Functional evaluation distinguishes MCI patients from healthy elderly people--the ADCS/MCI/ADL scale

An explorative study of the relationship between functional and cognitive decline in older persons with mild cognitive impairment and Alzheimer’s disease

Introduction

This study explored the relationship between functional decline on three advanced activities of daily living and cognitive decline in elderly persons. The use of everyday technology, driving a vehicle, and performing complex economic activities are advanced activities of daily living domains presumed to be sensitive to early cognitive decline and therefore of interest for the profession of occupational therapy.

Method

We included 45 persons with mild cognitive impairment, 48 persons with Alzheimer’s disease, and 50 cognitively healthy controls. Functional impairment due to cognitive decline was evaluated by the advanced activities of daily living tool. Cognitive disability indices were computed for the investigated advanced activities of daily living domains and correlated with the Mini Mental State Examination and the Cambridge Examination for Mental Disorders of the Elderly, Cognitive Part.

Results

The cognitive disability index for performing complex economic activities and the cognitive disability index for the three advanced activities of daily living domains together differed significantly between the three groups. For the whole sample, the advanced activity of daily living cognitive disability indices correlated strongly with the cognitive measures. Within each separate group, few correlations were found.

Conclusion

This study contributes to the field of knowledge for occupational therapy by emphasizing the value of assessment of advanced activities of daily living in early cognitive decline. For the occupational therapy profession, further research is required in the interaction between functional decline and cognition in early cognitive decline.

Engagement in Instrumental Activities of Daily Living, Social Activities, and Use of Everyday Technology in Older Adults with and without Cognitive Impairment

Introduction:

Little is known about how subtle activity limitations may be manifested and clinically detected in people with mild cognitive impairment, but these people have been found to experience greater challenges with everyday technology use. The aim of this study was to investigate levels and profiles of engagement in activities, and their associations with perceived difficulty in technology use, for people with mild cognitive impairment, and to compare this group to people with Alzheimer's disease and to controls.

Method:

Samples with mild cognitive impairment (n = 37), Alzheimer's disease (n = 37), and controls (n = 44) were included. Based on raw data from the Frenchay Activity Index, a Rasch model was used to generate linear measures. Analysis of variance and differential item functioning were used.

Results:

The analysis yielded a profile of decreased engagement in specific activities even in mild cognitive impairment. The association between activity engagement and difficulty with everyday technology use was stronger in people with mild cognitive impairment and Alzheimer's disease than in controls.

Conclusion:

Taken together, engagement in outdoor activities showed the greatest decrease of all activity types for the group with mild cognitive impairment, suggesting that participation in life outside the home is threatened. The results also suggest that challenges in managing technology are restricting people with cognitive impairment more than they restrict controls.

Developing dementia prevention trials: baseline report of the Home-Based Assessment study

This report describes the baseline experience of the multicenter, Home-Based Assessment study, designed to develop methods for dementia prevention trials using novel technologies for test administration and data collection. Nondemented individuals of 75 years of age or more were recruited and evaluated in-person using established clinical trial outcomes of cognition and function, and randomized to one of 3 assessment methodologies: (1) mail-in questionnaire/live telephone interviews [mail-in/phone (MIP)]; (2) automated telephone with interactive voice recognition; and (3) internet-based computer Kiosk. Brief versions of cognitive and noncognitive outcomes were adapted to each methodology and administered at baseline and repeatedly over a 4-year period. "Efficiency" measures assessed the time from screening to baseline, and staff time required for each methodology. A total of 713 individuals signed consent and were screened; 640 met eligibility and were randomized to one of 3 assessment arms; and 581 completed baseline. Dropout, time from screening to baseline, and total staff time were highest among those assigned to internet-based computer Kiosk. However, efficiency measures were driven by nonrecurring start-up activities suggesting that differences may be mitigated over a long trial. Performance among Home-Based Assessment instruments collected through different technologies will be compared with established outcomes over this 4-year study.

A complex multimodal activity intervention to reduce the risk of dementia in mild cognitive impairment--ThinkingFit: pilot and feasibility study for a randomized controlled trial

BACKGROUND

Dementia affects 35 million people worldwide and is currently incurable. Many cases may be preventable because regular participation in physical, mental and social leisure activities during middle age is associated with up to 47% dementia risk reduction. However, the majority of middle-aged adults are not active enough. MCI is therefore a clear target for activity interventions aimed at reducing dementia risk. An active lifestyle during middle age reduces dementia risk but it remains to be determined if increased activity reduces dementia risk when MCI is already evident. Before this can be investigated conclusively, complex multimodal activity programmes are required that (1) combine multiple health promoting activities, (2) engage people with MCI, and (3) result in sufficient adherence rates.

