Rural-Urban Differences in Cognition: Findings From the Advanced Cognitive Training for Independent and Vital Elderly Trial.

ObjectivesWe examined associations between three geographic areas (urban, suburban, rural) and cognition (memory, reasoning, processing speed) over a 10-year period. Methods: Data were obtained from 2539 participants in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial. Multilevel, mixed-effects linear regression was used to estimate cognitive trajectories by geographical areas over 10 years, after adjusting for social determinants of health. Results: Compared to urban and suburban participants, rural participants fared worse on all cognitive measures-memory (B = -1.17 (0.17)), reasoning (B = -1.55 (0.19)), and processing speed (B = 0.76 (0.19)) across the 10-year trajectory. Across geographic areas, greater economic stability, health care access and quality, and neighborhood resources were associated with better cognition over time. Discussion: Findings highlight the importance of geographical location when examining cognition later in life. More research examining place-based life experiences is needed to make the greatest impact on geographically diverse communities.

Problem Solving Training for Veterans with Complex Comorbidities: Treatment Delivery Adaptations during COVID-19.

OBJECTIVES: To summarize adaptations due to COVID-19 for VA Problem Solving Training (PST) for clinicians serving medically complex patients and to compare patient mental health outcomes in the year before (2019) and during COVID-19 (2020). METHODS: Clinicians attended a multi-day workshop and up to 6 months of small-group consultation for two training cases. In 2019 and 2020, 122 Veteran patients completed baseline and posttreatment measures of depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7 item), and negative problem-solving beliefs (Negative Problem Orientation Questionnaire). Qualitative data were collected on clinician's pandemic-related treatment implementation challenges. RESULTS: Program adaptations during COVID-19 addressed challenges due to delivering treatment by telephone, video, or in person; Veteran patient recruitment barriers; and privacy issues for telephone and video. Veterans in both pre-pandemic and COVID-19 cohorts had significant improvements in depression, anxiety, and negative problem-solving beliefs, with no significant differences in the amount of improvement between the two cohorts. CONCLUSIONS: Flexibilities afforded to clinicians delivering the PST training program during the pandemic addressed key obstacles and barriers to recruitment, and implementation did not diminish the effectiveness of the intervention. CLINICAL IMPLICATIONS: Findings support continued implementation of the PST training program with added flexibility to treatment delivery beyond the pandemic.

Health literacy, sociodemographic factors, and cognitive training in the active study of older adults.

OBJECTIVE: Health literacy is critical for understanding information from health-care providers and correct use of medications and includes the capacity to filter other information in navigating health care systems. Older adults with low health literacy exhibit more chronic health conditions, worse physical functioning, and poorer mental health. This study examined the relationship between sociodemographic variables and health literacy, and the impact of cognitive training on change in health literacy over 10 years in older adults. METHODS: Participants (N = 2,802) aged 65 years and older completed assessments, including reading and numeracy health literacy items, as part of the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study. We evaluated baseline sociodemographic variables and change in health literacy over a 10-year period in individuals exposed to cognitive training in reasoning, processing speed, memory, or a no-contact control condition. RESULTS: Age, sex, race, education level, and general cognitive functioning at baseline were all associated with baseline health literacy in older adults. Predictors of change in health literacy over the 10-year follow-up were age, race, education level, general cognitive functioning, and neighborhood income; disparities in health literacy because of race attenuated over time, while the effect of age increased over time. Health literacy was generally stable across the ACTIVE intervention groups over 10 years. CONCLUSIONS: The present study showed important disparities in health literacy level and change over 10 years. Cognitive training did not significantly impact health literacy, suggesting that alternative approaches are needed to reduce the disparities.

Neighborhood Predictors of Cognitive Training Outcomes and Trajectories in ACTIVE.

We examined the influence of neighborhood socioeconomic position (SEP), racial/ethnic composition, and living in a major city on cognitive trajectories and intervention outcomes. Data came from the Advanced Cognitive Training for Independent and Vital Elderly study ( N = 2,438). Mixed effects analyses examined the associations between neighborhood variables and memory, reasoning, speed of processing, and everyday cognition, estimating differences in initial gains (potentially related to practice) and long-term rate of change over 10 years. The effect of reasoning training on initial gain was weaker for individuals in a major city. For everyday cognition, there was a stronger initial gain for memory-trained and control participants in areas with more racial/ethnic minorities and for speed-trained and control individuals in higher SEP areas. The racial/ethnic minority effect was no longer significant after adjustment for multiple comparisons. Neighborhood factors may be more important in practice-related improvement than in long-term change.

