The Role of State Versus Trait Anxiety on Cognition in Older Adults With Major Depressive Disorder.

OBJECTIVE: Anxiety superimposed on late life depression (LLD) results in greater changes to prefrontal and medial temporal brain regions compared to depression alone. Yet, the combined impact of anxiety and depression on cognition in LLD has not been thoroughly investigated. The current study investigated whether annual changes in state and trait anxiety were associated with cognitive changes in older adults with major depression. We hypothesized that the presence of anxiety among older depressed adults would be associated with worse cognitive performance in the domains of memory and executive functioning over time. DESIGN: Three-year longitudinal observational study of older adults with LLD who were offered antidepressant treatment. SETTING: Academic Health Center. METHODS: Participants included 124 adults aged 60+ who met criteria for major depression at baseline. The association between anxiety and cognition was examined with separate multilevel linear models that addressed both between-subject and within-person effects of state and trait anxiety on cognitive functioning tests. RESULTS: Individuals who experienced annual increases in anxiety above his/her personal average also experienced cognitive decline. Increases in state anxiety were associated with declines in memory and global cognition. By contrast, increases in trait anxiety were associated with declines in mental flexibility and memory. These findings remained significant even when controlling for changes in depression over time. CONCLUSION: In LLD, individual increases in state and trait anxiety were associated with cognitive declines in different domains.

Factor Structure of the Repeatable Battery for the Assessment of Neuropsychological Status in Huntington's Disease.

OBJECTIVE: The Repeatable Battery for the Assessment of Neuropsychological Status is a commonly used neuropsychological screening tool that is useful in a Huntington's disease (HD) population given its relatively brief administration time and assessment of multiple cognitive domains. Although 5 index scores are calculated, this structure has not been universally supported in clinical samples, which have often found a two- and three-factor structure to be better fitting. This study explored the Repeatable Battery for the Assessment of Neuropsychological Status factor structure in a large HD sample, which has not been done to date. METHOD: In total, 147 individuals with HD completed the Repeatable Battery for the Assessment of Neuropsychological Status. An exploratory factor analysis was conducted to explore the Repeatable Battery for the Assessment of Neuropsychological Status factor structure. RESULTS: Consistent with the findings from a majority of other clinical samples investigated, our results revealed a better fitting two-factor structure (verbal and visual). CONCLUSION: The traditional Repeatable Battery for the Assessment of Neuropsychological Status index structure may not be valid in HD, which yields important clinical and research implications.

Psychometrics of the AAN Caregiver Driving Safety Questionnaire and contributors to caregiver concern about driving safety in older adults.

ABSTRACTBackground:The American Academy of Neurology (AAN) updated their practice parameters in the evaluation of driving risk in dementia and developed a Caregiver Driving Safety Questionnaire, detailed in their original manuscript (Iverson Gronseth, Reger, Classen, Dubinsky, & Rizzo, 2010). They described four factors associated with decreased driving ability in dementia patients: history of crashes or citations, informant-reported concerns, reduced mileage, and aggressive driving. METHOD: An informant-reported AAN Caregiver Driving Safety Questionnaire was designed with these elements, and the current study was the first to explore the factor structure of this questionnaire. Additionally, we examined associations between these factors and cognitive and behavioral measures in patients with mild cognitive impairment or early Alzheimer's disease and their informants. RESULTS: Exploratory factor analysis revealed a four-component structure, consistent with the theory behind the AAN scale composition. These four factor scores also were significantly associated with performance on cognitive screening instruments and informant reported behavioral dysfunction. Regressions revealed that behavioral dysfunction predicted caregiver concerns about driving safety beyond objective patient cognitive dysfunction. CONCLUSIONS: In this first known quantitative exploration of the scale, our results support continued use of this scale in office driving safety assessments. Additionally, patient behavioral changes predicted caregiver concerns about driving safety over and above cognitive status, which suggests that caregivers may benefit from psychoeducation about cognitive factors that may negatively impact driving safety.

