Active bilingualism delays the onset of mild cognitive impairment

Protective effect of bilingualism on aging, MCI, and dementia: A community-based study

INTRODUCTION

Lifelong bilingualism is associated with a delayed age at onset of dementia, but evidence from community-based studies is limited. We investigated the relationship between bilingualism and the prevalence of cognitive impairment in a linguistically diverse community.

METHODS

A door-to-door community study was conducted from January to December 2021 in urban Bengaluru, India. 1234 individuals aged ≥60 years participated in the study. Participants were diagnosed with no cognitive impairment (NCI), mild cognitive impairment (MCI), or dementia using established diagnostic criteria.

RESULTS

Dementia prevalence was higher in monolinguals (4.9%) than bilinguals (0.4%) (P = .001). The prevalence of MCI was also higher in monolinguals (8.5%) than bilinguals (5.3%) (P = .001). The study also revealed better cognitive function in bilinguals than monolinguals with NCI, after controlling for confounding variables.

DISCUSSION

The current study provides significant support for the protective effect of bilingualism on cognitive impairment in an urban community with extensive bilingual interactional contexts in everyday life.

HIGHLIGHTS

Bilingualism has been demonstrated to protect against dementia and mild cognitive impairment in a linguistically diverse community with extensive code-switching contexts. Bilingual older individuals had superior baseline cognitive performance compared to monolingual older individuals. Bilingualism was found to have an independent effect on general cognition after adjusting for major social determinants of health in the group without cognitive impairment.

A neural mechanism of cognitive reserve: The case of bilingualism

Cognitive Reserve (CR) refers to the preservation of cognitive function in the face of age- or disease-related neuroanatomical decline. While bilingualism has been shown to contribute to CR, the extent to which, and what particular aspect of, second language experience contributes to CR are debated, and the underlying neural mechanism(s) unknown. Intrinsic functional connectivity reflects experience-dependent neuroplasticity that occurs across timescales ranging from minutes to decades, and may be a neural mechanism underlying CR. To test this hypothesis, we used voxel-based morphometry and resting-state functional connectivity analyses of MRI data to compare structural and functional brain integrity between monolingual and bilingual older adults, matched on cognitive performance, and across levels of second language proficiency measured as a continuous variable. Bilingualism, and degree of second language proficiency specifically, were associated with lower gray matter integrity in a hub of the default mode network - a region that is particularly vulnerable to decline in aging and dementia - but preserved intrinsic functional network organization. Bilingualism moderated the association between neuroanatomical differences and cognitive decline, such that lower gray matter integrity was associated with lower executive function in monolinguals, but not bilinguals. Intrinsic functional network integrity predicted executive function when controlling for group differences in gray matter integrity and language status. Our findings confirm that lifelong bilingualism is a CR factor, as bilingual older adults performed just as well as their monolingual peers on tasks of executive function, despite showing signs of more advanced neuroanatomical aging, and that this is a consequence of preserved intrinsic functional network organization.

Bilingual neurocognitive resiliency, vulnerability, and Alzheimer's disease biomarker correlates in Latino older adults enrolled in the Health and Aging Brain Study - Health Disparities (HABS-HD)

INTRODUCTION

The effects of bilingualism on neuropsychological test performance in bilinguals with and without cognitive impairment are not well-understood and are relatively limited by small sample sizes of Latinos.

METHODS

Using analysis of covariance (ANCOVA), we explored patterns of cognitive performance and impairment across a large sample of community-dwelling bilingual and monolingual Latino older adults with (n = 180) and without (n = 643) mild cognitive impairment (MCI) enrolled in HABS-HD.

RESULTS

Bilinguals demonstrated cognitive resiliency in the form of significantly better performance on the Trail Making Test and Digit Symbol Substitution Test, observed across the cognitively unimpaired and MCI groups. In contrast, bilinguals demonstrated cognitive vulnerability in the form of significantly poorer performance and higher impairment rates on phonemic fluency in the MCI phase, only. Follow-up analyses revealed less balanced bilinguals demonstrated poorer performance and higher impairment rates on this measure, supported by lower levels of plasma Aβ 42/40.

DISCUSSION

Patterns of cognitive performance and impairment differ as a function of bilingualism. Bilingualism must be considered when evaluating cognitive and biomarker outcomes in Latino older adults.

Highlights

Latino bilinguals perform better on measures of processing speed and coding.Latino bilinguals with MCI demonstrate cognitive vulnerability in verbal fluency.Less balanced bilinguals demonstrate greatest vulnerability anchored by Aβ 42/40.