Parkinson's disease and the Stroop color word test: processing speed and interference algorithms.

OBJECTIVE: Processing speed alters the traditional Stroop calculations of interference. Consequently, alternative algorithms for calculating Stroop interference have been introduced to control for processing speed, and have done so in a multiple sclerosis sample. This study examined how these processing speed correction algorithms change interference scores for individuals with idiopathic Parkinson's disease (PD, n = 58) and non-PD peers (n = 68). METHOD: Linear regressions controlling for demographics predicted group (PD vs. non-PD) differences for Jensen's, Golden's, relative, ratio, and residualized interference scores. To examine convergent and divergent validity, interference scores were correlated with standardized measures of processing speed and executive function. RESULTS: PD-non-PD differences were found for Jensen's interference score, but not Golden's score, or the relative, ratio, and residualized interference scores. Jensen's score correlated significantly with standardized processing speed but not executive function measures. Relative, ratio, and residualized scores correlated with executive function but not processing speed measures. Golden's score did not correlate with any other standardized measures. CONCLUSIONS: The relative, ratio, and residualized scores were comparable for measuring Stroop interference in processing speed-impaired populations. Overall, the ratio interference score may be the most useful calculation method to control for processing speed in this population.

Predictors of Retest Effects in a Longitudinal Study of Cognitive Aging in a Diverse Community-Based Sample.

Better performance due to repeated testing can bias long-term trajectories of cognitive aging and correlates of change. We examined whether retest effects differ as a function of individual differences pertinent to cognitive aging: race/ethnicity, age, sex, language, years of education, literacy, and dementia risk factors including apolipoprotein E ε4 status, baseline cognitive performance, and cardiovascular risk. We used data from the Washington Heights-Inwood Columbia Aging Project, a community-based cohort of older adults (n=4073). We modeled cognitive change and retest effects in summary factors for general cognitive performance, memory, executive functioning, and language using multilevel models. Retest effects were parameterized in two ways, as improvement between the first and subsequent testings, and as the square root of the number of prior testings. We evaluated whether the retest effect differed by individual characteristics. The mean retest effect for general cognitive performance was 0.60 standard deviations (95% confidence interval [0.46, 0.74]), and was similar for memory, executive functioning, and language. Retest effects were greater for participants in the lowest quartile of cognitive performance (many of whom met criteria for dementia based on a study algorithm), consistent with regression to the mean. Retest did not differ by other characteristics. Retest effects are large in this community-based sample, but do not vary by demographic or dementia-related characteristics. Differential retest effects may not limit the generalizability of inferences across different groups in longitudinal research.

Relationship Between Type 2 Diabetes Mellitus and Cognitive Change in a Multiethnic Elderly Cohort.

OBJECTIVES: To examine the association between diabetes mellitus and cognitive functioning at baseline and cognitive change over time in a large, ethnically diverse sample of older adults. DESIGN: Prospective cohort study. SETTING: Washington Heights-Inwood Columbia Aging Project, a community-based, prospective study of risk factors for dementia in northern Manhattan, New York City. PARTICIPANTS: Hispanic, non-Hispanic black, and non-Hispanic white men and women aged 65 and older without dementia at baseline (N = 1,493). MEASUREMENTS: Participants underwent baseline and follow-up cognitive and health assessments approximately every 18 months. Generalized estimating equations were used to examine the longitudinal association between diabetes mellitus and cognition. RESULTS: Diabetes mellitus was associated with poorer baseline cognitive performance in memory, language, processing speed and executive functioning, and visuospatial abilities. After adjusting for age, education, sex, race and ethnicity, and apolipoprotein-ε4, participants with diabetes mellitus performed significantly worse at baseline than those without in language and visuospatial abilities. There were no differences between those with and without diabetes mellitus in terms of rate of cognitive change over a mean follow-up time of 6 years. CONCLUSION: The rate of cognitive change in elderly persons with and without diabetes mellitus is similar, although cognitive performance is poorer in persons with diabetes mellitus. These findings suggest that cognitive changes may occur early during the diabetes mellitus process and highlight the need for studies to follow participants beginning at least in midlife, before the typical later-life onset of dementia.

The role of early-life educational quality and literacy in explaining racial disparities in cognition in late life.

