News for Professionals Archives
Ask the BCAT Faculty: Age Requirement for the Self-Assessment of Cognition
From the Provider:
“I am an internist with a largely geriatric practice. We have started using the SAC in our practice. We have been asking patients or their adult children to complete the SAC before their next medical appointment if the patient is taking a memory enhancer or if there is a memory complaint. Sometimes it is completed in the waiting room, sometimes at home. Surprisingly, we have found that many of the adult children not only complete the SAC with their parents in mind, but also for themselves. I suppose we all worry about our memory. Because we have younger people taking it too, is there a minimal age limit for the SAC?”
Bob, Orlando, FL
BCAT Faculty Response:
Thank you for your email question. Since we have made the Self-Assessment of Cognition (SAC) scale available for free on the BCAT website, a number of people have emailed questions about how best to use this screening tool. Just to be clear, the SAC is a self-assessment instrument that can be completed by either the patient or a knowledgeable informant, such as a family member, personal care worker, facility or agency staff, or friend. The SAC is a screening tool, designed to identify those who likely have a memory or cognitive problem. It should not be used as a stand-alone diagnostic test. It is effective in indicating who should be administered the BCAT or BCAT-SF. It can also identify who might benefit from validated cognitive exercises. The SAC is an ideal tool for a community healthcare practice because it can help the professional recognize who should receive a formal cognitive evaluation, and can be easily integrated into the Annual Wellness Visit. The SAC was designed for people who are age 50 and above. This does not mean that it could not detect cognitive impairment in someone younger than 50, but that it was validated for persons of 50 and older. Therefore, we recommend it for this age group.
Ask the BCAT Faculty: Are Psychotic Symptoms Common in FTD?
Question from the Provider:
I understand that frontotemporal dementia (FTD) affects the frontal and temporal lobes. In our rehab center, we have recently treated a number of patients who have been diagnosed with FTD. Many of them have also been paranoid. Is psychosis in general and paranoia in particular common in FTD patients? I was taught that psychosis was uncommon in FTD.
BCAT Faculty Response:
Thank you for your question! FTD is a clinical neurodegenerative disorder that primarily affects the frontal and/or temporal lobes. It is best thought of as a spectrum disorder or umbrella category, which covers a number of different variants of similar types of dementia. FTD is more common among younger patients than what one typically finds in Alzheimer's disease. Your question about whether psychosis is common is a very good one. Previous studies have indicated that psychotic symptoms are relatively uncommon in FTD compared to other dementias, especially Alzheimer's. However, more recent studies suggest that psychosis is more common than originally reported. For example, Waldo and her colleagues (2015) investigated occurrence rates of psychosis in a sample of 97 FTD patients. They found that 32% of their sample presented with psychotic symptoms. Moreover, paranoid ideas were found in nearly 21% of their sample. One possible reason why earlier studies did not find higher rates of psychosis may be because FTD is so difficult to diagnose. Often patients with psychiatric disorders are later discovered to have FTD.
FTD patients often have executive control issues. Because the BCAT provides an executive control functions factor score (ECFF), it can be useful in identifying possible FTD patients. FTD patients tend to have low ECFF scores, while having relatively high contextual memory factor scores (CMF) on the BCAT.
Ask the BCAT Faculty: Are older adults with memory problems more likely to be lonely?
From the Provider:
I am a social worker who sees geriatric patients and their families. In my practice, I routinely administer the BCAT to older patients to assess cognitive functioning, and I now ask family members to complete the SAC (the cognitive self-assessment screening measure the BCAT team developed) to get their input. I have an observation I want to share with the BCAT team and ask a question. My observation is that many older adults who are cognitively impaired also seem lonely. I don’t think that they are necessarily depressed however. My question is about the relationship between memory problems and loneliness. Are older adults with memory problems more likely to be lonely?
BCAT Faculty Answer:
Thank you for your question Sarah. Of course, loneliness can be an important concern among older adults. In research, the term loneliness has been understood in two ways. There is the construct called “emotional loneliness,” which refers to the emotional state associated with an absence of attachment to a special person or loved one. This is how most people understand loneliness. There is also the term, “social loneliness,” which refers to a lack of connectedness or satisfaction with one’s social networks. I believe your comment and question is about emotional loneliness. There is a fair amount of research showing that lonely older adults are more likely than non-lonely people to report chronic stressors, experience negative thoughts, and be depressed. However, there also appears to be a correlation between cognitive impairment and loneliness, not related to depression.
Boss, Kang, & Branson (2015) published a review article in which they looked at peer-reviewed studies that investigated the relationship between cognitive impairment and emotional loneliness in older adults. What they found was a correlation between poor cognitive ability and loneliness. Cognitive impairment was associated with reports of higher loneliness. So, the more cognitive impairment, the more loneliness. This occurred whether people were depressed or not. Certainly depressed people are often more likely to report feeling lonely, but reports of loneliness in cognitively impaired adults often occur even when not depressed.
Why is there an apparent correlation between cognitive impairment and loneliness? One possible explanation is that people with significant general cognitive impairment lack the skills necessary to initiate and maintain social ties, especially the ability for conversation. Conversation is a key activity for lowering loneliness. So, not having the cognitive abilities necessary to maintain social ties, especially through conversation, can result in loneliness.
Since you administer the BCAT, take a look at the Executive Control Function Factor score (ECFF). People with executive impairment (low ECFF scores) may be more likely to feel lonely than older adults with high ECFF scores. Of course, this does not mean that all people with low ECFF scores will be lonely! Also, for reports or observations of loneliness, you might want to check for possible depression by administering the BADS (Brief Anxiety and Depression Scale).
Thank you for your question!
Ask the BCAT Faculty: Life Satisfaction in Long-term Care Residents
Question from the Provider:
My question is about life satisfaction in nursing home and assisted living residents. I am an occupational therapist, starting a new wellness program in some of our contracted facilities. Our therapists will be providing life enrichment to long-term care residents. We will be using BCAT tools (Working Memory Exercise Book, MemPics) to help improve life satisfaction and wellness. I know that the BCAT Research Center has published research findings showing high rates of depression in these residents. Do you also have information about levels of life satisfaction?
BCAT Faculty Answer:
Thank you for your question, Stephanie. We have some data regarding life satisfaction in nursing home and assisted living residents. While we were validating the MemPics program, we asked our sample of residents with relatively mild dementia how satisfied they were with their lives. What did we find? Approximately 68% of the sample reported being satisfied with their lives overall (combines mildly satisfied, satisfied, and extremely satisfied), 29% reported being dissatisfied (combines mildly dissatisfied, dissatisfied, and extremely dissatisfied), and 3% felt neutral (neither satisfied nor dissatisfied).
There are not a lot of data about life satisfaction in nursing home and assisted living residents reported in the literature. Our findings suggest that about one-third report feeling neutral or dissatisfied with their current lives. Interestingly, these rates are similar to depression rates. However, this does not mean that all residents who report low life satisfaction are also depressed. You might also want to know that life satisfaction was not correlated with reports of meaningful engagement using MemPics. In other words, the ability to engage meaningfully in MemPics was not dependent on one’s life satisfaction. We hope this response was helpful and good luck with your new program!
Ask the BCAT Faculty: Cognition and Medical Decision Making
Question from the Provider:
I recently attended a conference in California on Elder Abuse, particularly regarding persons with dementia. A case was presented about whether an older nursing home resident on a ventilator had enough capacity to decide to refuse life-sustaining treatment. She recently had a serious stroke, was able to minimally talk, was confused, and wanted to go off the ventilator and die. She had no guardian or legal surrogate decision maker. We had a lively discussion about this case with different opinions expressed about her capacity to go off the ventilator. The presenter used the BCAT to determine that the resident had severe cognitive impairment, and was not a competent decision maker. I know that you can’t really comment on this case because you don’t know the patient, but can you briefly talk about how one should evaluate a person’s capacity to make health care decisions?
BCAT Faculty Answer:
Thank you for your question! I can address it in general terms by talking about best practices involving aspects of the decisional capacity evaluation process, specific to cognitive impairment (as opposed to other psychiatric impairments). However, this is a big topic, and I can only address it in a narrow manner in this response. Each U.S. State has specific regulations and laws concerning informed consent and competency, and they should be followed. However, there are a few basic clinical concepts that are an important part of capacity evaluations. I am making a distinction between legal competence (determined by the legal system) and decisional capacity (determined by a clinician), and focusing on clinical capacity. Keep in mind that “best practice” capacity evaluations are not the same thing as “standard practice.” Unfortunately, there is little applied consistency in how evaluators determine decisional capacity. That being said, there is general agreement that evaluations of decisional capacity to consent to treatment (or refuse treatment) in persons with suspected cognitive impairment should include four functional elements. These are:
- Expressing a choice. Can the person communicate a choice adequately?
- Understanding. Does the patient comprehend diagnostic and treatment-related information?
- Appreciation. Can the patient relate treatment information to herself? Understanding treatment-related information is necessary, but not sufficient. The patient must also recognize that it applies to her.
- Reasoning. Does the patient think rationally and does she logically process information?
If the answer to any of these questions is “no”, then the patient may well not possess sufficient capacity for the specific situation being evaluated. The BCAT can be used to help the clinician address these issues. It can make a unique contribution because of its ability to stage cognitive impairment and identify memory and executive deficits. However, an adequate evaluation should also include careful interviews with the patient and other key informants.
I hope you found this helpful. Thank you for your question!
Your National Online MemPics® Survey Results
A couple of months ago, we asked you to complete an online survey about the impact of meaningful activities on the health and well-being for persons with dementia. The survey was a component of a much larger project investigating the efficacy of MemPics® as a tool for increasing meaningful engagement. Last month, we shared with you the empirical findings supporting MemPics® as a superior program, not only for improving meaningful engagement in persons with dementia, but in enhancing the relationships of caregivers with those for whom they provide care. Both persons with dementia and their caregivers reported that MemPics® created opportunities to meaningfully “remember and relate.”
In the national online survey, we were interested in your opinions about the concept of meaningful engagement and MemPics® as a tool for creating meaningful activities for persons with dementia and their caregivers. We received responses from a diverse group of professionals – rehab therapists, social workers, nurses, recreation therapists, other healthcare professionals, and facility managers from 30 states plus the District of Columbia. The average age of survey respondents was 47 (age range was 24-60). The average years working in geriatrics was 18. Here is what you said:
Regarding the concept of meaningful engagement:
- 98% endorsed the idea that meaningful activities improve the nursing home environment, while 97% reported that they improve the assisted living environment
- 97% recommended that persons with dementia engage in meaningful activities at least once a day
- 98% endorsed the idea that meaningful activities positively impact life-quality for persons with dementia, while 97% reported that they improve well-being
- 93% thought that offering meaningful activities reduce agitation in persons with dementia
- 92% thought that meaningful activities improve mood functioning in persons with dementia
- 87% reported that engagement in meaningful activities reduces the need to use antipsychotics in persons with dementia
Regarding the use of MemPics® specifically:
- 92% of respondents reported wanting to learn more about the MemPics® program for persons with dementia and their caregivers
- 90% agreed with the statement, “I would find MemPics® useful within my scope of practice”
- 89% reported that their patients would enjoy MemPics®
- 84% reported that they would recommend MemPics® to their patients or residents (whether they had dementia or not)
The online survey results are consistent with other research findings regarding meaningful engagement and MemPics®. Both persons with dementia and their caregivers think that it is important to have meaningful activities daily, and that MemPics® is effective in creating such opportunities. One of the challenges for persons with dementia is that their cognitive impairments often make it difficult to find or create meaningful activities. Therefore, it is very important that caregivers and residential communities create meaningful activities for persons with dementia.
