1
|
Cappa SF, Ribaldi F, Chicherio C, Frisoni GB. Subjective cognitive decline: Memory complaints, cognitive awareness, and metacognition. Alzheimers Dement 2024. [PMID: 39051174 DOI: 10.1002/alz.13905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 03/20/2024] [Accepted: 04/20/2024] [Indexed: 07/27/2024]
Abstract
Cognitive complaints are common in elderly subjects and are a frequent reason for referral to memory clinics. If the complaints are not associated with objective cognitive impairment, the condition is labelled subjective cognitive decline (SCD). SCD is often considered as a stage antedating objective impairment, and an at-risk condition for subsequent dementia. Recent large-scale studies indicate that a significantly increased risk of clinical progression in subjects with SCD is associated with positivity for Alzheimer's disease (AD) biomarkers, a finding supporting the notion that SCD can be due to different mechanisms not associated with neurodegeneration, including functional cognitive disorders. In this paper we present a selective review of research on the relations among SCD, cognitive awareness, and metacognitive abilities. We propose that longitudinal studies of metacognitive efficiency in SCD may provide useful cues about the risk of progression to dementia and the possible presence of a functional cognitive disorder, with different implications for the management of this prevalent aging-related condition. HIGHLIGHTS: Subjective cognitive decline (SCD), a common cause of referral to memory clinics, can be due to multiple conditions. The predictive value of SCD for progression to Alzheimer's disease (AD) dementia is high in association with AD biomarker positivity. The awareness of cognitive decline is the mechanism responsible for the emergence of SCD and metacognition is the underlying neuropsychological function. The awareness of cognitive decline in clinical patients is usually assessed comparing an informant rating to the patient self-assessment, a method that can be affected by informant bias. While there is strong evidence that awareness starts to decline with the onset of objective cognitive impairment, progressively leading to the anosognosia of AD, the status of metacognitive efficiency in SCD needs to be further investigated. Quantitative, performance-based indexes of metacognitive efficiency may contribute both to the assessment of progression risk and to the management of subjects with functional cognitive disorders.
Collapse
Affiliation(s)
- Stefano F Cappa
- University Institute of Advanced Studies and IRCCS Mondino Foundation Pavia, Pavia, Italy
| | - Federica Ribaldi
- Laboratory of Neuroimaging of Aging (LANVIE), University of Geneva, Geneva, Switzerland
- Geneva Memory Center, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland
| | - Christian Chicherio
- Geneva Memory Center, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland
- Center for Interdisciplinary Study of Gerontology and Vulnerability (CIGEV), University of Geneva, Geneva, Switzerland
| | - Giovanni B Frisoni
- Laboratory of Neuroimaging of Aging (LANVIE), University of Geneva, Geneva, Switzerland
- Geneva Memory Center, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland
| |
Collapse
|
2
|
López-Martos D, Suárez-Calvet M, Milà-Alomà M, Gispert JD, Minguillon C, Quijano-Rubio C, Kollmorgen G, Zetterberg H, Blennow K, Grau-Rivera O, Sánchez-Benavides G. Awareness of episodic memory and meta-cognitive profiles: associations with cerebrospinal fluid biomarkers at the preclinical stage of the Alzheimer's continuum. Front Aging Neurosci 2024; 16:1394460. [PMID: 38872632 PMCID: PMC11169691 DOI: 10.3389/fnagi.2024.1394460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
Introduction The lack of cognitive awareness, anosognosia, is a clinical deficit in Alzheimer's disease (AD) dementia. However, an increased awareness of cognitive function, hypernosognosia, may serve as a marker in the preclinical stage. Subjective cognitive decline (SCD) might correspond to the initial symptom in the dynamic trajectory of awareness, but SCD might be absent along with low awareness of actual cognitive performance in the preclinical stage. We hypothesized that distinct meta-cognitive profiles, both hypernosognosia and anosognosia, might be identified in preclinical-AD. This research evaluated the association between cerebrospinal fluid (CSF) AD biomarkers and the awareness of episodic memory, further exploring dyadic (participant-partner) SCD reports, in the preclinical Alzheimer's continuum. Methods We analyzed 314 cognitively unimpaired (CU) middle-aged individuals (mean age: 60, SD: 4) from the ALFA+ cohort study. Episodic memory was evaluated with the delayed recall from the Memory Binding Test (MBT). Awareness of episodic memory, meta-memory, was defined as the normalized discrepancy between objective and subjective performance. SCD was defined using self-report, and dyadic SCD profiles incorporated the study partner's report using parallel SCD-Questionnaires. The relationship between CSF Aβ42/40 and CSF p-tau181 with meta-memory was evaluated with multivariable regression models. The role of SCD and the dyadic contingency was explored with the corresponding stratified analysis. Results CSF Aβ42/40 was non-linearly associated with meta-memory, showing an increased awareness up to Aβ-positivity and a decreased awareness beyond this threshold. In the non-SCD subset, the non-linear association between CSF Aβ42/40 and meta-memory persisted. In the SCD subset, higher Aβ-pathology was linearly associated with increased awareness. Individuals presenting only study partner's SCD, defined as unaware decliners, exhibited higher levels of CSF p-tau181 correlated with lower meta-memory performance. Discussion These results suggested that distinct meta-cognitive profiles can be identified in preclinical-AD. While most individuals might experience an increased awareness associated with the entrance in the AD continuum, hypernosognosia, some might be already losing insight and stepping into the anosognosic trajectory. This research reinforced that an early anosognosic profile, although at increased risk of AD-related decline, might be currently overlooked considering actual diagnostic criteria, and therefore its medical attention delayed.
