Predictive models for delay in medical decision-making among older patients with acute ischemic stroke: a comparative study using logistic regression analysis and lightGBM algorithm

OBJECTIVE

To explore the factors affecting delayed medical decision-making in older patients with acute ischemic stroke (AIS) using logistic regression analysis and the Light Gradient Boosting Machine (LightGBM) algorithm, and compare the two predictive models.

METHODS

A cross-sectional study was conducted among 309 older patients aged ≥ 60 who underwent AIS. Demographic characteristics, stroke onset characteristics, previous stroke knowledge level, health literacy, and social network were recorded. These data were separately inputted into logistic regression analysis and the LightGBM algorithm to build the predictive models for delay in medical decision-making among older patients with AIS. Five parameters of Accuracy, Recall, F1 Score, AUC and Precision were compared between the two models.

RESULTS

The medical decision-making delay rate in older patients with AIS was 74.76%. The factors affecting medical decision-making delay, identified through logistic regression and LightGBM algorithm, were as follows: stroke severity, stroke recognition, previous stroke knowledge, health literacy, social network (common factors), mode of onset (logistic regression model only), and reaction from others (LightGBM algorithm only). The LightGBM model demonstrated the more superior performance, achieving the higher AUC of 0.909.

CONCLUSIONS

This study used advanced LightGBM algorithm to enable early identification of delay in medical decision-making groups in the older patients with AIS. The identified influencing factors can provide critical insights for the development of early prevention and intervention strategies to reduce delay in medical decisions-making among older patients with AIS and promote patients' health. The LightGBM algorithm is the optimal model for predicting the delay in medical decision-making among older patients with AIS.

Low household income, financial literacy, or financial health: Which is the strongest risk factor and outcome of depressive symptomatology?

BACKGROUND

Depression's relations to psychosocial processes are complex, bidirectional, and include financial functioning. The current study compared the extent to which household income, financial literacy (knowledge and skill), and financial health (saving, spending, borrowing, and planning behavior) were risk factors and outcomes of depression.

METHODS

A United States national sample of working-aged adults (N = 6565) completed self-report measures of financial functioning and depression in years 2020 and 2022. Depression scales assessed both negative (depressive symptoms) and positive (life satisfaction) affective dimensions.

RESULTS

Lower income, less financial literacy, and especially poorer financial health correlated significantly with more depressive symptoms and lower life satisfaction. Poorer financial health demonstrated the strongest prospective relations with increasing depressive symptoms and decreasing life satisfaction over the two-year retest interval. In parallel, higher depressive symptoms and lower life satisfaction each predicted subsequent decreases in financial health.

LIMITATIONS

Results from this longitudinal, observational study suggested but could not establish causal connections between depression and financial functioning. The study's novel results require replication before clinical application.

CONCLUSIONS

More so than low income or limited financial literacy, poor financial health is both a risk factor and potential outcome of depression, including more depressive symptoms and lower life satisfaction. If these findings are replicated, financial health may be an important research and clinical target for depression assessment, prevention, and treatment.

Association Between Small Vessel Disease and Financial Capacity: A Study Based on Cognitively Normal Older Adults

Background

Financial capacity is vital for the elderly, who possess a substantial share of global wealth but are vulnerable to financial fraud.

Objective

We explored the link between small vessel disease (SVD) and financial capacity in cognitively unimpaired (CU) older adults via both cross-sectional and longitudinal analyses.

Methods

414 CU participants underwent MRI and completed the Financial Capacity Instrument-Short Form (FCI-SF). Subsequent longitudinal FCI-SF data were obtained from 104, 240, and 141 participants at one, two, and four years, respectively. SVD imaging markers, encompassing white matter hyperintensities (WMH), cerebral microbleeds (CMB), and lacune were evaluated. We used linear regression analyses to cross-sectionally explore the association between FCI-SF and SVD severity, and linear mixed models to assess how baseline SVD severity impacted longitudinal FCI-SF change. The false discovery rate method was used to adjust multiple comparisons.

