News for Professionals Archives
Insomnia & Suicidal Ideation in Older Adults
Insomnia is more prevalent among older adults than in any other age group. It is interesting to note that older adults, especially men, struggle with insomnia but often accept less sleep without complaint. Suicide rates for adults aged 65 and older are more than 30% higher than for those below age 65. The rate of suicide attempts to death is disturbingly high for older adults with a ratio of 4:1. Lethal suicide attempts by younger people as a whole is 25:1. Michael Nadorff and his colleagues designed a study to investigate the possible connection between insomnia and suicidal ideation in older adults.
Key study features:
- 81 adults aged 65 and older participated
- Participants completed surveys about sleep, symptoms of depression, and suicidal ideation
- They found that insomnia symptoms were significantly related to suicidal ideation
- They also found that the relationship between insomnia was mediated by depressive symptoms
The “take-away” – Insomnia often precedes depression in late life, and when untreated, tends to make depressive symptoms worse. Insomnia can be a risk factor for suicide, as it can exacerbate depressive symptoms which can ultimately lead to suicidal ideation.
This study can be found in the Journals of Gerontology, Series B (March, 2013).
Let Me Guess How Old You Are
So you think that you’re good at guessing someone’s age? Maybe not. Voelkle and colleagues recently investigated accuracy and bias in age estimation across the adult life span. For this purpose, they selected 154 adults (young, middle and older adults) of both genders and asked them to assign ages for 171 young, middle, and older adult faces. They used over 2000 photographs portraying different facial expressions. What did they find?
- The age of older faces was more difficult to estimate than younger faces.
- Older and younger adults were more accurate and less biased in estimating the age of members of their own age group.
- No same-gender bias was found (e.g., women were no better at estimating age of other women then they were estimating age of men).
- In general, age estimation accuracy decreases with age
For more information about this study, see Psychology & Aging (June 2012).
The Impact of Emotion on Associative Memory Among Older Adults
Associative memory refers to the ability to remember features of a person, object, or event as a whole experience. There is research suggesting that as we age, we tend to lose associative memory clarity. This may be related to structural changes in the prefrontal cortex and hippocampus. Strong negative emotion has been found to interfere with associative memory for all adults. A recent study was reported in which the authors examined whether emotion impairs associative memory more dramatically among older adults than younger adults.
Key study features:
- 32 young adults and 32 older adults participated in the study.
- While there were differences between the two groups in terms of associative memory (younger subjects did better than older subjects), negative emotions did not inhibit memory performance more dramatically among the older sample than it did for the younger adult sample.
For more information on this study, click here.
Late-Life Cognitive Activity on Cognitive Health
A growing body of longitudinal studies is finding that frequent participation in cognitively stimulating activities is associated with decreased rates of cognitive decline in old age. In the April edition of Neurology, Wilson and colleagues tested the hypothesis that late-life participation in mentally stimulating activities positively affects cognitive functioning among older adults. They followed and analyzed results from over a thousand older adults using a longitudinal design (over nearly five years). Cognitive functioning was measured by administering a neuro-cognitive battery of tests. Cognitive activities were measured by administering a 7-item, 5-point scale. The researchers found that level of cognitive activity on a given year predicted global cognitive function in the following year. They report that this demonstrates that mental stimulation in old age leads to improved cognitive functioning. One should keep in mind that the results are based on self-reported cognitive activity and are subject to reporter bias. Also, persons with dementia were excluded from the study. Therefore, the results may not generalize to persons who already have cognitive impairment.
Do Older Adults Regularly Use the Internet?
Do older adults regularly use the Internet? According to a recently published survey by the Pew Research Center, 53% of American adults ages 65 and older use the Internet or email.
Some other interesting findings from the Pew study:
- If they start using the Internet, most older adults will use it daily (70%)
- After age 75, Internet use drops off sharply
- 70% of seniors own a cell phone, which is up from 57% two years ago
- Nearly one third of the seniors who are online use social networking sites like Facebook and LinkedIn
- Whereas 18% of all adults own e-book readers, only 3% of people over 75 do
- Email continues to be the dominant online communication tool for seniors
- Of those seniors who use the Internet, 86% use email
Empathy & Age
One common definition of empathy is the propensity to “experience perspectives and feelings more congruent with another’s situation than with [one’s] own” (Decety & Lamm, 2006). Quite a lot of research has investigated empathy in people younger than 65, but relatively little has focused on older adults. Ed O’Brien and his colleagues recently compared self-reported empathy in three large cross-sectional samples of American adults aged 18-90.
Key study features:
- Over 72,000 subjects participated across the three samples
- Participants completed the Interpersonal Reactivity Index (Davis, 1983), which measures “empathic concern” and “perspective taking.”
- In all three samples, empathy conformed to an inverse-U-shaped curve: Middle-aged adults reported higher empathy than both young adults and older adults.
- Another finding was that women reported more empathy than men.
To learn more about this study, see the Journals of Gerontology: Series B (March, 2013).
BCAT Certification Through e-Learning
We are happy to announce that healthcare professionals who are interested in using the BCAT Test System can become certified through our online course beginning May 15, 2013. This is a three-hour e-learning program that focuses on all five of The BCAT System tests. Successful completion of this Certified BCAT Test System Administrator course will be required in order to use the BCAT, BCAT-Short Form, WIPE Depression Screen, Kitchen Picture Test of Judgment (KPT), and the BCIS (for severe cognitive impairment). For many healthcare disciplines, continuing education credits for this three-hour course will be available. More information will soon be available on the BCAT University page.
Impact of GED Education on Incident IADLs
For years, research has demonstrated that education matters when it comes to predicting morbidity, mortality, and functional disability. Those with less than a high school education are at higher risk for each. Given the increasing number of people who obtain the General Educational Development (GED) diploma, it may prove helpful to understand whether the GED is predictive of functional disability. In a recently published article by Liu and colleagues (The Gerontologist, April, 2013), findings are presented from research investigating whether adults 50 years and older with GEDs have increased risk for incident instrumental activities of daily living (IADLs) as compared with high school graduates.
Key study findings:
- Survey data
- 9426 subjects from the Health and Retirement Study
- HS degree holders had lower risks for incident IADLs
- No significant differences were found between GED holders and respondents without HS degrees in terms of developing IADL disabilities
The “Take-away” – While GEDs may be seen as equivalent to high school diplomas, in terms of functions status (IADLs), they are not. In fact, GED holders more resemble persons without HS credentials than they do HS graduates in terms of functional disabilities.
