The picture superiority effect in patients with Alzheimer's disease and mild cognitive impairment

Animations to communicate public health prevention messages: a realist review protocol

INTRODUCTION

With digital and social media advances, animated health communications (health animations) are highly prevalent globally, yet the evidence base underpinning them remains unclear and limited. While individual studies have attempted to explore the effectiveness, acceptability and usability of specific features of health animations, there is substantial heterogeneity in study design, comparators and the animation design and content. Consequently, there is a need to synthesise evidence of health animations using an approach that recognises this contextual complexity, which may affect their impact.

METHODS AND ANALYSIS

This project aims to understand why, how, for whom, to what extent and in which contexts health animations are expected to promote preventive health behaviours. We will conduct a realist review following Pawson's five iterative stages to (1) define the review scope and locate existing theories; (2) search for evidence; (3) select and appraise evidence; (4) extract data and (5) synthesise data and refine theory. Engagement with stakeholders involved in developing, testing, implementing or commissioning health communications, including animations, will allow the initial programme theory to be tested and refined. The findings will be reported in accordance with Realist and Meta-narrative Evidence Syntheses: Evolving Standards.

ETHICS AND DISSEMINATION

Ethical approval for the public stakeholder work was provided by the Northumbria University Research Ethics Committee. We will disseminate the findings widely through outputs tailored to target specific professional, public and patient audiences. Dissemination will occur through stakeholder engagement as part of the research, a peer-reviewed publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42023447127.

Towards Visualization Thumbnail Designs That Entice Reading Data-Driven Articles

As online news increasingly include data journalism, there is a corresponding increase in the incorporation of visualization in article thumbnail images. However, little research exists on the design rationale for visualization thumbnails, such as resizing, cropping, simplifying, and embellishing charts that appear within the body of the associated article. Therefore, in this paper we aim to understand these design choices and determine what makes a visualization thumbnail inviting and interpretable. To this end, we first survey visualization thumbnails collected online and discuss visualization thumbnail practices with data journalists and news graphics designers. Based on the survey and discussion results, we then define a design space for visualization thumbnails and conduct a user study with four types of visualization thumbnails derived from the design space. The study results indicate that different chart components play different roles in attracting reader attention and enhancing reader understandability of the visualization thumbnails. We also find various thumbnail design strategies for effectively combining the charts' components, such as a data summary with highlights and data labels, and a visual legend with text labels and Human Recognizable Objects (HROs), into thumbnails. Ultimately, we distill our findings into design implications that allow effective visualization thumbnail designs for data-rich news articles. Our work can thus be seen as a first step toward providing structured guidance on how to design compelling thumbnails for data stories.

Revisiting Snodgrass and Vanderwart in photograph form: The Keele Photo Stimulus Set (KPSS)

Over the last 40 years, object recognition studies have moved from using simple line drawings, to more detailed illustrations, to more ecologically valid photographic representations. Researchers now have access to various stimuli sets, however, existing sets lack the ability to independently manipulate item format, as the concepts depicted are unique to the set they derive from. To enable such comparisons, Rossion and Pourtois (2004) revisited Snodgrass and Vanderwart's (1980) line drawings and digitally re-drew the objects, adding texture and shading. In the current study, we took this further and created a set of stimuli that showcase the same objects in photographic form. We selected six photographs of each object (three color/three grayscale) and collected normative data and RTs. Naming accuracy and agreement was high for all photographs and appeared to steadily increase with format distinctiveness. In contrast to previous data patterns for drawings, naming agreement (H values) did not differ between grey and color photographs, nor did familiarity ratings. However, grey photographs received significantly lower mental imagery agreement and visual complexity scores than color photographs. This suggests that, in comparison to drawings, the ecological nature of photographs may facilitate deeper critical evaluation of whether they offer a good match to a mental representation. Color may therefore play a more vital role in photographs than in drawings, aiding participants in judging the match with their mental representation. This new photographic stimulus set and corresponding normative data provide valuable materials for a wide range of experimental studies of object recognition.

Drawing improves memory in patients with hippocampal damage

The hippocampus plays a critical role in the formation of declarative memories, and hippocampal damage leads to significant impairments in new memory formation. Drawing can serve as a form of multi-modal encoding that improves declarative memory performance relative to other multimodal encoding strategies such as writing. We examined whether, and to what extent, patients with hippocampal damage could benefit from the mnemonic strategy of drawing. Three patients with focal hippocampal damage, and one patient with both hippocampal and cortical lesions, in addition to 22 age-, sex-, and education-matched controls, were shown a list of words one at a time during encoding and instructed to either draw a picture or repeatedly write each word for 40 s. Following a brief filled delay, free recall and recognition memory for words from both encoding trial types were assessed. Controls showed enhanced recall and recognition memory for words drawn versus those that were written, an effect that was even more pronounced in patients with focal hippocampal damage. By contrast, the patient with both hippocampal and cortical lesions showed no drawing-mediated boost in either recall or recognition memory. These findings demonstrate that drawing is an effective encoding strategy, likely accruing from the engagement of extra-hippocampal processes including the integration of cortical-based motor, visual, and semantic processing, enabling more elaborative encoding.

Icono: a universal language that shows what it says

This article lays out the foundation of a new language for easier written communication that is inherently reader-friendly and inherently international. Words usually consist of strings of sounds or squiggles whose meanings are merely a convention. In Icono, instead, they typically are strings of icons that illustrate what they stand for. "Train," for example, is expressed with the icon of a train, "future" with the icon of a clock surrounded by a clockwise arrow, and "mammal" with the icons of a cow and a mouse-their combination's meaning given by what they have in common. Moreover, Icono reveals sentence structure graphically before, rather than linguistically after, one begins reading. On smartphones and computers, writing icons can now be faster than writing alphabetic words. And using simple pictures as words helps those who struggle with conditions like dyslexia, aphasia, cerebral palsy, and autism with speech impairment. Because learning its pronunciation or phonetic spelling is optional rather than a prerequisite, and because it shows what it says, Icono is bound to be easier to learn to read-and then easier to read-than any other language, including our own.