Does Language Distance Modulate the Contribution of Bilingualism to Cognitive Reserve in Seniors? A Systematic Review

We report a systematic review and exploratory meta-regression investigating the hypothesis that the effects of bilingualism on cognitive reserve are modulated by the distance between the pair of languages a bilingual uses. An inclusive multiple database search was performed in order to identify all relevant published research conducted in bilingual seniors. A combination of qualitative and quantitative synthesis methods were used in order to investigate our research questions. Results suggest that healthy bilingual seniors speaking more distant language pairs show improved monitoring performance on cognitive tasks. Evidence regarding a modulatory influence of language distance (LD) on the age of dementia diagnosis was inconclusive due to the small number of published studies meeting our inclusion criteria. We recommend more detailed reporting of individual differences in bilingual experience to assess the impact of LD and other variables on typical cognitive aging and the development of dementia. Linguistic differences in samples should also be considered as a constraint on bilingual advantages in future studies. Preregistration: PROSPERO CRD42021238705; OSF DOI 10.17605/OSF.IO/VPRBU.

Can Speaking More Than One Language Help Prevent Alzheimer's Disease?

Alzheimer's disease (AD) is an age-related neurocognitive disorder that is epidemic in the elderly population. Currently, there are limited pharmacological interventions, and this has heightened the urgency to identify potential preventable or modifiable risk factors that promote resilience to the neuropathological effects of AD. The regular use of two or more languages is one such factor that may increases cognitive reserve through the long-standing executive control involved in managing multiple languages in the brain. There is also evidence that bilingualism is associated with increased brain reserve or maintenance, particularly in frontal-executive structures and networks. This review examines the current, sometimes conflicting literature on bi/multilingualism and AD. These studies have confounding variations in the assessment of age of second language onset, language proficiency, language usage, and whether determining incidence of AD or age of symptom onset. Despite these limitations, most publications support the presence of increased frontal-executive reserve that compensates for the development of AD neuropathology and, thereby, delays the emergence of clinical symptoms of dementia by about 4-5 years. Although regularly speaking more than one language does not protect against AD neuropathology, the delay in its clinical expression has a potentially significant impact on the lifelong morbidity from this age-related disease. Learning other languages may be an important modifiable factor for delaying the clinical expression of AD in later life.

Multifactorial approaches to study bilingualism in the aging population: Past, present, future

A better understanding and more reliable classification of bilinguals has been progressively achieved through the fine-tuning methodology and simultaneously optimizing the measurement tools. However, the current understanding is far from generalization to a larger population varying in different measures of bilingualism-L2 Age of acquisition (L2 AOA), L2 usage and exposure, and L2 proficiency. More recent studies have highlighted the importance of modeling bilingualism as a continuous variable. An in-depth look at the role of bilingualism, comparing groups, may be considered a reductionist approach, i.e., grouping based on one measure of bilingualism (e.g., L2 AOA) may not account for variability in other measures of bilingualism (L2 exposure, L2 use or L2 proficiency, amongst others) within and between groups. Similarly, a multifactorial dimension is associated with cognitive performance, where not all domains of cognition and subcomponents are equally influenced by bilingualism. In addition, socio-cultural and demographical factors may add another dimension to the impact of bilingualism on cognitive performance, especially in older adults. Nevertheless, not many studies have controlled or used the multiple socio-cultural and demographical factors as a covariate to understand the role of different aspects of bilingualism that may influence cognitive performance differently. Such an approach would fail to generalize the research findings to a larger group of bilinguals. In the present review paper, we illustrate that considering a multifactorial approach to different dimensions of bilingual study may lead to a better understanding of the role of bilingualism on cognitive performance. With the evolution of various fine-tuned methodological approaches, there is a greater need to study variability in bilingual profiles that can help generalize the result universally.

The Nuance of Bilingualism as a Reserve Contributor: Conveying Research to the Broader Neuroscience Community

The neurological notion of “reserve” arises from an individually observable dissociation between brain health and cognitive status. According to the cognitive reserve hypothesis, high-reserve individuals experience functional compensation for neural atrophy and, thus, are able to maintain relatively stable cognitive functioning with no or smaller-than-expected impairment. Several lifestyle factors such as regular physical exercise, adequate and balanced nutrition, and educational attainment have been widely reported to contribute to reserve and, thus, lead to more successful trajectories of cognitive aging (CA). In recent years, it has become clear that bilingualism is also a potential reserve contributor. Yet, there is little communication between the neuroscience of bilingualism research community and researchers working in the field of CA more generally, despite compelling reasons for it. In fact, bilingualism tends to be overlooked as a contributory factor in the CA literature, or reduced to a dichotomous trait, despite it being a complex experience. Herein, we discuss issues that are preventing recognition of bilingualism as a reserve contributor across all literatures, highlight the benefits of including language experiences as a factor of interest across research disciplines, and suggest a roadmap to better integrate bilingualism and aging moving forward. We close with calls toward a model of aging that examines the contributions across lifestyle factors, including that of bilingual experience.