30-Day Rehospitalizations & Post-Acute Nurse Retention
After acute hospitalization, many older adults with complex medical conditions are directly discharged to skilled nursing facilities for post-acute or long-term care. Approximately one fourth of these Medicare skilled nursing home transfers will be readmitted to hospitals within 30 days. It has been estimated that 28-40% of these could have been prevented with higher quality post-acute nursing home care. Previous research has linked nursing home quality to licensed nurse retention. To better understand whether nurse retention is associated with 30-day rehospitalizations, Kali Thomas and her colleagues investigated the possible association between the two.
Key study features:
- The used archival data from 681 Florida nursing homes
- They found that licensed nurse retention in nursing homes was significantly related to the 30-day hospital readmission rate
- Higher retention was associated with few readmissions
This study is published in The Gerontologist, 53(3), 211-221.
Time Discrimination in Traumatic Brain Injury Patients
Time management skills are required for most daily activities. While the traumatic brain injury (TBI) literature is full of indications that TBI patients suffer from cognitive impairments, few studies have looked at time management skills. Mioni, Stablum, and Cantagallo (JCEN, 2012) designed a study to assess temporal abilities in TBI patients using a time discrimination task.
Twenty-seven TBI patients (ages = 18–60 years) and 27 controls (ages = 20–60 years) were asked to discriminate between two time intervals presented sequentially. Participants were also asked to perform two tasks to assess attention, speed-of-processing (the Stroop task), and working memory (the n-back task) abilities.
Primary finding: The TBI patients were less accurate than the controls on the time discrimination task and showed greater time-order error effects.
Cognitive Processing Speed in Persons with Multiple Sclerosis
Patients, families, and practitioners have observed that Multiple Sclerosis (MS) patients can experience delays in cognitive processing speed (CPS). In an attempt to understand underlying factors that may contribute to these delays, Sandroff and Motl published their research findings in a recent edition of the Journal of Clinical and Experimental Neuropsychology (2012).
They designed a cross-sectional study examining associations among aerobic capacity, muscle strength, balance, and cognitive processing speed (CPS). 31 persons with multiple sclerosis (MS) and 31 matched controls participated. Participants completed neuropsychological tests and aerobic capacity (i.e., peak oxygen consumption), muscular strength (i.e., asymmetry between knee muscles), and balance (i.e., postural sway) assessments.
They found that aerobic capacity (r = .27), postural sway (r = −.40), and knee extensor asymmetry (r = −.25) were associated with CPS in those with MS and accounted for differences in CPS between MS and control groups. This was a cross-sectional study reporting correlational data (does not imply that these factors actually cause cognitive processing delay, but that they are associated with it). One implication of their findings is that aerobic, balance, and resistance training might be avenues for improving CPS in this population.
Social Support and Religious Attendance in Later Life
A considerable amount of research has documented that older adults are more at risk for loneliness and associated negative health consequences. Retirement, relocation, spousal and other deaths, and social migration can make social networks smaller. Some research suggests that one of the motivating factors in religious attendance (e.g., attending services, going to congregational events) is to either hold onto or increase social integration and support. Rote, Hill, and Ellison (2013) tested their model that social integration and social support are key mechanisms that link religious attendance and loneliness.
Key study features:
- They used data from the national Social Life, Health, and Aging Project (data from 2165 subjects were selected)
- Subjects were aged 57-85
- The researchers found that religious attendance was associated with higher levels of social integration and social support, and that social integration and social support were associated with lower levels of reported loneliness.
- They conclude that religious attendance may protect older adults against loneliness by integrating them into a larger and supportive social network.
For more information about this study, click here.
Programs that Locate Wandering Elders
Given an aging society and increased life expectancies, the incidents of “wandering” of older adults with cognitive deficits will increase. While there are several programs developed to locate wanderers, there is actually little research on how effective they may be in locating wanders, and whether they are significantly more effective than informal efforts. Gina Petonito and her colleagues address this and other issues in a recently published article in The Gerontologist (2013). They review three prominent programs: Safe Return, Project Lifesaver, and Silver Alert.
- Regarding Safe Return: The program was established in 1993 by the Alzheimer’s Association. AA partnered with MedicAlert. Funding comes from a one-time enrollment fee of approximately $50 and annual renewals of $25. It is a 24-hour national program maintaining a database of 145,000 registered individuals. Registrants wear an identifying bracelet of necklace. If a user is missing, caregivers call an emergency telephone number.
- Regarding Project Lifesaver: Targets people with “Alzheimer’s, Autism, Down Syndrome, dementia, and other related disorders.” Enrolled individuals wear a transmitter. Caregivers notify their local Project Lifesaver if a member is missing. The company partners with for-profit agencies that supply the locating equipment. Funding comes from donations, a Department of Justice grant, and individual enrollment (about $25).
- Regarding Silver Alert: Relies on integrating media, traffic signs, and law enforcement to inform the public of missing older adults who are cognitively impaired. The program also often broadcasts information about the missing person through television stations. The first program was established in 2006 in Georgia, and now at least 32 states have the program. There is a bill to nationalize the program. It is a free program based on the Amber Alert concept.
The researchers point out that it is unclear just how effective these programs are in locating cognitively impaired wanders. More research should be done to test them, and determine what features are most effective. They advocate that different categories of “missing” be established, differentiating among wandering, actually missing, and critical risk factors.
Reducing Hospital Readmissions by Improving Nurse Working Conditions
Can nursing work factors affect hospital readmission rates? Provisions in the Affordable Care Act increase hospitals’ financial accountability if readmissions occur too quickly after discharge. In an interesting study by McHugh and colleagues published in the journal Medical Care, there is support for the idea that improving nurses’ hospital work and staffing patterns may be effective in preventing readmissions.
Key study features:
- Data came from 412 California, New Jersey, and Pennsylvania hospital nurses surveys, as well as the American Hospital Association Annual Survey
- Hospitals with “good” working conditions (a factor of work environment, staffing patterns, nurse education) experienced reductions in 30-day readmissions for heart failure, heart attack, and pneumonia, compared with hospitals with poorer working conditions
- Highly educated nurses were associated with modest improvement in reduced readmissions for pneumonia, but not for heart conditions
- One implication is that hospitals might want to invest in improving work environment variables to reduce 30-day readmissions.
