Rate of conversion from mild cognitive impairment to dementia in a Thai hospital-based population: A retrospective cohort

Bu zhong Yiqi Decoction ameliorates mild cognitive impairment by improving mitochondrial oxidative stress damage via the SIRT3/MnSOD/OGG1 pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Bu-Zhong-Yi-Qi Decoction(BZYQD) is a traditional formula commonly used in China, known for its effects in tonifying Qi and raising Yang. It can relieve symptoms of cognitive impairment such as forgetfulness and lack of concentration caused by qi deficiency, which is common in aging and debilitating. However, much of the current research on BZYQD has been focused on its impact on the digestive system, leaving its molecular mechanisms in improving cognitive function largely unexplored.

AIM OF THE STUDY

Cognitive decline in the aging central nervous system is intrinsically linked to oxidative damage. This study aims to investigate the therapeutic mechanism of BZYQD in treating mild cognitive impairment caused by qi deficiency, particularly through repair of mitochondrial oxidative damage.

MATERIALS AND METHODS

A rat model of mild cognitive impairment (MCI) was established by administering reserpine subcutaneously for two weeks, followed by a two-week treatment with BZYQD/GBE. In vitro experiments were conducted to assess the effects of BZYQD on neuronal cells using a H2O2-induced oxidative damage model in PC12 cells. The open field test and the Morris water maze test evaluated the cognitive and learning memory abilities of the rats. HE staining and TEM were employed to observe morphological changes in the hippocampus and its mitochondria. Mitochondrial activity, ATP levels, and cellular viability were measured using assay kits. Protein expression in the SIRT3/MnSOD/OGG1 pathway was analyzed in tissues and cells through western blotting. Levels of 8-OH-dG in mitochondria extracted from tissues and cells were quantified using ELISA. Mitochondrial morphology in PC12 cells was visualized using Mito Red, and mitochondrial membrane potential was assessed using the JC-1 kit.

RESULTS

BZYQD treatment significantly improved cognitive decline caused by reserpine in rats, as well as enhanced mitochondrial morphology and function in the hippocampus. Our findings indicate that BZYQD mitigates mtDNA oxidative damage in rats by modulating the SIRT3/MnSOD/OGG1 pathway. In PC12 cells, BZYQD reduced oxidative damage to mitochondria and mtDNA in H2O2-induced conditions and was associated with changes in the SIRT3/MnSOD/OGG1 pathway.

CONCLUSION

BZYQD effectively counteracts reserpine-induced mild cognitive impairment and ameliorates mitochondrial oxidative stress damage through the SIRT3/MnSOD/OGG1 pathway.

Maintenance effects of short-period intensive creative expressive arts-based program (SPI-CrEAS) on cognitive function older adults with mild cognitive impairment: A pilot study

OBJECTIVES

To assess the maintenance effectiveness of a short-period intensive creative expressive arts-based storytelling (SPI-CrEAS) program in older patients with mild cognitive impairment (MCI).

METHODS

This two-arm, single-blinded, pilot, randomized controlled trial was conducted at XXX and included 38 participants who had previously completed a 24-week CrEAS project. Eligible participants were randomly assigned to receive intensive CrEAS program twice weekly for an additional 12 weeks (short-period intensive [SPI]-CrEAS) or complete their daily activities (control group). Linear mixed-model regression was used to analyze baseline and intra-group and inter-group comparisons at different follow-up periods.

RESULTS

At the 12-week follow-up, verbal function (Verbal Fluency Test, P=0.021) improved significantly in the SPI-CrEAS group compared with the control group. The cognitive benefits of SPI-CrEAS were sustained with twice-weekly training for 3 months, lasting for up to 9 months.

CONCLUSIONS

The initial cognitive improvement following CrEAS was sustained at follow-up and boosted by SPI-CrEAS.