Collapse
Affiliation(s)
- David López-Martos
- Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
- Hospital del Mar Research Institute (IMIM), Barcelona, Spain
| | - Marc Suárez-Calvet
- Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
- Hospital del Mar Research Institute (IMIM), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
- Servei de Neurologia, Hospital del Mar, Barcelona, Spain
| | - Marta Milà-Alomà
- Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
- Department of Veterans Affairs Medical Center, Northern California Institute for Research and Education (NCIRE), San Francisco, CA, United States
- Department of Radiology, University of California San Francisco, San Francisco, CA, United States
| | - Juan Domingo Gispert
- Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
- Hospital del Mar Research Institute (IMIM), Barcelona, Spain
- Centro de Investigación Biomédica en Red Bioingeniería, Biomateriales y Nanomedicina, Madrid, Spain
| | - Carolina Minguillon
- Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
- Hospital del Mar Research Institute (IMIM), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
| | | | | | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, United Kingdom
- UK Dementia Research Institute at UCL, London, United Kingdom
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, Hong Kong SAR, China
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Paris Brain Institute, ICM, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
- Neurodegenerative Disorder Research Center, Division of Life Sciences and Medicine, and Department of Neurology, Institute on Aging and Brain Disorders, University of Science and Technology of China and First Affiliated Hospital of USTC, Hefei, China
| | - Oriol Grau-Rivera
- Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
- Hospital del Mar Research Institute (IMIM), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
- Servei de Neurologia, Hospital del Mar, Barcelona, Spain
| | - Gonzalo Sánchez-Benavides
- Barcelonaβeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
- Hospital del Mar Research Institute (IMIM), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable, Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
3
|
Huang L, Li Q, Lu Y, Pan F, Cui L, Wang Y, Miao Y, Chen T, Li Y, Wu J, Chen X, Jia J, Guo Q. Consensus on rapid screening for prodromal Alzheimer's disease in China. Gen Psychiatr 2024; 37:e101310. [PMID: 38313393 PMCID: PMC10836380 DOI: 10.1136/gpsych-2023-101310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/19/2023] [Indexed: 02/06/2024] Open
Abstract
Alzheimer's disease (AD) is a common cause of dementia, characterised by cerebral amyloid-β deposition, pathological tau and neurodegeneration. The prodromal stage of AD (pAD) refers to patients with mild cognitive impairment (MCI) and evidence of AD's pathology. At this stage, disease-modifying interventions should be used to prevent the progression to dementia. Given the inherent heterogeneity of MCI, more specific biomarkers are needed to elucidate the underlying AD's pathology. Although the uses of cerebrospinal fluid and positron emission tomography are widely accepted methods for detecting AD's pathology, their clinical applications are limited by their high costs and invasiveness, particularly in low-income areas in China. Therefore, to improve the early detection of Alzheimer's disease (AD) pathology through cost-effective screening methods, a panel of 45 neurologists, psychiatrists and gerontologists was invited to establish a formal consensus on the screening of pAD in China. The supportive evidence and grades of recommendations are based on a systematic literature review and focus group discussion. National meetings were held to allow participants to review, vote and provide their expert opinions to reach a consensus. A majority (two-thirds) decision was used for questions for which consensus could not be reached. Recommended screening methods are presented in this publication, including neuropsychological assessment, peripheral biomarkers and brain imaging. In addition, a general workflow for screening pAD in China is established, which will help clinicians identify individuals at high risk and determine therapeutic targets.