For more information on this study, click here.
"Social Slights" Among Older Adults
Social contacts and conversations are central to our well-being. While individuals differ as to how much they require, generally speaking, insufficient social stimulation has a negative impact on our psychological and somatic health. Previous research has shown that older adults might be less negatively impacted by “social slights” or exclusion from social interactions than younger adults. Why this may be the case is unclear. In an attempt to add to our understanding of this, Löckenhoff and her colleagues published their findings on social exclusion in The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences (2013).
- 40 younger adults (22-39) and 40 older adults (58-89) participated
- Participates played a version of “Cyberball,” in which they were progressively excluded
- Older adults were less likely than younger adults to respond negatively to mild levels of social exclusions
- However, both groups responded similarly to pronounced social exclusion
While not specifically addressed in this research, the generalizability of these findings to assisted-living and nursing facilities is interesting. Both types of facilities have complex social and residential dynamics. If it is the case that more pronounced social exclusion does negatively impact on well-being, facilities should be mindful in their design of activity programs to promote positive social interactions and reduce social exclusion.
Bilingualism and Delaying Onset of MCI
A number of recent studies demonstrate that bilingualism might delay the onset of dementia. It appears that this effect is associated with life-long bilingualism, not necessarily recent acquisition of a second language. Reporting their findings in the Journals of Gerontology (2012), Ossher and colleagues extended the question of delay to subjects with Mild Cognitive Impairment (MCI). More specifically, does bilingualism delay the onset of amnestic MCI or multi-domain MCI?
Details of the study:
- 111 subjects were recruited
- clinical evaluations were conducts by two neuropsychologists
- for amnestic MCI, bilingual subjects experienced a delay in onset compared with monolingual subjects
- bilingual amnestic MCI subjects were 4.5 years older than monolingual subjects at the time of diagnosis
- however, for multi-domain MCI, no bilingual delay was found
- the researchers contend that life-long bilingualism may serve a protective function for amnestic MCI
Single-domain MCI refers to the condition in which one primary cognitive domain is significantly impaired. This is typically memory, and referred to as amnestic MCI. In multi-domain MCI, more than one cognitive domain is impaired, but not to the degree to which a diagnosis of dementia can be accurately made.
Depression in Long-Term Care
Depression is common in long-term care settings. Unfortunately, it is often unrecognized. As a result many residents needlessly suffer from a disorder that is generally treatable. Publishing in the Journal of the American Medical Directors Association, Mugdha and Blazer reviewed this literature.
- Up to 35% of long-term care residents have depressive symptoms
- Physicians and nursing staff often fail to identify depression
- Less than 50% of the cases of depression were recognized by nursing staff
- Probable reasons for failure in identifying depression are that providers are not looking for depression, and depression is comorbid with other conditions
- It is important to identify depression since it often responds positively to treatment
Cross-cultural Caregiving: Results from a Hong Kong Study
Numerous studies have documented various "burden" syndromes associated with spousal caregivers. While most of these studies have focused on Western people, cross-cultural and ethnic studies of caregiving in other countries are increasing. A recent study of caregivers in Hong Kong is one interesting example.
Key features of this study:
- females were more often caregivers
- caregivers were on average two years younger than their care recipients, but suffered from the same number of chronic illnesses
- despite their age, caregivers provided more than 14 hours of care per day
- caregiving was a risk factor for depression, but becoming depressed was more associated with attitudes about role and self
- having social support resources did not predict depression
The researchers discuss conceptual issues inherent to this population. One of which is whether caregivers could be more at risk given Confucian ideology that emphasizes moral imperatives associated with roles in society.
For more information about this study, click here.
How Well do People Understand Alzheimer's Disease?
Dementia in general, and Alzheimer's disease in particular, represent major public health concerns. As such, how well do people understand them? A number of surveys have been conducted in the U.S., but fewer in other countries. In a recent study about Alzheimer's disease in Britain, Hudson and colleagues examined questions about the public's knowledge about AD.
Specific features of their research:
- 312 subjects participated by responding to a questionnaire about Alzheimer's disease.
- Subjects completed the Alzheimer's disease knowledge scale (ADKS).
- In general and regardless of age, education, and disease familiarity, participants demonstrated a good understanding of a number of AD features.
- However, knowledge gaps existed more meaningfully in these areas: the disease course, such as life expectancy and increased fall risk; conditions that can exacerbate cognitive decline in AD, such as inadequate nutrition; and conditions that can simulate AD symptoms, especially depression.
They conclude that educational campaigns are important in order to reduce negative disease impact.
For more information about this study, click here.
Executive Functions and Diabetes Self-Management
Diabetes is a growing public health burden in the U.S. and in many industrialized nations. Among older adults, Type II diabetes is on the rise. This age population also shares a high prevalence of cognitive impairment, especially in the executive functions. Therefore, the issue of whether impaired executive capacity is a risk factor for diabetes management is important to understand. In a recently published article in the journal, Aging and Mental Health (2012), Nguyen and colleagues reported their findings about whether compromised executive functions (They also looked at affective disorders, but these findings will not be reported in this review) are a risk factor for diabetic management.
About their study:
- 563 independently living rural older adults (age 60 and older) participated
- Three measures of executive functions were used: Animal Fluency, Brief Attention Test, and Digit Span Backward
- Blood glucose as measured by A1C was the main outcome measure
- Executive functions were significantly associated with A1C levels
- Poor executive functions were associated with high glucose levels, and stronger executive functions were associated with lower glucose levels
They conclude that low executive abilities are a potential barrier to self-care of managing glucose levels.
BCAT- Short Form (BCAT-SF) and Primary Care
In order to meet the rapidly expanding numbers of older adults with dementia and MCI, we will need effective and brief cognitive screening tools. In a recent survey of primary care specialists, doctors, and nurse practitioners reported that they believe that cognitive screening should be part of primary care assessments. However, given the number and complexity of health issues among their patients, time is at a premium, and often cognitive screening is not done. They advocate for screening tools that can be completed in less than five minutes. One screening tool that can be administered rapidly and that has robust psychometric properties is the BCAT – Short Form.