METHODS

We designed the ThinkingFit programme to engage people with MCI in a complex intervention comprised of three activity components: physical activity, group-based cognitive stimulation (GCST) and individual cognitive stimulation (ICST). Engagement and adherence was promoted by applying specific psychological techniques to enhance behavioural flexibility in an early pre-phase and during the course of the intervention. To pilot the intervention, participants served as their own controls during a 6- to 12-week run-in period, which was followed by 12 weeks of activity intervention.

RESULTS

Out of 212 MCI patients screened, 163 were eligible, 70 consented and 67 completed the intervention (mean age 74 years). Activity adherence rates were high: physical activity = 71%; GCST = 83%; ICST = 67%. Significant treatment effects (p < .05) were evident on physical health outcomes (decreased BMI and systolic blood pressure, [pre/post values of 26.3/25.9 kg/m2 and 145/136 mmHg respectively]), fitness (decreased resting and recovery heart rate [68/65 bpm and 75/69 bpm]), and cognition (improved working memory [5.3/6.3 items]).

CONCLUSIONS

We found satisfactory recruitment, retention and engagement rates, coupled with significant treatment effects in elderly MCI patients. It appears feasible to conduct randomized controlled trials of the dementia prevention potential of complex multimodal activity programmes like ThinkingFit.

TRIAL REGISTRATION

ClinicalTrials.gov registration nr: NCT01603862; date: 17/5/2012.

Patterns of functioning in older adults with mild cognitive impairment: a two-year study focusing on everyday technology use

OBJECTIVES

Early detection is vital for persons with mild cognitive impairment (MCI) who are at risk of activity and participation limitations, and crosssectional studies suggest the ability to use everyday technology (ET) to be a sensible tool. However, group level analyses fail to inform us about how functioning can vary over time for individuals. This study aimed at exploring and describing patterns of functioning over two years in a sample newly classified with MCI, with a special focus on perceived difficulty in ET use and involvement in everyday activities. In addition, cognitive functioning and conversion to dementia were studied.

METHOD

37 older adults (aged ≥ 55) with MCI were assessed at inclusion, and at 6, 12, and 24 months. Longitudinal case plots for the variables under study were analyzed based on strict criteria using a person-oriented approach. Paired t-tests from baseline and 24 months were also conducted to analyze change.

RESULTS

The 32 participants who remained in the study after two years showed three distinct patterns of functioning over time: stable/ascending (n = 10), fluctuating (n = 10), and descending (n = 12), with the highest conversion to dementia in the descending pattern (58%). The perceived ability to use ET decreased or fluctuated in 50% of the sample. However, on a group level, a significant difference between baseline and 24 months was found only regarding cognitive function.

CONCLUSION

As the need for support is individual and likely to alter over time, repeated evaluations of activity involvement and difficulty in ET use are suggested to target timely interventions for persons with MCI.

Information processing speed and 8-year mortality among community-dwelling elderly Japanese

Background

Cognitive function is an important contributor to health among elderly adults. One reliable measure of cognitive functioning is information processing speed, which can predict incident dementia and is longitudinally related to the incidence of functional dependence. Few studies have examined the association between information processing speed and mortality. This 8-year prospective cohort study design with mortality surveillance examined the longitudinal relationship between information processing speed and all-cause mortality among community-dwelling elderly Japanese.

Methods

A total of 440 men and 371 women aged 70 years or older participated in this study. The Digit Symbol Substitution Test (DSST) was used to assess information processing speed. DSST score was used as an independent variable, and age, sex, education level, depressive symptoms, chronic disease, sensory deficit, instrumental activities of daily living, walking speed, and cognitive impairment were used as covariates.

Results

During the follow-up period, 182 participants (133 men and 49 women) died. A multivariate Cox proportional hazards model showed that lower DSST score was associated with increased risk of mortality (hazard ratio [HR] = 1.62, 95% CI = 0.97–2.72; HR = 1.73, 95% CI = 1.05–2.87; and HR = 2.55, 95% CI = 1.51–4.29, for the third, second, and first quartiles of DSST score, respectively).

Conclusions

Slower information processing speed was associated with shorter survival among elderly Japanese.