Results

Cross-sectional analysis revealed a significant association between baseline WMH and Bank Statement (BANK, β=-0.194), as well as between lacune number and Financial Conceptual Knowledge (FC, β= -0.171). These associations were stronger in APOE ɛ4 carriers, with β= -0.282 for WMH and BANK, and β= -0.366 for lacune number and FC. Longitudinally, higher baseline SVD total score was associated with severe FCI-SF total score decrease (β= -0.335). Additionally, baseline WMH burden predicted future decreases in Single Checkbook/Register Task (SNG, β= -0.137) and FC (β= -0.052). Notably, the association between baseline WMH and SNG changes was amplified in APOE ɛ4 carriers (β= -0.187).

Conclusions

Severe SVD was associated with worse FCI-SF and could predict the decline of financial capacity in CU older adults.

Change in Decision-Making Analysis and Preferences in Old Age

OBJECTIVES

To test the hypotheses that decision making ability declines in old age and that a higher level of cognitive reserve is associated with a reduced rate of decline.

METHODS

As part of an ongoing cohort study, 982 older adults without dementia at study enrollment completed measures of purpose in life and cognitive activity which were used as markers of cognitive reserve. At annual intervals thereafter, they completed 6 tests of decision making.

RESULTS

In a factor analysis of baseline decision making scores, 3 measures (financial/health literacy, financial/health decision making, scam susceptibility) loaded on an "analytic" factor and 3 (temporal discounting small stakes, temporal discounting large stakes, risk aversion) loaded on a "preferences" (for temporal discounting and avoiding risk) factor. During a mean of 4.7 years of follow-up (standard deviation = 2.9), analytic factor scores decreased (mean = 0.042-unit per year, standard error [SE] = 0.006, p < .001) and preferences factor scores increased (mean = 0.021-unit per year, SE = 0.006, p < .001), with a correlation of 0.13 (p < .001) between rates of change. Evidence of an association between cognitive reserve and decision making was mixed with purpose in life related to change in analytic decision making, whereas past (but not current) cognitive activity was related to change in decision making preferences.

DISCUSSION

Decision making analysis and preferences change over time in late life. Change over time in decision making components is relatively independent and differentially related to age and cognitive reserve.

Item Response Analysis of the Financial Capacity Instrument-Short Form

OBJECTIVE

The Financial Capacity Instrument-Short Form (FCI-SF) is a performance-based measure of everyday financial skills that takes 15 min to administer. Although the FCI-SF has demonstrated excellent psychometric properties, advanced psychometric methods such as item response theory (IRT) can provide important information on the performance of individual test items in measuring financial capacity and in distinguishing between healthy and cognitively impaired individuals.

METHOD

Participants were 272 older adults diagnosed with mild cognitive impairment (MCI) and 1,344 cognitively healthy controls recruited from the Mayo Clinic Study of Aging at the Mayo Clinic in Rochester, Minnesota and also from the Cognitive Observations in Seniors study at the University of Alabama at Birmingham. Participants in each study were administered the FCI-SF, which evaluates coin/currency calculation, financial conceptual knowledge, use of a checkbook/register, and use of a bank statement.

RESULTS

A unidimensional two-parameter logistic model best fit the 37 FCI-SF Test items, and most FCI-SF items fit the unidimensional two-parameter model well. The results indicated that all FCI-SF items robustly distinguished cognitively healthy controls from persons with MCI.

CONCLUSIONS

The study results showed that the FCI-SF performed well under IRT analysis, further highlighted the psychometric properties of the FCI-SF as a valid and reliable measure of financial capacity, and demonstrated the clinical utility of the FCI-SF in distinguishing between cognitively normal and cognitively impaired individuals.

Treatment preferences among adults with normal cognition and cognitive impairment

BACKGROUND

Although patient participation in treatment decisions is important for preference-concordant care delivery, it is largely unknown how cognitive impairment influences treatment preferences. We investigated whether treatment preferences for the care of serious illness differ between adults with and without cognitive impairment in hypothetical clinical scenarios.

METHODS

Data from the 2018 Health and Retirement Study were used. The sample included 1291 self-respondents (201 respondents with cognitive impairment, and 1090 with normal cognition). We examined treatment preferences for life-extending, limited, and comfort care options in two hypothetical clinical scenarios where the respondent imagines a patient with (1) good physical health with severe cognitive impairment consistent with dementia; and (2) with physical impairment due to a heart attack, but normal cognition. Respondents specified whether they were unsure, or if they would want or not want each treatment option. Linear probability models were used to compare treatment preferences by cognitive status.