Some important features of the BCAT – Short Form (BCAT-SF):
- It can be administered in less than five minutes
- It consists of six items
- 21 possible points, with a “cut” score differentiating dementia from non-dementia
- Scores of 15 and below indicate dementia; scores of 16 and above indicate non-dementia
- It has an online scoring and interpretive system
- It is derived from the full BCAT, and contains items representing the three cognitive clusters: contextual memory, executive functions, and attentional capacity
- The BCAT-SF is predictive of ADLs and IADLs
- The development and validation study is published in the journal, Aging and Mental Health.
More information on the BCAT-SF can be found at www.thebcat.com
Depression and Cognitive Impairment Among Nursing Home Residents
Depression and cognitive impairment are common among nursing home residents. Effective treatment can depend on whether care providers accurately understand the level of depression in their residents. Studies have documented a "disconnect" between resident and staff ratings of resident depression, independent of cognitive functioning. This issue was investigated by Gail Towsley and her colleagues and reported in the journal, Aging and Mental Health (2012).
Key features of the study:
- 395 pairs of residents and nurses
- 28 nursing homes participated
- Average resident was white, female and had Mild Cognitive Impairment (MCI)
- Depression measured by interviewing both residents and nurses
- Depression measure used was the Cornell Scale for Depression in Dementia (CSDD)
- High discrepancy between resident and nurse ratings in resident depression
- Implications: importance in obtaining resident input when assessing depression, and educating staff in how best to assess depression (especially in residents with cognitive impairment).
For more information about the Cornell, click here.
Greater Cognitive Decline in Women than Men
Using a meta-analysis from 15 independent studies, Karen Irvine and her colleagues investigated the question of whether there are differences in cognitive decline between men and women with Alzheimer's disease. They found that in the five cognitive domains investigated, women deteriorated more rapidly than men.
One interesting aspect of gender differences in terms of cognitive processing is that differences seem to exist in normal children and adults — but in a different direction. It appears that Alzheimer's disease changes the balance, with women experiencing steeper or more rapid declines than men. In the Irvine study, this was found in both memory and verbal abilities. The second finding is striking because normal women often have stronger verbal skills.
Their study was published in the Journal of Clinical and Experimental Neuropsychology (2012). To review the study, click here.
Does Cognitive Function Predict Falls?
Not only can falls lead to physical and psychological traumas, they represent a significant risk factor for death among older adults. Therefore, predicting falls can create important opportunities for preventive interventions. In a recently published study, Chen, Peronto, and Edwards investigated, among other issues, whether cognitive function is (1) associated with falls, and (2) predicts falls.
509 community-dwelling older adults participated in the study. Measures of executive function, cognitive processing speed, psychomotor speed, and other known risk factors were administered. Key study results: (1) poor executive functions (based on the Trail Making Test) and slower psychomotor speed (Digit Symbol Test) were significantly associated with falls (This does not mean they cause falls.); (2) executive functions were not found to independently predict falls; (3) only medication use (4 or more), visual acuity, and psychomotor speed were predictors of falls.
Some additional considerations: The sample is community-based, and nursing and assisted living facility populations may have different fall predictions. Previous research has found executive functions to be a predictor of falls. While the number of medications was a significant predictor of falls, the researchers didn't look at specific medications that could increase fall likelihood (e.g., narcotics). Finally, the rate of falls in their sample was small, potentially impacting their findings.
Key implication - a simple measure of psychomotor speed may be a good and fast method for predicting falls in community-dwelling older adults.
Depression and MCI
Italian longitudinal study that investigated the comorbidity of MCI and depression, the researchers found depressive symptoms to be present in more than 63% of those with a diagnosis of MCI.
Some specifics of the study:
In the Italian Longitudinal Study on Aging, 2,963 individuals from 5,632 65- to 84-year-old subjects were evaluated at the 1st and 2nd survey, with a 3.5-year follow-up. Depressive symptoms were measured with the Geriatric Depression Scale.
Among the 2,963 participants, 139 prevalent MCI cases were diagnosed. 63.3% of them had depressive symptoms. During the 3.5-year follow-up, estimated incidence of depressive symptoms was 29.6 per 100 person-years.
The Risk of Dementia for Spouses Caring for Demented Partners
One of the better known studies that has investigated the effects of having a spouse with dementia on one’s own risk for incident dementia comes from the large, longitudinal Cache County Aging Health and Memory project. Maria Norton and numerous collaborating researchers reported their findings in 2010. Specific details of their study:
Methodology - Population-based study of incident dementia in spouses of persons with dementia.
Setting - Rural county in northern Utah.
Participants - 2,442 subjects (1,221 married couples) aged 65 and older.
Results - Spouses living with a demented partner experienced had a six-fold increase in risk of incident dementia compared to subjects whose spouses were dementia free.
Conclusion - Stress associated with dementia caregiving may exert substantial risk for the development of dementia in spousal caregivers.
Racial Differences in Caregiver Symptomatology & Medication Use
While it is clear that dementia caregivers are more likely to be depressed than same age non-caregivers, differences among racial groups in terms of symptoms and psychotropic treatment is less well understood.
Thorpe and colleagues shed some light on possible racial differences. Their research investigated African-American and white caregivers of older adults with dementia. Specifically they examined relationships between race and psychotropic drug use (antidepressant, antianxiety, sedative/hypnotic agents) in informal caregivers with symptoms of depression who provide care for elderly relatives with progressive dementia. Data was obtained and analyzed from two thousand thirty-two African-American and white female caregivers of elderly male veterans diagnosed with probable Alzheimer's disease or vascular dementia.
Depressive symptoms were measured using a modified version of the Center for Epidemiological Studies Depression Scale. Antidepressant, antianxiety, and sedative/hypnotic agents were indexed using the Veterans Affairs medication classification system.
They found that among the entire caregiver sample with depressive symptoms, 19% used antidepressants, 23% antianxiety agents, and 2% sedative/hypnotics. However, African-American caregivers with depressive symptoms were significantly less likely than whites with depressive symptoms to be using antidepressants and antianxiety medications. One can argue that both racial groups underutilize medications when depressed. However, this appears to be particularly so for African-American.
Physically Simulated Sport Play and Cognitive Function
Ever wonder if the physically simulated video games (think Wii Tennis as an example) on the market could enhance cognitive functioning in older adults? Maillot, Perrot, and Hartly investigated this question and recently published their findings in the journal, Psychology and Aging (2012, Vol. 27). They note that there is ample evidence that physical exercise can have a positive benefit on cognitive processing in older adults. Could video games that require movement also have positive cognitive affects?