Do statins impair cognition? A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: In 2012, the United States Food and Drug Administration (FDA) issued a warning regarding potential adverse effects of HMG-CoA reductase inhibitors (statins) on cognition, based on the Adverse Events Reporting System and a review of the medical literature. We aimed to synthesize randomized clinical trial (RCTs) evidence on the association between statin therapy and cognitive outcomes. METHODS: We searched MEDLINE, EMBASE, and Cochrane CENTRAL through December 2012, and reviewed published systematic reviews of statin treatment. We sought RCTs that compared statin treatment versus placebo or standard care, and reported at least one cognitive outcome (frequency of adverse cognitive events or measurements using standard neuropsychological cognitive test scores). Studies reporting sufficient information to calculate effect sizes were included in meta-analyses. Standardized and unstandardized mean differences were calculated for continuous outcomes for global cognition and for pre-specified cognitive domains. The main outcome was change in cognition measured by neuropsychological tests; an outcome of secondary interest was the frequency of adverse cognitive events observed during follow-up. RESULTS: We identified 25 RCTs (all placebo-controlled) reporting cognitive outcomes in 46,836 subjects, of which 23 RCTs reported cognitive test results in 29,012 participants. Adverse cognitive outcomes attributable to statins were rarely reported in trials involving cognitively normal or impaired subjects. Furthermore, meta-analysis of cognitive test data (14 studies; 27,643 participants) failed to show significant adverse effects of statins on all tests of cognition in either cognitively normal subjects (standardized mean difference 0.01, 95% confidence interval, CI, -0.01 to 0.03, p = 0.42) or Alzheimer's disease subjects (standardized mean difference -0.05, 95% CI -0.19 to 0.10, p = 0.38). CONCLUSIONS: Statin therapy was not associated with cognitive impairment in RCTs. These results raise questions regarding the continued merit of the FDA warning about potential adverse effects of statins on cognition.

Family Intervention: Telephone Tracking (FITT): a pilot stroke outcome study.

OBJECTIVE: The goal of this study was to preliminarily test the efficacy of a telephone intervention, Family Intervention: Telephone Tracking, designed to assist stroke survivors and their primary caregivers during the first 6 months after stroke. METHOD: Forty-nine stroke survivors and their caregivers were randomly assigned to treatment as usual or treatment as usual plus the telephone intervention. Global outcomes are reported for health care utilization, family functioning, and general functioning. RESULTS: Family and general functioning were positively and significantly changed at 3 and 6 months. Health care utilization was positively and significantly changed at 3 months. CONCLUSION: Findings suggest that the model has the potential to decrease health care utilization and improve quality of life for stroke survivors and their caregivers. Further study is warranted.

Screening for Mild Cognitive Impairment Using the Dementia Rating Scale-2.

This study examined the sensitivity and specificity of the Dementia Rating Scale-2 (DRS-2) to distinguish individuals with mild cognitive impairment (MCI) from both patients with Alzheimer's disease (AD) and healthy controls (HCs). A total of 50 HCs, 98 patients with MCI, and 49 patients with AD completed a neurological examination and battery of neuropsychological tests that included the DRS-2. Across almost all subscales of the DRS-2, patients with AD scored significantly worse than patients with MCI who in turn performed more poorly than the HCs. The only exception was the construction subscale where no significant difference was found between patients with MCI and the HCs. At a cutoff of 136, the sensitivity was 71% and specificity was 86% for distinguishing between patients with MCI and the HCs. Sensitivity was 82% and specificity was 78% for distinguishing between patients with MCI and patients with AD (cutoff score <124). For distinguishing between patients (with MCI and AD) and the HCs, sensitivity was 81% and specificity was 86% at a cutoff of 136. Our findings suggest the DRS-2 is a brief, easily administered cognitive test that appears to be useful in assisting with the detection of MCI.

Dimensions of caregiver burden in dementia: impact of demographic, mood, and care recipient variables.