RESULTS

Respondents with cognitive impairment were more likely to report that they were unsure about treatment options across both clinical scenarios compared to those with normal cognition. For the limited treatment option, cognitive impairment was associated with a lower rate of expressing a treatment preference by 7.3 (p = 0.070) and 8.5 (p = 0.035) percentage points for dementia and heart attack scenarios, respectively. Among those who articulated preferences, cognitive impairment was associated with a higher rate of preference for life-extending treatment in both dementia (30.1% vs. 20.0%, p = 0.044) and heart attack scenarios (30.0% vs. 20.2%, p = 0.033).

CONCLUSIONS

Compared to those with normal cognition, cognitive impairment was associated with greater uncertainty about treatment preferences and higher rates of aggressive care preferences among those who specified preferences. Further research should assess whether preferences for aggressive care become more common as cognition declines in order to improve preference-concordant care delivery for patients with cognitive impairment.

The impact of mild cognitive impairment on decision-making under explicit risk conditions: Evidence from the Personality and Total Health (PATH) Through Life longitudinal study

OBJECTIVE

Previous research has indicated that cognition and executive function are associated with decision-making, however the impact of mild cognitive impairment (MCI) on decision-making under explicit risk conditions is unclear. This cross-sectional study examined the impact of MCI, and MCI subtypes, on decision-making on the Game of Dice Task (GDT), among a cohort of older adults.

METHOD

Data from 245 older adult participants (aged 72-78 years) from the fourth assessment of the Personality and Total Health Through Life study were analyzed. A diagnostic algorithm identified 103 participants with MCI, with subtypes of single-domain amnestic MCI (aMCI-single; n = 38), multi-domain amnestic MCI (aMCI-multi; n = 31), and non-amnestic MCI (n = 33), who were compared with an age-, sex-, education-, and income-matched sample of 142 cognitively unimpaired older adults. Decision-making scores on the GDT (net score, single number choices, and strategy changes) were compared between groups using nonparametric tests.

RESULTS

Participants with MCI showed impaired performance on the GDT, with higher frequencies of single number choices and strategy changes. Analyses comparing MCI subtypes indicated that the aMCI-multi subtype showed increased frequency of single number choices compared to cognitively unimpaired participants. Across the sample of participants, decision-making scores were associated with measures of executive function (cognitive flexibility and set shifting).

CONCLUSION

MCI is associated with impaired decision-making performance under explicit risk conditions. Participants with impairments in multiple domains of cognition showed the clearest impairments. The GDT may have utility in discriminating between MCI subtypes.

Exploring the predictors of financial impairment in Huntington's disease using the Enroll-HD dataset

OBJECTIVES

Huntington's disease (HD) is a neurodegenerative disease in which cognitive and behavioural symptoms impair the performance of instrumental activities of daily living, including the handling of finances. We sought to determine the prevalence of financial dysfunction in HD, and the demographic and clinical predictors of such impairments.

METHODS

We analysed longitudinal data for pre-manifest gene carriers and HD patients from the Enroll-HD dataset. Financial dysfunction was determined by finance-related items in the Total Functional Capacity (TFC) and Functional Assessment (FA) scales. A binary logistical regression model was used to investigate the predictive value of demographic and clinical factors for the development of financial dysfunction.

RESULTS

Financial impairment was found to be common in HD gene carriers, and over half required financial assistance within 5 years from diagnosis. Cognitive impairment, apathy, unemployment and disease severity predicted financial dysfunction in manifest patients. For pre-manifest patients, the predictors were proximity to disease onset and depression.

CONCLUSIONS

Loss of financial autonomy is common in HD, and cognitive and psychiatric factors are important in its development. Clinicians must be vigilant to identify patients that may be vulnerable to financial exploitation.

Association of Performance on the Financial Capacity Instrument-Short Form With Brain Amyloid Load and Cortical Thickness in Older Adults

Background and Objectives

To investigate the association of the Financial Capacity Instrument-Short Form (FCI-SF) performance and timing total scores with brain β-amyloid and cortical thickness in cognitively unimpaired (CU) (at baseline) older adults.