Thirty-two independently living older adults participated in the study. Sixteen were randomly assigned to the experiment group (receiving physically simulated video games training – Wii games) and the remaining sixteen were assigned to the control group (no Wii training). Based on a pre-post design, using neuropsychological instruments to measure cognitive performance, the researchers found:
- Participants in the experiment group did better on the Wii games at post-testing as compared to the control group.
- Participants in the experimental group improved in two cognitive areas – executive control and processing speed, compared to the control group.
- No group difference were found in visuospatial abilities.
- The possible affect of the video games on memory was not investigated.
The researchers conclude that these types of videos can improve some areas of cognitive functioning. As a compliment or alternative to conventional exercising, video games that utilize physically simulated sport play have advantages for older adults. For example, they can be facility- or home-based, they can mitigate against environmental barriers to exercises, they allow choice among activities, and can be fun.
There are limitations to this study. Two of them are: They used a homogeneous small sample size that limits generalization of the findings. They made no comparisons to sedentary video games.
Hearing Loss and Dementia
Dr. Lin and colleagues, as part of the Baltimore Longitudinal Study of Aging, published their findings about a possible direct link between hearing loss and dementia for some older adults.
Below, we highlight important features of their study:
- Their objective was to determine whether hearing loss is associated with dementia, especially Alzheimer's disease.
- This was a prospective study of 639 subjects who underwent audiometric testing and were dementia-free.
- During a median follow-up of almost 12 years, subjects found to have dementia had substantially more severe hearing loss than non-demented subjects.
- They controlled for other possible causative variables.
- They concluded that hearing loss is independently associated with incident dementia.
- It is unclear if hearing loss is a marker for early-stage dementia or is instead a risk factor for dementia.
Brain Reserve and SuperAgers
Gradual decline in brain mass and in memory is a normal part of aging. Whereas most normal older adults maintain absolute memory skills into very late life, forgetfulness and lapses in attention are a common feature of aging. However, some older adults, the so-called SuperAgers, don't seem to experience cognitive decline. It appears that they have brains that are more resistant to both normal cortical atrophy and dementia.
Theresa Harrison and her colleagues looked at the relationship between brain size and cognitive abilities. While their sample size is small, their findings are very interesting. 12 SuperAgers (over 80 years of age with no memory deficits) were compared to 10 age controls and 14 middle-aged controls. They compared performances on cognitive testing and neuroimaging. They found that whole-brain thickness in the SuperAgers was no less than that found in the middle-agers. That is, cortical volume did not decline with age. The researchers show a positive correlation between cortical brain volume and memory performance.
MCI and Everyday Functioning
Previous research has demonstrated that people with Mild Cognitive Impairment (MCI) often have more difficulties completing everyday tasks (instrumental activities of daily living) than do people with normal cognitive functioning. Much of this research measured "everyday" functioning in artificial environments or through proxy (reports from others) assessments. Fewer studies have used direct measurement of everyday task performance. In a recently published article in the journal, Neuropsychology, Maureen Schmitter-Edgecombe and colleagues compared everyday task performance of 38 MCI subjects with 38 matched normal subjects. They focused on whether the MCI patients would perform as well as the control group on directly observable daily tasks. They found that the MCI group required more time to complete daily tasks and showed poorer task performance. One explanation for the performance differences was that MCI subjects had poorer memory which compromised their ability to keep track of multiple task goals.
The Stroop Test and Detecting Dementia
Functional MRI (fMRI) studies show that Stroop tasks activate the prefrontal cortex. This is not surprising given that Stroop tasks involve selective attention, sustained focus, set-shifting, and mental control (i.e., maintaining focus on one of two competing demands)—cognitive skills that are largely frontal lobe-associated. The frontal lobes are typically compromised in diseases such as Alzheimer's. So, one important question is whether a Stroop test is sensitive to early detection of Alzheimer's disease.
Hutchison, Balota, & Duchek investigated this hypothesis and published their results in the journal Psychology and Aging (Sep, 2010). Using a Stroop procedure, the researchers compared performances across young adults, older adults, and persons with "very mild" dementia. Their results (based on error rates) indicate that the Stroop procedure can discriminate between cognitively normal adults and those with mild dementia. That is, it can be used as an early detection screening tool for dementia. Furthermore, its discriminatory power was greater than other cognitive tests investigated. Younger adults and older adults also performed significantly different on this instrument.
Driving with Dementia
The realities of both voluntary and forced driving "retirement" are complex, and can have profound psychological and practical ramifications. At least two states, Maryland and California, have addressed driving safety issues for older adults to determine if unique standards should be applied to this population. Other states have either begun their own investigations or are reviewing research in this area. Whether most or all states will adopt separate driving evaluation standards, the following facts are pertinent to understanding this important national conversation. The information mostly comes from the National Highway Safety Administration 2009 dataset.
- There are approximately 28 million Americans 70 years of age or older. Approximately 78% of them are licensed drivers. This does not mean that they all actually drive.
- Older drivers tend to drive fewer miles per year, but keep their licenses longer and drive more miles collectively as a result.
- As a group, older drivers appear to be involved in fewer fatal crashes than in previous years, but still are the second highest at-risk age category for fatal crashes (after teens).
- While older drivers have relatively low crashes per capital, they have high rates of crashes per miles driven.
- The rate of fatalities relative to crashes is highest among older adults. This is likely primarily due to the frailer health status of older drivers as compared with younger drivers.
- Physical, cognitive, and visual deficits can play a major role in crashes for older adults.
- More than half of of the States require older drives to have more frequent driving renewals.
Homebound Older Adults and Telehealth
Homebound older adults represent an isolated and at-risk group for poor health and high medical costs. This population often does not receive preventive or adequate routine healthcare. Hence, alternative interventions such as Telehealth may prove effective for homebound older adults. Dr. Zvi Gellis and colleagues (see The Gerontologist, August 2012) investigated health outcomes for heart, respiratory, and associated mental health using a Telehealth intervention. In a randomized controlled trial, 51 older adults were treated for heart disease or COPD with Telehealth procedures. The Telehealth patients reported greater improvement in general health and depressive symptoms than did patients in the control group (patients receiving usual care). Furthermore, the control group had more visits to the emergency department than the Telehealth group. The researchers concluded that Telehealth may represent an efficient and effective intervention strategy for homebound older adults.