Ask the BCAT Faculty: How often do People with MCI Convert to Dementia?
Question from the field:
I am a speech therapist who works in nursing homes. The majority of my patients have mild dementia or MCI. I realize that one of the strengths of the BCAT is that it is very sensitive to MCI and can subtype MCI. We always tell families that if the patient has MCI, they should be prepared for possible dementia over the next several years. But it is unclear how often people convert from MCI to dementia. Different studies report different findings. Can you help clarify?
BCAT Faculty Response:
Good question Stacey! In our view, mild cognitive impairment (MCI) is indeed an important risk factor for dementia. Studies do vary in reporting conversion rates, and generally, most experts believe that the annual conversion rate from MCI to dementia is somewhere around 10% per year. This means that 10% of individuals with MCI will progress to dementia in a given year. To put this into context, approximately 2% of people with no signs of MCI convert to dementia per year. This means that if a person has MCI, she is five times more likely to convert.
Research studies that have investigated MCI-to-dementia conversion rates are often challenged by a number of important issues that can influence their results. Measuring MCI in the real world and tracking conversion to dementia is complicated. First, many researchers have used cognitive screening tools that are not very accurate in identifying MCI. One result can be an underestimate of true conversion rates. Also, the age of people with MCI is an important factor. For example, if an 85-year-old person is diagnosed with MCI and is in poor health, she may die from a medical disorder before she converts to dementia. Finally, the majority of people who have MCI are not diagnosed, limiting our understanding of MCI-to-dementia conversion rates.
We think it is a good idea to tell people with MCI (and their families) that progression to dementia is very possible. Because cognitive rehabilitation and specific working memory exercises may be most effective in improving cognition and delaying dementia when started early, informing MCI patients of their conditions can be critically important to life quality and independence. This is one reason why we advocate for using tools like the BCAT, which has a strong sensitivity for detecting MCI.
The Rising Global Tide of Dementia
This summer, the Alzheimer’s Association International Conference (AAIC) was held in Washington, DC. One of the take-away themes from this annual conference was that dementia incidence rates will steeply increase over the next few decades, not just in the U.S., but globally. Details of the expected rates of dementia can also be found in the recently published, World Alzheimer Report 2015. In this compendium, specific facts, figures, and prevalence estimates about Alzheimer’s disease and related dementias are presented. Based on current trends, it is clear that the number of people expected to have dementia will far exceed healthcare infrastructures. This is especially likely for low and middle income countries, who will likely experience a widening gap between the number of people with dementia and resources (medical and economic) necessary to care for them. Here are some facts and estimates that are particularly alarming:
- Around the word there will be 9.9 million new cases of dementia in 2015. This is about one every three seconds.
- In 2015, nearly 47 million people will be living with dementia. This number will almost double every 20 years through 2050. We can expect over 131 million people worldwide to be living with dementia by 2050.
- In 2015, 58% of all people with dementia will live in low and middle income countries. This percentage should be 68% by 2050.
- For 2015, the total estimated worldwide cost of dementia is $818 billion. By 2030, it will be $2 trillion.
- If the cost of global dementia care were the GDP of an actual country, it would be the 18th largest economy in the world.
- Which of the following four regions has the largest number of people living with dementia in 2015 - the Americas, Europe, Africa, or Asia? (Asia has nearly 23 million, Europe 10.5 million, the Americas (north and south) have 9.4 million, and Africa has 4 million.
It is clear that efforts to manage dementia care should be global, well-coordinated, and well-funded.
This summer at AAIC, the BCAT Research Center presented the findings from three research projects. They pertained to the efficacy of the BCAT Brain Rehabilitation program, a comparison of the cognitive functioning levels of subacute rehab patients and long-term care residents, and an analysis of BCAT training across healthcare disciplines. To read the abstracts, and download the posters, visit the BCAT Research Center page.
Mid-Life Risk Factors for Alzheimer's Disease
During a recent BCAT training program, the instructor was asked why some people with Alzheimer’s disease (AD) have relatively few plaques and tangles and others have many. Generally speaking, the amyloid plaques and neurofibrillary tangles are considered the primary causes of AD, so the question raised during the training program was a very good one. In our view, understanding the causal factors of AD is complex, and just focusing on tangles and plaques is too simplistic. We emphasize the importance of identifying risk factors for AD that may or may not contribute to the production of plaques and tangles, but may cause AD and related dementias. Moreover, lifestyle and specific health factors during the mid-life years may be critical in determining whether ones develops AD or other dementias.
Two review-based studies provide some insights. In their review of the literature, Barnes and Yaffe (2011) identified seven largely modifiable risk factors for AD. They were physical inactivity, obesity, smoking, low education, depression, diabetes, and hypertension. The researchers estimate that up to half of AD cases worldwide (17 million) and in the US (nearly 3 million) are potentially attributable to these factors. Furthermore, a 10–25% reduction in all of these risk factors could potentially prevent between 1-3 million AD cases worldwide and 184,000–492,000 cases in the US. Similarly, based on a meta-analysis, Jin-Tai Yu and colleagues (2015) identified nine risk factors that might explain up to 67% of AD cases. These were obesity, carotid artery narrowing, low educational achievement, hyperhomocysteine (a type of amino acid), depression, hypertension, frailty, current smoking, and type 2 diabetes (Asian-background populations).
Many of the risk factors identified in these studies are closely correlated. To make it simple, we suggest that people in their middle years embrace six healthy lifestyle behaviors, and that they be integrated into daily living. These are: physical exercise, no smoking, treat depression if and when it occurs, keep blood pressure within normal ranges, keep weight at healthy levels, and add cognitive challenges to your daily routine (use evidence-based cognitive exercise). One easy way to remember to practice these brain-healthy behaviors is to use this acronym:
A – Add cognitive stimulation
N – No smoking
T – Treat depression
H – Healthy weight
E – Exercise
M – Manage hypertension
The good news is that these behaviors are largely within your control! So, while you cannot prevent AD with any certainty, you can choose a lifestyle that reduces your risk of AD and related dementias.
I Still Remember How to Ride A Bicycle
During a recent BCAT training program in Georgia, an occupational therapist asked a question about relearning and maintaining specific instrumental activities of daily living (IADL) skills. She wanted to know if patients with dementia can learn basic skills that have motor sequencing components, like brushing teeth and simple cooking steps. The general answer is a qualified “yes.”
I was reminded of a study by Kawai and colleagues who investigated the long-term abilities of people with dementia to learn and maintain procedural memories. Procedural memory refers to the memory of “how to do things.” It tends to involve activities that can be performed without a lot of thinking, that are more or less done unconsciously. Procedural memory is created through repeating an activity over and over again so it can be performed automatically. Examples include brushing our teeth, singing a familiar song, walking, talking, writing our signature, and riding a bike. They are well-rehearsed, behavioral routines. Kawai found that people with probable Alzheimer’s dementia could learn and maintain motor-type procedural memories for long periods of time.
Our experience at the BCAT Research Center also supports this finding, as rehabilitation therapists reported that patients with BCAT scores below 25 (which indicate moderate dementia) were been able to learn motor-related IADLs. The effectiveness of learning was improved when therapists had patients do both cognitive sequencing exercises (from the BCAT Working Memory Exercise Book) in addition to repetition of actual motor sequences of the IADL. For example, in the BCAT Working Memory Exercise Book, there is an exercise called Arrange the Pictures, which focuses on sequencing IADL tasks. In this exercise, patients are presented with a series of pictures in which the sequence of an IADL is incorrect (e.g., Self-Management of Medications: Taking Medication, Getting a Prescription, Preparing Medication). The patient is asked to arrange the pictures in the correct order (e.g., Getting a Prescription, Preparing Medication, Taking Medication.) Success appears to be enhanced when therapists pair this cognitive processing exercise (the patient arranges the pictures in the correct order) with repeated practicing of actual motor sequences of the IADL (having the patient physically do at least a part of the sequence).
The good news is that people with dementia can often learn IADL tasks. This is enhanced when there is both a cognitive exercise (such as working memory exercises) that is combined with motor-task repetitions that tap into procedural memories (old and automatic behaviors).
Generalized Anxiety Disorder in Late-Life: Overlooked and Under-Recognized
Let’s start this post with a question. Which of the following disorders is most common among community-dwelling older adults?
If you answered “c”, you were correct. The clinical research tells an interesting story. While dementia, particularly Alzheimer’s disease, and depression receive the most attention, anxiety disorders are more prevalent. Moreover, among the five principal anxiety disorders, generalized anxiety disorder (GAD) is by far the most common. Estimates of anxiety disorders among community-dwelling older adults range from 10-20%. In comparison, rates of depression range between 5-15%, while rates of dementia range from 8-14%. In long-term care settings, occurrence rates increase for all three disorders, and especially for dementia. Studies conducted by the BCAT Research Center generally confirm occurrence rates reported by other researchers. In nursing homes and assisted-living communities, dementia is the most common of the three disorders (approximately 60%), followed by depression and anxiety (both approximately 30%). Among the mood disorders, depression has received far more clinical, policy, and media attention than anxiety, despite the fact that it is not more common than anxiety disorders. Quite simply stated, GAD is overlooked and under-diagnosed. There are at least three reasons for this: (1) the historical bias that anxiety disorders primarily affect younger people (especially children and adolescents); (2) accurate and accessible screening instruments have been lacking; and (3) anxiety is often missed when it is expressed in somatic terms (complaints about pain and other medical ailments). For example, fatigue, headaches, insomnia, irritability, and muscle pain can be common physical expressions of GAD.
So what exactly is GAD? While symptoms vary, the most common indication is a persistent worry or obsession about a small or large concern that is out of proportion to the impact of the event. Among older adults, a common trigger is “fear of falling” (typically following an actual fall), although almost any event can be a trigger. Because GAD is a common, often debilitating condition among older adults and is highly treatable, identification is critical. Therefore, in community and long-term care practice, it is important to ask patients questions about anxiety. One effective method for detecting GAD, is to administer the Brief Anxiety and Depression Scale (BADS). The BADS was designed for any clinician and health care setting, and can be administered in three minutes or less. It can be completed by the patient or her family/proxy. For more information about the BADS, see the BCAT Test System page or for more information about the research, please visit this link. .
The Take-Away: GAD is common among older adults, typically responds well to treatment (especially cognitive-behavioral therapy), and is under-diagnosed. In order to effectively treat GAD, we have to first identify it!
Please forward this post to other people who may be interested in this topic.
Follow us on Twitter: @The_BCAT
Ask the BCAT Faculty: Prescription Abuse among Older Adults
Question from the Field:
I have a question about older adults and prescription abuse. I just read an article about the high rates of prescription drugs abused in the general population. I would think that the rates are likely high among older adults too. Does the BCAT Research Center have information about this? I’m a speech therapist and many of my patients are taking addictive drugs that they were prescribed. Some have been taking them for years. Thank you!
BCAT Faculty Response:
Thank you for your question Jen. It is a good one, and timely. Prescription drug abuse is the use of prescribed medication in a way not intended by the prescribing doctor or clinician. While older adults make up about 14% of the general U.S. population (about 45 million people), they consume approximately 25% of all prescribed medications. Some studies suggest that the prevalence of abuse of these drugs by older people is as high as 11%. The most commonly abused prescribed medications are the opiates (pain medications) and sedative/hypnotics (mostly benzodiazepines). However, rates of alcohol dependence as well as abuse of over-the-counter drugs are also high. Interaction effects between alcohol and prescription (or over-the-counter) drugs can also be a problem.