Collapse
Affiliation(s)
- Lin Huang
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qinjie Li
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yao Lu
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fengfeng Pan
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liang Cui
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Wang
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ya Miao
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianlu Chen
- Center for Translational Medicine and Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yatian Li
- Shanghai BestCovered, Shanghai, China
| | | | - Xiaochun Chen
- Department of Neurology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jianping Jia
- Department of Neurology, National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Qihao Guo
- Department of Gerontology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
4
|
Mimmack KJ, Gagliardi GP, Marshall GA, Vannini P. Measurement of Dimensions of Self-awareness of Memory Function and Their Association With Clinical Progression in Cognitively Normal Older Adults. JAMA Netw Open 2023; 6:e239964. [PMID: 37097631 PMCID: PMC10130951 DOI: 10.1001/jamanetworkopen.2023.9964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/12/2023] [Indexed: 04/26/2023] Open
Abstract
IMPORTANCE The ability to separately explore 2 dimensions of self-awareness of memory function-increased and decreased awareness-in cognitively normal older adults provides an important opportunity to understand subtle changes in either direction in relation to risk of Alzheimer disease. OBJECTIVE To investigate the association of a novel measure for self-awareness of memory function with future clinical progression in individuals who were cognitively normal at baseline. DESIGN, SETTING, AND PARTICIPANTS This cohort study used data from the Alzheimer's Disease Neuroimaging Initiative, a multicenter study. Participants were older adults who were cognitively normal (ie, Clinical Dementia Rating [CDR] global score of 0) at baseline and had at least 2 years of follow-up. Data were collected from June 2010 to December 2021 and pulled from the University of Southern California Laboratory of Neuro Imaging database on January 18, 2022. Clinical progression was defined as the first instance of 2 consecutive follow-up CDR scale global scores of 0.5 or greater. MAIN OUTCOMES AND MEASURES A traditional awareness score was measured by calculating the mean discrepancy between the participant and their study partner's scores on the Everyday Cognition questionnaire. An unawareness or heightened awareness subscore was generated by capping item-level positive or negative differences at zero before averaging. The main outcome-risk of future clinical progression-was analyzed for each baseline awareness measure using Cox regression analysis. Longitudinal trajectories of each measure were additionally compared using linear mixed-effects models. RESULTS The 436-person sample included 232 (53.2%) female participants, with a mean (SD) age of 74.5 (6.7) years; 25 participants (5.7%) were Black, 14 (3.2%) Hispanic, and 398 (91.3%) White; and 91 participants (20.9%) clinically progressed over their period of observation. Survival analyses showed that a 1-point improvement on the unawareness subscore was associated with an 84% reduction in progression hazard (hazard ratio, 0.16 [95% CI, 0.07-0.35]; P < .001), or equivalently, a 1-point decrease was associated with a 540% increase in progression hazard (95% CI, 183% to 1347%), with no significant results for the heightened awareness or traditional scores. CONCLUSIONS AND RELEVANCE In this cohort study of 436 cognitively normal older adults, unawareness, rather than heightened awareness, of memory decline was strongly associated with future clinical progression, providing further support that discordant self- and informant-reported cognitive decline may provide important information to practitioners.
Collapse
Affiliation(s)
- Kayden J. Mimmack
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Geoffroy P. Gagliardi
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Gad A. Marshall
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Alzheimer Research and Treatment, Boston, Massachusetts
| | - Patrizia Vannini
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Center for Alzheimer Research and Treatment, Boston, Massachusetts
| |
Collapse
|
5
|
Zhuang K, Chen X, Cassady KE, Baker SL, Jagust WJ. Metacognition, cortical thickness, and tauopathy in aging. Neurobiol Aging 2022; 118:44-54. [PMID: 35868093 PMCID: PMC9979699 DOI: 10.1016/j.neurobiolaging.2022.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022]
Abstract
We investigated self-rating of cognitive task performance (self-appraisal) and the difference between self-rating and actual task performance (appraisal discrepancy) in cognitively healthy older adults and their relationship with cortical thickness and Alzheimer's disease (AD) biomarkers, amyloid and tau. All participants (N = 151) underwent neuropsychological testing and 1.5T structural magnetic resonance imaging. A subset (N = 66) received amyloid-PET with [11C] PiB and tau-PET with [18F] Flortaucipir. We found that worse performers had lower self-appraisal ratings, but still overestimated their performance, consistent with the Dunning-Kruger effect. Self-appraisal rating and appraisal discrepancy revealed distinct relationships with cortical thickness and AD pathology. Greater appraisal discrepancy, indicating overestimation, was related to thinning of inferior-lateral temporal, fusiform, and rostral anterior cingulate cortices. Lower self-appraisal was associated with higher entorhinal and inferior temporal tau. These results suggest that overestimation could implicate structural atrophy beyond AD pathology, while lower self-appraisal could indicate early behavioral alteration due to AD pathology, supporting the notion of subjective cognitive decline prior to objective deficits.