Prognostic value of cerebral injury following transfemoral aortic valve implantation

AIMS

To evaluate the impact of serological, imaging and clinical measures of cerebral injury on patient self-sufficiency and survival after transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

Before and three days after TAVI, neuron-specific enolase (NSE), cerebral diffusion-weighted magnetic resonance imaging (DW-MRI) and neurological performance utilising National Institutes of Health Stroke Scale (NIHSS) were assessed. Self-sufficiency was determined with established score systems (instrumental activities of daily living score, Barthel Index). Parameters of cerebral injury were investigated for their impact on self-sufficiency and all-cause mortality after 30 days and one year. Sixty-one patients were enrolled (logistic EuroSCORE: 26.4±18.1, STS score: 7.9±5.7), of whom 39 completed the imaging protocol. The incidences of NSE increase, new embolic events in DW-MRI, and neurological deficit early after TAVI were 52.4%, 71.8% and 6.6%, respectively. The degree of concomitant comorbidities, reflected by higher risk scores, had significant impact on outcome. Plasma levels of NSE and new emboli in DW-MRI were neither related to self-sufficiency nor to survival one year after TAVI.

CONCLUSIONS

In this observational pilot study, "silent" cerebral injury is neither related to dependent lifestyle nor to mortality during the first year after TAVI. However, long-term follow-up is needed to elucidate fully the impact of silent stroke. Clinical trials number: NCT00883285.

Learning and using technology in intertwined processes: A study of people with mild cognitive impairment or Alzheimer’s disease

People with mild cognitive impairment and Alzheimer’s disease are likely to be challenged by the multitude of everyday technology in today’s society. The aim of this study was to explore how they try to prohibit, avoid or solve problems in everyday technology use, maintain skills, and learn to use new technology. To explore how the participants applied and reasoned about using everyday technology in real-life situations interviews were conducted while the participants used their own technology in their homes. Interviews were conducted with 20 participants with mild cognitive impairment ( n = 10) or Alzheimer’s disease ( n = 10). The analyses were inspired from grounded theory and resulted in one core category and three sub-categories that represent sub-processes in the core. The core finding presents a continuous, intertwined process of learning and using everyday technology, highlighting how the context was interwoven in the processes. The participants used a rich variety of management strategies when approaching technology, including communication with the everyday technologies on different levels. The findings underscore that it is important to support continued use of everyday technology as long as it is valued and relevant to the person with mild cognitive impairment or Alzheimer’s disease. The intertwined process of learning and using everyday technology suggests how support could target different sub-processes.

Sahlgrenska Academy Self-reported Cognitive Impairment Questionnaire (SASCI-Q)--a research tool discriminating between subjectively cognitively impaired patients and healthy controls

BACKGROUND

Subjective cognitive impairment (SCI) is a potential early marker for actual cognitive decline. The cognitive manifestation of the SCI stage is, however, largely unknown. Self-report instruments developed especially for use in the SCI population are lacking, and many SCI studies have not excluded mild cognitive impairment and dementia. We developed and tested a patient-based questionnaire on everyday cognitive function aiming to discriminate between patients with subjective, but not objective, cognitive impairment and healthy controls.

METHODS

Individuals experiencing cognitive impairment were interviewed to generate a pool of items. After condensing to 97 items, we tested the questionnaire in 93 SCI patients seeking care at a memory clinic (age M = 64.5 years, Mini-Mental State Examination (MMSE) M = 29.0) and 50 healthy controls (age M = 69.6 years, MMSE M = 29.3). Further item reduction was conducted to maximize that remaining items would discriminate between SCI patients and controls, using a conservative α level and requiring medium to high effect sizes. Internal consistency reliability and convergent validity was subsequently examined.

RESULTS

Forty-five items discriminated between the groups, resulting in the Sahlgrenska Academy Self-reported Cognitive Impairment Questionnaire (SASCI-Q). Internal consistency was high and correlations to a single question on memory functioning were of medium to large sizes. Most remaining items were related to the memory domain.

CONCLUSION

The SASCI-Q discriminates between SCI patients and healthy controls and demonstrates satisfying psychometric properties. The instrument provides a research method for examining SCI and forms a foundation for future examining which SCI symptoms predict objective cognitive decline. The cognitive manifestation of the SCI stage is mostly related to experiences of memory deficits.

The advanced activities of daily living: a tool allowing the evaluation of subtle functional decline in mild cognitive impairment

OBJECTIVES

Assessment of advanced activities of daily living (a-ADL) can be of interest in establishing the diagnosis of Alzheimer's disease (AD) in an earlier stage, since these activities demand high cognitive functioning and are more responsive to subtle changes. In this study we tested a new a-ADL tool, developed according to the International Classification of Functioning, Disability and Health (ICF). The a-ADL tool is based on the total number of activities performed (TNA) by a person and takes each subject as his own reference. It distinguishes a total disability index (a-ADL-DI), a cognitive disability index (a-ADL-CDI), and a physical disability index (a-ADL-PDI), with lower score representing more independency. We explored whether these indices allow distinction between cognitively healthy persons, patients with Mild Cognitive Impairment (MCI) and patients with mild AD.

