measures. In addition to baseline test scores and demographic information, the current study also examined the role of short-term practice effects in predicting test scores after 1 year. Consistent with prior research on younger adults, baseline test performances were the strongest predictors of future test performances, accounting for 25%–58% of the variance. Short-term practice effects significantly added to the predictability of all nine of the cognitive tests examined (3%–22%). Future studies should continue extending SRB methodology for older adults, and the inclusion of practice effects appears to add to the prediction of future cognition.
Predicting cognition; Practice effects
With the rapid growth of the assisted living (AL) industry, the number of AL residences providing dementia care continues to increase. The purpose of this article is to describe and compare demographic characteristics; frequency and type of psychiatric diagnoses; level of cognition, depression, and anxiety symptoms; and use of psychotropic medication among older adults in dementia-specific assisted living (DSAL) and traditional assisted living (TAL) residences. Secondary analysis of screening data collected during a cross-sectional, descriptive pilot project compared 18 participants from two DSAL facilities and 28 participants from three TAL facilities. DSAL participants with dementia were more cognitively impaired than TAL participants with dementia (p < 0.001) and used more antipsychotic (67%), anxiolytic (60%), antidepressant (53%), and cognitive-enhancing (87%) medications. No statistically significant differences in demographic factors or levels of anxiety or depression were observed among residents in either setting.
Practice effects, defined as improvements in cognitive test performance due to repeated exposure to the test materials, have traditionally been viewed as sources of error. However, they might provide useful information for predicting cognitive outcome. The current study used three separate patient samples (older adults with mild cognitive impairments, individuals who were HIV +, individuals with Huntington’s disease) to examine the relationship between practice effects and cognitive functioning at a later point. Across all three samples, practice effects accounted for as much as 31 to 83% of the variance in the follow-up cognitive scores, after controlling for baseline cognitive functioning. If these findings can be replicated in other patients with neurodegenerative disorders, clinicians and researchers may be able to develop predictive models to identify the individuals who are most likely to demonstrate continued cognitive decline across time. The ability to utilize practice effects data would add a simple, convenient, and non-invasive marker for monitoring an individual patient’s cognitive status. Additionally, this prognostic index could be used to offer interventions to patients who are in the earliest stages of progressive neurodegenerative disorders.
practice effects; cognitive outcome; Mild Cognitive Impairment; HIV; Huntington’s disease
Studies have shown that individuals with psychiatric or general medical illness can benefit from interventions designed to enhance decisional capacity for research informed consent. In some cases, interventions have been rather lengthy or complex. The current study was designed to determine whether a brief intervention could improve decisional capacity in people with schizophrenia. Thirty individuals with schizophrenia and 30 healthy comparison participants were presented with a hypothetical research scenario. Decisional capacity was assessed with the MacArthur Competence Assessment Tool–Clinical Research version. Those with schizophrenia received a brief intervention aimed at improving understanding of the research protocol, after which decisional capacity was reassessed. A neuropsychological battery and symptom rating scales were also administered. At baseline, the schizophrenia group earned significantly lower scores than the comparison group on 2 aspects of decisional capacity (understanding, appreciation). At follow-up, the schizophrenia group had improved significantly on understanding and was no longer significantly different from the comparison group on any of the 4 dimensions of decisional capacity. Follow-up analyses also showed a significant effect of the intervention on a subset of the schizophrenia group who had performed most poorly at baseline. Participants with schizophrenia earned significantly lower scores than those in the comparison group across multiple neuropsychological domains. These findings add to the existing literature indicating that brief interventions can improve decisional capacity in individuals with schizophrenia, despite the fact that the illness typically causes significant cognitive dysfunction. The use of such interventions will enable a larger number of people with schizophrenia to make informed decisions regarding research participation.
informed consent; decisional capacity; ethics; schizophrenia
As the United States population ages, an unprecedented proportion of the population will be aged 70 and older. Knowledge of alcohol use and its consequences in this age group is not well known. In light of the disparate findings pointing to negative outcomes with excessive drinking yet also benefits of moderate drinking, the true risk of alcohol use in late life needs more investigation.
This study examined the correlates and 2-year health outcomes related to alcohol use in 7,434 elders aged 70 years or older. Data was collected as part of the Assets and Health Dynamics of the Oldest Old (AHEAD), a nationwide health and economic study of elders. Data from Wave 1 and Wave 2 of AHEAD are presented. Frequency and quantity of drinking was assessed by self-report as was health status, lifetime alcohol or psychiatric problems, presence of chronic illness, functional impairment, and depressive symptoms. Cognitive status was assessed using a brief measure.
Approximately 44% of the sample reported any alcohol use in the past three months, with the majority of drinking less than daily. Daily drinking was associated with being Caucasian, married, in relatively good health, and having good affective and cognitive status. Drinking was not associated with negative health outcomes two years later and was protective against stroke and functional impairment. Decline in drinking between Wave 1 and Wave 2 was strongly associated with poor health.
This study offers no evidence of negative health outcomes for drinking moderately and confirms the U-shaped curve often found in studies of alcohol and health. Nonetheless, cessation of drinking was associated with poor health suggesting the health benefits of moderate drinking may result from selection of a healthy group of people capable of sustained moderate drinking. Public health recommendations for moderate drinking must take this phenomenon into account.