Polygenic Score for Conscientiousness Is a Protective Factor for Reversion from Mild Cognitive Impairment to Normal Cognition

Spontaneous reversion from mild cognitive impairment (MCI) to normal cognition (NC) is little known. Based on the data of the Genetics of Personality Consortium and MCI participants from Alzheimer's Disease Neuroimaging Initiative, the authors investigate the effect of polygenic scores (PGS) for personality traits on the reversion of MCI to NC and its underlying neurobiology. PGS analysis reveals that PGS for conscientiousness (PGS-C) is a protective factor that supports the reversion from MCI to NC. Gene ontology enrichment analysis and tissue-specific enrichment analysis indicate that the protective effect of PGS-C may be attributed to affecting the glutamatergic synapses of subcortical structures, such as hippocampus, amygdala, nucleus accumbens, and caudate nucleus. The structural covariance network (SCN) analysis suggests that the left whole hippocampus and its subfields, and the left whole amygdala and its subnuclei show significantly stronger covariance with several high-cognition relevant brain regions in the MCI reverters compared to the stable MCI participants, which may help illustrate the underlying neural mechanism of the protective effect of PGS-C.

Memory complaint in a middle-income country: a four-year longitudinal study in a cohort with low-education

BACKGROUND

 Memory complaints are frequent in older adults and are associated with higher risk of cognitive decline.

OBJECTIVE

 To investigate the functional outcome of individuals with memory complaints followed up at primary care centers.

METHODS

 Data were collected between 2016 e 2020 in primary health care centers in Brazil. Patients underwent the Brief Cognitive Screening Battery, and the Functional Activities Questionnaire.

RESULTS

 The initial sample (2016) comprised 91 individuals classified into those with subjective cognitive decline (SCD, n = 15), mild cognitive impairment (MCI, n = 45), or dementia (n = 31). During follow-up, 8 individuals (8.8% of the initial sample) died and 26 (28.5% of the initial sample) were not found. Fifty-seven participants underwent clinical reassessment. Of 15 individuals with SCD, 7 were not found (46.7%), 4 (26.7%) progressed to MCI, and 4 (26.7%) remained stable. Of 45 individuals with MCI, 11 were not found (24.4%), 2 (4.4%) died, 6 (13.4%) progressed to dementia, 12 (26.7%) regressed to SCD, and 14 (31.1%) remained stable. Of 31 individuals with dementia, 8 were not found (25.8%), 6 (19.4%) died, 2 (6.5%) regressed to SCD, 7 (22.6%) regressed to MCI, and 8 remained stable (25.8%). Clinical improvement was due to the treatment of reversible causes, such as B12 hypovitaminosis and mood disorders. Older age, lower Mini-Mental State Examination, and higher scores of memory complaint, but not the use of benzodiazepines and of proton pump inhibitors, were predictors of functional status.

CONCLUSION

 Despite their limits (short sample size, missing data), these results support the idea that adequate screening, follow-up, and treatment of reversible causes of dementia in primary care are essential.

A qualitative exploration of 40 Hz sound and music for older adults with mild cognitive impairment

Emerging evidence suggests that 40 Hz auditory stimulation may benefit cognition. Nested within a randomized crossover trial, this qualitative study evaluates the acceptability and experience of three auditory interventions-self-selected music, 40 Hz sound, and a novel combination, termed 40 Hz music-in individuals with Mild Cognitive Impairment (MCI). Semi-structured interviews were conducted with individuals with MCI post-intervention exposure. Findings indicated a preference for self-selected music due to its memory-boosting and emotional benefits, while responses to 40 Hz sound were mixed, with several participants reporting discomfort. The composite 40 Hz music intervention showed promise, striking a balance by enhancing user experience and mitigating the 40 Hz sound's negative aspects. Engagement was influenced by personal music interests, listening routines, and support networks. This study highlights the potential of integrating 40 Hz sound with personalized music to offer a more acceptable 40 Hz auditory intervention for cognition in older adults with MCI.