Why do we have this growing problem of prescription abuse among older adults? There are a number of reasons, but here are some key ones to consider. First, in the United States and in many other countries, older adults are proportionately the fastest growing cohort group. Therefore, trends are magnified. So, if the estimated rate of prescription drug abuse is 11%, and if we have 45 million older adults in the U.S., then approximately 4.8 million older adults may be abusing prescription medications today. It is estimated that by the year 2040, the number of older adults will increase by 50%. Assuming no other changes, this could mean that over 7 million older adults could be abusing prescription drugs. Second, older adults often have medical conditions that are associated with pain. As a result, healthcare prescribers are more likely to prescribe “pain meds”; unfortunately, these can contribute to abuse, as they tend to be addictive, especially the opiates. Opiates remain the mainstay of pain management among older patients. Third, not all misuse of medication is intentional. Older adults living in the community who have significant cognitive problems tend to (mis)manage their medications, often with poor oversight by spousal caregivers who may also have cognitive deficits. Doctors are not always effective at identifying these at-risk older adults. Finally, in the United States, we live in a “medications first” culture. It is far easier to prescribe a medication than to carefully recommend and take responsibility for non-pharmacologic interventions (like exercise, diet, cognitive stimulation, social support). Of course for older adults, this is compounded by a fragmented medical system in which patients often see multiple doctors for multiple conditions, often with poor medical coordination.
There are remedies for this situation, however. Adequately educating patients about prescribed medications would go a long way to reducing abuse. This would include carefully talking about not just the benefits, but the possible risks. Ensuring that patients understand the presented information is key. Stressing to prescribers the importance of patient education, and taking the time to assess the cognitive skills of both patient and caregiver is crucial. Doctors, particularly specialists, need to accurately know all medications (including over-the-counter ones) prescribed by all other providers.
Ask the BCAT Faculty: Older Adults and Mild Traumatic Brain Injury (or Concussion)
Question from the Field:
In my work as a PT, I have treated many patients who have had falls that have caused bone fractures. Often, they have also hit their heads. During their hospital visits, if there was no indication of a brain bleed, they were discharged to subacute rehab for recovery from bone fractures, with little attention to possible traumatic brain injury (TBI). I have noticed that these patients seem slow to process information. Of course, it is hard to tell if this processing delay is their baseline functioning, or the result of TBI. Can you comment on the impact of possible concussions on post-acute rehab?
BCAT Faculty Response:
The Importance of Social Support to Our General Health
Human beings of any age normally look to family, friends, and community resources for support. As the saying goes, No man or woman is an island. Support can be expressed in many ways, but typically takes the form of emotional, financial, or educational help. The circle of people who give us support is collectively referred to as a “social network.” When people withdraw from their social networks, we often assume that they are depressed and refer to them as “self-isolating.” There is quite a bit of evidence that social support is important for our psychological health, but does it buffer against declines in our general health? In other words, are people who have inadequate social networks more likely to get sick and possibly die than those with adequate social support? If so, then older adults may be more vulnerable than younger people because they are more likely to experience losses of important people in their social networks due to illness and death.
So, what do we know about the relationship between social support and general health? Two studies provide some insights – one published some time ago and one published fairly recently. Drs. Heller and Mansbach confirmed that as we get older, the size of our social networks gets smaller, as does the collective amount of emotional support we receive from our social network. However, they found that one of the most important predictors of life satisfaction was not the size of the social network, but its quality. Specifically, higher life satisfaction was associated with having at least one “intimate” or important person to talk to and to get emotional support from. Moreover, the absence of such a person in an older adult’s life negatively impacted mood.
In a broader study, Dr. Ann Marie White and her colleagues investigated whether US community-dwelling older adults who reported low social support also reported poorer general health status. Their study was based on over 3,400 adults aged 60 and older. What did they find? First, the perception of having adequate emotional support was associated with better self-reported health status. Conversely, perceived low social support was a predictor of poorer health. Second, this finding pertained to both men and women. Interestingly, they also found that the presence or absence of a spouse was not a strong predictor of health status as long as one received support from others. Also, older persons who only obtained support from family networks were more apt to report poorer health than were other older persons with broader social networks (including friends in the social networks).
Here are some key “take-away” points:
- If you are an older adult, take care of your social network. Having a confidante or intimate matters to your health.
- If you are a healthcare professional or interested party, ask questions about an older person’s social network so you can identify whether the person is at risk for health problems.
- The size of the social network is less important than the presence of at least one person who is a confidante.
- Each person has unique social support needs. Research suggests that whether a social network is adequate depends mostly on the person’s satisfaction with it.
- Because social networks tend to get smaller as we age, joining organizations where members have shared experiences and values can provide opportunities for improving social support.
Ask the BCAT Faculty: Cognitive Set Shifting on the BCAT
Question from the Field:
I am an occupational therapist working in both a nursing home and home care. I've been using the BCAT for three years with all my patients who are fifty or older. One of my favorite items is the set-shifting item. I've found it to be very helpful in identifying a lot of functional problems, especially problems with patients self-managing their medications. Are there BCAT studies that have looked at the set-shifting item as a predictor of problems like self-management of medications?
BCAT Faculty Response:
Thank you for your question Meredith. The BCAT set-shifting item is an important part of the Executive Control Functions Factor, what we call the ECFF. When you enter BCAT scores in the online program, one of the scores you get is the ECFF. Previous research has indeed shown that the ECFF predicts functional status, especially IADLs. So, you should see a connection between the set-shifting item and medication management skills.
The set-shifting item was developed through a number of years of research. For those of you who may not be familiar with set-shifting, it is an executive skill that involves switching attention from one task to another. Set-shifting is associated with cognitive flexibility and problem-solving. It has been shown to be predictive of performance on a number of tasks of daily living. During the development of the BCAT, we looked at both written and oral (verbal) versions of the set-shifting item. We wanted to emphasize an oral approach because so many older adults have visual and graphomotor (handwriting) problems. These can make written set-shifting items difficult for other reasons, and could bias the test results. We discuss this issue in one of the early BCAT studies.
One way to understand the connection between our set-shifting item and medication management is through basic neurophysiology. The pre-frontal cortex of the brain, which is located in the front part of the frontal lobe, is generally thought to be responsible for executive functions. These directly involve such cognitive skills as set-shifting, organization, planning, and other "regulation and control" abilities. Of course, these executive skills directly impact functional abilities like medication self-management.
The BCAT set-shifting item is representative of the executive functions in general, and the executive functions are critical to successful self-management. Keep in mind that working memory is also associated with the prefrontal region. There is empirical support that working memory exercises, under the right circumstances, can improve specific IADLs. This is one reason why we emphasize patients doing working memory exercises like those found in the BCAT Working Memory Exercise Book.
I hope you found this response helpful!
In-person Live Training versus On-demand Video Training
In healthcare, as in many industries, the financial burden associated with training can be significant for individual providers (such as the costs of continuing education courses) and organizations (who pay or reimburse for training). Questions about the value and utility of training are important. For example, to what extent does learning associated with a training program decay over time, especially if the provider does not subsequently use skills learned during the training on a regular basis? Is it important to participate in "booster" sessions to help ensure mastery of learned material? What are the relative advantages and disadvantages of live training versus virtual training (examples include on-demand video training and scheduled webinars)?
The BCAT Research Center recently addressed many of these questions as part of a research grant. The primary purposes of the study were to investigate three questions pertinent to training professionals in the BCAT Test System. The main research questions were:
1) After initial "in-person, live training,” to what degree does the provider's mastery of the BCAT Test System decay?
2) Does subsequent on-demand video training "boost" and maintain skills?
3) How does initial video on-demand training compare to initial in-person live training?
To answer these questions, we analyzed the responses of a sample of nurses and rehab therapists, working in eight nursing homes, who participated in BCAT training. What did we find? Here are some of the preliminary results. We plan to publish a fuller report in the near future.
1) We measured provider mastery of the BCAT Test System initially, and again 19 months later. There was a substantial decay in mastery over time. In fact, there was a 30% decrease in BCAT knowledge over this period. One explanation for this decrease is simple lack of use. This is consistent with the literature, as researchers have long recognized that "use it or lose it" applies to skill retention. From a cost-based utility standpoint, concentrating training on providers who will then use the BCAT is a good investment.
2) All professionals who participated in the on-demand video BCAT booster training sessions improved their skills as measured by a post-test. The preliminary finding is that booster sessions appear to improve skills, restoring much of the providers' mastery. Moreover, those who participated in the booster sessions achieved "passing" grades, demonstrating proficiency in the BCAT Test System.
3) How does initial on-demand BCAT training compare to in-person, live training? To address this question, we asked professionals who participated in both training formats to rate several features of these different training formats. Participants rated both types of programs highly in terms of ease of learning the material and "positive return on investment" of time. However, the on-demand training program received higher marks for its convenience, ability to replay and review the training content, and facilitation of "learning at my own pace." The in-person live training was judged to be "more interesting." We believe this may be due to the opportunity for participants to ask questions and engage one another.
Also, with respect to the on-demand video training, participants agreed, or strongly agreed, with these statements:
- The length of the on-demand video training was appropriate to gain an understanding of the material.
- Watching the on-demand training video did not significantly add to my current workload.
- Finally, all participants agreed that the on-demand training video significantly boosted previously learned BCAT skills.
Some initial takeaway points:
- Both in-person live training and on-demand video training have relative strengths and weaknesses.
- Both can provide sufficient opportunities to learn new skills. Booster sessions are necessary to maintain learned skills, and on-demand video training is a convenient and efficient method for this.
- When possible, adding a live component to the video training (such as discussions and demonstrations) could synthesize important advantages of both in-person live training and video training.
BCAT Certification at the Organizational Level
Health care providers in geriatrics are well aware of the high base rate of cognitive impairment in general, and dementia in particular, in their patients and residents. This is certainly the case in the allied health care fields of home care, acute and sub-acute rehabilitation, facility-based care, and hospitals. More than ever, it is important that we integrate time-efficient, highly accurate diagnostic instruments with memory enhancing tools that promote meaningful engagement. The BCAT Cognitive Approach is arguably the most effective system for accomplishing this.
Companies that are BCAT certified have market distinction in very competitive industries. For the first time, descriptions of and applications for BCAT Certification at the organization level are directly accessible from the BCAT website homepage. (www.thebcat.com). For those organizations who apply for and meet certification standards, we now grant three specific industry certification levels. Certification is based on the commitment of integrating the BCAT Cognitive Approach into organizational programming. Specific certification statuses are available for:
- Home Care Companies
- Rehabilitation Companies
- Seniors housing, facilities, hospitals, and other health care organizations
Each organization can apply for one of three certification levels. For Gold status, organizations must demonstrate mastery in meeting specific standards in training staff, utilization of BCAT tools, and post-test benchmarks. Participants in the training programs complete post-tests to demonstrate high-level proficiency. This is the highest BCAT Certification Level. For Silver status, organizations must demonstrate excellence in meeting training, utilization and post-test benchmark standards. Participants in the training programs complete post-tests to demonstrate basic proficiency. For Bronze status, organizations must demonstrate their commitment to these standards, but do not have training and utilization benchmarks.
Applications for each certification level are “fillable” and accessible directly from the website. Initial applications are reviewed by the BCAT Team monthly.
Why achieve BCAT certification? First, organizations that embrace certification train their staff to use highly sensitive cognitive assessment instruments. Accurate measurement of cognitive functioning facilitates effective treatment and management. Second, the BCAT offers a variety of tools to enhance cognitive functioning and promote meaningful resident and patient engagement. The BCAT Cognitive Approach is unique in that it integrates both assessments and interventions. Third, companies that are BCAT certified have market distinction in very competitive industries.