Collapse
Affiliation(s)
- Kailin Zhuang
- Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA, USA
| | - Xi Chen
- Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA, USA; Molecular Biophysics and Integrated Bioimaging, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
| | - Kaitlin E Cassady
- Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA, USA; Molecular Biophysics and Integrated Bioimaging, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
| | - Suzanne L Baker
- Molecular Biophysics and Integrated Bioimaging, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
| | - William J Jagust
- Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA, USA; Molecular Biophysics and Integrated Bioimaging, Lawrence Berkeley National Laboratory, Berkeley, CA, USA.
| |
Collapse
|
6
|
Cacciamani F, Godefroy V, Brambati SM, Migliaccio R, Epelbaum S, Montembeault M. Differential Patterns of Domain-Specific Cognitive Complaints and Awareness Across the Alzheimer's Disease Spectrum. Front Aging Neurosci 2022; 14:811739. [PMID: 35813963 PMCID: PMC9261482 DOI: 10.3389/fnagi.2022.811739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/29/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Characterizing self- and informant-reported cognitive complaints, as well as awareness of cognitive decline (ACD), is useful for an early diagnosis of Alzheimer's disease (AD). However, complaints and ACD related to cognitive functions other than memory are poorly studied. Furthermore, it remains unclear which source of information is the most useful to distinguish various groups on the AD spectrum. Methods: Self- and informant-reported complaints were measured with the Everyday Cognition questionnaire (ECog-Subject and ECog-StudyPartner) in four domains (memory, language, visuospatial, and executive). ACD was measured as the subject-informant discrepancy in the four ECog scores. We compared the ECog and ACD scores across cognitive domains between four groups: 71 amyloid-positive individuals with amnestic AD, 191 amnestic mild cognitive impairment (MCI), or 118 cognitively normal (CN), and 211 amyloid-negative CN controls, selected from the ADNI database. Receiver operating characteristic curves analysis was performed to evaluate the accuracy of the ECog and ACD scores in discriminating clinical groups. Results: Self- and informant-reported complaints were generally distributed as follows: memory, language, executive, and visuospatial (from the most severe to the least severe). Both groups of CN participants presented on average more memory and language complaints than their informant. MCI participants showed good agreement with their informants. AD participants presented anosognosia in all domains, but especially for the executive domain. The four ECog-StudyPartner sub-scores allowed excellent discrimination between groups in almost all classifications and performed significantly better than the other two classifiers considered. The ACD was excellent in distinguishing the participants with AD from the two groups of CN participants. The ECog-Subject was the least accurate in discriminating groups in four of the six classifications performed. Conclusion: In research, the study of complaint and anosognosia should not be reduced solely to the memory domain. In clinical practice, non-amnestic complaints could also be linked to Alzheimer's disease. The presence of an informant also seems necessary given its accuracy as a source of information.
Collapse
Affiliation(s)
- Federica Cacciamani
- ARAMISLab, Inserm, CNRS, Sorbonne Université, Inria, Paris Brain Institute (ICM), Pitié-Salpêtrière Hospital, Paris, France
- PHARes Team, Bordeaux Population Health, University of Bordeaux, Inserm, Bordeaux, France
| | - Valérie Godefroy
- FrontLab, Paris Brain Institute (ICM), Pitié-Salpêtrière Hospital, Paris, France
| | - Simona M. Brambati
- Department of Psychology, University of Montreal, Montreal, QC, Canada
- Centre de recherche de l’Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada
| | - Raffaella Migliaccio
- FrontLab, Paris Brain Institute (ICM), Pitié-Salpêtrière Hospital, Paris, France
- Institute of Memory and Alzheimer’s disease (IM2A), Pitié-Salpêtrière Hospital, Paris, France
| | - Stéphane Epelbaum
- ARAMISLab, Inserm, CNRS, Sorbonne Université, Inria, Paris Brain Institute (ICM), Pitié-Salpêtrière Hospital, Paris, France
- Institute of Memory and Alzheimer’s disease (IM2A), Pitié-Salpêtrière Hospital, Paris, France
| | - Maxime Montembeault
- Douglas Mental Health University Institute, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, QC, Canada
- Memory & Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, United States
| |
Collapse
|
7
|