Methods

A total of 309 participants (aged 70 years or older) of the Mayo Clinic Study of Aging underwent 11C-Pittsburgh compound B PET amyloid imaging and MRI, and completed the FCI-SF. Abnormal amyloid PET was defined as standardized uptake value ratio ≥1.48 in an Alzheimer disease (AD)-related region of interest and reduced AD signature cortical thickness as ≤2.68 mm (neurodegeneration). A cohort of 218 (of the 309) participants had follow-up visits (every 15 months) with FCI-SF data for longitudinal analysis (number of visits including baseline, median [range]: 2 [2-4]). In the analysis, we used linear regression and mixed-effects models adjusted for age, sex, education, apolipoprotein E ε4 allele status, global cognitive z score, and previous FCI-SF testing.

Results

Participants' mean age (SD) was 80.2 (4.8) years (56.3% male individuals). In cross-sectional analysis, abnormal amyloid PET (vs normal) was associated with a lower FCI-SF total score and slower total composite time. In longitudinal analysis, FCI-SF total score declined faster (difference in annualized rate of change, beta coefficient [β] [95% confidence interval (CI)] = -1.123 [-2.086 to -0.161]) and FCI-SF total composite time increased faster (difference in annualized rate of change, β [95% CI] = 16.274 [5.951 to 26.597]) for participants with neurodegeneration at baseline (vs those without). Participants who exhibited both abnormal amyloid PET and neurodegeneration at baseline had a greater increase in total composite time when compared with the group without abnormal amyloid and without neurodegeneration (difference in annualized rate of change, β [95% CI] = 16.750 [3.193 to 30.307]).

Discussion

Performance and processing speed on the FCI-SF were associated with imaging biomarkers of AD pathophysiology in CU (at baseline) older adults. Higher burdens of imaging biomarkers were associated with longitudinal worsening on FCI-SF performance. Additional research is needed to delineate further these associations and their predictive utility at the individual person level.

Medicolegal Implications of Mild Neurocognitive Disorder

INTRODUCTION

The syndromes of mild cognitive impairment (MCI) or mild neurocognitive disorder (MiND), often prodromal to dementia (Major Neurocognitive Disorder), are characterized by acquired clinically significant changes in one or more cognitive domains despite preserved independence. Mild impairment has significant medicolegal consequences for an affected person and their care system. We review the more common etiologies of MiND and provide a systematic review of its medicolegal implications.

METHODS

We conducted a systematic review of the peer-reviewed English literature on medicolegal aspects of MCI or MiND using comprehensive search terms and expanding our review to include sources cited by these reports.

RESULTS

Impairment of memory, executive function, social cognition, judgment, insight or abstraction can alter an individual's abilities in a variety of areas that include decision making, informed consent, designation of a surrogate decision-maker such as a health care proxy, understanding and management of financial affairs, execution of a will, or safe driving.

CONCLUSION

Even mild cognitive impairment can have significant behavioral consequences. Clinicians can assist care partners and persons with MCI or MiND by alerting them to the medicolegal concerns that often accompany cognitive decline. Early recognition and discussion can help a care system manage medicolegal risk more effectively and promote thoughtful advance planning.

Economic decision-making in the continuum between healthy aging and Alzheimer's Disease: A systematic review of 20 years of research

The effect of pathological aging on economic decision-making is a topic of major relevance as impairments in this domain place older adults at increased risk for financial abuse. This review aims to characterize decision-making across the continuum that goes from healthy aging to Alzheimer's Dementia. We included 42 studies comparing patients with Mild Cognitive Impairment (MCI) and healthy older adults, patients with Alzheimer's Disease (AD) and healthy older adults, and patients with MCI and patients with AD. Substantial evidence emerged suggesting that both MCI as AD affect economic decision-making. However, a non-negligible number of behavioural tasks failed to find significant differences between patients and controls, and no differences were reported between patients with MCI and AD. On the contrary, measures of financial capacity reached more robust findings, showing that healthy older adults had better performance than patients, while MCI patients showed better performance than AD patients. This review presents the main conclusions that may be drawn from significant findings, as well as the hypotheses and recommendations for future research.