Estimating dementia risk in an African American population using the DCTclock

The prevalence of Alzheimer's disease (AD) and related dementias (ADRD) is increasing. African Americans are twice as likely to develop dementia than other ethnic populations. Traditional cognitive screening solutions lack the sensitivity to independently identify individuals at risk for cognitive decline. The DCTclock is a 3-min AI-enabled adaptation of the well-established clock drawing test. The DCTclock can estimate dementia risk for both general cognitive impairment and the presence of AD pathology. Here we performed a retrospective analysis to assess the performance of the DCTclock to estimate future conversion to ADRD in African American participants from the Rush Alzheimer's Disease Research Center Minority Aging Research Study (MARS) and African American Clinical Core (AACORE). We assessed baseline DCTclock scores in 646 participants (baseline median age = 78.0 ± 6.4, median years of education = 14.0 ± 3.2, 78% female) and found significantly lower baseline DCTclock scores in those who received a dementia diagnosis within 3 years. We also found that 16.4% of participants with a baseline DCTclock score less than 60 were significantly more likely to develop dementia in 5 years vs. those with the highest DCTclock scores (75-100). This research demonstrates the DCTclock's ability to estimate the 5-year risk of developing dementia in an African American population. Early detection of elevated dementia risk using the DCTclock could provide patients, caregivers, and clinicians opportunities to plan and intervene early to improve cognitive health trajectories. Early detection of dementia risk can also enhance participant selection in clinical trials while reducing screening costs.

The risk of developing dementia in the COVID-19 pandemic; a cohort study

OBJECTIVES

The effects of the COVID-19 pandemic on cognitive decline are not fully understood. Higher social activity and relationships have been associated with decreased risk of dementia. We hypothesised that risk of transition to dementia would increase after the start of the first national lockdown.

METHODS

We obtained data from the Brains for Dementia (BDR) cohort, which has collected roughly annual data on 3726 older adults with and without dementia since 2008. Data continued to be collected during the lockdowns, although by telephone and/or video call instead of in person. Individuals diagnosed with dementia at study entry were excluded from this study as were individuals with only one visit. Cognitive status was classified using the Clinical Dementia Rating (CDR) global score. Poisson regression with cubic splines to account for differences in age was used to compare the incidence of dementia before and after March 1st 2020.

RESULTS

Out of 2242 individuals, 208 individuals developed dementia before and 50 developed dementia after 01/03/20. The incidence rate ratio of developing dementia after 01/03/20 was 0.847 (0.538-1.335) p = 0.570. In our secondary analysis we found that the positive association between mild cognitive impairment (MCI) and dementia incidence decreased after 1/3/20 (interaction effect p = 0.031).

CONCLUSION

The incidence of dementia as defined using the CDR global score did not change significantly after the first lockdown began, but we found evidence that lockdown decreased the positive association between MCI and dementia incidence. This may reflect that individuals were progressing to dementia more rapidly and thus missing the MCI stage or that assessing patients over the phone made diagnosing MCI more challenging.

The impact of musical reward responses on cognitive function in older adults with type 2 diabetes

Cognitive decline is prevalent in older adults with type 2 diabetes (T2DM). The use of music has emerged to improve cognitive health. Even though reward from music has been shown to improve cognitive function, no studies have focused on specific factors of musical reward. This study investigated which factors of musical reward impact cognitive function in older adults with T2DM. A secondary data analysis was conducted with 185 older adults with T2DM and subjective cognitive decline. Among the musical reward factors, mood regulation significantly influenced subjective cognitive function (β = 0.315; p < 0.001). The findings suggest that music interventions for older adults with T2DM may need to focus on managing their psychological states for the intervention to have beneficial effects on cognitive function. Future rigorous studies with larger sample sizes should be done to obtain robust evidence for optimal music interventions for older adults with T2DM.

Association between the neutrophil-to-lymphocyte ratio and cognitive impairment: a meta-analysis of observational studies

Background

Systemic inflammation is one of the underlying mechanisms of cognitive impairment. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a systemic inflammation indicator. This meta-analysis aimed to evaluate the association between high NLR and cognitive impairment (CI) risk.

Method

A comprehensive systematic search was conducted to identify eligible studies published until May 30, 2023. The reference group comprised patients with the lowest NLR level, whereas the exposure group comprised those with the highest NLR level. The main outcome was to examine the relationship between NLR and CI risk. The secondary outcome included the association between patient characteristics or comorbidities and CI risk.

