Lost in space(s): multimodal neuroimaging of disorientation along the Alzheimer's disease continuum

Orientation is a fundamental cognitive faculty, allowing the behaving self to link his/her current state to their internal representations of the external world. Once exclusively linked to knowledge of the current place and present time, in recent years, the concept of orientation has evolved to include processing of social, temporal, and abstract relations. Concordantly with the growing focus on orientation, spatial disorientation has been increasingly recognized as a hallmark symptom of Alzheimer's disease (AD). However, few studies have sought to explore disorientation along the AD continuum beyond the spatial domain. 51 participants along the AD continuum performed an orientation task in the spatial, temporal and social domains. Under functional magnetic resonance imaging (fMRI), participants determined which of two familiar places/events/people is geographically/ chronologically/ socially closer to them, respectively. A series of analyses revealed disorientation along the AD- continuum to follow a three-way association between (1) orientation domain, (2) brain region, and (3) disease stage. Specifically, participants with MCI exhibited impaired spatio-temporal orientation and reduced task-evoked activity in temporoparietal regions, while participants with AD dementia exhibited impaired social orientation and reduced task-evoked activity in frontoparietal regions. Furthermore, these patterns of hypoactivation coincided with Default Mode Network (DMN) sub-networks, with spatio-temporal orientation activation overlapping DMN-C and social orientation with DMN-A. Finally, these patterns of disorientation- associated hypoactivations coincided with patterns of fluorodeoxyglucose (FDG) hypometabolism and cortical atrophy characteristic to AD-dementia. Taken together, our results suggest that AD may constitute a disorder of orientation, characterized by a biphasic process as (1) early spatio-temporal and (2) late social disorientation, concurrently manifesting in task-evoked and neurodegenerative changes in temporoparietal and parieto-frontal brain networks, respectively. We propose that a profile of disorientation across multiple domains offers a unique window into the progression of AD.

From objects to acting: Repopulating psychology with people who act

This article builds on Billig’s (2013) claim that psychologists use too many nouns, which leads to inappropriately objectifying human beings and human functioning. Rather than treating human beings as physical objects or things in order to emulate the natural sciences, Billig calls for repopulating psychology with people who act. After summarizing Billig’s analysis, I argue that using nouns reflects prior theoretical assumptions about human functioning that inform psychology’s experimental and quantitative methods. I question varied theoretical assumptions and outline an alternative theoretical framework for conceptualizing what people do by positing action as a unit of analysis for psychology. This action perspective provides a theoretical basis for using verbs to characterize human functioning. Conceptualizing human functioning holistically and in terms of dynamic qualitative processes can transform psychology into a science focused on understanding the complexities of what people do as they act in relation to others in varied cultural contexts.

Deep brain stimulation for people with Alzheimer's disease: Anticipating potential effects on the tripartite self

Memory dysfunction and cognitive impairments due to Alzheimer’s disease can affect the selfhood and identity of afflicted individuals, causing distress to both people with Alzheimer’s disease and their caregivers. Recently, a number of case studies and clinical trials have been conducted to determine the potential of deep brain stimulation as a therapeutic modality for people with Alzheimer’s disease. Some of these studies have shown that deep brain stimulation could induce flashbacks and stabilize or even improve memory. However, deep brain stimulation itself has also been attributed as a potential threat to identity and selfhood, especially when procedure-related adverse events arise. We anticipate potential effects of deep brain stimulation for people with Alzheimer’s disease on selfhood, reconciling information from medical reports, psychological, and sociological investigations on the impacts of deep brain stimulation or Alzheimer’s disease on selfhood. A tripartite model of the self that extends the scope of Rom Harré’s and Steve Sabat’s social constructionist framework was used. In this model, potential effects of deep brain stimulation for Alzheimer’s disease on Self 1 or singularity through use of first-person indexicals, and gestures of self-reference, attribution, and recognition; Self 2 or past and present attributes, knowledge of these characteristics, and continuity of narrative identity; and Self 3 or the relational and social self are explored. The ethical implications of potential effects of deep brain stimulation for Alzheimer’s disease on the tripartite self are then highlighted, focusing on adapting informed consent procedures and care provided throughout the trial to account for both positive and negative plausible effects on Self 1, Self 2, and Self 3.

Qualitative assessment of self-identity in people with advanced dementia

This study aimed to understand the preserved elements of self-identity in persons with moderate to severe dementia attributable to Alzheimer's disease. A semi-structured interview was developed to explore the narrative self among residents with dementia in a residential care facility, and residents without dementia in an independent living setting. The interviews were transcribed verbatim from audio recordings and analyzed for common themes, while being sensitive to possible differences between the groups. The participants with dementia showed evidence of self-reference even though losses in explicit memory were evident. The most noticeable difference between the two groups was time frame reference. Nonetheless, all participants showed understanding of their role in relationships and exhibited concrete preferences. Our findings suggest that memory loss and other cognitive deficits associated with moderate to severe dementia do not necessarily lead to a loss of “self.”