METHODS

Participants were on average 80 years old (SD 4.6; 66-90), were community dwelling, and were diagnosed as (1) cognitively healthy subjects (n=26); (2) patients with MCI (n = 17), or (3) mild AD (n = 25), based upon extensive clinical evaluation and a set of global, cognitive, mood and functional assessments. The a-ADL-tool was not part of the clinical evaluation.

RESULTS

The a-ADL-CDI was significantly different between the three groups (p<.01). The a-ADL-DI was significantly different between MCI and AD (p<.001). The tool had good psychometrical properties (inter-rater reliability; agreement between patient and proxy; correlations with cognitive tests). Although the sample size was relatively small, ROC curves were computed for the a-ADL-DI and a-ADL-CDI with satisfactory and promising results.

CONCLUSION

The a-ADL-CDI and a-ADL-DI might offer a useful contribution to the identification and follow up of patients with mild cognitive disorders in an older population.

Detection of activity limitations in older adults with MCI or Alzheimer's disease through evaluation of perceived difficulty in use of everyday technology: a replication study

OBJECTIVES AND METHODS

Earlier research indicates that the ability to use everyday technology (ET) may be sensitive to subtle functional change. People with mild cognitive impairment (MCI) have been identified as significantly more disabled in ET use compared to controls, albeit less disabled than people with dementia. The aim of this study was to investigate the replicability of these findings using an improved version of the Everyday Technology Use Questionnaire (ETUQ) to compare perceptions of relevance and difficulty in ET use in participants with MCI or Alzheimer's disease (AD) and controls. Additional aims were to explore the validity of ETUQ, and the relationships between perceived difficulty in ET use and cognitive status, mood state, and involvement in everyday life activities. In total, 118 participants were included, 37 with AD, 37 with MCI, and 44 controls.

RESULTS

Analyses confirmed that the rating scale of the ETUQ functioned well. The three groups overlapped but differed significantly in their perceptions of ETs relevance (p < 0.05) as well as of difficulties in ET use (p < 0.001). Moderate correlations were also found between ETUQ measures and cognitive status, mood, and involvement in activities, the strongest being that between ETUQ measures and involvement in activities (r = 0.563).

CONCLUSION

Taken together, the findings underscore the plausibility of disability already in people with MCI, as the use of ET strongly correlates to involvement in activities. It is therefore important that professionals who meet older adults with cognitive impairment take this aspect of function into account in assessments and targeted interventions.

The process of decline in advanced activities of daily living: a qualitative explorative study in mild cognitive impairment

BACKGROUND

The notion of "minimal impairment in instrumental activities of daily living (i-ADL)" is important in the diagnosis of mild cognitive impairment (MCI), but is presently not adequately operationalized. ADL is stratified according to difficulty, complexity, and also to vulnerability to early cognitive changes in a threefold hierarchy: basic activities of daily living (b-ADL), i-ADL, and advanced activities of daily living (a-ADL). This study aims to gain a deeper understanding of the functional decline in the process of MCI.

METHODS

In a qualitative design, 37 consecutive patients diagnosed with amnestic (a)-MCI and their proxies were interviewed at two geriatric day hospitals. Constant comparative analysis was used for the analysis.

RESULTS

The a-ADL-concept emerged as important in the diagnosis of MCI. All participants were engaged in a wide range of activities, which could be clustered according to the International Classification of Functioning, Disability and Health (ICF). Participants reported subtle difficulties in performance. A process of functional decline was identified in which adaptation and coping mechanisms interacted with the process of reduced skills, leading to an activity disruption and an insufficiency in functioning.

CONCLUSION

This study asserts the inclusion of an evaluation of a-ADL in the assessment of older persons. When evaluating ADL at three levels (b-ADL, i-ADL, and a-ADL), all the activities one can perform in daily living are covered.

Patient self-report for evaluating mild cognitive impairment and prodromal Alzheimer's disease

Patient-reported outcome (PRO) measures are used to evaluate disease and treatments in many therapeutic areas, capturing relevant aspects of the disorder not obtainable through clinician or informant report, including those for which patients may have a greater level of awareness than those around them. Using PRO measures in mild cognitive impairment (MCI) and prodromal Alzheimer's disease (AD) presents challenges given the presence of cognitive impairment and loss of insight. This overview presents issues relevant to the value of patient report with emphasis on the role of insight. Complex activities of daily living functioning and executive functioning emerge as areas of particular promise for obtaining patient self-report. The full promise of patient self-report has yet to be realized in MCI and prodromal AD, however, in part because of lack of PRO measures developed specifically for mild disease, limited use of best practices in new measure development, and limited attention to psychometric evaluation. Resolving different diagnostic definitions and improving clinical understanding of MCI and prodromal AD will also be critical to the development and use of PRO measures.