Results

This meta-analysis included 11 studies published between 2018 and 2023, involving 10,357 patients. Patients with CI had a higher NLR than those without (mean difference=0.35, 95% confidence interval [CI]: 0.26-0.44, p < 00001, I2 = 86%). Consistently, pooled results revealed an association between high NLR and CI risk (odds ratio [OR]=2.53, 95% CI:1.67-3.82, p<0.0001, I2 = 84%). Furthermore, aging (mean difference =4.31 years, 95% CI:2.83-5.8, p < 0.00001, I2 = 92%), diabetes (OR=1.59, 95% CI:1.35-1.88, p < 0.00001, I2 = 66%), and hypertension (OR=1.36, 95% CI:1.19-1.57, p < 0.00001, I2 = 0%) were significant risk factors for CI. However, no significant associations were observed between CI and male gender (OR = 0.84, 95% CI:0.64-1.11, p = 0.22, I2 = 81%), body mass index (mean = -0.32 kg/m2, 95% CI: -0.82, 0.18, p = 0.2, I2 = 82%), alcohol consumption (OR = 1.11, 95% CI:0.95-1.3, p = 1.35, I2 = 0%), and smoking (OR = 0.99, 95% CI:0.87-1.13, p = 0.86, I2 = 0%). Meta-regression found that diabetes and hypertension, but not age, significantly moderated the association between NLR and CI.

Conclusion

This meta-analysis showed a significant association between high NLR and increased CI risk. Moreover, meta-regression identified diabetes and hypertension, but not age, as significant moderating factors in the relationship between NLR and CI. To validate and strengthen these findings, further large-scale studies are required.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023430384, identifier CRD42023430384.

Screening for Mild Cognitive Impairment with Speech Interaction Based on Virtual Reality and Wearable Devices

Significant advances in sensor technology and virtual reality (VR) offer new possibilities for early and effective detection of mild cognitive impairment (MCI), and this wealth of data can improve the early detection and monitoring of patients. In this study, we proposed a non-invasive and effective MCI detection protocol based on electroencephalogram (EEG), speech, and digitized cognitive parameters. The EEG data, speech data, and digitized cognitive parameters of 86 participants (44 MCI patients and 42 healthy individuals) were monitored using a wearable EEG device and a VR device during the resting state and task (the VR-based language task we designed). Regarding the features selected under different modality combinations for all language tasks, we performed leave-one-out cross-validation for them using four different classifiers. We then compared the classification performance under multimodal data fusion using features from a single language task, features from all tasks, and using a weighted voting strategy, respectively. The experimental results showed that the collaborative screening of multimodal data yielded the highest classification performance compared to single-modal features. Among them, the SVM classifier using the RBF kernel obtained the best classification results with an accuracy of 87%. The overall classification performance was further improved using a weighted voting strategy with an accuracy of 89.8%, indicating that our proposed method can tap into the cognitive changes of MCI patients. The MCI detection scheme based on EEG, speech, and digital cognitive parameters proposed in this study provides a new direction and support for effective MCI detection, and suggests that VR and wearable devices will be a promising direction for easy-to-perform and effective MCI detection, offering new possibilities for the exploration of VR technology in the field of language cognition.

Effectiveness of online-based cognitive intervention in community-dwelling older adults with cognitive dysfunction: A systematic review and meta-analysis

BACKGROUND

Mild cognitive impairment (MCI) or mild dementia imposes a substantial burden on patients, families, and social systems. For MCI or mild dementia patient, cognitive training is required to prevent progression to dementia. With advances in digital health, cognitive interventions using information and communication technology (ICT) have become essential for maintaining independence and functioning in dementia patients.

OBJECTIVES

This study aimed to examine the effectiveness of an ICT-based cognitive intervention in community-dwelling older adults with MCI or mild dementia.

METHODS

A literature search was performed in four databases: Ovid-Medline, Ovid-EMBASE, Cochrane Library, and CINAHL. We selected studies published up to April 15, 2021, on topics related to cognitive interventions using ICT in older adults with MCI or mild dementia.

RESULTS

Forty-four studies were included in the analysis. Our meta-analysis showed that ICT-based cognitive interventions significantly improved the Mini-Mental State Examination score in the intervention group compared with that in the control group. Additionally, cognitive training using ICT was significantly effective for a period of more than 30 min, more than 6 weeks, and multi-domain content. Moreover, a significant reduction in depression was found in the intervention group compared with that in the control group.

CONCLUSIONS

ICT-based cognitive intervention had a positive effect on cognitive function, depression, and quality of life in older adults with MCI or mild dementia. Application of ICT-based cognitive training to community-dwelling older adults with MCI or mild dementia should be expanded, and nurses should play a pivotal role in mediating between these older adults.