Familiarity Deficits for Words and Objects in Amnestic Mild Cognitive Impairment in a Context Minimizing the Role of Recollection

OBJECTIVES

Amnestic mild cognitive impairment (aMCI) is associated with cortical thinning in perirhinal and entorhinal cortices, key regions of the brain supporting familiarity. Individuals with aMCI demonstrate familiarity deficits in their behavior, often repeating questions in the same conversation. While familiarity deficits in healthy aging are minimal, past studies measuring familiarity in aMCI have mixed results, perhaps due to the influence of recollection. We therefore used a paradigm that minimized the influence of recollection, and hypothesized that familiarity would be impaired in aMCI relative to age-matched controls, but not in healthy older adults relative to younger adults. We also hypothesized that familiarity deficits in aMCI would be greater for objects than words because the perirhinal cortex plays a significant role in visual discrimination.

METHODS

A sample of 36 younger adults, 38 cognitively intact older adults, and 30 older adults with aMCI made absolute frequency judgments for words and objects seen a variable number of times in an incidental encoding task. Estimates of familiarity were derived from correlating participants' frequency judgments with the actual frequency of presentation.

RESULTS

Familiarity was largely spared in healthy aging, with minor deficits in familiarity for words. Familiarity deficits were evident in aMCI comparably for words and objects.

DISCUSSION

The present research underscores the need to study familiarity in contexts minimizing recollection, particularly when comparing groups with different levels of recollection, and adds to our understanding of the phenomenology of aMCI. Familiarity deficits may provide an early biomarker of dementia risk.

An examination of task factors that influence the associative memory deficit in aging

Aging is accompanied by a decline in associative memory, whereas item memory remains relatively stable compared to young adults. This age-related associative deficit is well replicated, but its mechanisms and influencing factors during learning are still largely unclear. In the present study, we examined mediators of the age-related associative deficit, including encoding intentionality, strategy instructions, the timing of the memory test (immediate vs. 24 h delayed) and the material being learned (words vs. pictures) in a within-subject design. Older and younger adults performed seven encoding tasks on word pairs and picture pairs on two consecutive days, followed by item and associative recognition tests. The associative deficit was evident after all encoding tasks. We found no evidence for a difference in the magnitude of the associative deficit between incidental vs. intentional learning conditions. However, there was some evidence for a larger associative memory deficit with pictures versus words when the encoding task was held equal. Sentence generation and interactive imagery instructions in which participants generated their own mediators reduced the magnitude of the associative deficit. However, increased encoding guidance through the provision of mediators did not lead to an alleviation of the deficit, potentially because the specified mediators were implausible or difficult for the older adults to reconcile with prior knowledge. Finally, we found some evidence for a reduced age-related associative deficit with a test delay of 24 h. These results contribute to a better understanding of the factors affecting the relative difficulty of older adults with encoding and retrieving novel associations.

Preserved Extra-Foveal Processing of Object Semantics in Alzheimer's Disease

Alzheimer's disease (AD) patients underperform on a range of tasks requiring semantic processing, but it is unclear whether this impairment is due to a generalised loss of semantic knowledge or to issues in accessing and selecting such information from memory. The objective of this eye-tracking visual search study was to determine whether semantic expectancy mechanisms known to support object recognition in healthy adults are preserved in AD patients. Furthermore, as AD patients are often reported to be impaired in accessing information in extra-foveal vision, we investigated whether that was also the case in our study. Twenty AD patients and 20 age-matched controls searched for a target object among an array of distractors presented extra-foveally. The distractors were either semantically related or unrelated to the target (e.g., a car in an array with other vehicles or kitchen items). Results showed that semantically related objects were detected with more difficulty than semantically unrelated objects by both groups, but more markedly by the AD group. Participants looked earlier and for longer at the critical objects when these were semantically unrelated to the distractors. Our findings show that AD patients can process the semantics of objects and access it in extra-foveal vision. This suggests that their impairments in semantic processing may reflect difficulties in accessing semantic information rather than a generalised loss of semantic memory.

Sensory Cueing of Autobiographical Memories in Normal Aging and Alzheimer's Disease: A Comparison Between Visual, Auditory, and Olfactory Information

BACKGROUND

Alzheimer's disease (AD) is a chronic, neurodegenerative disease resulting in a progressive decline of autobiographical memories (AMs) which favors the development of psycho-behavioral disorders. One of the most popular psychosocial interventions in dementia care, Reminiscence Therapy, commonly uses sensory cueing to stimulate AMs retrieval. However, few empirical studies have investigated the impact of sensory stimulation on AMs retrieval in AD.

OBJECTIVE

Our goal was to determine the most relevant cue for AMs retrieval in patients with early to mild AD when comparing odors, sounds and pictures.

METHODS

Sixty AD patients, 60 healthy older adults (OA), and 60 healthy young adults (YA) participated in our study. Participants were presented with either 4 odors, 4 sounds, or 4 pictures. For each stimulus, they were asked to retrieve a personal memory, to rate it across 3 dimensions (emotionality, vividness, rarity) and then to date it.

RESULTS

Overall, results showed no clear dominance of one sensory modality over the others in evoking higher-quality AMs. However, they show that using pictures is the better way to stimulate AD patients' AM, as it helps to retrieve a higher number of memories that are also less frequently retrieved, followed by odors. By contrast, auditory cueing with environmental sounds presented no true advantage.

CONCLUSION

Our data should help dementia care professionals to increase the efficiency of Reminiscence Therapy using sensory elicitors. Other clinical implications and future directions are also discussed.

Recognition Memory Dysfunction Relates to Hippocampal Subfield Volume: A Study of Cognitively Normal and Mildly Impaired Older Adults

OBJECTIVES

The current study examined recognition memory dysfunction and its neuroanatomical substrates in cognitively normal older adults and those diagnosed with mild cognitive impairment (MCI).

METHODS

Participants completed the Mnemonic Similarity Task, which provides simultaneous measures of recognition memory and mnemonic discrimination. They also underwent structural neuroimaging to assess volume of medial temporal cortex and hippocampal subfields.

RESULTS

As expected, individuals diagnosed with MCI had significantly worse recognition memory performance and reduced volume across medial temporal cortex and hippocampal subfields relative to cognitively normal older adults. After controlling for diagnostic group differences, however, recognition memory was significantly related to whole hippocampus volume, and to volume of the dentate gyrus/CA3 subfield in particular. Recognition memory was also related to mnemonic discrimination, a fundamental component of episodic memory that has previously been linked to dentate gyrus/CA3 structure and function.