Behavioral Activation with Bereaved Older Adults
Over the past decade, there has been increasing interest in a specific cognitive-behavior therapy called, Behavioral Activation. Sometimes referred to as a "third generation" behavioral therapy, BA places emphasis on behavior over cognition. It aims to increase reinforcing activities, decrease avoidance behaviors, and bring about positive changes in thoughts, mood, and everyday living. BA has been commonly applied to problems of mood (depression, anxiety), and more recently to depressed and anxious older adults. In a newly published review, Holland & Diliberto (Clinical Gerontologist, July-September 2012) discuss positive applications of BA to bereaved older adults.
Benefits of BA for older adults include:
- Since the focus is on behavior, not cognition, patients with memory impairment can still benefit.
- Many older adults are resistive to "talk therapy." BA is brief and action-oriented, and many older adults are more comfortable with this approach.
- BA utilizes activities that are/were pleasurable for the patient, facilitating acceptance of the strategies.
- BA effectively targets "avoidance behaviors" that tend to keep patients depressed or anxious.
- BA is a good alternative and/or compliment to medications.
Naturally when we think of Olympic athletes, we picture late teenagers and young adults as Olympians. However, not all Olympic athletes fit into this age range. Below are some interesting facts about some of the oldest Olympians.
- The oldest male Olympian was Oscar Swahn of Sweden. He was 72 years, 281 days old when he competed at the 1920 Olympics in shooting.
- In 1936, Arthur von Pongracz of Austria also competed in Dressage at age 72, becoming one of the oldest competitors at the Olympics.
- In Beijing 2008, equestrian rider Hiroshi Hoketsu became the oldest Japanese Olympic representative at age 67. Hoketsu will be 71 when he competes in the London Olympics.
- Louis, Count du Douet de Graville (69 years, 95 days), competed in Equestrian in the 1900 Olympics. He is the oldest male gold medalist.
- The oldest woman to compete in the Olympics was British rider Lorna Johnstone, who participated in Equestrian at the 1972 Olympic Games. She was 70 years and 5 days old.
- In 1908, British archery winner Sybil "Queenie" Newall became the oldest woman ever to win an Olympic gold medal, she was aged 53 years, 275 days.
Competitiveness Across the Life Span
We live in a competitive society. Access to societal opportunities- jobs, entry exams, public office, college, social clubs- is regulated through competition. A common life span theory about competitive preferences predicts gradual decline as we age. However, a recently published study challenges this view. Some highlights from the research of Mayr, Wozniak, Davidson, Kuhns, & Harbaugh, published in the journal, Psychology and Aging (June 2012), are:
- competitive preference increased across the life span
- competitive preference peaked around age fifty
- across all age categories, men had stronger competitive preferences
- 543 subjects, age range was 25-74
- a definition of competitive preference was defined by a hypothetical financial risk test
- limitations: actual risk aversion was not studied, subjects older than 74 were not included, the competitive preference test was not a real-world situation
Marital Satisfaction in the Later Years
Studies have reported that marital quality seems to increase in later adulthood. Researchers have commented on the U-shaped curve whereby marital satisfaction appears highest in the early and late years of marital life, and lowest in the middle years. In a study just published in The Journals of Gerontology, Li & Fung report a similar finding and offer other insights.
These researchers assessed partner discrepancies and marital quality. They were primarily interested in how older married couples close the gap between ideal and perceived marriage quality in order to feel marital satisfaction. They found that husbands adjusted their expectations of their partners, and this likely produced higher marital satisfaction. This is consistent with life-span theory. Wives reported fairly consistent marital satisfaction ratings and may not have needed to make cognitive adjustments in the later years.
Telephone-Based CBT Caregiver Therapy
Epidemiologic studies indicate that there are more than five million adults in the United States with Alzheimer's disease. This figure will more than double over the next few decades. At the same time, the number of caregivers will also rapidly increase. Because African Americans with dementia are particularly likely to have informal (family and friends) caregivers, the question of caregiver burnout is a critical issue. Caregivers of all ethnicities are at increased risk for psychological, behavioral, and medical problems. A recent study was published that looked at the possible benefit of telephone-based cognitive-behavioral therapy for improving psychological functioning for African American caregivers.
Some highlights of their study, which can be found in the journal, Rehabilitation Psychology, vol. 57, follow below. The primary authors are Robert Glueckauf and W. Shuford Davis.
- pilot study based on telehealth technology
- small sample (14 participants)
- caregiver burden measured by Subjective Burden subscale of the CAI, Assistance Support subscale of the ISEL
- results show that the telephone-based treatment improved depression and subjective burden
- study limitations: very small sample, subject selection bias
American Coffee Consumption
There is little doubt that Americans like their coffee. More than 50% of adults drink coffee daily.
Some interesting facts about coffee consumption:
- While more than 50% of adults drink coffee daily, another 30% drink coffee occasionally
- In a recent survey by the American Coffee Association, 83% of consumers reported brewing their previous day's coffee at home
- Coffee consumption in the U.S. ranks eighth in the world
- Coffee consumption in 2012 is trending 7% over 2011 levels
- The average consumer drinks three cups a day
- The U.S. coffee market is nearly 20 billion dollars per year
- The average coffee cup size is nine ounces
- 35% of coffee drinkers prefer their coffee black
- 65% of coffee consumption takes place during breakfast hours
- Seattle has 10 times more coffee stores per 100,000 residents than the United States has overall
- The United States imports more than $4 billion dollars of coffee each year
Air Travel for Older Adults with Dementia
While commercial air travel is one of the safest means of transportation, it may not be for older adults with dementia. The human body undergoes physiological and psychological changes at high altitudes (22,500 feet above sea level) that can contribute to emotional distress and Delirium. James Low and Daniel Chan present a good review of the possible impact of air travel for older people in general in their article, Air Travel in Older People, Age and Ageing, (2002). Geri Hall, focusing specifically on people with dementia, compiled travel guidelines in article entitled, Travel Guidelines for People with Dementing Illness.
Can Adults Learn Second Languages?