Changes of tRNA-Derived Fragments by Alzheimer's Disease in Cerebrospinal Fluid and Blood Serum

BACKGROUND

Alzheimer's disease (AD) is the most common type of dementia, affecting individuals over 65. AD is also a multifactorial disease, with disease mechanisms incompletely characterized, and disease-modifying therapies are marginally effective. Biomarker signatures may shed light on the diagnosis, disease mechanisms, and the development of therapeutic targets. tRNA-derived RNA fragments (tRFs), a family of recently discovered small non-coding RNAs, have been found to be significantly enhanced in human AD hippocampus tissues. However, whether tRFs change in body fluids is unknown.

OBJECTIVE

To investigate whether tRFs in body fluids are impacted by AD.

METHODS

We first used T4 polynucleotide kinase-RNA-seq, a modified next-generation sequencing technique, to identify detectable tRFs in human cerebrospinal fluid and serum samples. The detectable tRFs were then compared in these fluids from control, AD, and mild cognitive impairment patients using tRF qRT-PCR. The stability of tRFs in serum was also investigated by checking the change in tRFs in response to protein digestion or exosome lysis.

RESULTS

Among various tRFs, tRF5-ProAGG seemed to be impacted by AD in both cerebrospinal fluid and serum. AD-impacted serum tRF5-ProAGG showed a correlation with the AD stage. Putative targets of tRF5-ProAGG in the hippocampus were also predicted by a computational algorithm, with some targets being validated experimentally and one of them being in a negative correlation with tRF5-ProAGG even using a small size of samples.

CONCLUSIONS

tRF5-ProAGG showed the potential as an AD biomarker and may play a role in disease progression.

Analysis of Costs for Imaging-Assisted Pharmaceutical Intervention in Alzheimer's Disease with Lecanemab: Snapshot of the First 3 Years

BACKGROUND

The approval of lecanemab for the treatment of Alzheimer's disease (AD) by the Food and Drug Administration in the United States has sparked controversy over issues of safety, cost, and efficacy. Furthermore, the prognostication of cognitive decline is prohibitively difficult with current methods. The inability to forecast incipient dementia in patients with biological AD suggests a prophylactic scenario wherein all patients with cognitive decline are prescribed anti-AD drugs at the earliest manifestations of dementia; however, most patients with mild cognitive impairment (approximately 77.7%) do not develop dementia over a 3-year period. Prophylactic response therefore constitutes unethical, costly, and unnecessary treatment for these patients.

OBJECTIVE

We present a snapshot of the costs associated with the first 3 years of mass availability of anti-AD drugs in a variety of scenarios.

METHODS

We consider multiple prognostication scenarios with varying sensitivities and specificities based on neuroimaging studies in patients with mild cognitive impairment to determine approximate costs for the large-scale use of lecanemab.

RESULTS

The combination of fluorodeoxyglucose and magnetic resonance was determined to be the most cost-efficient at $177,000 for every positive outcome every 3 years under an assumed adjustment in the price of lecanemab to $9,275 per year.

CONCLUSIONS

Imaging-assisted identification of cognitive status in patients with prodromal AD is demonstrated to reduce costs and prevent instances of unnecessary treatment in all cases considered. This highlights the potential of this technology for the ethical prescription of anti-AD medications under a paradigm of imaging-assisted early detection for pharmaceutical intervention in the treatment of AD.

Effectiveness of Computerized Cognitive Training in Delaying Cognitive Function Decline in People With Mild Cognitive Impairment: Systematic Review and Meta-analysis

Background

With no current cure for mild cognitive impairment (MCI), delaying its progression could significantly reduce the disease burden and improve the quality of life for patients with MCI. Computerized cognitive training (CCT) has recently become a potential instrument for improvement of cognition. However, the evidence for its effectiveness remains limited.

Objective

This systematic review aims to (1) analyze the efficacy of CCT on cognitive impairment or cognitive decline in patients with MCI and (2) analyze the relationship between the characteristics of CCT interventions and cognition-related health outcomes.