OBJECTIVE: While typically examined as a unitary construct, there is evidence that caregiver burden may be composed of several dimensions. The purpose of this study was to examine the factor structure of the Zarit Burden Interview (ZBI) in a sample of dementia caregivers and to explore the relationship between these factors and demographic, mood, and care recipient variables. DESIGN: Cross-sectional. SETTING: Academic medical center. PARTICIPANTS: 206 spousal or adult child caregivers for patients with mild to moderate dementia residing in the community. MEASUREMENTS: Caregiver measures included the ZBI, Center for Epidemiologic Studies Depression Scale, and the Burns Relationship Satisfaction Scale. Patient measures included scores on the Dementia Rating Scale, Lawton-Brody Activities of Daily Living scale, and Revised Memory and Behavior Problems Checklist. RESULTS: Factor analysis revealed three dimensions of caregiver burden: direct impact of caregiving upon caregivers' lives, guilt, and frustration/embarrassment. Caregiver depression and age emerged as unique predictors of the first two factors. Caregivers' satisfaction with their relationship with the patient and patients' functional independence also uniquely predicted the direct impact of caregiving upon caregivers' lives. Patients' behavioral problems and caregivers' level of relationship satisfaction with the care recipient served as unique predictors of frustration/embarrassment. CONCLUSIONS: Findings demonstrate the multidimensionality of caregiver burden among dementia caregivers. Given the unique predictors of each dimension of burden, caregivers may benefit from different types of tailored interventions specific to the subtype of burden they are experiencing.

Processing speed in normal aging: effects of white matter hyperintensities and hippocampal volume loss.

Changes in cognitive functioning are said to be part of normal aging. Quantitative MRI has made it possible to measure structural brain changes during aging which may underlie these decrements which include slowed information processing and memory loss. Much has been written on white matter hyperintensities (WMH), which are associated with cognitive deficits on tasks requiring processing speed and executive functioning, and hippocampal volume loss, which is associated with memory decline. Here we examine volumetric MRI measures of WMH and hippocampal volume loss together in relation to neuropsychological tests considered to be measures of executive functioning and processing speed in 81 non-demented elderly individuals, aged 75-90. Correlational analysis showed that when controlling for age, both greater WMH volume and smaller hippocampal volume were correlated with slower performances on most tests with the exception of a battery of continuous performance tests in which only WMH was correlated with slower reaction time (RT). We then performed a series of hierarchical multiple regression analyses to examine the independent contributions of greater WMH volume and reduced hippocampal volume to executive functioning and processing speed. The results showed that for the four measures requiring executive functioning and speed of processing, WMH volume and hippocampal volume combined predicted between 21.4% and 37% of the explained variance. These results suggest that WM integrity and hippocampal volume influence cognitive decline independently on tasks involving processing speed and executive function independent of age.

Self-reported depressive syndromes in mild cognitive impairment and mild Alzheimer's disease.

BACKGROUND: There is suggestion that self-reported depressive syndromes can independently manifest in the general population as cognitive/affective or somatic/vegetative. The Beck Depression Inventory, 2nd edition (BDI-II), a self-report measure of depressive symptoms, has been shown to support this two-factor structure. However, this finding has not been examined in an older adult sample with cognitive impairment. In order to determine whether older adults with cognitive impairments exhibit similarly independent cognitive/affective and somatic/vegetative depressive syndromes, we explored the factor structure of the BDI-II in this population. METHODS: Participants were 228 older adults (mean age = 74, SD = 7.9) diagnosed with mild cognitive impairment (MCI; n = 137) or early Alzheimer's disease (n = 85), who completed the BDI-II as part of an outpatient neuropsychological evaluation. Exploratory principal component factor analysis with direct Oblimin rotation was conducted, and a two-factor solution was specified based on our theoretical conceptualization of the cognitive/affective and somatic/vegetative items from the scale. RESULTS: The first factor represented cognitive/affective symptoms of depression (e.g. self-dislike, pessimism, worthlessness), and accounted for 36% of the variance. Adding the second factor, reflecting somatic/vegetative items (e.g. sleep and appetite changes, loss of energy), accounted for an additional 6.8% of the variance. CONCLUSION: Results supported the presence of two distinct depressive syndromes, cognitive/affective and somatic/vegetative symptoms. Thus, cognitively impaired older adults report mood symptoms relatively similarly to younger and midlife adults. This supports the validity of self-reported mood in this group, and the results may have implications for psychiatric treatment in this population.