DISCUSSION

Results reveal that hippocampal subfield volume is sensitive to individual differences in recognition memory in older adults independent of clinical diagnosis. This supports the notion that episodic memory declines along a continuum within this age group, not just between diagnostic groups.

Development and evaluation of an augmented reality education program for pediatric research

BACKGROUND

Children often have limited understanding of clinical research and what they might expect from participating in a clinical study. Studies, however, suggest that multimedia delivery of medical and research information may promote greater understanding and engagement compared with standard written approaches.

AIM

This study was designed to examine the effects of a novel interactive augmented reality (AR) program on children's understanding of clinical research.

METHODS

Children (ages 7-13 years) were randomized to receive the basic information about clinical research using either a printed storybook (control) or the same storybook enhanced using a video see-through AR iPad program (AR) with embedded interactive quizzes. Children were interviewed to assess their understanding of the material before (pre-test) and after (post-test) receiving either of the randomized interventions. Both parents and children completed short surveys to measure their perceptions of the information delivery.

RESULTS

Ninety-one parent/child dyads were included in the analysis. There were no differences between the control and AR children's pre-test understanding of the research information. However, both groups demonstrated significant and similar improvements in post-test understanding. Parents of children in the AR group found the information to be of higher quality and greater clarity compared with the control group, and 91.7% of children in the AR group found the inclusion of interactive quizzes to be helpful. Both parents and children found the AR program very easy to use and 85.0 % and 71.2%, respectively, indicated that if recruited for a future study that they would prefer information delivered using some type of iPad AR program together with a discussion with the researcher.

CONCLUSIONS

Results demonstrated the importance of providing children and parents with information in an easy to read and visually compelling manner. Although both groups demonstrated improved understanding, children and their parents preferred the AR program and reported a preference for receiving information using computer-based technology. Given the seemingly insurmountable challenge of keeping children and families engaged in health research related information exchange, the use of AR would appear to provide a novel and effective vehicle for enhancing children's and parents assimilation and understanding of research (and medical) information and as a potential tool to optimize the informed consent and assent processes.

RELEVANCE FOR PATIENTS

This study reinforces the importance in providing information to research participants and patients in an easy-to-read and visually salient manner. Although the AR program used in this study did not result in an increased level of understanding, AR was deemed the preferred method of information delivery. It is hoped that the results of this study will serve as a platform for future studies.

Drawing pictures at encoding enhances memory in healthy older adults and in individuals with probable dementia

We explored the efficacy of drawing pictures as an encoding strategy to enhance memory performance in healthy older adults and individuals with probable dementia. In an incidental encoding phase, participants were asked to either draw a picture or write out each word from a set of 30 common nouns for 40 seconds each. Episodic memory for the target words was compared in a group of healthy older adults to individuals with probable dementia (MMSE/MOCA range 4 to 25). In two experiments we showed that recall and recognition performance was higher for words that were drawn than written out during encoding, for both participant groups. We suggest that incorporating visuo-perceptual information into memory enhanced performance by increasing reliance on visual-sensory brain regions, which are relatively intact in these populations. Our findings demonstrate that drawing is a valuable technique leading to measurable gains in memory performance for individuals with probable dementia.

Alzheimer's Disease, Visual Search, and Instrumental Activities of Daily Living: A Review and a New Perspective on Attention and Eye Movements

Many instrumental activities of daily living (IADLs), like cooking and managing finances and medications, involve finding efficiently and in a timely manner one or several objects within complex environments. They may thus be disrupted by visual search deficits. These deficits, present in Alzheimer's disease (AD) from its early stages, arise from impairments in multiple attentional and memory mechanisms. A growing body of research on visual search in AD has examined several factors underlying search impairments in simple arrays. Little is known about how AD patients search in real-world scenes and in real settings, and about how such impairments affect patients' functional autonomy. Here, we review studies on visuospatial attention and visual search in AD. We then consider why analysis of patients' oculomotor behavior is promising to improve understanding of the specific search deficits in AD, and of their role in impairing IADL performance. We also highlight why paradigms developed in research on real-world scenes and real settings in healthy individuals are valuable to investigate visual search in AD. Finally, we indicate future research directions that may offer new insights to improve visual search abilities and autonomy in AD patients.

Listening to the Picture-Superiority Effect

The picture-superiority effect (PSE) refers to the finding that, all else being equal, pictures are remembered better than words ( Paivio & Csapo, 1973 ). Dual-coding theory (DCT; Paivio, 1991 ) is often used to explain the PSE. According to DCT, pictures are more likely to be encoded imaginally and verbally than words. In contrast, distinctiveness accounts attribute the PSE to pictures' greater distinctiveness compared to words. Some distinctiveness accounts emphasize physical distinctiveness ( Mintzer & Snodgrass, 1999 ) while others emphasize conceptual distinctiveness ( Hamilton & Geraci, 2006 ). We attempt to distinguish among these accounts by testing for an auditory analog of picture superiority. Although this phenomenon, termed the auditory PSE, occurs in free recall ( Crutcher & Beer, 2011 ), we were unable to extend it to recognition across four experiments. We propose a new framework for understanding the PSE, wherein dual coding underpins the free-recall PSE, but conceptual distinctiveness underpins the recognition PSE.

Development and evaluation of brochures for fall prevention education created to empower nursing home residents and family members

AIMS AND OBJECTIVES

In this study, we describe the development of evidence- and theory-based fall prevention educational material and its evaluation from the users' perspectives.

BACKGROUND

To reduce risk factors for falling in nursing homes, nursing staff must enact multifactorial fall prevention intervention programmes. A core component of these programmes is to educate residents and their family members, both verbally and in a written form. However, users can only benefit from educational material if it is based on current scientific evidence, easy to understand and process and customised.

DESIGN

We followed a structured procedure during the development process, while considering various aspect of quality. To assess the understandability and usefulness of the resulting educational materials, we conducted a qualitative content analysis study.

METHODS

The educational materials development process incorporated several iterative steps including a systematic literature search and the application of frameworks for designing and writing the materials. To evaluate the material, we performed six focus group discussions separately with residents, family members and nursing staff from two nursing homes (total of 32 participants).

RESULTS

Residents' brochures included clear information on avoiding external risks as well as coping strategies after a fall event. Family members' brochures were more comprehensive, including both concrete tips and outlining the advantages and disadvantages of interventions. Residents and family members had no difficulties understanding the material and tried to apply the content to their individual situations. Nursing staff commented on some ambiguities and incongruities relating to current nursing care practice.