Ask the BCAT Faculty: Does Life-long Intellectual Enrichment Lower the Risk for Alzheimer’s Disease?
From a Provider:
I have a question about life-long cognitive stimulation. We tell patients and their families that continuing to stimulate the mind may delay the onset of Alzheimer's disease in people likely to develop it. Is there good science that supports this claim? In our facility, we recently had an 84-year-old man who was a distinguished college professor and who continued to read and write everyday. He had a BCAT score of 38. He scored in the MCI range. I can't help think that his score would have been lower if he hadn’t continued to read so much.
This is a very good question that really can be divided into two questions. One, do high educational achievement and cognitively challenging occupations protect or buffer against developing Alzheimer's disease? Two, does continued intellectual stimulation throughout adulthood buffer or delay the onset of Alzheimer's disease in persons who have the genetic predisposition to develop it?
The quick answer to your general questions is that there is evidence that high educational achievement and more intellectually demanding jobs may delay the onset of dementia. Also, there is research showing that lifelong learning and cognitive stimulation also may be protective. However, most of this research is correlational, not causal. This means that people with high educational/occupational achievement, and people who routinely cognitively challenge themselves, are less likely to have Alzheimer's. However, one cannot definitively say these factors cause a delay in Alzheimer's disease.
A recently published study is germane to your question. Published online in the June 2014 edition of JAMA Neurology,Vemuri, Lesnick, Przybelski and colleagues looked at the association between lifetime intellectual enrichment and cognitive decline in older adults. Based on a prospective longitudinal study in which nearly 2,000 population-based older adults participated, they found that cognitive performance was lower in individuals with less education/occupation achievement and who had less mid-life cognitive activity. Conversely, higher education/occupation achievement was associated with higher levels of cognition. Also, higher levels of midlife cognitive activity were associated with higher levels of cognition in the older adult years. Perhaps the most striking study finding reported was that for people who had the APOE4 gene (for Alzheimer’s disease), lifetime intellectual enrichment appeared to delay the onset of cognitive impairment by more than 8 years.
Depression as a Mortality Risk Factor
A substantial body of research supports the view that depression is associated with increased non-suicide mortality. Unfortunately, major depression is fairly common in later life and is certainly a cause of decreased life quality. Many studies have demonstrated that depression increases the risk of death by more than 50%, depending on various contributory factors (e.g., specific health status, marital status). That is, depressed older adults are more likely to experience premature death than those who are not depressed. We recently reviewed a study that focused on the relationship between major depression and non-suicide mortality. This research was conducted by Onge, Krueger, & Rogers (2014), and their results were recently published in the Journal of Gerontology: Social Sciences.
Based on a large national health interview survey (N = 11,369 adults aged 50 and older), the researchers addressed three main questions: (1) what is the association between depression and non-suicide mortality; (2) what is the association between depression and cardiovascular disease and cancer; and (3) are there specific health behaviors that might serve as potential mediators of the association between major depression and mortality. The study was a longitudinal design with a 6-year follow up-period.
- Major depression was associated with a 43% increase in the risk of death, after accounting for sociodemographic characteristics, health behaviors, and health conditions.
- For those without cardiovascular disease at baseline, major depression was associated with a 2.68 fold increase in the risk of cardiovascular disease mortality, and a 1.82 fold increase for those with baseline cardiovascular disease.
- Positive health behaviors (low alcohol use, positive physical activity, no smoking status) reduced mortality risk for those with depression by 17% overall, and by 3% for cardiovascular disease and 12% for cancer.
In addition to lowering life quality, major depression is a mortality risk factor. The risk of dying from cardiovascular disease or cancer is increased if one is also depressed. The actual risk may be mitigated by routine positive health behaviors, but these do not eliminate all risk caused by depression. Depression is generally regarded as a treatable illness. That being the case, the fact that depression is under-diagnosed in older adults can mean that more older persons experience both decreased life quality and increased mortality than need be.
From the BCAT Faculty
Dr. William Mansbach was invited to write a guest blog post about Mild Cognitive Impairment (MCI) for Dynamic Learning Group Online. In this blog, he addresses specific subtypes of MCI and the importance of identifying MCI in rehabilitation patients specifically. Of course, this topic is relevant to all healthcare professionals evaluating and treating older adults. To read this blog, click here.
The Dynamic Group is now offering a course on MCI taught by Dr. Mansbach. Continuing education credits are available. The course is entitled, MCI Today, Dementia Tomorrow. To review this course, click here.
Adult Day Services: Do they provide temporary relief or longer-term remedies for family caregivers?
There is ample evidence that family caregivers, particularly those who care for loved ones with dementia, encounter high levels of care-related stressors and often exhibit negative emotional and cognitive stress responses. This is especially the case when caregiving is daily and over extended periods of time. Many family caregivers seek adult day services (ADS) for their loved ones who have dementia – an intervention with possible rewards for both the identified individual as well as the caregiver. While adult day services can offer individuals with dementia purposeful social and cognitive stimulation, can these programs also offer family caregivers meaningful stress relief? And if so, is the relief temporary or more long-term?
These are complex questions, whose answers could inform health care policy and eventually lead to effective support for family caregivers. Unfortunately, these questions can only be partially answered by the available body of empirical evidence. Zarit and his colleagues* provide some insights into these issues as they examined the effects of adult day services on family caregivers of individuals with dementia. These researchers found that family caregivers did indeed have lower exposure to care-related stressors on days when their loved ones went to ADS, and generally more positive experiences on those days. Furthermore, caregivers reported experiencing feeling less anger on ADS days and more positive affect. These findings seem to support the idea that ADS provides at least temporary respite for family caregivers. It is unclear, however, if the relief caregivers experience on ADS days carries over to non-ADS days. In this study, ADS had no main effect on depressive or anxiety symptoms in caregivers, despite contributing to the lowering of care-related stress and improving affect.
What are needed are more longitudinal studies that track the effect of ADS on caregiver stress over time. Certainly there is reason to believe that lowering caregiver stress periodically may provide some protection against the destructive effects of chronic stress associated with caregiving.
*Reference: Zarit, S.H., Ki, K, Femia, E.E., Almeida, D.M., & Kleine, L.C. (2014). The effects of adult day services on family caregivers’ daily stress, affect, and health: Outcomes from the Daily Stresss and Health (DaSH) Study. The Gerontologist, 54(4), 570-579.
Ask the BCAT Faculty: Recognizing Threat from Faces
A question from the field:
I recently went to a conference about violence toward the elderly. The focus of one of the presentations was on educating older adults so that they would be “less vulnerable” in threatening social situation. The presenter described older adults as more trusting and less able to read facial and body cues of would-be perpetrators of crimes. My question is this—Are older adults less capable of recognizing social threats than younger adults?
BCAT Faculty response:
This question is a little outside the scope of most questions that we receive. However, we can provide some information we hope will be useful. I believe you, and the conference presenter, are referring to what has been called a “positivity bias.” Castle et al. (2012) and other researchers have suggested that older adults tend to attribute more trustworthiness from faces that younger adults see as more threatening. As a result, it has been suggested that this positivity bias can lead to increased vulnerability of older adults. Some research has demonstrated that older adults have a tendency to not only see faces as more trustworthy than do younger adults, but also less hostile and less dangerous.
However, the literature is not consistent and no consensus exists in terms of how accurate older adults may be in detecting hostility or threat in the faces and behaviors of others. You might be interested in a recently published study by Boshyan and colleagues (2104, Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 69(5), 710-718). These researchers reported findings from two studies in which they investigated the positivity bias described above. In their research, they presented 24 pictures of Caucasian young men to study participants. The researchers compared the responses of younger and older adults in recognizing aggressiveness. They found that, despite previous evidence, older adults appear to be just as accurate as younger adults in detecting aggressiveness in others.
Of course, whether older adults will appropriately act once they detect aggression in others is a different, and potentially more important question. There may not be an age bias here, as there is a good deal of evidence that younger adults, when confronted by ambiguous or clearly aggressive situations, often fail to protect themselves. Perhaps protecting vulnerable older adults has more to do with appropriate safety action, and less to do with the ability to detect aggression in others.
Thank you for this interesting question.
Introducing the Brief Anxiety and Depression Scale (BADS)
The BCAT Research Center is happy to announce the development of a new screening tool for identifying depression and anxiety in older adults. The team will be reporting their research in the journal, International Psychogeriatrics. An online version should be available at www.thebcat.com within the next few months, followed by the print version of the article. The publication describing the development of the BADS culminates a three-year project that has focused on improving assessment of mood issues in older adults.
The BADS will replace the WIPE Depression Scale in the BCAT Test System, as it is broader and encompasses both depression and anxiety items. All those who have BCAT licenses or access to the BCAT Test System will have free access to the BADS. The target date for loading the BADS into the BCAT Test System is December 12, 2014. We will be distributing more information about the BADS in the coming weeks.
From a clinical perspective, the BADS can be administered in three minutes or less for most patients. We have included an Abstract to help introduce the BADS. It is below.
Background: Depression and anxiety are common among long-term care residents, yet both appear to be under-recognized and under-treated. In our survey of 164 geriatric health care professionals from 34 U.S. states, 96% of respondents reported that a new instrument that rapidly assesses both depression and anxiety is needed. The Brief Anxiety and Depression Scale (BADS) is a new screening tool that can identify possible major depressive episodes (MDE) and generalized anxiety disorders (GAD) in long-term care residents.
Method: The psychometric properties of the BADS were investigated in a sample of 224 U.S. long-term care residents (aged 80.52 ± 9.07). Participants completed a battery of several individually administered mood and cognitive tests, including the BADS. MDE and GAD were diagnosed based on the DSM-IV-TR criteria.
Results: Adequate internal consistency and construct validity were found. A principle component analysis (PCA) revealed an Anxiety Factor and a Depression Factor, which explained 50.26% of the total variance. The Anxiety Factor had a sensitivity of .73 and specificity of .81 for identifying GAD (PPV = .69, NPV =.84). The Depression Factor had a sensitivity of .76 and a specificity of .73 for identifying MDE (PPV = .77, NPV = .72).
Conclusions: The BADS appears to be a reliable and valid screening instrument for MDE and GAD in long-term residents. The BADS can be rapidly administered, is sensitive to mood diagnoses in both non-demented and demented patients, and produces separate depression and anxiety factor scores that can be used clinically to identify probable mood diagnoses.
The Importance of Cognitive Screening Before Surgery
Many healthcare professionals, patients, and their families are familiar with what is called postoperative cognitive dysfunction (POCD). Unfortunately, brain dysfunction is a common postoperative medical and psychosocial problem. While there is no current official diagnostic category for POCD, most indications of the syndrome involve deficits in the cognitive domains of attention, memory, and executive functions. POCD is more common among older adult surgery patients, and has been documented after numerous different types of surgeries (e.g., cardiac, orthopedic, brain). Recent literature reviews suggest that 30-80% of older adults show immediate signs of POCD after surgery, 30-40% show persisting symptoms for at least a week, and 10-15% show symptoms much longer. POCD has significant and negative consequences, including longer hospital stays, higher medical costs, higher risk for hospital readmission, premature withdrawal from the workforce, and greater mortality.