Chapman S, Joyce JL, Barker MS, Sunderaraman P, Rizer S, Huey ED, Dworkin J, Gu Y, Cosentino S. Subjective Cognitive Decline Is More Accurate When Metamemory Is Better. Front Aging Neurosci 2022; 14:787552. [PMID: 35370602 PMCID: PMC8965471 DOI: 10.3389/fnagi.2022.787552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Subjective cognitive decline (SCD) has emerged as one of the first manifestations of Alzheimer's disease (AD). However, discrepancies in its relationship with tests of memory and other cognitive abilities have hindered SCD's diagnostic utility. Inter-individual heterogeneity in metamemory, or memory awareness, and the use of clinical measures of cognition lacking sensitivity to early cognitive dysfunction, may contribute to these discrepancies. We aimed to assess if the relationship between SCD and markers of early cognitive dysfunction is moderated by metamemory abilities. Methods The sample included 79 cognitively healthy older adults (77% female, 68% White, and 32% Black participants) with a mean age of 74.4 (SD = 6.1) and 15.9 (SD = 2.7) years of education. Metamemory was assessed using an episodic Feeling of Knowing test with four 5-item trials. Outcome measures included a resolution metric defined as a gamma correlation reflecting the accuracy of item-level predictions ("Will you know the correct answer?"). Early cognitive dysfunction was measured through the Loewenstein-Acevedo Scale for Semantic Interference and Learning (LASSI-L) and the Short-Term Memory Binding Test (STMB), measures sensitive to preclinical AD. SCD was assessed with a 20-item questionnaire that asked participants to compare themselves to others their age on a 7-point Likert scale. Regression analyses examined whether a potential relation between SCD and early cognitive dysfunction was moderated by metamemory. Results Subjective cognitive decline was associated with susceptibility to semantic proactive interference such that greater complaints were associated with increased susceptibility to semantic proactive interference (b = -0.30, p = 0.003) only. Metamemory moderated the association between SCD and susceptibility to and recovery of semantic proactive interference such that those with more accurate metamemory showed a stronger association between increased complaints and susceptibility to semantic proactive interference (b = -0.71, p = 0.005; b = -0.62, p = 0.034). Metamemory, however, did not moderate the association of SCD with retroactive semantic interference nor short term memory binding. Discussion The accuracy of an individual's metamemory, specifically their ability to adjust moment to moment predictions in line with their performance, can influence the extent to which SCD maps onto objective cognition. Such self-referential assessment should be considered when interpreting SCD.
Collapse
Affiliation(s)
- Silvia Chapman
- Cognitive Neuroscience Division, Columbia University Irving Medical Center, New York, NY, United States
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University Irving Medical Center, New York, NY, United States
| | - Jillian L. Joyce
- Cognitive Neuroscience Division, Columbia University Irving Medical Center, New York, NY, United States
- Gertrude H. Sergievsky Center, Columbia University Irving Medical Center, New York, NY, United States
| | - Megan S. Barker
- Cognitive Neuroscience Division, Columbia University Irving Medical Center, New York, NY, United States
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University Irving Medical Center, New York, NY, United States
| | - Preeti Sunderaraman
- Cognitive Neuroscience Division, Columbia University Irving Medical Center, New York, NY, United States
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University Irving Medical Center, New York, NY, United States
- Gertrude H. Sergievsky Center, Columbia University Irving Medical Center, New York, NY, United States
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States
- Department of Neurology, Boston University School of Medicine, Boston, MA, United States
- Brain Aging Program, Framingham Heart Study, Framingham, MA, United States
| | - Sandra Rizer
- Cognitive Neuroscience Division, Columbia University Irving Medical Center, New York, NY, United States
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University Irving Medical Center, New York, NY, United States
| | - Edward D. Huey
- Cognitive Neuroscience Division, Columbia University Irving Medical Center, New York, NY, United States
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University Irving Medical Center, New York, NY, United States
- Gertrude H. Sergievsky Center, Columbia University Irving Medical Center, New York, NY, United States
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, United States
| | - Jordan Dworkin
- Cognitive Neuroscience Division, Columbia University Irving Medical Center, New York, NY, United States
- Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, United States
| | - Yian Gu
- Cognitive Neuroscience Division, Columbia University Irving Medical Center, New York, NY, United States
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University Irving Medical Center, New York, NY, United States
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States
| | - Stephanie Cosentino
- Cognitive Neuroscience Division, Columbia University Irving Medical Center, New York, NY, United States
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University Irving Medical Center, New York, NY, United States
- Gertrude H. Sergievsky Center, Columbia University Irving Medical Center, New York, NY, United States
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, United States
| |
Collapse
|
8
|