CONCLUSIONS

By involving users in the development of evidence-based educational materials, nursing staff can achieve a high acceptance rate for the materials and motivate users to address the topic.

IMPLICATIONS FOR PRACTICE

The involvement of users is essential for developing educational material that meets users' needs. Educational material should be used as part of an overall strategy to educate residents and family members in nursing homes.

A short cut to the past: Cueing via concrete objects improves autobiographical memory retrieval in Alzheimer's disease patients

Older adults diagnosed with Alzheimer's disease (AD) have difficulties accessing autobiographical memories. However, this deficit tends to spare memories dated to earlier parts of their lives, and may partially reflect retrieval deficits rather than complete memory loss. Introducing a novel paradigm, the present study examines whether autobiographical memory recall can be improved in AD by manipulating the sensory richness, concreteness and cultural dating of the memory cues. Specifically, we examine whether concrete everyday objects historically dated to the participants' youth (e.g., a skipping rope), relative to verbal cues (i.e., the verbal signifiers for the objects) facilitate access to autobiographical memories. The study includes 49 AD patients, and 50 healthy, older matched control participants, all tested on word versus object-cued recall. Both groups recalled significantly more memories, when cued by objects relative to words, but the advantage was significantly larger in the AD group. In both groups, memory descriptions were longer and significantly more episodic in nature in response to object-cued recall. Together these findings suggest that the multimodal nature of the object cues (i.e. vision, olfaction, audition, somatic sensation) along with specific cue characteristics, such as time reference, texture, shape, may constrain the retrieval search, potentially minimizing executive function demands, and hence strategic processing requirements, thus easing access to autobiographical memories in AD.

Negative Bias in the Perception and Memory of Emotional Information in Alzheimer Disease

BACKGROUND

There is some controversy about the ability of patients with Alzheimer disease (AD) to experience and remember emotional stimuli. This study aims to assess the emotional experience of patients with AD and the existence of emotional enhancement of memory. We also investigated the influence of affective state on these processes.

METHODS

Sixty pictures from the International Affective Picture System were administered to 106 participants (72 patients with AD and 54 controls). Participants performed immediate free recall and recognition tasks. Positive and Negative Affect Schedule was used to assess the participants' current affect.

RESULTS

Patients identified the valence of unpleasant pictures better than of others pictures and experienced them as more arousing. Patients and controls recalled and recognized higher number of emotional pictures than of neutral ones. Patients discriminated better the unpleasant pictures. A mood congruent effect was observed on emotional experience but not on memory. Positive affect was associated with better immediate recall and with a more liberal response bias.

CONCLUSION

Patients with AD can identify the emotional content of the stimuli, especially of the unpleasant ones, and the emotional enhancement of memory is preserved. Affective state does not explain the differences in the processing and memory of emotional items between patients and controls.

Development of a tool to facilitate real life activity retraining in hand and arm therapy

Introduction

Successful recovery of upper extremity function after stroke is more likely when the affected limb is used regularly in daily life. We developed an iPad (Apple) application called the ‘Aid for Decision-Making in Occupation Choice for Hand’ to facilitate daily upper extremity use. This study examined the suitability of items and pictures in the Aid for Decision-Making in Occupation Choice for Hand, and tested a paper prototype of the application (which has since been produced).

Method

We used a Delphi method with 10 expert occupational therapists to refine the items in the aid. Next, we prepared pictures of items in the aid and confirmed their suitability by testing them with 10 patients (seven stroke, three cervical spondylotic myelopathy). Nine occupational therapists conducted field tests with a paper prototype of the aid in clinical practice to examine its utility.

Results

After four Delphi rounds, we selected 130 items representing activities of daily living, organized into 16 categories. Of 130 pictures, 128 were recognizable to patients as representing the intended activities. Based on testing of the paper prototype, we found the Aid for Decision-Making in Occupation Choice for Hand process was suitable for clinical practice, and could be organized into six steps.

Conclusion

The Aid for Decision-Making in Occupation Choice for Hand process may promote daily upper extremity use. This application, since developed, now needs to be clinically tested in its digital form.

The use of metacognitive strategies to decrease false memories in source monitoring in patients with mild cognitive impairment

Patients with amnestic mild cognitive impairment (MCI) and Alzheimer's disease (AD) often demonstrate high rates of false memories, leading to stressful and frustrating situations for both patients and caregivers in everyday life. Sometimes these false memories are due to failures in monitoring the source of the information. In the current study, we examined interventions aimed to enhance the use of the metacognitive "recall-to-reject" memory strategy. Such interventions could improve source memory and decrease false memory in patients with MCI. Because the picture superiority effect (better memory for pictures compared to words) has been shown to be present in both patients with MCI and healthy older controls, we investigated whether pictures could help patients with MCI use a recall-to-reject strategy in a simulation of real-world source memory task. In this experiment, patients with MCI and healthy older adults were asked to simulate preparing for and then taking a trip to the market. Subjects first studied 30 pictures of items in their "cupboard," followed by a list of 30 words of items on their "shopping list." At test, participants saw 90 pictures (30 cupboard, 30 list, 30 new) organized as they would be if walking down the market aisles, and are provided with either standard or metacognitive instructions. With standard instructions, they were asked if they needed to buy the item. With the metacognitive instructions, they were asked a series of questions to help guide them through a recall-to-reject strategy to highlight the different sources of memories. Results showed that the metacognitive instructions did significantly reduce the false memory rates for patients with MCI. Further studies need to investigate how to best implement these practical strategies into the everyday lives of patients.