POCD is further complicated by the fact that many older surgery patients have preexisting/coexisting cognitive impairments. Therefore, it is not always clear if postoperative cognitive deficits reflect baseline preoperative ones, or whether they are the direct result of the surgical context (e.g., anesthesia, pain medications, medical organic complications). Moreover, patients who have dementia face greater risks and challenges in recovering from surgeries than cognitively normal people. Largely overlooked, yet very prevalent, are older patients who have preexisting Mild Cognitive Impairment (MCI). With this syndrome, patients demonstrate cognitive impairment, especially in memory, but do not meet criteria for dementia. However, approximately 70% of MCI patients will develop dementia, and the syndrome can be understood as a pre-dementia condition for many people. It is estimated that between 15 and 20% of Americans age 70 and older have MCI. This is also a demographic with high surgery utilization. Surgeons, other healthcare providers, families, and patients often assume that deficits in memory (consistent with amnestic MCI) are benign “senior moments,” rather than indications of real clinical problems. This is of particular concern because there is a strong association between MCI and impairment in the so-called higher levels of activities of daily living (e.g., managing finances, food preparation, arranging transportation).
Given the negative effects of POCD, why then do we not routinely screen for cognitive impairment before surgery? Preoperative cognitive assessment could identify those persons who are most at risk for negative cognitive outcomes post surgery, and would provide a baseline for making postoperative cognitive functioning comparisons. Management of post surgeries could certainly be improved by using validated screening instruments pre-surgery. The BCAT- Short Form (BCAT-SF) is an ideal screening tool because: (1) it can be administered in three minutes or less; (2) can be administered by a licensed professional or medical technician; (3) is sensitive to MCI; (4) has been validated in medical settings; (5) measures attention, contextual memory, and executive functions – cognitive symptoms most commonly associated with POCD; and (6) the BCAT-SF and BCAT are commonly used in post-acute rehabilitation as part of postsurgical recovery and treatment.
For more information about how to use the BCAT-SF to improve medical care, go to www.thebcat.com.
Maryland Resident Cognition Project
Who is Most Likely to be Prescribed Antipsychotics?
Selected findings from the Maryland Resident Cognition Project1
In American nursing homes, antipsychotic use continues to be common, with more than 25% of residents receiving an antipsychotic medication at least once in a seven-day cycle. Antipsychotic medications are taken by nearly one-third of residents with dementia. While these agents have been approved by the US Food & Drug Administration for the treatment of schizophrenia and bipolar mania, they have not been approved for the behavioral and psychological symptoms associated with dementia (referred to as BPSD). Yet, the “off-label” use of these drugs is frequent in US nursing home residents, despite the fact that treatment efficacy appears to be quite limited. More importantly, serious safety concerns have emerged for demented individuals who are taking antipsychotics.
From a risk perspective, it is important to understand who is most likely to be prescribed antipsychotics. As a result, prescribers would have important information for making better risk-reward decisions about using these medications; and potentially safer interventions could be used (e.g., behavioral management strategies, MemPics). So who is most at risk? Let’s reframe this as a multiple-choice question for you to answer: Who of the following nursing home residents are most likely to be prescribed antipsychotics?
- Those with Mild Cognitive Impairment (MCI)
- Those with mild dementia
- Those with moderate to severe dementia
- Those with depression
If you answered “c”, you made the correct choice. Among all residents with dementia who are prescribed antipsychotics, 60% are moderately to severely demented (based on BCAT scores). This is likely because off-label use of antipsychotics are typically used to reduce BPSD, and residents with moderate to severe dementia are more likely to exhibit BPSD than residents at other stages of cognitive impairment. Also, it is easier to prescribe medications than introduce behavioral treatments.
The take-away? Having more advanced dementia is a risk factor for being prescribed antipsychotics. Because antipsychotics are associated with higher health risks, these residents have increased health and safety risks.
1The Maryland Resident Cognition Project is a multi-disciplinary, public-private sector effort at improving cognitive and functional assessment and treatment of long-term care and short stay residents.
Ask the BCAT Faculty: Choose Your Brain Rehabilitation Programs Wisely
From the Provider:
I read a summary of the recent Stanford Center on Longevity report on bran training. It seems like the scientific community is skeptical that a lot of these programs really work. As a speech therapist who works with older patients with memory problems, I see a lot of potential in cognitive rehabilitation programs for patients. Do you have any advice or recommendations about the clinical applications of brain training?
Thank you for your question Mary. The Stanford Center on Longevity consensus report about brain training does indeed remind us that caution and good science are important in choosing cognitive rehabilitation programs when we work with patients. Certainly, our review of the scientific literature reveals that many cognitive training programs that are based on science, are not always validated by it. At the BCAT Research Center, we work very hard at validating our tests and treatment programs before clinicians use them. In fact, we are about to release some recent findings about the efficacy of the cognitive (brain) rehabilitation program, Memory Match. You may recall that Memory Match is one of three online brain rehabilitation modules on our website and part of the BCAT Approach.
In a matched-groups design study, older rehabilitation patients were assigned to a treatment group or control group. The treatment group participated in a three-week period of Memory Match sessions, while the control group did not receive Memory Match treatment. BCAT scores were obtained at baseline and during a post-assessment phase. Treatment group participants who received the three-week treatment obtained significantly higher BCAT scores at post-assessment than did participants in the control group over the same period. Additional evidence for the efficacy of the Memory Match program was found by comparing responses on a self-report inventory of cognitive ability between the two groups. Those participants in the treatment group reported higher cognitive abilities than did those from the control group. Finally, 85% of the participants receiving the Memory Match treatment attributed at least some of their improvement in cognition to this cognitive rehabilitation program.
In this study, the participants had relatively mild cognitive deficits. Patients with severe dementia were not included. Therefore, one should be careful about generalizing to severely impaired patients. The results are promising. So, when choosing cognitive rehabilitation programs for patient care make sure that they are validated by good science!
For more information about this study or Memory Match, please contact us at: email@example.com. Put Memory Match in the subject line.
Alzheimer's Disease Facts and Figures
As healthcare professionals and policy experts try to come to terms with the increasing incidence and prevalence of Alzheimer’s disease and related dementias, more attention is also being focused on those individuals who provide informal care to dementia patients. Unpaid caregivers, 85% of whom are family members, are particularly at risk for a host of physical, emotional, and financial burdens. In the US, there are more than 15 million unpaid caregivers for people with dementia. Below, we highlight some of the more striking statistics associated with unpaid caregivers. As a professional community, it is imperative that we consider Alzheimer’s disease and related dementias as “family and community” illnesses. Therefore, treatment and support for caregivers is essential – for their welfare and for those for whom they care.
Here are some important findings recently reported in the 2015 Alzheimer’s Disease Facts and Figures report:
- In 2014, caregivers provided an estimated 17.9 billion hours of informal assistance, a contribution calculated in financial terms of $217.7 billion.
- Approximately 2/3 of all caregivers are female, and 34% are age 65 or older.
- “Sandwich generation” caregivers are particularly vulnerable as they care for both parents and children. It is estimated that 23% of caregivers for parents with dementia also take care of children under the age of 18.
- For most caregivers, caring is a long-term proposition. 86% of dementia caregivers provide assistance for more than a year.
- Caregiving for persons with dementia can take a tremendous toll. Approximately 40% of caregivers suffer from depression, as opposed to 5-17% of peers who are not caregivers. 47% of caregivers report financial strain associated with caregiving. 74% of caregivers report concerns about their own health associated with caregiving.
Clearly the toll of dementia impacts the patient, the family, and the community. Healthcare professionals must consider and plan for the burden on caregivers. Their health is just as important as the health status of those who have dementia. Assessment of mood (using screening tool like the BADS) and cognition (the SAC Self-Assessment of Cognition scale, the BCAT Test System) should become routine.
Ask the BCAT Faculty: Is there empirical evidence for "Pre-MCI"?
"I was recently at a conference and the speaker mentioned that there may be a 'pre-MCI' stage. He was referring to patients who have very mild cognitive problems but who will likely progress to dementia eventually. Is there evidence for this as a real clinical stage?"
During the past 15 years, clinical interest and research concerning the construct of Mild Cognitive Impairment (MCI) has rapidly expanded. As research interest and clinical applications have grown, it has become apparent that MCI is a heterogeneous and complex construct. The debate continues as to whether subtypes have different etiologies and disease progressions, and questions remain as to subtype prevalence and prognosis. One particularly interesting development has been the identification of possible pre-MCI and pre-MCI subtypes (Chao et al., 2010; Duara et al., 2011; Loewenstein et al., 2013; Saykin, et al., 2006).
What exactly is pre-MCI? There appear to be subsets of people who demonstrate mild impairment in cognition and function (e.g., instrumental activities of daily living), but do not fit into a MCI subtype (e.g., amnestic MCI, executive MCI, multi-domain MCI), and are not demented. Based on objective neuro-cognitive tests, like the BCAT, these individuals show impairment, but do not meet the strict testing standards of significant impairment oHow should they be classified?
At the BCAT Research Center, we have just completed a study assessing the construct of pre-MCI. We found an identifiable subset of patients who met the general criteria for MCI, but did not quite meet the classifications of amnestic, executive, or multi-domain subtypes. These (undifferentiated) MCI patients could be described as having pre-MCI. This makes sense, since undifferentiated MCI refers to patients whose cognitive deficits do not quite approach the memory or executive impairments needed for amnestic or executive MCI. Patients with undifferentiated MCI may progress to a more definitive MCI subtype over time.
Some issues for you to bear in mind:
- MCI is a complex and likely transitional level of cognitive impairment.
- Just like dementia has stages, it is likely that MCI also has degrees of impairment, including a "pre" level.
- It is important that selection of objective tests identifying MCI can detect possible pre-MCI.
Differentiating Levels of Cognitive Functioning: a Comparison of the BIMS and the BCAT
The Brief Interview for Mental Status (BIMS) is currently the most used cognitive screening tool in American nursing homes. However, very few studies have evaluated its screening abilities, and a number of questions have arisen concerning its utility for predicting cognitive impairment. How effective is the BIMS in detecting cognitive impairment?
For the first time, the BIMS and the BCAT were compared in a head-to-head peer-reviewed study. Both cognitive tools were found to predict cognitive diagnoses generally, but only the BCAT was able to identify residents’ at all specific cognitive levels (normal, MCI, mild dementia, moderate-severe dementia). The BIMS did not differentiate between residents with normal cognition and those with mild cognitive impairment, or between mild and moderate dementia. The BCAT accounted for an additional 47% ability to predict cognitive impairment over and above BIMS scores.
The ability to identify residents with cognitive impairment is critical to effective care plans and interventions, and can facilitate appropriate staff interactions so important to residents’ quality of life (Singer & Luxenberg, 2003).
Studies show that approximately 70% of nursing home residents have some type of cognitive impairment (Centers for Medicare & Medicaid Services CMS, 2010), and many studies estimate that approximately 50% of all residents meet criteria for dementia (Magaziner et al., 2000).
Conclusion: Based on these findings, the BCAT appears to be more sensitive than the BIMS in predicting cognitive levels for nursing home residents. The BCAT can be effectively used for cognitive assessment, treatment interventions, and discharge planning.
This published study is now available online in the journal, Aging and Mental Health. To read the journal article, please click here.
Using Working Memory Exercises to Improve Everyday Functioning
Cognitive impairment is prevalent in older adults, as are associated declines in instrumental activities of daily living (IADL). There is growing evidence that some cognitive training, especially exercises that concentrate on working memory, can improve cognition and IADL performance. This issue of improving IADLs is critical as it impacts on independent living opportunities, hospital readmissions, and psychological well-being. In a recent study in the Journal of the American Geriatric Society, Rebok et al. (2014) reported their findings from a ten-year longitudinal study that looked at the effects of cognitive training on everyday functioning of older adults. Participants were aged 65 and older, and had mild or normal cognitive deficits. Potential participants who had moderate to severe dementia were excluded from the study. All participants were evaluated with a neuropsychological battery both before the cognitive training and afterward. The training consisted of ten small group sessions that included working memory and other cognitive skills. For participants who went through the training, less difficulty in IADLs was reported, and gains held when measured ten years later. It is interesting that improvement was measured in IADLs even when some cognitive areas did not improve.