Dynamic Effects of Immersive Bilingualism on Cortical and Subcortical Grey Matter Volumes

Bilingualism has been shown to induce neuroplasticity in the brain, but conflicting evidence regarding its specific effects in grey matter continues to emerge, probably due to methodological differences between studies, as well as approaches that may miss the variability and dynamicity of bilingual experience. In our study, we devised a continuous score of bilingual experiences and we investigated their non-linear effects on regional GM volume in a sample of young healthy participants from an immersive and naturalistic bilingual environment. We focused our analyses on cortical and subcortical regions that had been previously proposed as part of the bilingual speech pipeline and language control network. Our results showed a non-linear relationship between bilingualism score and grey matter volume of the inferior frontal gyrus. We also found linear increases in volumes of putamen and cerebellum as a function of bilingualism score. These results go in line with predictions for immersive and naturalistic bilingual environments with increased intensity and diversity of language use and provide further evidence supporting the dynamicity of bilingualism’s effects on brain structure.

Incidence and Cognitive Decline of Alzheimer's Disease and Other Dementia by Apolipoprotein ε4 Allele Presence: A Community-Based Cohort Study in Korean Elderly

OBJECTIVE

This study aimed to investigate the role of apolipoprotein E (APOE) ε4 allele to the incidence of dementia and cognitive decline in a cohort of a Korean community.

METHODS

From a community-based dementia-free cohort, 357 participants were genotyped. Participants underwent 2 cognitive assessments separated by a hiatus between 6 to 7 years and were diagnosed as healthy control (n=297), Alzheimer's disease (AD) (n=44), and other dementia (n=16) at the second assessment. Incidence risk and onset age of disease according to APOE ε4 presence were analyzed in AD and other dementia. Differences in cognitive decline rate depending on APOE ε4 were also examined across all groups.

RESULTS

The relative risks and onset age of dementia were not different by the presence of the APOE ε4 allele. Cognitive decline was more prominent in the presence of APOE ε4 allele (score change=7.4) than non-presence (score change=3.1), and this interaction was significant only in the AD group (F=10.51, p=0.003).

CONCLUSION

The APOE ε4 alleles can be a critical factor in predicting cognitive change for AD in the Korean community population but not in predicting AD incidence. This finding suggest that clinicians consider the presence of APOE ε4 allele examining patients with rapid declining dementia.

How does bilingualism modify cognitive function? Attention to the mechanism

It has been claimed that bilingual experience leads to an enhancement of cognitive control across the lifespan, a claim that has been investigated by comparing monolingual and bilingual groups performing standard executive function (EF) tasks. The results of these studies have been inconsistent, however, leading to controversy over the essential assumptions underlying the research program, namely, whether bilingualism produces cognitive change. We argue that the source of the inconsistency is not in the evidence but rather in the framework that has typically been used to motivate the research and interpret the results. We examine the componential view of EF with its central role for inhibition and argue that it provides a poor fit to both bilingual experience and the results of these studies. As an alternative, we propose a more holistic account based on attentional control that overrides the processes in the componential model of EF and applies to a wider range of tasks. The key element in our account is that behavioral differences between monolingual and bilingual individuals reflect differences in the efficiency and deployment of attentional control between the two language groups. In support of this point we show how attentional control provides a more satisfactory account for a range of findings that cannot reasonably be attributed to inhibition. We also suggest that group differences will emerge only when the attentional demands of a task exceed the control abilities of one of the groups, regardless of the EF components involved. We then review literature from across the lifespan to evaluate the extent to which this account is consistent with existing evidence, and conclude with some suggestions on how the field may be advanced by new lines of empirical enquiry.

The effects of bilingualism on hippocampal volume in ageing bilinguals

Long-term management of more than one language has been argued to contribute to changes in brain and cognition. This has been particularly well documented in older age, where bilingualism has been linked to protective effects against neurocognitive decline. Since memory difficulties are key aspects of this decline, herein we examine potential effects of bilingualism on the hippocampus, a brain structure related to memory that is particularly vulnerable to cognitive ageing. Hippocampal volume has been shown to increase as a result of second language learning and use in younger adults. However, it is unknown if this is maintained throughout the lifespan. We examine hippocampal volume and episodic memory performance in a participant sample consisting of healthy older individuals with a wide range of experiences in exposure and using a second language. Results reveal greater hippocampal volume calibrated to degree of quantified dual language use. Our results mirror those of immersive active bilingualism in younger populations, suggesting that long-term active bilingualism leads to neuroprotective effects in the hippocampus. We discuss this in the context of literature proposing bilingualism-induced brain reserve in the older age.