White Matter Deterioration May Foreshadow Impairment of Emotional Valence Determination in Early-Stage Dementia of the Alzheimer Type

In Alzheimer Disease (AD), non-verbal skills often remain intact for far longer than verbally mediated processes. Four (1 female, 3 males) participants with early-stage Clinically Diagnosed Dementia of the Alzheimer Type (CDDAT) and eight neurotypicals (NTs; 4 females, 4 males) completed the emotional valence determination test (EVDT) while undergoing BOLD functional magnetic resonance imaging (fMRI). We expected CDDAT participants to perform just as well as NTs on the EVDT, and to display increased activity within the bilateral amygdala and right anterior cingulate cortex (r-ACC). We hypothesized that such activity would reflect an increased reliance on these structures to compensate for on-going neuronal loss in frontoparietal regions due to the disease. We used diffusion tensor imaging (DTI) to determine if white matter (WM) damage had occurred in frontoparietal regions as well. CDDAT participants had similar behavioral performance and no differences were observed in brain activity or connectivity patterns within the amygdalae or r-ACC. Decreased fractional anisotropy (FA) values were noted, however, for the bilateral superior longitudinal fasciculi and posterior cingulate cortex (PCC). We interpret these findings to suggest that emotional valence determination and non-verbal skill sets are largely intact at this stage of the disease, but signs foreshadowing future decline were revealed by possible WM deterioration. Understanding how non-verbal skill sets are altered, while remaining largely intact, offers new insights into how non-verbal communication may be more successfully implemented in the care of AD patients and highlights the potential role of DTI as a presymptomatic biomarker.

Preserved conceptual implicit memory for pictures in patients with Alzheimer's disease

The current study examined different aspects of conceptual implicit memory in patients with mild Alzheimer's disease (AD). Specifically, we were interested in whether priming of distinctive conceptual features versus general semantic information related to pictures and words would differ for the mild AD patients and healthy older adults. In this study, 14 healthy older adults and 15 patients with mild AD studied both pictures and words followed by an implicit test section, where they were asked about distinctive conceptual or general semantic information related to the items they had previously studied (or novel items). Healthy older adults and patients with mild AD showed both conceptual priming and the picture superiority effect, but the AD patients only showed these effects for the questions focused on the distinctive conceptual information. We found that patients with mild AD showed intact conceptual picture priming in a task that required generating a response (answer) from a cue (question) for cues that focused on distinctive conceptual information. This experiment has helped improve our understanding of both the picture superiority effect and conceptual implicit memory in patients with mild AD in that these findings support the notion that conceptual implicit memory might potentially help to drive familiarity-based recognition in the face of impaired recollection in patients with mild AD.

Improvement of encoding and retrieval in normal and pathological aging with word-picture paradigm

OBJECTIVES

During the aging process, there is a progressive deficit in the encoding of new information and its retrieval. Different strategies are used in order to maintain, optimize or diminish these deficits in people with and without dementia. One of the classic techniques is paired-associate learning (PAL), which is based on improving the encoding of memories, but it has yet to be used to its full potential in people with dementia. In this study, our aim is to corroborate the importance of PAL tasks as instrumental tools for creating contextual cues, during both the encoding and retrieval phases of memory. Additionally, we aim to identify the most effective form of presenting the related items.

METHOD

Pairs of stimuli were shown to healthy elderly people and to patients with moderate and mild Alzheimer's disease. The encoding conditions were as follows: word/word, picture/picture, picture/word, and word/picture.

RESULTS

Associative cued recall of the second item in the pair shows that retrieval is higher for the word/picture condition in the two groups of patients with dementia when compared to the other conditions, while word/word is the least effective in all cases.

CONCLUSION

These results confirm that PAL is an effective tool for creating contextual cues during both the encoding and retrieval phases in people with dementia when the items are presented using the word/picture condition. In this way, the encoding and retrieval deficit can be reduced in these people.

Episodic memory in normal aging and Alzheimer disease: Insights from imaging and behavioral studies

Age-related cognitive changes often include difficulties in retrieving memories, particularly those that rely on personal experiences within their temporal and spatial contexts (i.e., episodic memories). This decline may vary depending on the studied phase (i.e., encoding, storage or retrieval), according to inter-individual differences, and whether we are talking about normal or pathological (e.g., Alzheimer disease; AD) aging. Such cognitive changes are associated with different structural and functional alterations in the human neural network that underpins episodic memory. The prefrontal cortex is the first structure to be affected by age, followed by the medial temporal lobe (MTL), the parietal cortex and the cerebellum. In AD, however, the modifications occur mainly in the MTL (hippocampus and adjacent structures) before spreading to the neocortex. In this review, we will present results that attempt to characterize normal and pathological cognitive aging at multiple levels by integrating structural, behavioral, inter-individual and neuroimaging measures of episodic memory.

Prevalence and cognitive impact of medial temporal atrophy in a hospital stroke service: retrospective cohort study

BACKGROUND

Cerebrovascular disease and neurodegeneration cause cognitive impairment and frequently coexist.

AIMS

Our objectives were to investigate the prevalence and cognitive impact of medial temporal lobe atrophy - a radiological marker often associated with Alzheimer's disease - in a hospital stroke service.

METHODS

Retrospective cohort study of patients from a hospital stroke service. Patients assessed for suspected ischemic stroke or transient ischemic attack, irrespective of final diagnosis, underwent neuropsychological testing and magnetic resonance imaging. medial temporal lobe atrophy, white matter hyperintensities, lacunes, and cerebral microbleeds were rated using established criteria and validated scales. The associations between medial temporal lobe atrophy and cognition were tested using multivariable logistic regression analyses, adjusted for age and imaging markers of cerebrovascular disease.

RESULTS

Three hundred and ninety-three patients were included, of whom 169 (43%; 95% confidence interval: 38·1-48·1%) had medial temporal lobe atrophy; in 38 patients (9·7%), medial temporal lobe atrophy was severe (mean score ≥2). In unadjusted logistic regression analyses in the whole cohort, mean medial temporal lobe atrophy score was associated with verbal memory, nominal and perceptual skills, executive function, and speed and attention. After adjustment for age, white matter hyperintensities, number of lacunes, presence of cerebral microbleeds, previous ischemic stroke or transient ischemic attack, and premorbid intelligence quotient, mean medial temporal lobe atrophy score remained associated with impairment in verbal memory (odds ratio: 1·64; 95% confidence interval 1·04-2·58) and nominal skills (odds ratio: 1·61; 95% confidence interval 1·04-2·48).

CONCLUSIONS

Medial temporal lobe atrophy is common and has an independent impact on cognitive function in a stroke service population, independent of confounding factors including age and magnetic resonance imaging markers of cerebrovascular disease. Medial temporal lobe atrophy is independently related to verbal memory and nominal skills, while small vessel pathology also contributes to speed and attention, and executive and perceptual functions.