A processural consent methodology with people diagnosed with dementia

Purpose

– The purpose of this paper is to develop an approach within the guidance of the Mental Capacity Act (2005) to meaningfully include people diagnosed with dementia (PDwD) in research endeavours.

Design/methodology/approach

– As part of a broader study of self-authored narratives of care experiences, PDwD were involved in the development and implementation of a process method of consent, in which consent conversations were contextual, responsive and ongoing, and were audited with the use of field diaries.

Findings

– Working within people’s relational contexts (i.e. care staff and family), eight participants with a range of dementia diagnoses and care needs made and verbally communicated research-related decisions. A desire to participate was consistently conveyed across research encounters, regardless of the extent of memory problems. Participants also demonstrated keen awareness of the links between memory problems, rights and inclusion, alongside a sense of personal identity and the capacities to clearly communicate this.

Research limitations/implications

– A process model of consent encouraged formal reflection upon ethical and pragmatic complexities, and is relevant to persons diagnosed with dementia making both care- and research-related decisions. Further work is needed to include people with a broader range of communication support needs.

Originality/value

– This research demonstrates substantial possibilities for eliciting and responding to the views of people with dementia diagnoses (previously excluded from research). Results open opportunities for genuine long-term research and care partnerships with PDwD for practice, service and policy development.

Preventing Loss of Independence through Exercise (PLIÉ): qualitative analysis of a clinical trial in older adults with dementia

OBJECTIVES

Preventing Loss of Independence through Exercise (PLIÉ) is a novel, integrative exercise program for individuals with dementia that combines elements of different conventional and complementary exercise modalities (e.g. tai-chi, yoga, Feldenkrais, and dance movement therapy) and focuses on training procedural memory for basic functional movements (e.g., sit-to-stand) while increasing mindful body awareness and facilitating social connection. This study presents analyses of qualitative data collected during a 36-week cross-over pilot clinical trial in 11 individuals.

METHODS

Qualitative data included exercise instructors' written notes, which were prepared after each class and also following biweekly telephone calls with caregivers and monthly home visits; three video-recorded classes; and written summaries prepared by research assistants following pre- and post-intervention quantitative assessments. Data were extracted for each study participant and placed onto a timeline for month of observation. Data were coded and analyzed to identify themes that were confirmed and refined through an iterative, collaborative process by the entire team including a qualitative researcher (SA) and the exercise instructors.

RESULTS

Three overarching themes emerged: (1) Functional changes included increasing body awareness, movement memory and functional skill. (2) Emotional changes included greater acceptance of resting, sharing of personal stories and feelings, and positive attitude toward exercise. (3) Social changes included more coherent social interactions and making friends.

CONCLUSIONS

These qualitative results suggest that the PLIÉ program may be associated with beneficial functional, emotional, and social changes for individuals with mild to moderate dementia. Further study of the PLIÉ program in individuals with dementia is warranted.

Social cognition in Alzheimer's disease: a separate construct contributing to dependence

The extent to which social cognitive changes reflect a discrete constellation of symptoms dissociable from general cognitive changes in Alzheimer's disease (AD) is unclear. Moreover, whether social cognitive symptoms contribute to disease severity and progression is unknown. The current multicenter study investigated cross-sectional and longitudinal associations between social cognition measured with six items from the Blessed Dementia Rating Scale, general cognition, and dependence in 517 participants with probable AD. Participants were monitored every 6 months for 5.5 years. Results from multivariate latent growth curve models adjusted for sex, age, education, depression, and recruitment site revealed that social cognition and general cognition were unrelated cross-sectionally and throughout time. However, baseline levels of each were related independently to dependence, and change values of each were related independently to change in dependence. These findings highlight the separability of social and general cognition in AD. Results underscore the relevance of considering social cognition when modeling disease and estimating clinical outcomes related to patient disability.

[A behavioural rating scale of activity engagement in psychogeriatric day care]

The Participation Scale was developed as an observational measure of activity engagement (as rated by group facilitators) of adult day care clients with mild to moderate dementia. In a consecutive sample of 448 subjects Mokken scaling procedure was conducted to assess the latent structure of 27 questionnaire items. The study included an exploratory and a confirmatory approach. For that purpose the sample was randomly divided into two halves. Exploratory analysis revealed three dimensions of participation that adequately captured the item structure: motivation (10 items; Loevinger's H = 0.48), competence (7 items; H = 0.56) and self-confidence (4 items; H = 0.57). The structure was validated in a confirmatory analysis. In a stepwise multiple regression model 49% of the variance in motivation was explained by independent behavioural measures of apathy and affect. Apathy and cognitive impairment were significant predictors of competence in participation (R(2) = 31.2%). Negative affect was the main predictor of reduced self-confidence (R(2) = 37.9%). Cross-validation of these exploratory regression models on the confirmatory sample explained 39.6%, 29.2% and 23.1% of the variance in motivation, competence and self-confidence, respectively. Test-retest intraclass correlation coefficients (ICC2(A,1)) as determined in a random subsample of 56 participants, were 0.77 (motivation), 0.85 (competence) and 0.76 (self-confidence). The three measures allow the differentiation and ordering of individual participants on separate dimensions of activity engagement in psychogeriatric day care.