Bilingualism, Executive Function, and the Brain: Implications for Autism

Autism spectrum disorder (ASD) is associated with marked heterogeneity with respect to the development of executive function abilities. The bilingual advantage refers to the observation that individuals who speak two languages perform better on executive function tasks than monolinguals under some circumstances. There is not yet consensus, however, as to whether this advantage can be reliably demonstrated, nor is there consensus regarding under which conditions it emerges. Bilingual and monolingual children with ASD have comparable developmental outcomes, particularly in the areas of core ASD symptoms, cognitive function, and language. Still, despite the potential advantages that bilingualism may confer, clinicians commonly advise against providing a bilingual environment for children with ASD. The purpose of the present review is to provide an up-to-date assessment of the limited literature on bilingualism in children with ASD in order to inform evidence-based practice. Studies suggest a potential bilingual advantage in ASD in the areas of nonverbal intelligence quotient, adaptive functioning, and expressive vocabulary. A limited yet growing literature provides preliminary evidence for enhanced executive function ability in some children with ASD. Taken together, current evidence suggests that although a bilingual advantage may not be universally present in typical development, it may manifest under specific circumstances, conferring advantage for populations in which executive function is compromised. Further work is needed to develop consistent, evidence-based guidelines around language recommendations for families of children with ASD and to better understand the cognitive and brain mechanisms giving rise to the bilingual advantage in clinical developmental populations.

Language Assessment in Multilingualism and Awake Neurosurgery

Multilingualism has become a worldwide phenomenon that poses critical issues about the language assessment in patients undergoing awake neurosurgery in eloquent brain areas. The accuracy and sensitivity of multilingual perioperative language assessment procedures is crucial for a number of reasons: they should be appropriate to detect deficits in each of the languages spoken by the patient; they should be suitable to identify language-specific cortical regions; they should ensure that each of the languages of a multilingual patient is tested at an adequate and comparable level of difficulty. In clinical practice, a patient-tailored approach is generally preferred. This is a necessary compromise since it is impossible to predict all the possible language combinations spoken by individuals and thus the availability of standardized testing batteries is a potentially unattainable goal. On the other hand, this leads to high inconsistency in how different neurosurgical teams manage the linguistic features that determine similarity or distance between the languages spoken by the patient and that may constrain the neuroanatomical substrate of each language. The manuscript reviews the perioperative language assessment methodologies adopted in awake surgery studies on multilingual patients with brain tumor published from 1991 to 2021 and addresses the following issues: (1) The language selected for the general neuropsychological assessment of the patient. (2) The procedures adopted to assess the dimensions that may constrain language organization in multilingual speakers: age and type of acquisition, exposure, proficiency, and use of the different languages. (3) The type of preoperative language assessment used for all the languages spoken by the patient. (4) The linguistic tasks selected in the intraoperative setting. The reviewed data show a great heterogeneity in the perioperative clinical workup with multilingual patients. The only exception is the task used during language mapping, as the picture naming task is highly preferred. The review highlights that an objective and accurate description of both the linguistic profile of multilingual patients and the specific properties of the languages under scrutiny can profitably support clinical management and decision making in multilingual awake neurosurgery settings.

Enriching activities during childhood are associated with variations in functional connectivity patterns later in life

Enriching early life experiences (e.g., sport, art, music, volunteering, language learning) during a critical period of brain development may promote structural and functional brain changes that are still present decades later (>60 years). We assessed whether a greater variety of enriching early life activities (EELA) before age 13 years were associated with individual differences in cortical and subcortical (hippocampus and amygdala) structure and function later in life (older adults aged 60-80 years). Results indicated no association between EELA and amygdala and hippocampus volumes, but higher functional connectivity between the amygdala and the insula was associated with more variety of EELA. EELA was not associated with cortical thickness controlling for sex, but sex-specific associations with the right pars opercularis were found. EELA was further associated with variations in functional connectivity patterns of the orbitofrontal cortex, driven by connecitivty to regions within the visual, somatosensory and limbic networks. Early life enriching activities appear to contribute to potential mechanisms of cognitive reserve (functional processes) more so than brain reserve (structure) later in life.