Gagliardi G, Vannini P. Episodic Memory Impairment Mediates the Loss of Awareness in Mild Cognitive Impairment. Front Aging Neurosci 2022; 13:802501. [PMID: 35126092 PMCID: PMC8814670 DOI: 10.3389/fnagi.2021.802501] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/30/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Loss of awareness is a common symptom in Alzheimer's Disease (AD) and responsible for a significant loss of functional abilities. The mechanisms underlying loss of awareness in AD is unknown, although previous findings have implicated dysfunction of primary executive functioning (EF) or episodic memory (EM) to be the cause. Therefore, our main study objective was to explore the involvement of EF and EM dysfunction in amyloid-related loss of awareness across the clinical spectrum of AD. METHODS A total of 895 participants (362 clinically normal [CN], 422 people with mild cognitive impairment [MCI] and 111 with dementia) from the Alzheimer's Disease Neuroimaging Initiative were used for the analyses. A sub-analysis was performed in 202 participants who progressed in their clinical diagnosis from CN to MCI or MCI to dementia as well as dementia patients. Mediation models were used in each clinical group with awareness (assessed with the Everyday Cognitive function questionnaire) as a dependent variable to determine whether EF and/or EM would mediate the effect of amyloid on awareness. We also ran these analyses with subjective and informant complaints as dependent variables. Direct correlations between all variables were also performed. RESULTS We found evidence for a decline in awareness across the groups, with increased awareness observed in the CN group and decreased awareness observed in the MCI and dementia groups. Our results showed that EM, and not EF, partially mediated the relationship between amyloid and awareness such that greater amyloid and lower EM performance was associated with lower awareness. When analyzing each group separately, this finding was only observed in the MCI group and in the group containing progressors and dementia patients. When repeating the analyses for subjective and informant complaints separately, the results were replicated only for the informant's complaints. DISCUSSION Our results demonstrate that decline in EM and, to a lesser degree, EF, mediate the effect of amyloid on awareness. In line with previous studies demonstrating the development of anosognosia in the prodromal stage, our findings suggest that decreased awareness is the result of an inability for the participant to update his/her insight into his/her cognitive performance (i.e., demonstrating a petrified self).
Collapse
Affiliation(s)
- Geoffroy Gagliardi
- Neurology, Brigham and Women's Hospital, Boston, MA, United States
- Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Cambridge, MA, United States
| | - Patrizia Vannini
- Neurology, Brigham and Women's Hospital, Boston, MA, United States
- Neurology, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Cambridge, MA, United States
| |
Collapse
|
9
|
Cacciamani F, Houot M, Gagliardi G, Dubois B, Sikkes S, Sánchez-Benavides G, Denicolò E, Molinuevo JL, Vannini P, Epelbaum S. Awareness of Cognitive Decline in Patients With Alzheimer's Disease: A Systematic Review and Meta-Analysis. Front Aging Neurosci 2021; 13:697234. [PMID: 34413767 PMCID: PMC8370471 DOI: 10.3389/fnagi.2021.697234] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Identifying a poor degree of awareness of cognitive decline (ACD) could represent an early indicator of Alzheimer's disease (AD). Objectives: (1) to understand whether there is evidence of poor ACD in the pre-dementia stages of AD; (2) to summarize the main findings obtained investigating ACD in AD; (3) to propose a conceptual framework. Data Sources: We searched Scopus, Pubmed, and the reference lists for studies published up to August 2020. Original research articles must report a measure of ACD and included individuals with AD dementia, or prodromal AD (or MCI), or being at risk for AD. Data Synthesis: All studies covering preclinical, prodromal, and AD dementia were systematically reviewed. We intended to perform a meta-analysis of empirical studies on preclinical AD or prodromal AD (or MCI), to compare ACD between clinical groups. Due to the paucity of literature on preclinical AD, meta-analysis was only possible for prodromal AD (or MCI) studies. Results: We systematically reviewed 283 articles, and conducted a meta-analysis of 18 articles on prodromal AD (or MCI), showing that ACD was not significantly different between patients with amnestic and non-amnestic MCI (SMD = 0.09, p = 0.574); ACD was significantly poorer in amnestic MCI (SMD = -0.56, p = 0.001) and mild AD (SMD = -1.39, p < 0.001) than in controls; ACD was also significantly poorer in mild AD than in amnestic MCI (SMD = -0.75, p < 0.001), as well as poorer than in non-amnestic MCI (SMD = -1.00, p < 0.001). We also discuss key findings on ACD in AD, such as its neural and cognitive correlates. Conclusions and Implications: We propose that patients may be complaining of their initial subtle cognitive changes, but ACD would soon start to decrease. The individual would show mild anosognosia in the MCI stage, and severe anosognosia in dementia. The evaluation of ACD (comparing self-report to cognitive scores or to informant-report) could be useful to guide the clinician toward a timely diagnosis, and in trials targeting early-stage AD.