Can adults learn second languages? Iverson and colleagues have conducted a body of research addressing this and related questions. This subject and whether foreign language exercises can be used as brain fitness are addressed in this week's BCAT blog. Read an abstract of one of the Iverson studies below:
Applied Psycholinguistics, page 1 of 16, 2011 doi:10.1017/S0142716411000300
Auditory training for experienced and inexperienced second-language learners: Native French speakers learning English vowels
PAUL IVERSON, MELANIE PINET, and BRONWEN G. EVANS
University College London
Received: January 14, 2009 Accepted for publication: October 24, 2010
ADDRESS FOR CORRESPONDENCE: Paul Iverson, Division of Psychology and Language Sciences, University College London, Chandler House, 2 Wakefield Street, London WC1N 1PF, UK. E-mail: firstname.lastname@example.org
ABSTRACT: This study examined whether high-variability auditory training on natural speech can benefit ex- perienced second-language English speakers who already are exposed to natural variability in their daily use of English. The subjects were native French speakers who had learned English in school; experienced listeners were tested in England and the less experienced listeners were tested in France. Both groups were given eight sessions of high-variability phonetic training for English vowels, and were given a battery of perception and production tests to evaluate their improvement. The results demonstrated that both groups learned to similar degrees, suggesting that training provides a type of learning that is distinct from that obtained in more naturalistic situations.
Positive Synergy between Cognitive & Physical Exercise
As reviewed in a recent BCAT blog, Yonas Geda and colleagues at the Mayo Clinic examined the relationship between computer use, physical exercise, and mild cognitive impairment. One issue they investigated was whether the combination of computer and physical activity was more positively associated with reductions in memory deficits than either one individually. In their study sample, 926 non-demented persons, aged 70-93, completed self-report questionnaires. Participants answered questions about their physical exercise, computer use, and caloric intake. Adjusting for age, sex, education, and medical issues (including depression), they found that participants who engaged in both moderate exercise and computer use had significantly decreased the likelihood of having MCI. The study did have some limitations. Participants were not given specific cognitive exercises to complete, so there was variability in what "computer use" actually meant. Similarly, definitions of physical activity of moderate intensity were not strictly defined. Finally, the data was based on self-reports, and was not independently corroborated by others. For more information about the study, go to Mayo Clinic Proceedings.
Tobacco & Activity as Predictors of Cognitive Change
The fact that the global population is aging, particularly in industrialized nations, is common knowledge. The world and particularly the U.S., is confronted with an ever increasing number of people with dementia. In industrialized countries it is estimated that dementia will overtake coronary heart disease as the number one cause of disability among older adults. In the U.S. healthcare costs for persons with dementia are three times higher than for those without dementia. Against this backdrop the issues associated with prevention in general and identification of protective factors of cognitive decline associated with dementia, are keys to improved health and lower healthcare costs. Ada Lo and colleagues recently published a review of existing research on tobacco, alcohol, adiposity (excessive body weight), and activities as predictors of cognitive change in older adults. Two of these "risk factors" are described here. With respect to tobacco use and activity level, the following findings are reported: (1) smoking in general increased memory decline (smokers versus non-smokers by history), but did not affect language skills nor visuospatial skills; (2) activity (active lifestyle) – physically, cognitively, and socially – seems to have protective cognitive effects and may enhance overall quality of life; (3) cognitive and physical activity appear more protective of cognitive functioning than pure social activities. Some noteworthy limitations of the research: only studies published in English were reviewed, there are limitations in comparing studies with heterogeneous methodologies, and definitions of "cognitive" domains varied across the studies reviewed. Despite these limitations, this meta-analysis points to promising lifestyle influences on cognitive functioning and dementia in the older years of life.
Transitions in Primary Caregiver: Gender Differences
Families are the "first line of defense" in providing community-based primary caregiving for older adults with cognitive and physical disabilities. But first line is often not the last line. When do caregivers throw in the towel and transition their loved ones to another caregiving situation (e.g., nursing home)? Susan Allen and her colleagues investigated this issue and looked at caregiver characteristics associated with care transitions of community-dwelling older adults. In their longitudinal study, data from 2,990 older adults (aged 70 and over) were analyzed. Over a two year period, more than half of the subjects experienced some sort of transition. The researchers also reported that females tended to hold onto primary caregiver roles longer than males. Hence, if you look at caregiver transition from a risk perspective, disabled older women cared for by either a husband or son are more at risk for transition to another informal caregiver or formal (e.g., nursing home) provider. The authors speculate as to why there are gender differences in caregiver transition. The article (May, 2012) was published in The Journals of Gerontology, 67B, 362-371.
Spanish version of the Geriatric Depression Scale
Most of the depression screening tools for elderly patients are either exclusively written in English or when translated, have not been normed in other languages. In a recently published article in International Psychogeriatrics (April, 2012), reliability and validity findings are presented for a Spanish version of the Geriatric Depression Scale. In this study, the targeted population was older adults (55 and older) with mild-moderate dementia. There is evidence that the GDS is not warranted for severely demented patients since it relies upon self-report responses. Severely demented patients were not included in this study. 96 community-dwelling older adults completed a battery of instruments including the GDS-15 and GDS-5, the Cornell Scale for Depression in Dementia (CSDD), a list of self-reported chronic health issues, MMSE, a functional status instrument (Barthel Index), a generic quality of life scale (WHOQOL-BREF), and sociodemographic information. This study was conducted in Spain. The study provides evidence that the GDS-15 and GDS-5 have reasonable reliability and validity as screening measures for a Spanish speaking population with mild to moderate dementia. There are several caveats to consider. One should be careful about generalizing to patients with more severe dementia. Also, the MMSE is a questionable instrument when used as the primary indicator of dementia, especially for persons with mild severity. Studies show that the sensitivity of the MMSE is questionable for people with Mild Cognitive Impairment (MCI) and mild dementia. Finally, depression should not be diagnosed solely on the basis of the GDS or any screening tool alone.
Executive Functions, Parkinson's Disease, & Activity Participation
Parkinson's disease (PD) is one of the most common movement disorders, affecting 1% of people older than 60 years of age. This is approximately 1 million Americans. PD is about 1.5 times more common in men than in women, and it becomes more common as one ages. The motor manifestations receive the most attention clinically, as PD is most noted as one of the movement disorders. However, individuals with PD, who are not demented, commonly have some cognitive concerns. One such example is executive function. In a recently published study by Foster and Hershey (2012), the relevance of executive functions in PD (without dementia) to instrumental, leisure, and social participation is reported. 24 persons with PD (no dementia) and 30 age-matched control volunteers participated. Executive function was assessed by administration of the Dys-executive Questionnaire. Complex activity participation was assessed by administration of the Activity Card Sort. This instrument consists of photographic cards depicting complex activities that fall into four domains: IADL, low physical-demand leisure activities, high-demand leisure activities, and social activities. Key study results: (1) individuals with PD (no dementia) had mild executive deficits; (2) these deficits were associated with reduced participation in IADL, leisure, and social activities. One could conclude that individuals with PD are at risk for problems in independent living (IADL) and well-being (leisure and social activities), due to cognitive deficits unrelated to their physical problems. Therefore from a treatment perspective, cognitive evaluation of PD patients is important.