The experience of self and threats to sense of self among relatives caring for people with Alzheimer's disease

This study explored how the relatives of people with Alzheimer's disease expressed Self 2 and Self 3 according to Harré's social constructionist theory of selfhood. Having a relative with Alzheimer's disease affects one's life. In this study, we concentrated on how close relatives of people with Alzheimer's disease experienced their sense of self. This study was descriptive and qualitative. Interviews were conducted with 20 relatives of 10 people with Alzheimer's disease from 2009 to 2011. The data were analysed according to Harré's social constructionist theory of selfhood including Selves 2 and 3. Participants reported that Alzheimer's disease challenged their personal attributes, relations and positioning. Understanding how Alzheimer's disease affects the sense of self among close relatives is important, as this knowledge is pivotal for supporting these relatives who are often informal caregivers in ways that enable a fulfilling and meaningful life.

A narrative analysis of poetry written from the words of people given a diagnosis of dementia

This study is underpinned by social constructionist epistemology, which points to the socially constructed character of our worlds, in that we co-create and are co-created by (including experience and identity) our social realities. Through narrative analysis of some poems from the words of people given a diagnosis of dementia, this study engaged in the process of meaning-making in relation to Self-construct and the wider social world. Some narratives evidenced speakers’ lack of agency over their experiences, not because of the ‘dementia’ but due to treatment and care contexts. Some narratives provided instances in which others positioned speakers into identity constructions contradictory to their life-long Self-constructs. Other narratives demonstrated that, through acknowledging and supporting ‘personhood’, speakers retained a sense of well-being and purpose in their social worlds. It is hoped that focusing on the words of individuals given dementia diagnoses, away from predominant bio-medical discourses, may facilitate professionals’ continuous reflection and person-centred practice.

Language, executive function and social cognition in the diagnosis of frontotemporal dementia syndromes

Frontotemporal dementia (FTD) represents a spectrum of non-Alzheimer's degenerative conditions associated with focal atrophy of the frontal and/or temporal lobes. Frontal and temporal regions of the brain have been shown to be strongly involved in executive function, social cognition and language processing and, thus, deficits in these domains are frequently seen in patients with FTD or may even be hallmarks of a specific FTD subtype (i.e. relatively selective and progressive language impairment in primary progressive aphasia). In this review we have attempted to delineate how language, executive function, and social cognition may contribute to the diagnosis of FTD syndromes, namely the behavioural variant FTD as well as the language variants of FTD including the three subtypes of primary progressive aphasia (PPA): non-fluent/agrammatic, semantic and logopenic. This review also addresses the extent to which deficits in these cognitive areas contribute to the differential diagnosis of FTD versus Alzheimer's disease (AD). Finally, early clinical determinants of pathology are briefly discussed and contemporary challenges to the diagnosis of FTD are presented.

How people with Alzheimer's disease express their sense of self: analysis using Rom Harré's theory of selfhood

The aim of this study was to use Harré's social constructionist theory of selfhood to describe how people with mild and moderate Alzheimer's disease (AD) express their sense of self. The findings show that Self 1, the embodied sense of being a person, was expressed fluently by participants through the use of first-person indexicals. Self 2, the experienced personal attributes and life narrative, had undergone changes. Those changes were not entirely for the worse; participants had also developed new skills in managing life with AD. In a lifetime perspective, those changes were minor and participants perceived themselves to be basically the same people that they were before having AD. When constructing Self 3, the social personae, participants usually described being supported by others, but sometimes described being exposed to malignant positioning. They also feared that they might become more exposed to negative attitudes as their AD progressed. However, participants were understanding towards the offensive behaviours of others.

Relatedness among people diagnosed with dementia: Social cognition and the possibility of friendship

In this study, we examined the social relatedness of people in the moderate stage of dementia as defined by their performance on standard tests and clinical examination. The individuals herein were observed in the natural social environment of an adult day center that they attended on weekdays. A number of important aspects of mutually desired, independently initiated, supportive social relationships were observed to exist, through which the principals revealed semiotic, or meaning-driven, behavior that would not be predicted by their meeting the criteria that contributed to their diagnosis. Losses in social functioning described in the DSM and associated with the clinical diagnosis of dementia appear to be caused more by social dynamics involving healthy others than by brain injury alone. Implications for the non-pharmacological treatment of people with dementia are explored and discussed within the context of Kitwood's idea of positive person work.