Collapse
Affiliation(s)
- Federica Cacciamani
- Institut du Cerveau, ICM, Hôpital de la Pitié-Salpêtrière, Paris, France
- Inserm, U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
- Sorbonne Université, Paris, France
- Inria, ARAMIS-Project Team, Paris, France
| | - Marion Houot
- Institut du Cerveau, ICM, Hôpital de la Pitié-Salpêtrière, Paris, France
- Sorbonne Université, Paris, France
- Institute of Memory and Alzheimer's Disease (IM2A), Centre of Excellence of Neurodegenerative Disease (CoEN), ICM, CIC Neurosciences, AP-HP, Department of Neurology, Hôpital de la Pitié-Salpêtrière, Sorbonne University, Paris, France
| | - Geoffroy Gagliardi
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Neurology, Center for Alzheimer Research and Treatment, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Bruno Dubois
- Institut du Cerveau, ICM, Hôpital de la Pitié-Salpêtrière, Paris, France
- Inserm, U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
- Sorbonne Université, Paris, France
- Institute of Memory and Alzheimer's Disease (IM2A), Centre of Excellence of Neurodegenerative Disease (CoEN), ICM, CIC Neurosciences, AP-HP, Department of Neurology, Hôpital de la Pitié-Salpêtrière, Sorbonne University, Paris, France
| | - Sietske Sikkes
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Neurology, Alzheimer Center Amsterdam, Amsterdam Neuroscience, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Gonzalo Sánchez-Benavides
- BarcelonaBeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
- Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Fragilidad y Envejecimiento Saludable (CIBERFES), Madrid, Spain
| | - Elena Denicolò
- Department of Biomedical Science and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - José Luis Molinuevo
- BarcelonaBeta Brain Research Center (BBRC), Pasqual Maragall Foundation, Barcelona, Spain
| | - Patrizia Vannini
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Neurology, Center for Alzheimer Research and Treatment, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Stéphane Epelbaum
- Institut du Cerveau, ICM, Hôpital de la Pitié-Salpêtrière, Paris, France
- Inserm, U 1127, Paris, France
- CNRS, UMR 7225, Paris, France
- Sorbonne Université, Paris, France
- Inria, ARAMIS-Project Team, Paris, France
- Institute of Memory and Alzheimer's Disease (IM2A), Centre of Excellence of Neurodegenerative Disease (CoEN), ICM, CIC Neurosciences, AP-HP, Department of Neurology, Hôpital de la Pitié-Salpêtrière, Sorbonne University, Paris, France
| |
Collapse
|
10
|
Gagliardi G, Kuppe M, Lois C, Hanseeuw B, Vannini P. Pathological correlates of impaired self-awareness of memory function in Alzheimer's disease. Alzheimers Res Ther 2021; 13:118. [PMID: 34172086 PMCID: PMC8234669 DOI: 10.1186/s13195-021-00856-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/02/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Impaired self-awareness of memory function, a.k.a. anosognosia, is a common symptom in Alzheimer's disease (AD); however, its pathological correlates remain unclear. Here, we investigated the impact of amyloid and tau on memory self-awareness. METHODS Two hundred thirty-six clinically normal (N) and 102 impaired (I) participants from the ADNI cohort were included. Amyloid (global) and tau burden (in entorhinal and inferior temporal cortices) were assessed using positron emission tomography (PET). Self-awareness of memory was assessed using discrepancy indexes of subjective participant-informant ratings, as well as participant-objective scores of memory performance. Subjective and objective values were derived from the Everyday Cognition memory questionnaire and Logical Memory (delayed recall). RESULTS Lower awareness (both methods) of memory function was associated with higher levels of pathology in the I group as compared to N. There was a significant effect of tauopathy, but not amyloidosis, on individual complaint, such that higher levels of tau associated with lower awareness. DISCUSSION Impaired self-awareness appears progressively in the evolution of the disease related to AD biomarkers. Discordant subjective and objective measures may be important for clinical consideration.
Collapse
Affiliation(s)
- Geoffroy Gagliardi
- Brigham and Women’s Hospital, Boston, MA USA
- Massachusetts General Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | | | - Cristina Lois
- Massachusetts General Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | - Bernard Hanseeuw
- Massachusetts General Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | - Patrizia Vannini
- Brigham and Women’s Hospital, Boston, MA USA
- Massachusetts General Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | | |
Collapse
|
11
|
A machine learning approach to screen for preclinical Alzheimer's disease. Neurobiol Aging 2021; 105:205-216. [PMID: 34102381 DOI: 10.1016/j.neurobiolaging.2021.04.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/06/2021] [Accepted: 04/23/2021] [Indexed: 11/22/2022]
Abstract
Combining multimodal biomarkers could help in the early diagnosis of Alzheimer's disease (AD). We included 304 cognitively normal individuals from the INSIGHT-preAD cohort. Amyloid and neurodegeneration were assessed on 18F-florbetapir and 18F-fluorodeoxyglucose PET, respectively. We used a nested cross-validation approach with non-invasive features (electroencephalography [EEG], APOE4 genotype, demographic, neuropsychological and MRI data) to predict: 1/ amyloid status; 2/ neurodegeneration status; 3/ decline to prodromal AD at 5-year follow-up. Importantly, EEG was most strongly predictive of neurodegeneration, even when reducing the number of channels from 224 down to 4, as 4-channel EEG best predicted neurodegeneration (negative predictive value [NPV] = 82%, positive predictive value [PPV] = 38%, 77% specificity, 45% sensitivity). The combination of demographic, neuropsychological data, APOE4 and hippocampal volumetry most strongly predicted amyloid (80% NPV, 41% PPV, 70% specificity, 58% sensitivity) and most strongly predicted decline to prodromal AD at 5 years (97% NPV, 14% PPV, 83% specificity, 50% sensitivity). Thus, machine learning can help to screen patients at high risk of preclinical AD using non-invasive and affordable biomarkers.