Methods

A systematic search was performed using MEDLINE, Cochrane, Embase, Web of Science, and Google Scholar. Full texts of randomized controlled trials of CCT interventions in adults with MCI and published in English language journals between 2010 and 2021 were included. Overall global cognitive function and domain-specific cognition were pooled using a random-effects model. Sensitivity analyses were performed to determine the reasons for heterogeneity and to test the robustness of the results. Subgroup analyses were performed to identify the relationship between the characteristics of CCT interventions and cognition-related effectiveness.

Results

A total of 18 studies with 1059 participants were included in this review. According to the meta-analysis, CCT intervention provided a significant but small increase in global cognitive function compared to that in the global cognitive function of the control groups (standardized mean difference=0.54, 95% CI 0.35-0.73; I2=38%). CCT intervention also resulted in a marginal improvement in domain-specific cognition compared to that in the control groups, with moderate heterogeneity. Subgroup analyses showed consistent improvement in global cognitive behavior in the CCT intervention groups.

Conclusions

This systematic review suggests that CCT interventions could improve global cognitive function in patients with MCI. Considering the relatively small sample size and the short treatment duration in all the included studies, more comprehensive trials are needed to quantify both the impact of CCT on cognitive decline, especially in the longer term, and to establish whether CCT should be recommended for use in clinical practice.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42021278884; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278884

The Asparaginyl Endopeptidase Legumain: An Emerging Therapeutic Target and Potential Biomarker for Alzheimer’s Disease

Alzheimer’s disease (AD) is incurable dementia closely associated with aging. Most cases of AD are sporadic, and very few are inherited; the pathogenesis of sporadic AD is complex and remains to be elucidated. The asparaginyl endopeptidase (AEP) or legumain is the only recognized cysteine protease that specifically hydrolyzes peptide bonds after asparagine residues in mammals. The expression level of AEPs in healthy brains is far lower than that of peripheral organs. Recently, growing evidence has indicated that aging may upregulate and overactivate brain AEPs. The overactivation of AEPs drives the onset of AD through cleaving tau and amyloid precursor proteins (APP), and SET, an inhibitor of protein phosphatase 2A (PP2A). The AEP-mediated cleavage of these peptides enhances amyloidosis, promotes tau hyperphosphorylation, and ultimately induces neurodegeneration and cognitive impairment. Upregulated AEPs and related deleterious reactions constitute upstream events of amyloid/tau toxicity in the brain, and represent early pathological changes in AD. Thus, upregulated AEPs are an emerging drug target for disease modification and a potential biomarker for predicting preclinical AD. However, the presence of the blood–brain barrier greatly hinders establishing body-fluid-based methods to measure brain AEPs. Research on AEP-activity-based imaging probes and our recent work suggest that the live brain imaging of AEPs could be used to evaluate its predictive efficacy as an AD biomarker. To advance translational research in this area, AEP imaging probes applicable to human brain and AEP inhibitors with good druggability are urgently needed.

Health-Related Predictors of Changes in Cognitive Status in Community-Dwelling Older Individuals

Given the rising numbers of older people living with dementia, this study focuses on identifying modifiable health-related factors associated with changes in cognitive status. The predictors of 1-year conversion from Preserved Cognitive Health (PCH) and Mild Cognitive Impairment (MCI) in older adults were evaluated. Two logistic regression models were performed on data from an Italian multicenter population-based study; both included sociodemographic factors, family history of dementia (FHD), risk behaviors, and depressive symptoms. The first model considered also disease clusters, while the second one included diseases' number and biochemical parameters. The sample involved 459 participants (61.4% women, median age 75 years). Of the 80 PCH individuals at baseline, after 1 year 35 (43.8%) were stable, 44 (55.0%) progressed to MCI, none to dementia, and one to unclassified status. Of the 379 MCI participants at baseline, after 1 year 281 (74.1%) remained stable, 38 (10.0%) reverted to PCH, 15 (4.0%) progressed to dementia, and 45 (11.9%) become unclassifiable. Hypertension/bone and joint diseases cluster was the only predictor of PCH progression to MCI; age and depression were associated with MCI progression to dementia; FHD was associated with MCI reversion to PCH. More diseases and fewer white blood cells were associated with MCI progression to dementia; more diseases and lower platelets were associated with the transition from MCI to unclassifiable; higher Na and lower TSH levels were associated with MCI reversion. The treatment or management of some chronic conditions and electrolyte imbalances may help attenuate cognitive deterioration in older adults with no or MCI.