Caregiver burden and depression in mild cognitive impairment.

Little is known about contributors to burden and depression in caregivers of patients with mild cognitive impairment (MCI) even though these patients experience cognitive, emotional, and behavioral changes. We examined caregiver burden and depression in 43 caregivers for patients with MCI as well as their associations with patients' neuropsychological status and behavioral symptoms. Almost 30% of caregivers reported clinically significant burden, whereas <5% reported significant depression. Increased caregiver burden was associated with greater disinhibited behaviors by patients, whereas increased caregiver depressive symptoms were associated with greater disinhibited behaviors as well as instrumental activity of daily living (ADL) impairments. Caregiver burden and depression were not associated with patients' neuropsychological performance. Results suggest these caregivers would benefit from interventions addressing both practical methods to provide ADL assistance and behavioral methods to address inappropriate behaviors in patients in the predementia stages.

Predicting functional impairments in cognitively impaired older adults using the Minnesota Cognitive Acuity Screen.

Despite their growing use, few studies have examined the associations between patients' performance on brief telephone-based cognitive assessments and their functional status. The purpose of this study was to examine the relationship between the Minnesota Cognitive Acuity Screen (MCAS), a very brief telephone-based dementia screening instrument, and functional impairment as rated by the Clinical Dementia Rating (CDR) scale in a sample of 176 individuals diagnosed with mild cognitive impairment or dementia. Results showed lower MCAS scores were correlated with poorer daily function as measured by CDR global scores and domain scores, and the MCAS orientation subscale was one of the strongest subscales in predicting functional status as it was uniquely predictive of all CDR domains. Findings suggest the MCAS appears to be useful in predicting patients' level of daily function and may be useful for quickly and easily monitoring patients' cognitive and functional status over time.

Neuropsychologists' beliefs about alcohol and dementia.

Alcohol-related dementia (ARD) is a controversial concept, and the prevailing view of neuropsychologists regarding this disorder is unknown. The purpose of this study was to gain an understanding of neuropsychologists' beliefs and practices regarding ARD. A total of 140 board-certified neuropsychologists completed an anonymous online survey about alcohol and dementia. Almost all respondents (93%) reported alcohol has direct neurotoxic effects, but most were unsure whether moderate alcohol use can be neuroprotective. The presence and course of cognitive deficits as well as functional impairments were rated as the most important factors to consider when making this diagnosis, and declines in memory, executive functions, and processing speed were most frequently observed cognitive changes. Neuropsychologists were mixed in their opinions about cognitive prognosis, with half the sample endorsing stability of cognitive deficits and about one-third of the group indicating gradual improvement. Although laboratory workup was not a major diagnostic consideration, 68% of respondents recommended treatment with vitamins and nutritional supplements. Findings are consistent with the research literature and suggest that while neuropsychologists generally believe alcohol can have direct neurotoxic effects, they vary in their beliefs about diagnosis, treatment, and prognosis. Future research should focus on providing diagnostic and treatment guidelines for ARD.

Use of the telephone-administered Minnesota Cognitive Acuity Screen to detect mild cognitive impairment.

This study determined the sensitivity and specificity of the telephone-administered Minnesota Cognitive Acuity Screen (MCAS) to distinguish mild cognitive impairment (MCI) from healthy controls (HCs) and from Alzheimer's disease (AD). A total of 100 individuals with MCI, 50 individuals with possible/probable AD, and 50 HCs were screened to exclude medical and psychiatric conditions affecting cognition. In-office evaluation included neuropsychological testing, neurologic examination, and neurodiagnostic work-up. Participants with AD obtained significantly lower MCAS total scores than participants with MCI, who in turn performed worse than the HC group. Sensitivity was 86% and specificity was 78% for distinguishing between MCI and HC. Sensitivity was 86% and specificity was 77% for discriminating between MCI and AD. Sensitivity was 91% and specificity was 78% for discriminating between impaired groups (MCI and AD) and HCs. Results suggest that the MCAS successfully discriminates MCI from HC and AD and has potential as an effective telephone-administered screening tool for memory disorders.