OBJECTIVES: Racial disparities in late-life cognition persist even after accounting for educational attainment. We examined whether early-life educational quality and literacy in later life help explain these disparities. METHOD: We used longitudinal data from the Washington Heights-Inwood Columbia Aging Project (WHICAP). Educational quality (percent white students; urban/rural school; combined grades in classroom) was operationalized using canonical correlation analysis. Late-life literacy (reading comprehension and ability, writing) was operationalized using confirmatory factor analysis. We examined whether these factors attenuated race-related differences in late-life cognition. RESULTS: The sample consisted of 1,679 U.S.-born, non-Hispanic, community-living adults aged 65-102 (71% black, 29% white; 70% women). Accounting for educational quality and literacy reduced disparities by 29% for general cognitive functioning, 26% for memory, and 32% for executive functioning but did not predict differences in rate of cognitive change. DISCUSSION: Early-life educational quality and literacy in late life explain a substantial portion of race-related disparities in late-life cognitive function.

Association of vascular risk factors with cognition in a multiethnic sample.

OBJECTIVES: To examine the relationship between cardiovascular risk factors (CVRFs) and cognitive performance in a multiethnic sample of older adults. METHOD: We used longitudinal data from the Washington Heights-Inwood Columbia Aging Project. A composite score including smoking, stroke, heart disease, diabetes, hypertension, and central obesity represented CVRFs. Multiple group parallel process multivariate random effects regression models were used to model cognitive functioning and examine the contribution of CVRFs to baseline performance and change in general cognitive processing, memory, and executive functioning. RESULTS: Presence of each CVRF was associated with a 0.1 SD lower score in general cognitive processing, memory, and executive functioning in black and Hispanic participants relative to whites. Baseline CVRFs were associated with poorer baseline cognitive performances among black women and Hispanic men. CVRF increase was related to baseline cognitive performance only among Hispanics. CVRFs were not related to cognitive decline. After adjustment for medications, CVRFs were not associated with cognition in Hispanic participants. DISCUSSION: CVRFs are associated with poorer cognitive functioning, but not cognitive decline, among minority older adults. These relationships vary by gender and medication use. Consideration of unique racial, ethnic, and cultural factors is needed when examining relationships between CVRFs and cognition.

Modelling longitudinal changes in older adults' memory for spoken discourse: findings from the ACTIVE cohort.

Episodic memory shows substantial declines with advancing age, but research on longitudinal trajectories of spoken discourse memory (SDM) in older adulthood is limited. Using parallel process latent growth curve models, we examined 10 years of longitudinal data from the no-contact control group (N = 698) of the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) randomised controlled trial in order to test (1) the degree to which SDM declines with advancing age, (2) the predictors of these age-related declines and (3) the within-person relationship between longitudinal changes in SDM and longitudinal changes in fluid reasoning and verbal ability over 10 years, independent of age. Individuals who were younger, were White, had more years of formal education, were male and had better global cognitive function and episodic memory performance at baseline demonstrated greater levels of SDM on average. However, only age at baseline uniquely predicted longitudinal changes in SDM, such that declines accelerated with greater age. Independent of age, within-person decline in reasoning ability over the 10-year study period was substantially correlated with decline in SDM (r = .87). An analogous association with SDM did not hold for verbal ability. The findings suggest that longitudinal declines in fluid cognition are associated with reduced spoken language comprehension. Unlike findings from memory for written prose, preserved verbal ability may not protect against developmental declines in memory for speech.

Video game training to improve selective visual attention in older adults.

The current study investigated the effect of video game training on older adult's useful field of view performance (the UFOV® test). Fifty-eight older adult participants were randomized to receive practice with the target action game (Medal of Honor), a placebo control arcade game (Tetris), a clinically validated UFOV training program, or into a no contact control group. Examining pretest-posttest change in selective visual attention, the UFOV improved significantly more than the game groups; all three intervention groups improved significantly more than no-contact controls. There was a lack of difference between the two game conditions, differing from findings with younger adults. Discussion considers whether games posing less challenge might still be effective interventions for elders, and whether optimal training dosages should be higher.

Dual-task effects of simulated lane navigation and story recall in older adults with and without memory impairment.