Assessment of the Financial Capacity in the Context of Normal and Pathological Cognitive Aging. Preliminary Analysis of the Portuguese Version of the Numerical Activities of Daily- Living- Financial (NADL-F)

Financial capacity (FC) is conceptualized as a dimension that encompasses a wide range of basic aptitudes and the capacity to judge and assess situations and make decisions according to one best interests. The Numerical Activities of Daily-Living-Financial (NADL-F) is an instrument of FC for clinical use developed in Italy. This study aims to perform a preliminary analysis on the psychometric characteristics of the Portuguese version of NADL-F. NADL-F as well as other neuropsychological instruments were administered to three groups: Healthy Control (n = 11); Mild Neurocognitive Disorder group (n = 19); Major Neurocognitive Disorder group (n = 19). NADL-F and its tasks were considered acceptable, showed good reliability for the entire sample (α = .808) and the majority of the domains correlated significantly with each other and with the total scale. Between group comparisons showed significant differences regarding all domains. Arithmetic, schooling and executive functioning accounted for 54.1% of the variance on the test. The Portuguese version of NADL-F proved to be an acceptable and valid instrument of assessing FC in the context of cognitive aging. NADL-F is an instrument that emulates real life financial situations, and it can be used in a second level of evidence in the clinical model of FC assessment.

BIOFACE: A Prospective Study of Risk Factors, Cognition, and Biomarkers in a Cohort of Individuals with Early-Onset Mild Cognitive Impairment. Study Rationale and Research Protocols

Background:

Mild cognitive impairment (MCI) due to Alzheimer’s disease (AD) diagnosis is based on cerebrospinal fluid (CSF) or neuroimaging biomarkers. Currently, non-invasive and inexpensive blood-based biomarkers are being investigated, such as neuronal-derived plasma exosomes (NPEs). Neuroinflammation and early vascular changes have been described in AD pathogenesis and can be traced in plasma and NPEs. However, they have not been studied in early onset MCI (EOMCI).

Objective:

To describe the rationale, design, and baseline characteristics of the participants from the BIOFACE cohort, a two-year observational study on EOMCI conducted at Fundació ACE. The study goal is to characterize the different phenotypes from a clinical, neuropsychological, and biomarker point of view and to investigate the CSF and plasma proteomics as well as the role of NPEs as early biomarkers of AD.

Methods:

Participants underwent extended neurological and neuropsychological batteries, multimodal biomarkers including brain MRI, blood, saliva, CSF, anthropometric, and neuro-ophthalmological examinations.

Results:

Ninety-seven patients with EOMCI were recruited. 59.8%were women. Mean age at symptom onset was 57 years; mean MMSE was 28. First degree and presenile family history of dementia was present in 60.8%and 15.5%, respectively. Depressive and anxiety disorders along with vascular risk factors were the most frequent comorbidities. 29%of participants were APOE ɛ4 carriers, and 67%showed a CSF normal ATN profile.

Conclusion:

BIOFACE is a two-year study of clinical, cognition, and biomarkers that will shed light on the physiopathology and the potential utility of plasma and NPEs as non-invasive early diagnostic and prognostic biomarkers in people younger than 65 years.

How well do people living with neurodegenerative diseases manage their finances? A meta-analysis and systematic review on the capacity to make financial decisions in people living with neurodegenerative diseases

Self and proxy reported questionnaires indicate that people living with a neurodegenerative disease (NDD) have more difficulties with financial decision-making (FDM) than healthy controls. Self-reports, however, rely on adequate insight into everyday functioning and might, therefore, be less reliable. The present study provides a comprehensive overview and meta-analysis of studies evaluating FDM in people living with an NDD. For this, the reliability of performance-based tests to consistently identify FDM difficulties in people living with an NDD compared to healthy controls is evaluated. Furthermore, the associations between FDM and disease severity, performances on standard measures of cognition and demographics are evaluated. All 47 included articles, consistently reported lower performances on performance-based FDM tests of people living with an NDD (including Alzheimer's disease, mild cognitive impairment, frontotemporal dementia, Parkinson's disease, multiple sclerosis or Huntington's disease) compared to healthy controls. The majority of studies, however, focused on Alzheimer's disease and mild cognitive impairment (k = 38). FDM performance appears to be related to cognitive decline, specifically in working memory, processing speed and numeracy.