Not all cognitive exercises have been shown to improve cognition and functional skills. One exercise that has been shown to positively impact working memory and IADLs is the number-symbol exercise. A good example of this can be found in the BCAT Working Memory Exercise Book.
For more information about the Rebok et al. (2014) study, you can read it here.
Ask the BCAT Faculty: How common are executive deficits in patients with Mild Cognitive Impairment (MCI)?
I recently read that there are several different MCI subtypes, and that amnestic MCI, single episode is the most common one. I’m a speech therapist, and I’m finding that a lot of my patients have pretty good memory, but seem to have a lot of executive deficits. Can you comment on this in general? Specifically, how common is executive MCI relative to amnestic MCI?
Karen, thank you for your question. The construct, Mild Cognitive Impairment (MCI), was first popularized in the seminal studies by Petersen and colleagues (Petersen et al., 1977; Petersen et al., 1999), in which general criteria for the syndrome were first described. In this generalized MCI construct, the patient has a subjective memory complaint, corroborated by an objective test, with no evidence of dementia, and generally preserved instrumental activities of daily living. This original research was based on a community cohort of older adults, and no subtypes were defined. Actual MCI subtypes were first presented in the literature a few years later (Petersen, 2004; Winblad et al., 2003), largely based on the International Working Group on Mild Cognitive Impairment (i.e., First Key Symposium in Stockholm, Sweden, 2003). Four subtypes were identified:
- amnestic MCI single domain: just memory is impaired
- amnestic MCI multi-domain: memory and at least one other cognitive domain are impaired
- non-amnestic, multi-domain: memory is basically intact, but two or more other cognitive domains are not
- non-amnestic MCI, single domain: one cognitive domain is impaired, but not memory. Perhaps the most common non-amnestic feature is “executive” impairment. This is particularly likely in nursing homes, assisted-living facilities, and hospitals.
Initially, the primary focus on MCI was to identify patients with memory problems who would develop Alzheimer’s disease. However, many researchers, especially those who have studied patients in nursing homes and medical settings, found that non-memory deficits were also common. This prevalence of individual subtypes has been an important research question at the BCAT Research Center. In fact, in a multi-year investigation of nursing home and assisted-living patients, we recently found that 37% of MCI patients had the amnestic single domain subtype, 9% had both amnestic and executive deficits, and 18% had the executive single subtype. Another 36% did not fit into any of these categories. It is likely that patients from this last category, what we describe as undifferentiated MCI, had some other cognitive issue (e.g., language, visuo-spatial), or had delirium. In the case of the later, there is a higher probability that they will revert to normal cognitive functioning once the underlying medical issues are resolved.
So in terms of your specific question about how common is executive MCI, we have found that 27% of our study participants have either single domain executive MCI (9%) or multi-domain MCI (19%) that includes executive impairment. I would say that your observations, Karen, are consistent with our findings.
For more information about MCI subtypes, we suggest that you read Busse et al. (2006). Here is the link: http://www.ncbi.nlm.nih.gov/pubmed/17190940
Sexual Expression in Long-Term Care*
From an American culture perspective, older adults are often considered asexual, particularly if they live in long-term care settings. However, older adults have been found to be sexual throughout the lifespan, including in nursing homes and assisted-living facilities. While quite a lot of attention has been focused on problematic expressions of sexuality, less has focused on appropriate and necessary expressions of intimacy and sexuality. The literature pertaining to sexual expression in nursing homes demonstrates that clear policies enabling healthy sexual expression are lacking, and this appears to be concurrent with relatively poor staff sensitivity to resident sexual expression.
In a recent publication, Cornelison and Doll (2013) investigated sexual expression in long-term care setting based on ombudsmen interviews. 31 in-depth interviews were conducted in six states. These cases involved ombudsmen interventions in conflict situations. 29 of the 31 ombudsmen interviewed reported that in the course of their work, they intervened in conflicts related to sexual expression. Sources of conflict tended to be clustered around five basic themes: general risk to residents (safety of residents involved), specific risk associated with residents with dementia (vulnerability to abuse due to cognitive impairment), limited knowledge about normal sexual expression and residents’ rights (pertaining to facility staff, residents, and their families), lack of privacy for intimate contact, and a clash of values around sexuality and sexual expression (staff, residents, their families).
The authors conclude that residents need advocates to support their rights in terms of sexuality. Furthermore, workplace training and education of staff are imperative in order to protect residents. Finally, a focus should be placed on formulating standards of practice to deal with ethically complex situations in long-term care facilities as they arise.
We would add that safeguarding sexual expression, by creating safe and private opportunities for intimacy, is consistent with person-centered care and resident voice. From this perspective, nursing homes and assisted living facilities should continue to evolve such that they resemble one’s home, not institutions.
* Cornelison, LJ & Doll, GM. (2013). Management of sexual expression in long-term care: Ombudsmen’s perspective. The Gerontologist, 53(5), 780-789.
Ask the BCAT Faculty: Are Patient Self-Reports Indicators of Potential Dementia?
A psychology professional writes to us...
“One of my colleagues attended the Alzheimer's Association International Conference in Boston this summer. He went to a session about a newly coined syndrome, Subjective Cognitive Decline (SCD). Apparently a study was presented showing that SCD predicts future MCI and dementia. This seems a little bit like a reach to me. Can you comment on this syndrome and related research?”
BCAT Faculty Response:
Thank you for your question regarding what many researchers and clinicians view as a potential early warning sign for Alzheimer's disease. The term, subjective cognitive decline (SCD), is not a true diagnostic term nor is SCD a widely accepted syndrome. It has been variously called "subjective cognitive impairment," "subjective memory impairment," among other descriptors. For clarity, we will use the term “subjective cognitive decline”, even though memory is by far the most commonly reported feature. Essentially, SCD refers to the self-reported perception of memory or cognitive problems. Alternately, subjective reports from key informants, such as family members, are also included.
At the AAIC this summer, five studies were reported about SCD. As a whole, these studies point to the possibility that SCD may be an early warning sign of dementia. For example, research showing links between SCD and beta-amyloid build-up and with ApoE4 (a genetic risk factor for Alzheimer's) were reported. These are exciting and potentially useful findings. However, one should be cautious about drawing clear conclusions. There are a number of problems with using self-reports about memory and cognitive changes as predictors of MCI and dementia.
First, the term SCD is vague and has been defined in various ways. There are no formal criteria for it. Therefore, clinicians may identify SCD variously (which causes confusion), and one cannot reliably compare outcome studies on SCD. Second, there is competing evidence that self-reports of memory decline may be better at identifying risks for depression and anxiety, than actual cognitive impairment. It is common and understandable to have worries about dementia and cognitive impairment. It is interesting to note a recent MetLife survey of American adults, which showed that over 30% of the respondents were fearful of Alzheimer's disease. This percentage is relatively close to worries about getting cancer. Third, the validity of cognitive subjective complaints is further complicated by the fact that many people do not know the difference between normal and impaired cognition. For example, studies show that normal forgetfulness is often confused with having dementia, and vice-versa. Fourth, psychological denial of memory and cognitive symptoms is common. This points to the problem of under-reporting cognitive changes.
Certainly, subjective memory and cognitive complaints are important in the early identification and management of cognitive impairment. To optimize the utility of SCD as a clinical concept, we make three recommendations. First, we need to develop a clear set of criteria for SCD. This would allow for more accurate clinical determinations and comparability of research on SCD. Second, we should encourage patients to use self-reported cognitive instruments that have been empirically validated. While limited in number, there are memory self-assessment scales that have been shown to identify possible impairment at early stages. We provide one of these helpful memory self-assessment on our website (http://thebcat.com/self-assessment-tools). It should not be used as a diagnostic tool, but as data to be reviewed by a healthcare professional. Third, efforts need to be made to better educate physicians and other professionals as to how to make sense of patient-reported and family-reported cognitive complaints. This would include helpful follow-up questions and guidelines for making referrals to experts for further evaluation.
Spousal Loss as a Mortality Risk Factor
Recent U.S. Census data shows that there are 14 million widowed people in the U.S. Approximately 11 million are female and 3 million are male. Considering all U.S. women over 75, about 57% are widowed. Furthermore, there is strong evidence that death of a spouse is associated with increased age-specific probability of dying for the surviving spouse. Older widowed adults are more likely to die than married older adults, assuming all other mortality factors are the same. However, there appear to be “moderating” factors that may help us understand and offer support to those women and men who are widowed. Some interesting statistics:
- Becoming widowed is associated with a 48% increase in mortality for the surviving spouse.
- Risk of death goes up if the surviving spouse is economically disadvantaged.
- Socioeconomic status appears to “buffer” surviving spouses.
- Mortality risk may be highest immediately following the death of a spouse, and tends to be reduced over time.
- For men, mortality risk increases if the wife’s death is unexpected. This is less the case for women who lose their husbands without warning.
Research shows that having strong social support systems and having financial resources may reduce the risk of death. Both appear to play a vital buffering role in protecting both men and women who lose spouses, especially shortly after spousal loss. From a clinical standpoint, these factors can help identify those most at risk and target intervention strategies.
To read an interesting research publication about this issue please visit this link.
Can the BCAT Test System Help Identify “At-Risk” Sub-Acute Patients?
A therapist writes....
I am a speech therapist and my company uses the BCAT Test System. Our company trainer said that the BCAT and the Kitchen Picture Test could be used to identify sub-acute patients who have high safety risks if they return home. One of our common issues is to find an objective method for recommending assisted living or more supportive care at home when we think that patients are at risk for safety. Can you comment on how to use the BCAT and Kitchen Picture Test in this way? Are there specific scores we should be focusing on? Thank you!
The BCAT faculty responds....
For those of you who have attended BCAT training or who are BCAT certified, you would be familiar with our view that cognition is a "vital sign." Accurate measurement of cognition in general and of specific cognitive domains can help predict function, and of course improve treatment outcomes. The BCAT Research Center designed a study investigating the abilities of the BCAT and Kitchen Picture Test (KPT) to identify patients who transfer from sub-acute nursing home care to one of three discharge destinations: home in the community, assisted living, or permanent placement in nursing homes. A goal of this research was to create safety “risk” indicators in sub-acute patients. Because the BCAT has been shown to predict both cognitive diagnosis and function (e.g., IADLs), and the KPT is a test that measures judgment specifically, we hypothesized that taken together, they could help predict discharge destinations.
In this study, BCAT scores below 25 and KPT scores below 5 (on the judgment subtest) separated those sub-acute patients who transferred to permanent nursing home placement versus those who discharged to assisted living or the community. From a safety standpoint, patients who had BCAT scores below 25 and KPT scores below 5 were more at risk for accidents and other types of problems than patients with scores above these thresholds.
The takeaway is that if you are working with a patient who scores below these values on both the BCAT and the KPT, and who is to be discharged to the community or assisted living, ensuring a very supportive safety plan is key. Otherwise, the risk for hospital readmissions and permanent nursing home placement is relatively high.
Ask the BCAT Faculty: Predicting Aggression in Dementia
A home health nurse sent this in...
"I am a home health nurse working in Maryland. I have a question about aggression in dementia. Is there research that looks at predicting aggressive behavior in dementia patients? I ask because I evaluate patients living at home once they leave the hospital and nursing home. I use the BCAT to see if they have dementia, but it’s hard to know if they will become aggressive toward their caregivers."