Bilingualism: Pathway to Cognitive Reserve

Cognitive reserve is characterized by a dissociation between cognitive level and brain structure, thereby reducing the impact of deteriorating brain structure on cognitive function. Cognitive reserve is therefore a promising approach to maintaining cognitive function and protecting against symptoms of dementia. The present paper evaluates evidence supporting the claim that bilingualism contributes to cognitive reserve. Four types of evidence are presented: (i) brain and cognitive function in healthy aging, (ii) age of onset of symptoms of dementia, (iii) relation between clinical level and neuropathology for patients, and (iv) rate of cognitive decline in later stages of dementia. In all cases, bilinguals revealed patterns that were consistent with the interpretation of protection from cognitive reserve when compared with monolinguals.

Lifelong Bilingualism Functions as an Alternative Intervention for Cognitive Reserve Against Alzheimer's Disease

Bilingualism has been reported to significantly delay the onset of dementia and plays an important role in the management of Alzheimer's disease (AD), a condition inducing impairment in the brain network and cognitive decline. Cognitive reserve is associated with the adaptive maintenance of neural functions by protecting against neuropathology. Bilingualism acts as a beneficial environmental factor contributing to cognitive reserve, although some potential confounding variables still need further elucidation. In this article, the relationship between bilingualism and cognitive reserve is discussed, interpreting the advantage of bilingualism in protecting against cognitive decline. In addition, the possible brain and biochemical mechanisms, supporting the advantageous effects of bilingualism in delaying the onset of dementia, involved in bilingualism are reviewed. Effectively, bilingualism can be considered as a pharmacological intervention with no side effects. However, the investigation of the pharmacological parameters of bilingualism is still at an early stage.

Moderation-Mediation Effects in Bilingualism and Cognitive Reserve

We first provide a critical review of the existing findings on bilingualism as a contributor to cognitive reserve from moderator-mediator warranting cause-effect research conclusions. We next address the question of direct or indirect effects between bilingualism and neurocognitive protective factors influencing the associated age-related mental deficits. The existing findings support bilingualism as a predictor and as a moderator. Third, we propose cognitive reserve models of bilingualism describing analytical approaches that allow testing of these models and hypotheses related to path strength and causal relationships between predictors, moderators, and mediators. Lastly and most importantly, we suggest using large datasets available via open repositories. This can aid in the testing of theoretical models, clarifying the roles of moderators and mediators, and assessing the research viability of multi-causal paths that can influence cognitive reserve. Creating collaborative datasets to test these models would greatly advance our field and identify critical variables in the study of the bilingual aging brain.

Voluntary Language Switching in the Context of Bilingual Aphasia

As studies of bilingual language control (BLC) seek to explore the underpinnings of bilinguals’ abilities to juggle two languages, different types of language switching tasks have been used to uncover switching and mixing effects and thereby reveal what proactive and reactive control mechanisms are involved in language switching. Voluntary language switching tasks, where a bilingual participant can switch freely between their languages while naming, are being utilized more often due to their greater ecological validity compared to cued switching paradigms. Because this type of task had not yet been applied to language switching in bilingual patients, our study sought to explore voluntary switching in bilinguals with aphasia (BWAs) as well as in healthy bilinguals. In Experiment 1, we replicated previously reported results of switch costs and mixing benefits within our own bilingual population of Catalan-Spanish bilinguals. With Experiment 2, we compared both the performances of BWAs as a group and as individuals against control group performance. Results illustrated a complex picture of language control abilities, indicating varying degrees of association and dissociation between factors of BLC. Given the diversity of impairments in BWAs’ language control mechanisms, we highlight the need to examine BLC at the individual level and through the lens of theoretical cognitive control frameworks in order to further parse out how bilinguals regulate their language switching.

Beyond Alzheimer's disease: Can bilingualism be a more generalized protective factor in neurodegeneration?

Bilingualism has been argued to have an impact on cognition and brain structure. Effects have been reported across the lifespan: from healthy children to ageing adults, including clinical (ageing) populations. It has been argued that active bilingualism may significantly contribute to the delaying of the expression of Alzheimer's disease symptoms. If bilingualism plays an ameliorative role against the expression of neurodegeneration in dementia, it is possible that it could have similar effects for other neurodegenerative disorders, including Multiple Sclerosis, Parkinson's and Huntington's Diseases. To date, however, direct relevant evidence remains limited, not least because the necessary scientific motivations for investigating this with greater depth have not yet been fully articulated. Herein, we provide a roadmap that reviews the relevant literatures, highlighting potential links across neurodegenerative disorders and bilingualism more generally.