Comparison of "Word" vs. "Picture" Version of the Free and Cued Selective Reminding Test (FCSRT) in Older Adults

Background

This study examined the psychometric relationship between the Word and Picture versions of the Free and Cued Selective Reminding Test (FCSRT) and developed an equation for score conversion.

Methods

One hundred and eight-seven participants were administered the FCSRT-Picture and FCSRT-Word on two visits using a randomized counterbalanced design.

Results

Participants had a mean age of 82.1 (standard deviation or SD = 5.4) and mean education of 14.5 (SD = 3.3) years. Mean FCSRT-Picture Free Recall score (mean 33.0 years, range: 17–44 years) was 7.9 points higher than the Word score (mean 25.1 years, range: 3–43 years). The Picture and Word FCSRT correlations for Free Recall and Total Recall were r = 0.56, P < .01 and r = 0.46, P < .01, respectively.

Discussion

The Picture and Word versions of the FCSRT were moderately associated in a sample of cognitively normal older adults. The score mean differences and variability between FCSRT-Picture and FCSRT-Word indicate that their scores should not be considered equivalent.

How to constrain and maintain a lexicon for the treatment of progressive semantic naming deficits: Principles of item selection for formal semantic therapy

The progressive degradation of semantic memory is a common feature of many forms of dementia, including Alzheimer's disease and the semantic variant of primary progressive aphasia (svPPA). One of the most functionally debilitating effects of this semantic impairment is the inability to name common people and objects (i.e., anomia). Clinical management of a progressive, semantically based anomia presents extraordinary challenges for neurorehabilitation. Techniques such as errorless learning and spaced-retrieval training show promise for retraining forgotten words. However, we lack complementary detail about what to train (i.e., item selection) and how to flexibly adapt the training to a declining cognitive system. This position paper weighs the relative merits of several treatment rationales (e.g., restore vs. compensate) and advocates for maintenance of known words over reacquisition of forgotten knowledge in the context of semantic treatment paradigms. I propose a system for generating an item pool and outline a set of core principles for training and sustaining a micro-lexicon consisting of approximately 100 words. These principles are informed by lessons learned over the course of a Phase I treatment study targeting language maintenance over a 5-year span in Alzheimer's disease and SvPPA. Finally, I propose a semantic training approach that capitalises on lexical frequency and repeated training on conceptual structure to offset the loss of key vocabulary as disease severity worsens.

Enhancing patient understanding of medical procedures: evaluation of an interactive multimedia program with in-line exercises

INTRODUCTION

Standard print and verbal information provided to patients undergoing treatments are often difficult to understand and may impair their ability to be truly informed. This study examined the effect of an interactive multimedia informational program with in-line exercises and corrected feedback on patients' real-time understanding of their cardiac catheterization procedure.

METHODS

151 adult patients scheduled for diagnostic cardiac catheterization were randomized to receive information about their procedure using either the standard institutional verbal and written information (SI) or an interactive iPad-based informational program (IPI). Subject understanding was evaluated using semi-structured interviews at baseline, immediately following catheterization, and 2 weeks after the procedure. In addition, for those randomized to the IPI, the ability to respond correctly to several in-line exercises was recorded. Subjects' perceptions of, and preferences for the information delivery were also elicited.

RESULTS

Subjects randomized to the IPI program had significantly better understanding following the intervention compared with those randomized to the SI group (8.3±2.4 vs 7.4±2.5, respectively, 0-12 scale where 12=complete understanding, P<0.05). First-time correct responses to the in-line exercises ranged from 24.3% to 100%. Subjects reported that the in-line exercises were very helpful (9.1±1.7, 0-10 scale, where 10=extremely helpful) and the iPad program very easy to use (9.0±1.6, 0-10 scale, where 10=extremely easy) suggesting good clinical utility.

DISCUSSION

Results demonstrated the ability of an interactive multimedia program to enhance patients' understanding of their medical procedure. Importantly, the incorporation of in-line exercises permitted identification of knowledge deficits, provided corrected feedback, and confirmed the patients' understanding of treatment information in real-time when consent was sought.

Ecological assessment of mild cognitive impairment and Alzheimer disease using the Rivermead Behavioural Memory Test

INTRODUCTION

The Rivermead Behavioural Memory Test (RBMT) is a short, ecologically-valid memory test battery that can provide data about a subject's memory function in daily life. We used RBMT to examine daily memory function in patients with mild cognitive impairment (MCI), Alzheimer disease (AD), and in healthy controls. We also evaluated differences between the memory profiles of subjects whose MCI remained stable after 1 year and those with conversion to AD.

PATIENTS AND METHODS

Sample of 91 subjects older than 60 years: 30 controls, 27 MCI subjects and 34 AD patients. Subjects were assessed using MMSE and RBMT.

RESULTS

The 40 men and 51 women in the sample had a mean age of 74.29±6.71 and 5.87±2.93 years of education. For the total profile and screening RBMT scores (P<.001) and total MMSE scores (P<.05), control subjects scored significantly higher than those with MCI, who in turn scored higher than AD patients. In all subtests, the control group (P<.001) and MCI group (P<.05) were distinguishable from the AD group. Prospective, retrospective, and orientation subtests found differences between the MCI and control groups (P<.05). MCI subjects who progressed to AD scored lower at baseline on the total RBMT and MMSE, and on name recall, belongings, story-immediate recall, route-delayed recall, orientation (P<.05), face recognition, story-delayed recall, and messages-delayed recall sections (P<.01).

CONCLUSIONS

RBMT is an ecologically-valid episodic memory test that can be used to differentiate between controls, MCI subjects, and AD subjects. It can also be used to detect patients with MCI who will experience progression to AD.

Pattern separation and pattern completion in Alzheimer's disease: evidence of rapid forgetting in amnestic mild cognitive impairment

Over the past four decades, the characterization of memory loss associated with Alzheimer's disease (AD) has been extensively debated. Recent iterations have focused on disordered encoding versus rapid forgetting. To address this issue, we used a behavioral pattern separation task to assess the ability of the hippocampus to create and maintain distinct and orthogonalized visual memory representations in patients with amnestic mild cognitive impairment (aMCI) and mild AD. We specifically used a lag-based continuous recognition paradigm to determine whether patients with aMCI and mild AD fail to encode visual memory representations or whether these patients properly encode representations that are rapidly forgotten. Consistent with the rapid forgetting hypothesis of AD, we found that patients with aMCI demonstrated decreasing pattern separation rates as the lag of interfering objects increased. In contrast, patients with AD demonstrated consistently poor pattern separation rates across three increasingly longer lags. We propose a continuum that reflects underlying hippocampal neuropathology whereby patients with aMCI are able to properly encode information into memory but rapidly lose these memory representations, and patients with AD, who have extensive hippocampal and parahippocampal damage, cannot properly encode information in distinct, orthogonal representations. Our results also revealed that whereas patients with aMCI demonstrated similar behavioral pattern completion rates to healthy older adults, patients with AD showed lower pattern completion rates when we corrected for response bias. Finally, these behavioral pattern separation and pattern completion results are discussed in terms of the dual process model of recognition memory.