BCAT Faculty Reply:
While we know quite a lot about common clinical features of dementia, we are less knowledgeable about predicting behaviors. This is especially unfortunate in cases of physical aggression, given that they potentially place caregivers (and patients) at risk. However, there is evidence supporting key risk factors for aggression. For example, severe dementia, depression, acute physical pain, increases in non-aggressive behavior (like pacing, disrobing, repetitive behaviors), and caregiver burden are associated with aggression in community-residing older adults who have dementia. Morgan, Sail, Snow, Davila, and colleagues recently investigated this issue by following 171 community older adults newly diagnosed with dementia. They found that both high caregiver stress and declining patient-caregiver relationships were associated with aggression. They also found that increased nonviolent displays of agitation, and reports of pain were risk factors.
It may be possible to decrease aggressive behaviors by first identifying risk factors for them. BCAT scores below 25, elevated WIPE depression scores, physical pain, and increases in nonviolent forms of agitation represent warning signs. They also are opportunities for intervention. So, educating caregivers is very important. However, predictions of when physical aggression will occur are more difficult to determine.
Note: The Morgan et al. (2013) article can be found in the journal, The Gerontologist.
Ask the BCAT Faculty: Memory Should be Measured in Two Ways
A neuropsychologist from Colorado writes...
"I have recently started using the BCAT in my practice, mostly to screen referred patients and then determine what other testing I should do. In my experience it is unusual to find a memory test that has both word list and story recall items. Usually, it is just word lists. Why does the BCAT have both?"
Memory has traditionally been assessed by either administering a list of words and asking patients to recall them immediately and again after a short delay ("word lists"), or by administering a short story and asking patients to recall details both immediately and after a delay ("story recall"). Initial correlational research suggested that these methods were essentially interchangeable. Clinicians typically chose the method they liked best. However, we now know that they are different, and likely measure different (though overlapping) aspects of memory. Word list and story recall processing may involve different underlying sub-neuro-circuits.
One of the key differences between the two assessment methods is the potential involvement of executive skills in making new memories. For example, stories provide semantically meaningful material, so performance on story tasks may benefit from the intrinsic semantic organization of the story. However, word list tasks require one to self-generate organizational strategies. Patients with executive functions impairment often do worse on word list tasks than story recall because they can't generate an organizational strategy for remembering the words. Story recall might be a purer assessment of memory, with less bias from executive processing. However, it should be noted that many studies have found that word lists are particularly sensitive in detecting memory impairment in patients who have generally intact executive skills.
Studies show, including BCAT research, that combining both story recall and word lists is the best and most accurate method for assessing memory. Clinically, the conclusion that a patient has memory impairment would be stronger when deficits are demonstrated in both story recall and word list recall.
This is why the BCAT includes both.
Ask the BCAT Faculty: Transitions from Assisted Living to Skilled Nursing Facilities
A facility operator in the mid-west writes to us saying:
“I am the executive director of a large assisted living community in Ohio. I am interested in understanding if there is a scientific way to identify AL residents who are at risk for prematurely transitioning to nursing homes. We lose many residents, not because they age in place, but because of acute changes in their health. I’m convinced that many of these transitions could be avoided. Any insight is appreciated.”
BCAT Faculty response:
During the last two decades, there has been a marked growth in the population of older adults residing in assisted living facilities (ALFs). One of the missions of the AL industry is to provide stable, home-like long-term care environments. However, permanent transitions from ALF to nursing homes occur with some regularity, though the risk factors involved are not well understood. One of the few published studies that investigated this issue was conducted by Rosenberg et al. (2006). They reported that declining health, chronic pain, appetite changes, and being widowed were risk factors for nursing homes transitions.
At the BCAT Research Center we have also identified several risk factors for permanent transition to nursing homes. The route to the nursing home generally goes through the hospital. That is, ALF residents are sent to the hospital due to an acute medical event, and subsequently transferred to the nursing home. Key non-financial (see note below) risk factors appear to be: depression, cognitive impairment, recent history of falls, and chronic pain. As these are general factors, we are in the process of determining which specific scores on tests measuring these factors best predict nursing home transitions. We plan to report our findings later this year.
In the meantime, and from a practical standpoint, we recommend that at admission and at least quarterly, AL facilities assess cognitive functioning, mood functioning, pain status, and ask about or monitor recent falls. For example, residents with low BCAT scores and high WIPE scores are more at risk for permanent nursing home transition. The probability of leaving the AL increases even more if the patient has chronic pain and has had at least two falls during the past 30 days. This should provide useful information about those at risk for exiting the facility, and create opportunities to put treatment plans in place that reduce the likelihood of permanent nursing home transitions.
Note: An important contributing factor for many transitions from assisted living to nursing homes is personal finances. We address this issue, particularly in light of additional pressures created by the recent recession, in another post.
Hospice Utilization in Nursing Homes
Approximately 25% Americans die in nursing homes. Despite the fact that end of life (EOL) experiences for so many people and their families occur within the context of nursing homes, the quality of EOL care appears to be uneven, and often inadequate in these settings. Hospice services can provide much needed support for residents and their families. Studies have demonstrated that nursing home residents receiving hospice services are less likely to be hospitalized, more likely to receive better pain management, and families are more likely to receive supportive services than patients at similar EOL stages but who do not receive hospice care.
Despite the benefits of hospice, utilization of services is relatively low in nursing homes among those who qualify for them. A recent study was published that investigated hospice utilization in nursing homes. Zheng, Mukamel, Caprio, and Temkin- Greener (2013) tracked 4540 long-term care residents in 290 facilities.
- the prevalence of hospice use was 18%
- the average length of stay for hospice patients was 93 days
- residents living in facilities reporting higher transfer of EOL residents to hospitals were less likely to use hospice services
Implications: Facility practices and policies about hospital transfer for EOL residents have a powerful impact on hospice choice at the individual resident level. The tendency to hospitalize residents who are "end of life" is associated with lower hospice utilization. One way to increase hospice use may be to lower hospital transfers for these residents.
The Zheng study can be found at: http://www.ncbi.nlm.nih.gov/pubmed/23231947
Ask the BCAT Faculty: MCI Caregiver Support Groups
A Geriatric Care Manager working in Texas writes to us saying...
“I run a monthly caregiver support group (for wives mostly) for those who take care of spouses with dementia. I know the participants find the group helpful, and I’ve even used the WIPE Depression Scale and found that after a few sessions, depression levels go down. I’ve been trying to start a similar group for caregivers who take care of spouses who have Mild Cognitive Impairment. I see this group as very underserved, and very vulnerable to depression. However, despite the need for support, I can’t seem to get this group off the ground. I can’t seem to get them to come. Is my experience common?”
Thank you for your question. While the practice of support groups for dementia caregivers has long been established, support groups for MCI caregivers are a more recent development. In some ways this tracks the recognition of dementia versus MCI. In healthcare and in the broader culture, we have been talking about dementia for a long time, but only recently has MCI received much attention. It is likely that as more people, including healthcare providers, become familiar with MCI, it will be easier to establish support groups. Even so, participation in support groups for dementia and MCI caregivers will likely have less than optimal participation for a host of reasons (e.g., denial of the condition, embarrassment or shame about needing help, lack of material support, failure of healthcare providers to make referrals).
We applaud your efforts in creating support group opportunities for MCI caregivers. We have written quite a lot about the high prevalence of depression and other psychological problems associated with MCI caregiving. The need for formal and informal support is high. Seeher, Low, Reppermund, and Brodaty (Alzheimer’s & Dementia 9, 2013) underscore this in their recently published review of MCI caregiver concerns. They report that depression and psychological comorbidity are common in MCI caregivers.
One of the barriers for MCI caregivers in seeking support is that they may not regard themselves as actual caregivers. Part of the problem may be with the term “Mild Cognitive Impairment.” The term suggests mild deficits, and does not communicate the need for caregiver support. This is very unfortunate since MCI can be severe and disabling. Furthermore, a majority of MCI patients will convert to dementia over time. We believe that if healthcare providers substituted the term “Transitional Cognitive Impairment” (TCI), caregivers would have a more realistic view of their loved one’s condition and would more likely seek support for themselves. Finally, we congratulate you on using an evidence-based depression scale in your work with caregivers. Using evidence-based methods of assessment leads to more positive treatment outcomes.
Insomnia & Suicidal Ideation in Older Adults
Insomnia is more prevalent among older adults than in any other age group. It is interesting to note that older adults, especially men, struggle with insomnia but often accept less sleep without complaint. Suicide rates for adults aged 65 and older are more than 30% higher than for those below age 65. The rate of suicide attempts to death is disturbingly high for older adults with a ratio of 4:1. Lethal suicide attempts by younger people as a whole is 25:1. Michael Nadorff and his colleagues designed a study to investigate the possible connection between insomnia and suicidal ideation in older adults.
Key study features:
- 81 adults aged 65 and older participated
- Participants completed surveys about sleep, symptoms of depression, and suicidal ideation
- They found that insomnia symptoms were significantly related to suicidal ideation
- They also found that the relationship between insomnia was mediated by depressive symptoms
The “take-away” – Insomnia often precedes depression in late life, and when untreated, tends to make depressive symptoms worse. Insomnia can be a risk factor for suicide, as it can exacerbate depressive symptoms which can ultimately lead to suicidal ideation.
This study can be found in the Journals of Gerontology, Series B (March, 2013).
Let Me Guess How Old You Are
So you think that you’re good at guessing someone’s age? Maybe not. Voelkle and colleagues recently investigated accuracy and bias in age estimation across the adult life span. For this purpose, they selected 154 adults (young, middle and older adults) of both genders and asked them to assign ages for 171 young, middle, and older adult faces. They used over 2000 photographs portraying different facial expressions. What did they find?
- The age of older faces was more difficult to estimate than younger faces.
- Older and younger adults were more accurate and less biased in estimating the age of members of their own age group.
- No same-gender bias was found (e.g., women were no better at estimating age of other women then they were estimating age of men).
- In general, age estimation accuracy decreases with age
For more information about this study, see Psychology & Aging (June 2012).
The Impact of Emotion on Associative Memory Among Older Adults
Associative memory refers to the ability to remember features of a person, object, or event as a whole experience. There is research suggesting that as we age, we tend to lose associative memory clarity. This may be related to structural changes in the prefrontal cortex and hippocampus. Strong negative emotion has been found to interfere with associative memory for all adults. A recent study was reported in which the authors examined whether emotion impairs associative memory more dramatically among older adults than younger adults.
Key study features:
- 32 young adults and 32 older adults participated in the study.
- While there were differences between the two groups in terms of associative memory (younger subjects did better than older subjects), negative emotions did not inhibit memory performance more dramatically among the older sample than it did for the younger adult sample.
For more information on this study, click here.
Late-Life Cognitive Activity on Cognitive Health
A growing body of longitudinal studies is finding that frequent participation in cognitively stimulating activities is associated with decreased rates of cognitive decline in old age. In the April edition of Neurology, Wilson and colleagues tested the hypothesis that late-life participation in mentally stimulating activities positively affects cognitive functioning among older adults. They followed and analyzed results from over a thousand older adults using a longitudinal design (over nearly five years). Cognitive functioning was measured by administering a neuro-cognitive battery of tests. Cognitive activities were measured by administering a 7-item, 5-point scale. The researchers found that level of cognitive activity on a given year predicted global cognitive function in the following year. They report that this demonstrates that mental stimulation in old age leads to improved cognitive functioning. One should keep in mind that the results are based on self-reported cognitive activity and are subject to reporter bias. Also, persons with dementia were excluded from the study. Therefore, the results may not generalize to persons who already have cognitive impairment.
Do Older Adults Regularly Use the Internet?