Collapse
|
12
|
Vannini P, Hanseeuw BJ, Gatchel JR, Sikkes SAM, Alzate D, Zuluaga Y, Moreno S, Mendez L, Baena A, Ospina-Lopera P, Tirado V, Henao E, Acosta-Baena N, Giraldo M, Lopera F, Quiroz YT. Trajectory of Unawareness of Memory Decline in Individuals With Autosomal Dominant Alzheimer Disease. JAMA Netw Open 2020; 3:e2027472. [PMID: 33263761 PMCID: PMC7711319 DOI: 10.1001/jamanetworkopen.2020.27472] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Recent studies have suggested that unawareness, or anosognosia, of memory decline is present in predementia stages of Alzheimer disease (AD) and may serve as an early symptomatic indicator of AD. OBJECTIVE To investigate the evolution of anosognosia of memory decline in individuals who carry the PSEN1 E280A variant for autosomal dominant AD compared with family members who do not carry the variant. DESIGN, SETTING, AND PARTICIPANTS This cohort study investigated a total of 2379 members of a Colombian kindred with autosomal dominant AD who were part of the Alzheimer's Prevention Initiative Registry. Assessments were completed at the University of Antioquia, Colombia, with data collected between January 1, 2000, and July 31, 2019. MAIN OUTCOMES AND MEASURES Awareness of memory function was operationalized using the discrepancy between self-report and study partner report on a memory complaint scale. Linear mixed effects models were used to assess memory self-awareness over age separately in variant carriers and noncarriers. RESULTS This study included 396 variant carriers (mean [SD] age, 32.7 [11.9] years; 200 [50.5%] female), of whom 59 (14.9%) were cognitively impaired, and 1983 cognitively unimpaired noncarriers (mean [SD] age, 33.5 [12.5] years; 1129 [56.9%] female). The variant carriers demonstrated increased awareness until the mean (SD) age of 35.0 (2.0) years and had anosognosia at approximately 43 years of age, approximately 6 years before their estimated median age of dementia onset (49 years; 95% CI, 49-51 years). Cognitively unimpaired noncarriers reported more complaints than their study partners aged 20 and 60 years (10.1 points, P < .001). On the awareness index, a decrease with age (mean [SE] estimate, -0.04 [0.02] discrepant-points per years; t = -2.2; P = .03) in the noncarriers and in the variant carriers (mean [SE] estimate, -0.21 [0.04] discrepant-points per years; t = -5.1; P < .001) was observed. CONCLUSIONS AND RELEVANCE In this cohort study, increased participant complaints were observed in both groups, suggesting that increased awareness of memory function was common and nonspecific to AD in this cohort. In variant carriers, awareness of memory function decreased in the predementia stages, reaching anosognosia close to the age of mild cognitive impairment onset, providing support for the usefulness of awareness of memory decline.
Collapse
Affiliation(s)
- Patrizia Vannini
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
| | - Bernard J. Hanseeuw
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Radiology, Harvard Medical School, Boston, Massachusetts
- Neurology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
- Institute of Neuroscience, Université Catholique de Louvain, Brussels, Belgium
| | - Jennifer R. Gatchel
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, McLean Hospital, Belmont, Massachusetts
| | - Sietske A. M. Sikkes
- Amsterdam University Medical Centers, Alzheimer Center Amsterdam, Amsterdam, the Netherlands
| | - Diana Alzate
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Yesica Zuluaga
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Sonia Moreno
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Luis Mendez
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Ana Baena
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Paula Ospina-Lopera
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Victoria Tirado
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Eliana Henao
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
- Department of Radiology, Hospital Pablo Tobón, Uribe, Medellin, Colombia
| | - Natalia Acosta-Baena
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Margarita Giraldo
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Francisco Lopera
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| | - Yakeel T. Quiroz
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, Massachusetts
- Department of Neurology, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Grupo de Neurociencias de Antioquia, School of Medicine, Universidad de Antioquia, Medellin, Colombia
| |
Collapse
|