Using pictures and words to understand recognition memory deterioration in amnestic mild cognitive impairment and Alzheimer's disease: a review

Difficulty recognizing previously encountered stimuli is one of the earliest signs of incipient Alzheimer's disease (AD). Work over the last 10 years has focused on how patients with AD and those in the prodromal stage of amnestic mild cognitive impairment make recognition decisions for visual and verbal stimuli. Interestingly, both groups of patients demonstrate markedly better memory for pictures over words, to a degree that is significantly greater in magnitude than their healthy older counterparts. Understanding this phenomenon not only helps to conceptualize how memory breaks down in AD, but also potentially provides the basis for future interventions. This review critically examines recent recognition memory work using pictures and words in the context of the dual-process theory of recognition and current hypotheses of cognitive breakdown in the course of very early AD.

Managing memory impairment in patients with Alzheimer’s disease

SUMMARY Memory impairment in patients with Alzheimer’s disease (AD) may be treated with cholinesterase inhibitors. Attention, alertness, initiative and memory (indirectly) may be treated with memantine. In addition to pharmacologic treatments, nonpharmacologic treatments, including external systems and devices, participation in social activities and exercise, as well as the use of habits, pictures and strategies, improve memory. We believe that although memory loss cannot be halted, both pharmacologic and nonpharmacologic treatments may help to improve AD patients’ memory and allow them to continue independent activities. Patients with mild cognitive impairment due to AD may be treated with nonpharmacologic therapies and with off-label cholinesterase inhibitors.

Memorial familiarity remains intact for pictures but not for words in patients with amnestic mild cognitive impairment

Understanding how memory breaks down in the earliest stages of Alzheimer's disease (AD) process has significant implications, both clinically and with respect to intervention development. Previous work has highlighted a robust picture superiority effect in patients with amnestic mild cognitive impairment (aMCI). However, it remains unclear as to how pictures improve memory compared to words in this patient population. In the current study, we utilized receiver operating characteristic (ROC) curves to obtain estimates of familiarity and recollection for pictures and words in patients with aMCI and healthy older controls. Analysis of accuracy shows that even when performance is matched between pictures and words in the healthy control group, patients with aMCI continue to show a significant picture superiority effect. The results of the ROC analysis showed that patients demonstrated significantly impaired recollection and familiarity for words compared controls. In contrast, patients with aMCI demonstrated impaired recollection, but intact familiarity for pictures, compared to controls. Based on previous work from our lab, we speculate that patients can utilize the rich conceptual information provided by pictures to enhance familiarity, and perceptual information may allow for post-retrieval monitoring or verification of the enhanced sense of familiarity. Alternatively, the combination of enhanced conceptual and perceptual fluency of the test item might drive a stronger or more robust sense of familiarity that can be accurately attributed to a studied item.

Assessment of cognition in early dementia

Better tools for assessing cognitive impairment in the early stages of Alzheimer's disease (AD) are required to enable diagnosis of the disease before substantial neurodegeneration has taken place and to allow detection of subtle changes in the early stages of progression of the disease. The National Institute on Aging and the Alzheimer's Association convened a meeting to discuss state of the art methods for cognitive assessment, including computerized batteries, as well as new approaches in the pipeline. Speakers described research using novel tests of object recognition, spatial navigation, attentional control, semantic memory, semantic interference, prospective memory, false memory and executive function as among the tools that could provide earlier identification of individuals with AD. In addition to early detection, there is a need for assessments that reflect real-world situations in order to better assess functional disability. It is especially important to develop assessment tools that are useful in ethnically, culturally and linguistically diverse populations as well as in individuals with neurodegenerative disease other than AD.

Categorization of novel tools by patients with Alzheimer's disease: category-specific content and process

We examined the interaction of content and process in categorizing novel semantic material. We taught patients with Alzheimer's disease (AD) and healthy age-matched seniors a category of plausible novel tools by similarity- and rule-based processes, and compared the results with our previous parallel study of categorization of novel animals, in which AD patients were selectively impaired at rule-based categorization. AD patients demonstrated learning in the novel tool study; however, in contrast to the novel animal study, they were impaired in similarity-based as well as rule-based categorization relative to healthy seniors. Healthy seniors' categorization strategies reflected process irrespective of category content; they frequently attended to a single feature following similarity-based training, and always attended to all requisite features following rule-based training. AD patients' categorization strategies, in contrast, reflected category content; they frequently attended to a single feature when categorizing novel animals by either categorization process, but rarely did so when categorizing novel tools. AD patients' ability to categorize novel tools correlated with preserved recognition memory, a pattern not found in the novel animal study. The category-specific role of memory, along with AD patients' performance profile, suggests content-specific distinctions between the categories. We posit that tool features are relatively arbitrary, placing greater demands on memory, while prior knowledge about animals such as constraints on appearance and feature diagnosticity facilitates the assimilation of novel animals into semantic memory. The results suggest that categorization processes are sensitive to category content, which influences AD patients' success at acquiring a new category.