Acute Bipolar I Presentation Across the Life Span
The literature on bipolar disorder across the life span reports few definitive conclusions, and quite a few conflicting ones. For example, it is not clear whether acute presentation of bipolar symptoms is similar for younger and older adult patients. For those who have life-long bipolar disorder, do psychotic and affective symptoms change as one ages? Some studies suggest that age is indeed a factor, while others arrive at the opposite conclusion. In a recent study published in the Journal of Geriatric Psychiatry and Neurology, Al Jurdi and colleagues recruited bipolar I patients between the ages of 20-59 (younger group) and 60 and older (older group), comparing their symptom profiles. No statistically significant differences were found in terms of psychotic features, mood elevation (mania and hypomania), and irritability. Furthermore, no statistically significant differences emerged between the two groups in terms of acute depression symptoms. In this study, age was not a differentiating factor in symptom presentation.
Donepezil (Aricept) and Memantine (Namenda) for Moderate-to-Severe AD
Most studies evaluating the efficacy of memory enhancers have focused on patients with mild-to-moderate Alzheimer's disease. In a recently published article in the New England Journal of Medicine, Howard et al. (March, 2012) investigated the treatment benefits of donepezil and memantine for patients with moderate-to-severe dementia. 295 community-dwelling patients who had been treated with donepezil for at least three months participated in the study. Outcome measures for cognition and function were, respectively, the standardized MMSE and the Bristol Activities of Daily Living Scale. The researchers had three objectives: (1) to test whether over a period of 52 weeks continuation of donepezil, as compared with discontinuation of this drug, would be associated with better cognition and function; (2) to test whether memantine treatment, as compared with placebo, would be associated with better cognition and function; and (3) to test whether combining donepezil and memantine would provide additive benefits. Results: (1) patients who continued with donepezil had better cognition and function scores than those who discontinued the drug; (2) patients who were assigned to receive memantine did better with cognition and function scores than those who were assigned placebo; and (3) there was no additive benefit in terms of cognition and function for using both drugs simultaneously. One should interpret these results with caution. The improvements in cognition and function associated with both drugs were small relative to the overall size of the decline in cognition and function. Furthermore the MMSE is a poor outcome measure for assessing change in cognition.
Prospective Memory and TBI
Prospective memory refers to our ability to remember to carry out intended actions in the future. Examples include remembering to take medications, pay bills, go to appointments, and manage a variety of instrumental activities of daily living (IADL). This differs from retrospective memory, which is more concerned with recalling events or details previously learned. Much of the time, these two memory features work in a complimentary fashion. In order to carry out an intended action, one has to be attentive and aware of when to perform an action (prospective), and at the same time, recall what action to perform (retrospective). There is a good deal of research looking at the impact of traumatic brain injury (TBI) on memory, especially retrospective memory. In a recently published article, Shital Pavawalla and colleagues looked at the relationship between TBI and prospective memory. They compared the prospective memory performances of 17 TBI and 17 "normal" control participants. The study findings support the view that TBI negatively effects prospective memory. TBI participants had significantly more difficulties recruiting the attentional skills necessary to carry out intended actions. One implication of this research is that attentional skills are critical to remembering to complete an intended action. Another is that individuals who have experienced a TBI may be at heightened safety risk and vulnerable to IADL failures. Furthermore, clinicians should be mindful in their evaluations of TBI patients to assess prospective and more traditional memory abilities. Readers should keep in mind that the study results are based on a small number of participants. The researchers did not differentiate among different types of TBI, nor did they track possible recovery of prospective memory over time.
Psychological & Physical Effects of Spousal Caregiving of MCI Patients
Recently published in the Journals of Gerontology, Jyoti Savla and colleagues reported on the psychological impact on care partners taking care of spouses with mild cognitive impairment (MCI). In their study, 30 spousal care partners participated in a diary study on behavioral problems associated with MCI, reporting on daily stressors and strains. They also provided saliva samples in order to record cortisol levels associated with stress. Key findings included: (1) care partners reported higher levels of negative affect when behavioral problems occurred toward the end of the day; (2) some MCI patients demonstrated a version of "sun-downing," not so different from what is often observed in demented patients; (3) on days in which behavioral problems were relatively high, cortisol levels in care partners were higher at the beginning of the day, remained higher, and receded at a lower rate. Normally, cortisol levels are highest in the morning and lowest at night. The study adds evidence to our understanding that caregiving places the caregiver at risk for both psychological and physiological symptoms.
Insulin Spray may Slow or Reverse Early Signs of Alzheimer's Disease
In a recently published article in the Archives of Neurology, Dr. Suzanne Craft and her colleagues report their findings that the administration of intranasal insulin may have a therapeutic benefit for adults with Mild Cognitive Impairment (MCI) or Alzheimer's disease (AD). Building on previous studies that found that low brain levels of insulin – the main hormone that turns sugar in the bloodstream into energy for cells – could contribute to Alzheimer's disease, the researchers recruited 104 adults, 64 of whom had amnestic MCI and 40 of whom were diagnosed with mild to moderate AD, to participate in their study. Participants received 20 IU of insulin or 40 IU of insulin for four months. One of the primary outcome measures used to track changes or improvement in memory was Story Recall. Participants who received the 20 IU dose showed improvement in Delayed Story Recall. Interesting, participants who received the 40 IU dose did not show improvement in this outcome measure. Studies investigating the possible benefits of intranasal insulin are at a preliminary stage, and insulin is not recognized as a viable treatment for cognitive disorders. It is not yet clear exactly why insulin could be beneficial for preserving and possibly enhancing memory. It is interesting to note that brain insulin receptors are densely localized in the hippocampus, which is a center for making new memories.
Intranasal Insulin Therapy for Alzheimer Disease and Amnestic Mild Cognitive Impairment: ...Craft et al.Arch Neurol.2011; 0: 20112331-10.