Cognitive Functioning, Life Satisfaction, and Their Relationship with the Financial Attitudes of Older Individuals Who Participate in an Active Aging Program

Life expectancy has increased in many countries throughout the world over recent years, leading to new challenges related to aging. A large part of the population is over 60 years old, and therefore studies that focus on financial autonomy and active aging are necessary. In this paper, we analyze the relationship between cognitive functioning and life satisfaction in relation to financial attitudes in a sample of 251 elderly adults (71% women) participating in an active aging program (M = 67.5, SD = 4.5). We used the Mini-Mental State Examination, the Satisfaction with Life scale, and a questionnaire about financial attitudes to gather data. Our results show that cognitive functioning and life satisfaction are related to certain financial attitudes. We also observed differences associated with gender, education level, and financial independence. According to our findings, life satisfaction should be taken into account when the financial attitudes of older adults are evaluated. The importance of support groups for the elderly is highlighted as well as of all those recreation and health programs, since they constitute a means of promoting well-being.

The role of limbic structures in financial abilities of mild cognitive impairment patients

Mild Cognitive Impairment (MCI) patients experience problems in financial abilities that affect everyday functioning. To date, the neural correlates of decline in this domain are unclear. This study aims at examining the correlation between the pattern of brain atrophy of MCI patients and performance on financial abilities. Forty-four MCI patients and thirty-seven healthy controls underwent structural magnetic resonance imaging, and assessment of financial abilitiesby means of the Numerical Activities of Daily Living Financial battery (NADL-F). As compared to healthy controls, MCI patients showed impaired performance in three out of the seven domains assessed by NADL-F: Item purchase, percentage, and financial concepts. The patients' performance in the NADL-F correlated with memory, language, visuo-spatial, and abstract reasoning composite scores. The analysis also revealed that volumetric differences in the limbic structures significantly correlated with financial abilities in MCI. Specifically, the patients' performance in the NADL-F was correlated with atrophy in the left medial and lateral amygdala and the right anterior thalamic radiation. These findings suggest that completing daily financial tasks involves sub-cortical regions in MCI and presumably also the motivational and emotional processes associated to them. Involvement of altered limbic structures in MCI patients suggests that impairment in financial abilities may be related to emotional and reflexive processing deficits.

Modification of everyday activities and its association with self-awareness in cognitively diverse older adults

Cognitive impairment (CI) in older adults is frequently accompanied by difficulty performing complex everyday activities (e.g., managing finances). However, it is unclear if and how older adults with CI modify their activities (i.e., Do individuals continue, monitor, seek help with, change their approach to, or stop different activities?). In the current study, we examined if older adults with CI are concerned about their ability to carry out complex activities, if and how they modify activities based on their concern, and the factors associated with activity modification. We hypothesized that older adults with CI will more frequently be concerned about, and modify, everyday activities than cognitively healthy (HE) older adults, and that higher awareness of memory loss in the CI group would relate to more frequent modification. The sample included 81 older adults (51 HEs; mean age 70.02 (7.34) and 30 CI; mean age 75.97 (8.12)). Compared to HEs, the CI group reported having more concern about, F(3,77) = 5.50, p = 0.02, and modifying a greater number of activities, F(3,77) = 5.02, p = 0.03. Medication management (30%) and completing taxes (33.3%) were among the most frequently modified activities for the CI and HE groups, respectively. In the CI group, higher memory awareness was associated with more concern (r = .53, p = .005) and activity modification (r = 0.55, p = .003). Findings provide novel information about how cognitively diverse older adults navigate complex activities in daily life. We propose a preliminary theoretical model by which self-awareness may influence navigation of everyday activities in the context of CI.

Healthcare and Financial Decision Making and Incident Adverse Cognitive Outcomes among Older Adults

OBJECTIVES

To determine if poorer healthcare and financial decision making forecasts adverse cognitive outcomes in old age. Specifically, we hypothesized that poorer decision making would be associated with an increased risk of incident Alzheimer's dementia, an increased risk of incident mild cognitive impairment (MCI), and a more rapid decline in cognition.

DESIGN

An ongoing prospective observational cohort study of aging (the Rush Memory and Aging Project).

SETTING

The greater Chicago area.

PARTICIPANTS

A total of 952 community-based older adults without dementia at baseline.

MEASUREMENTS

Participants completed a measure of healthcare and financial decision making at baseline and underwent annual standardized evaluations to track clinical status and cognitive functions (global cognition, episodic memory, semantic memory, working memory, perceptual speed, and visuospatial ability).