Using stimulus form change to understand memorial familiarity for pictures and words in patients with mild cognitive impairment and Alzheimer's disease

Although it is generally accepted that patients with amnestic mild cognitive impairment (aMCI) and patients with Alzheimer's disease (AD) have significantly impaired recollection, recent evidence has been mixed as to whether these patients demonstrate impaired memorial familiarity. Recent work suggests that familiarity may remain intact for pictures, but not for words. Further, a recent event-related potential (ERP) study suggests that enhanced conceptual processing of pictures may underlie this intact familiarity. However, to date there has been no direct comparison of perceptual and conceptual-based familiarity for pictures and words in patients with aMCI and AD. To investigate this issue, patients with aMCI, patients with AD, and healthy older adults underwent four study-test conditions of word-word, picture-picture, word-picture, and picture-word. When stimuli undergo form change, it has been suggested that only conceptual processing can help support recognition in the absence of recollection. Our results showed that patients successfully relied on perceptual and conceptual-based familiarity to improve recognition for the within format conditions over the across format conditions. Further, results suggested that patients with aMCI and AD are able to use enhanced conceptual processing of pictures compared to words to allow them to overcome the deleterious effects of form change in a similar manner as controls. These results help us begin to understand which aspects of memory are impaired and which remain relatively intact in patients with aMCI and AD. This understanding can then in turn help us to assess, conceptualize, and build behavioral interventions to help treat these patients.

Response bias for picture recognition in patients with Alzheimer disease

OBJECTIVE

To investigate whether changing recognition stimuli from words to pictures would alter response bias in patients with Alzheimer disease (AD).

BACKGROUND

Response bias is an important aspect of memory performance in patients with AD, as they show an abnormally liberal response bias compared with healthy older adults. We have previously found that despite changes in discrimination produced by varying the study and test list length, response bias remained remarkably stable in both patients with AD and older adult controls.

METHODS

Patients with mild AD and healthy older adults underwent two separate study-test sessions of pictures and words. For both pictures and words, increasing study-test list lengths were used to determine whether bias changed as a factor of discrimination or task difficulty.

RESULTS

Consistent with apriori hypotheses, healthy older adults showed increased discrimination and shifted to a more liberal response bias for pictures compared with words. In contrast, despite their higher level of discrimination for pictures, patients with AD showed a similar response bias for both pictures and words. Bias was consistent across varying study-test lengths for both groups.

CONCLUSIONS

These results suggest that response bias is a relatively invariant factor of an individual with AD that remains liberal regardless of discrimination or stimulus type.

The episodic memory system: neurocircuitry and disorders

The ability to encode and retrieve our daily personal experiences, called episodic memory, is supported by the circuitry of the medial temporal lobe (MTL), including the hippocampus, which interacts extensively with a number of specific distributed cortical and subcortical structures. In both animals and humans, evidence from anatomical, neuropsychological, and physiological studies indicates that cortical components of this system have key functions in several aspects of perception and cognition, whereas the MTL structures mediate the organization and persistence of the network of memories whose details are stored in those cortical areas. Structures within the MTL, and particularly the hippocampus, have distinct functions in combining information from multiple cortical streams, supporting our ability to encode and retrieve details of events that compose episodic memories. Conversely, selective damage in the hippocampus, MTL, and other structures of the large-scale memory system, or deterioration of these areas in several diseases and disorders, compromises episodic memory. A growing body of evidence is converging on a functional organization of the cortical, subcortical, and MTL structures that support the fundamental features of episodic memory in humans and animals.

Learning and forgetting new names and objects in MCI and AD

We studied how subjects with mild cognitive impairment (MCI), early Alzheimer's disease (AD) and age-matched controls learned and maintained the names of unfamiliar objects that were trained with or without semantic support (object definitions). Naming performance, phonological cueing, incidental learning of the definitions and recognition of the objects were tested during follow-up. We found that word learning was significantly impaired in MCI and AD patients, whereas forgetting patterns were similar across groups. Semantic support showed a beneficial effect on object name retrieval in the MCI group 8 weeks after training, suggesting that the MCI patients' preserved semantic memory can compensate for impaired episodic memory. The MCI group performed equally well as the controls in the tasks measuring incidental learning and recognition memory, whereas the AD group showed impairment in this respect. Both the MCI and the AD group benefited less from phonological cueing than the controls. Our findings indicate that word learning is compromised in both MCI and AD, whereas long-term retention of newly learned words is not affected to the same extent. Incidental learning and recognition memory seem to be well preserved in MCI.

Preserved frontal memorial processing for pictures in patients with mild cognitive impairment

Amnestic mild cognitive impairment (aMCI) has been conceptualized as a transitional stage between healthy aging and Alzheimer's disease (AD). Therefore, understanding which aspects of memory are impaired and which remain relatively intact in these patients can be useful in determining who will ultimately go on to develop AD, and subsequently designing interventions to help patients live more engaged and independent lives. The dual-process model posits that recognition memory decisions can rely on either familiarity or recollection. Whereas research is fairly consistent in showing impaired recollection in patients with aMCI, the results have been mixed regarding familiarity. A noted difference between these studies investigating familiarity has been stimulus type. The goal of the current investigation was to use high-density event-related potentials (ERPs) to help elucidate the neural correlates of recognition decisions in patients with aMCI for words and pictures. We also hoped to help answer the question of whether patients can rely on familiarity to support successful recognition. Patients and controls participated in separate recognition memory tests of words and pictures while ERPs were recorded during retrieval. Results showed that ERP components typically associated with familiarity and retrieval monitoring were similar between groups for pictures. However, these components were diminished in the patient group for words. Based on recent work, the authors discuss the possibility that implicit conceptual priming could have contributed to the enhanced ERP correlate of familiarity. Further, the authors address the possibility that enhanced retrieval monitoring may be needed to modulate increased familiarity engendered by pictures.

An evaluation of recollection and familiarity in Alzheimer's disease and mild cognitive impairment using receiver operating characteristics

There is a need to investigate exactly how memory breaks down in the course of Alzheimer's disease (AD). Examining what aspects of memorial processing remain relatively intact early in the disease process will allow us to develop behavioral interventions and possible drug therapies focused on these intact processes. Several recent studies have worked to understand the processes of recollection and familiarity in patients with mild cognitive impairment (MCI) and very mild AD. Although there is general agreement that these patient groups are relatively unable to use recollection to support veridical recognition decisions, there has been some question as to how well these patients can use familiarity. The current study used receiver operating characteristic (ROC) curves and a depth of processing manipulation to understand the effect of MCI and AD on the estimates of recollection and familiarity. Results showed that patients with MCI and AD were impaired in both recollection and familiarity, regardless of the depth of encoding. These results are discussed in relation to disease pathology and in the context of recent conflicting evidence as to whether familiarity remains intact in patients with MCI. The authors highlight differences in stimuli type and task difficulty as possibly modulating the ability of these patients to successfully use familiarity in support of memorial decisions.