While driving is a complex task, it becomes relatively automatic over time although unfamiliar situations require increased cognitive effort. Much research has examined driving risk in cognitively impaired elders and found little effect. This study assessed whether mildly memory impaired elders made disproportionate errors in driving or story recall, under simultaneous simulated driving and story recall. Forty-six healthy (61% women; mean age = 76.4) and 15 memory impaired (66% women, mean age = 79.4) elders participated. Cognitive status was determined by neuropsychological performance. Results showed that during dual-task conditions, participants stayed in lane more, and recalled stories more poorly, than when they did the tasks separately. Follow-up analysis revealed that verbatim recall, in particular, was reduced while driving for healthy participants. While memory impaired participants performed more poorly than healthy controls on both tasks, cognitive status was not associated with greater dual-task costs when driving and story recall were combined.

The influence of cognitive training on older adults' recall for short stories.

OBJECTIVE: This article investigated how a multicomponent memory intervention affected memory for prose. We compared verbatim and paraphrased recall for short stories immediately and 1, 2, 3, and 5 years post-intervention in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) sample. METHOD: We studied 1,912 ACTIVE participants aged 65 to 91. Participants were randomized into one of three training arms (Memory, Reasoning, Speed of Processing) or a no-contact Control group; about half of the trained participants received additional booster training 1 and 3 years post-intervention. RESULTS: Memory-trained participants showed higher verbatim recall than non-memory-trained participants. Booster-memory training led to higher verbatim recall. Memory training effects were evident immediately following training and not after 1 year following training. DISCUSSION: Results suggest that multifactorial memory training can improve verbatim recall for prose, but the effect does not last without continued intervention.

Neighborhood Influences on Late Life Cognition in the ACTIVE Study.

Low neighborhood-level socioeconomic status has been associated with poorer health, reduced physical activity, increased psychological stress, and less neighborhood-based social support. These outcomes are correlates of late life cognition, but few studies have specifically investigated the neighborhood as a unique source of explanatory variance in cognitive aging. This study supplemented baseline cognitive data from the ACTIVE (Advanced Cognitive Training for Independent and Vital Elderly) study with neighborhood-level data to investigate (1) whether neighborhood socioeconomic position (SEP) predicts cognitive level, and if so, whether it differentially predicts performance in general and specific domains of cognition and (2) whether neighborhood SEP predicts differences in response to short-term cognitive intervention for memory, reasoning, or processing speed. Neighborhood SEP positively predicted vocabulary, but did not predict other general or specific measures of cognitive level, and did not predict individual differences in response to cognitive intervention.

Older adults' engagement with a video game training program.

OBJECTIVES: The current study investigated older adults' level of engagement with a video game training program. Engagement was measured using the concept of Flow (Csikszentmihalyi, 1975). METHODS: Forty-five older adults were randomized to receive practice with an action game (Medal of Honor), a puzzle-like game (Tetris), or a gold-standard Useful Field of View (UFOV) training program. RESULTS: Both Medal of Honor and Tetris participants reported significantly higher Flow ratings at the conclusion, relative to the onset of training. DISCUSSION: Participants are more engaged in games that can be adjusted to their skill levels and that provide incremental levels of difficulty. This finding was consistent with the Flow theory (Csikszentmihalyi, 1975).

Event-related fMRI of category learning: differences in classification and feedback networks.

Eighteen healthy young adults underwent event-related (ER) functional magnetic resonance imaging (fMRI) of the brain while performing a visual category learning task. The specific category learning task required subjects to extract the rules that guide classification of quasi-random patterns of dots into categories. Following each classification choice, visual feedback was presented. The average hemodynamic response was calculated across the eighteen subjects to identify the separate networks associated with both classification and feedback. Random-effects analyses identified the different networks implicated during the classification and feedback phases of each trial. The regions included prefrontal cortex, frontal eye fields, supplementary motor and eye fields, thalamus, caudate, superior and inferior parietal lobules, and areas within visual cortex. The differences between classification and feedback were identified as (i) overall higher volumes and signal intensities during classification as compared to feedback, (ii) involvement of the thalamus and superior parietal regions during the classification phase of each trial, and (iii) differential involvement of the caudate head during feedback. The effects of learning were then evaluated for both classification and feedback. Early in learning, subjects showed increased activation in the hippocampal regions during classification and activation in the heads of the caudate nuclei during the corresponding feedback phases. The findings suggest that early stages of prototype-distortion learning are characterized by networks previously associated with strategies of explicit memory and hypothesis testing. However as learning progresses the networks change. This finding suggests that the cognitive strategies also change during prototype-distortion learning.