RESULTS

During up to 9 years of follow-up (M = 5.2 y; standard deviation = 2.7), 156 participants developed Alzheimer's dementia (16.4% of 952), 253 participants developed MCI (33.2% of 760), and each cognitive measure declined (all Ps < .001). In Cox proportional hazards models adjusted for age, sex, and education, poorer decision making was associated with an increased risk of incident Alzheimer's dementia (hazard ratio [HR] = 1.17; 95% confidence interval [CI] = 1.10-1.24; P < .001) and incident MCI (HR = 1.16; 95% CI = 1.10-1.22; P < .001). Further, in linear mixed-effects models, poorer decision making among those who were initially free of cognitive impairment was associated with a more rapid decline in global cognition and four of five specific cognitive domains (all Ps < .05).

CONCLUSION

Our results suggest that poorer healthcare and financial decision making heralds adverse cognitive outcomes in old age. J Am Geriatr Soc 67:1590-1595, 2019.

Verbal fluency and risk of dementia

OBJECTIVE

Verbal fluency is a common neuropsychological test that is impaired in dementia. We test whether verbal fluency is a prospective risk factor for incident dementia, cognitive impairment not dementia (CIND), and conversion from CIND to dementia.

METHODS

Participants (N = 18 189) from the Health and Retirement Study were administered a standard test of verbal fluency and were assessed for cognitive status every 2 years between baseline and 6 years' follow-up.

RESULTS

Every standard deviation increase in verbal fluency was associated with an approximately 60% reduced risk of incident dementia, an approximately 25% reduced risk of incident CIND, and an approximately 25% reduced risk of conversion from CIND to dementia. These associations were independent of age, gender, education, race, ethnicity, and APOE risk status. The associations were slightly weaker (but still significant) for African Americans and individuals with lower education. There was no interaction between verbal fluency and APOE risk status.

CONCLUSION

Verbal fluency is an easily administered task that is predictive of incident cognitive impairment.

Scam Awareness Related to Incident Alzheimer Dementia and Mild Cognitive Impairment: A Prospective Cohort Study

BACKGROUND

Decreased scam awareness may be an early indicator of impending Alzheimer dementia and its precursor, mild cognitive impairment, but prior studies have not systematically examined the associations between scam awareness and adverse cognitive outcomes.

OBJECTIVE

To test the hypothesis that low scam awareness is associated with increased risk for incident Alzheimer dementia, mild cognitive impairment, and Alzheimer disease pathology in the brain.

DESIGN

Prospective cohort study of aging.

SETTING

Community-based study in the greater Chicago metropolitan area.

PARTICIPANTS

935 older persons initially free of dementia.

MEASUREMENTS

Scam awareness was measured via questionnaire, incident Alzheimer dementia and mild cognitive impairment were documented in detailed annual cognitive and clinical evaluations, and Alzheimer disease neuropathology was quantified after death among a subset of persons who died (n = 264). Proportional hazards models examined associations between scam awareness and incident Alzheimer dementia and mild cognitive impairment. Regression models examined associations between scam awareness and Alzheimer disease pathology, particularly β-amyloid burden and tau tangle density.

RESULTS

During a mean of about 6 years (SD, 2.4) of observation, 151 persons (16.1%) developed Alzheimer dementia. Low scam awareness was associated with increased risk for Alzheimer dementia (hazard ratio [HR], 1.56 [95% CI, 1.21 to 2.01]; P < 0.001), such that each 1-unit increase in scam score (indicating lower awareness) was associated with about a 60% increase in dementia risk. Low scam awareness was also associated with increased risk for mild cognitive impairment (HR, 1.47 [CI, 1.20 to 1.81]; P < 0.001). These associations persisted even after adjustment for global cognitive function. Finally, low scam awareness was associated with a higher burden of Alzheimer pathology in the brain, particularly β-amyloid (estimated increase [±SE] in β-amyloid per 1-unit increase in scam score, 0.22 ± 0.10 unit; P = 0.029).

LIMITATION

The measure of scam awareness used here is too weak for prediction at the individual level.

CONCLUSION

Low scam awareness among older persons is a harbinger of adverse cognitive outcomes and is associated with Alzheimer disease pathology in the brain.

PRIMARY FUNDING SOURCE

National Institute on Aging.