Do older adults regularly use the Internet? According to a recently published survey by the Pew Research Center, 53% of American adults ages 65 and older use the Internet or email.
Some other interesting findings from the Pew study:
- If they start using the Internet, most older adults will use it daily (70%)
- After age 75, Internet use drops off sharply
- 70% of seniors own a cell phone, which is up from 57% two years ago
- Nearly one third of the seniors who are online use social networking sites like Facebook and LinkedIn
- Whereas 18% of all adults own e-book readers, only 3% of people over 75 do
- Email continues to be the dominant online communication tool for seniors
- Of those seniors who use the Internet, 86% use email
Ask the BCAT Faculty: What Matters for People with Dementia?
I work in an assisted-living facility in Illinois. We embrace the “culture change” philosophy, and have worked hard the past two years to change our facility from an institution to a real home. We use the BCAT to help determine what activities our residents can participate in, and to what degree they can make their own choices (Like take their medications themselves if they choose). Our biggest challenge is with our dementia residents. How do we make sure that we are providing meaning in their lives since they can’t always tell us what they want?
BCAT Faculty Answer:
This is an interesting question. During the last several years, a number of researchers have tried to better understand what people with dementia value in their residential environments. By interviewing families and caregivers, a consensus is emerging. High on the list are: time with family; “conversation” with friends, family, and staff; exercising some control in their environments; quality of activities rather than quantity of them; and opportunities to feel productive (this could be as basic as folding napkins).
Two studies in particular provide some useful information about this issue. Wendy Moyle and her colleagues (2011) found that having purposeful relationships with family and other people, needing some control over their lives, and feeling productive were important life satisfaction variables for residents who have dementia. Meanwhile, Carolyn Popham and Martin Orrell (2012) found that while meaningful activities, such as outings, are important, staff attitudes, training, and commitment are also essential to satisfaction and meaning for older adults with dementia. *
Using the “culture change” philosophy to improve the lives of older adults with dementia is important. Creating residential environments that promote purpose can only be accomplished and sustained when staffs are trained, motivated, and aware of what residents, at an individual level, need to have purpose in their lives. This begins with the understanding that having dementia does not preclude having life quality.
*Both studies can be found in the Journal, Aging & Mental Health.
Inter-rater Agreement in Using the CSDD for Assessing Depression
Older adults with possible depression often require special assessment instruments if they have significant cognitive impairment. A common feature of dementia is the inability to effectively communicate subjective mood states. Consequently, obtaining information from other sources (by proxy) is key to accurately identifying depression. The Cornell Scale for Depression in Dementia (CSDD) is one such instrument that was developed specifically for older adults with significant cognitive impairment. Several studies have also indicated that it is a reliable depression scale for older adults who are cognitively intact. One of the unique features of the CSDD is that it requires interviewing both the patient and an informant. Inter-rater agreement is key to the validity of the CSDD. The higher the rate of the agreement, the more valid the results are likely to be.
However, studies have reported mixed results regarding the inter-rater agreement between patients and informants. In a recent study in Thailand, researchers compared inter-rater agreement for patients with and without cognitive impairment. They also analyzed the CSDD factor structure, though that feature of their research will not be reviewed here.
Key findings: (1) They found a statistically moderate agreement between ratings from patients and their informants for the entire sample (including patients with and without cognitive impairment). (2) However, inter-rater agreement between cognitively impaired patients and their informants was much stronger (0.71) than between cognitively intact patients and their informants.
Takeaway: (a) This study supports the use of proxy raters for assessing patients with cognitive impairment. One of the strengths of the CSDD for assessing depression in patients with dementia is the use of proxy ratings, and points to the importance of incorporating the views of other knowledgeable people. (b) The benefit of proxy ratings for intact patients may be less important. In fact, other studies have found that informants tend to under-rate depressive symptoms in cognitively intact patients. One might conclude that putting particular emphasis on the ratings of intact patients (over those from their proxies) would lead to more accurate diagnoses of depression.
For more information about this study, go to Clinical Interventions in Aging, Discrepancies in Cornell Scale for Depression in Dementia (CSDD) items between residents and caregivers, and the CSDD’s Factor structure (2013).
Ask the BCAT Faculty: What is the Prevalence of Depression?
An occupational therapist from Connecticut writes…
“I understand that there is a lot of depression in nursing home patients. Our company has started using the WIPE Depression Scale, and it seems that more than a third of our rehab patients are depressed. Can you give us information about how common depression is in nursing homes and whether our impressions are correct?”
BCAT faculty response…
Thank you for writing us. Certainly the question of prevalence of depression in nursing home residents in general and sub-acute rehab patients in particular is very important. Researchers have reported a range between 20 and 50% for incident depression in nursing homes. A generally reliable figure appears to be approximately 35%. This number is higher when one includes those with sub-threshold symptoms (i.e., depressive symptoms are present, but do not meet actual criteria for major depression). There is very little data about whether sub-acute patients have higher or lower rates. We have found that rehab patients have about the same level of depression as long-term care residents, but may have higher levels of anxiety. This is understandable given the transitional nature of sub-acute care (e.g., “Will I be able to go home?” “Can I manage the steps in the house?” “Will I regain my ability to walk?”).
There are a number of issues that complicate accurate measurement of depression. Here are some of them: (1) Clinically, we distinguish between major depression and minor depression, the later defined by sub-threshold symptoms that don’t quite meet criteria for major depression, but that still negatively impact life quality. Assessments don’t necessarily differentiate between the two categories. (2) Depression is often unrecognized and misdiagnosed as most assessments are informal (i.e., based on observation). The Centers of Medicare & Medicaid Services (CMS) has recognized this, and consequently mandated inclusion of a depression screening tool (PHQ-9) in the MDS 3.0 to improve detection of depression. (3) Another problem with accurate diagnosis is called “measurement error.” This is when the assessment tools have questionable validity. This may be pertinent to the PHQ-9 as there are a number of questions about its accuracy. We are addressing this at the BCAT Research Center and will be reporting our findings later this year. (4) Depression is frequently comorbid with other problems that are common in long-term care, such as cognitive impairment, medical illness, and functional impairment, and staffs may attribute symptoms to the wrong condition. This is particularly the case when patients have significant pain issues. (5) Staffs are rarely trained in identifying key indicators of depression, and therefore may not recognize them.
Accurate identification of depressive symptoms is essential to treatment and well-being. The WIPE Depression Scale was designed to focus on depression symptoms, not depression diagnosis per se. We recommend that therapists look at how patients respond to each of the four questions, not just the total WIPE score. This can provide useful information for effective treatment, and help explain why some depressed patients do poorly in rehab. Finally, because the prevalence of depression is high in nursing home patients, it is important to work collaboratively with other providers, including behavioral health and primary care. If a rehab therapist suspects depression in a patient who is not receiving treatment for it, conveying this information within the team can lead to more rapid improvement in mood and ultimately in rehab outcomes.
Ask the BCAT Faculty: Does Music Protect Memories?
A speech therapist in Ohio writes to us with this question:
"I have heard that people with Alzheimer's disease are able to retain memory of music- both words and melodies- while losing other cognitive functions, including basic language skills. Would this mean that the music centers are more protected against the deterioration of dementia?"
BCAT Faculty Response:
Ask the BCAT Faculty: About the Accuracy of MCI Test Results
We received the following question from a psychologist in England:
"I understand that dementia is thought of as a progressive condition, and that once accurately diagnosed, a return to "normal" functioning is not likely. I was thinking that this would be true of MCI; however, we have seen a number of patients in our clinic who were diagnosed with MCI, but who later improved in their cognitive functioning to normal levels. I thought MCI was a transitional stage between normal functioning and dementia. If so, why would MCI patients later test in the normal range? Can you clarify for us."
BCAT Faculty Response:
Excellent question. Let’s start with some basics. You are correct in your thinking that an accurate diagnosis of dementia would suggest that a return to normal cognitive functioning very unlikely. Of course, an accurate dementia diagnosis would rule out transient medical conditions that can cause temporarily cognitive declines. Delirium is one of the more significant acute medical conditions that tends to lower cognitive performance on cognitive tests, and can look like dementia. Therefore, it is important to rule out infections, multiple drugs effects, dehydration, poor nutrition and other causes of delirium. Furthermore, psychiatric conditions, such as depression and excessive anxiety, can falsely suggest dementia (i.e., pseudo-dementia). Once these other factors are accounted for, then testing results showing dementia are quite stable.
The same can be said of Mild Cognitive Impairment (MCI). Here too, it is important to rule out medial and other factors that can artificially lower test scores and cause false positives (i.e., saying a patient has MCI when she is actually cognitively normal). However with MCI, we have an additional complication in making an accurate diagnosis. We refer to this as "the sensitivity problem." Many of the cognitive screening instruments commonly used by providers are not reliable in accurately identifying MCI. Two examples are the MMSE and the 3MS (Modified Mini-Mental Status Examination). MCI diagnoses should be made using convergent data and sensitive cognitive instruments. Otherwise, misdiagnoses will be more common.
There is a recently published article that bears on the issue of stability of MCI diagnosis. Brodaty and his colleagues reported (Alzheimer's & Dementia, 2013, Vol 9, 310-317) new findings regarding MCI from the Sydney Memory and Ageing Study. One of the questions they investigated was whether Mild Cognitive Impairment (MCI) is a stable stage (rate of reverting to normal functioning). They found a reversion rate of 28%, which they described as evidence for relative stability of the MCI classification. In our view, their reversion rate may overestimate true reversion. Had they not made MCI classifications based, in large part, on the MMSE (which has poor sensitivity to MCI); used more than a two-year follow-up period; and not excluded subjects who had deficits in instrumental activities of daily living, they made have found a lower conversion rate.
Using instruments like the BCAT, which not only has been shown to be sensitive to MCI, but can provide information about specific MCI subtypes (amnestic, executive, multi-domain, undifferentiated), will improve diagnostic accuracy and lead to more stable results. One should anticipate some reversion since the mildest forms of MCI have a thin "just noticeable difference" point relative to normal cognitive functioning. We expect that a more accurate reversion rate, based on sensitive measures, and using more than one diagnostic tool, is somewhere between 15-20%. And of course, the skill of the clinician plays an important role in determining a diagnosis of MCI.
On Assessing Judgment
One important area of research at the BCAT Research Center is the investigation and development of effective instruments for measuring practical judgment. Because problems in judgment are a common feature of dementia and place patients at risk for a host of everyday problems, identifying and developing tools for measuring this construct are very important. We define judgment as the capacity to make appropriate decisions, in specific contexts, after careful consideration of available information and probable outcomes.
We recently published research in which we investigated the validity of a judgment instrument commonly used by neuropsychologists. We were interested in determining if the Judgment Test of the Neuropsychological Assessment Battery (NAB) has acceptable "incremental validity."
Incremental validity is used to determine whether a test will increase the predictive ability of an existing method of assessment. In other words, incremental validity seeks to answer if an additional test adds meaningful information above and beyond what simpler, already existing methods provide (like a clinical interview).
We found that the Judgment Test of the NAB does in fact, have incremental validity, and one might want to include it in assessing older adults with possible deficits in judgment.
Below, we provide the Abstract of the article. If you would like more information about the NAB, or about the Kitchen Picture Test (the BCAT Judgment Test), please contact us at firstname.lastname@example.org.
The Judgment Test of the Neuropsychological Assessment Battery (NAB): Psychometric Considerations in an Assisted-Living Sample
A total of 82 older adults recruited from assisted-living facilities completed the Judgment subtest of the Neuropsychological Assessment Battery. The internal consistency reliability of Judgment scores in this sample, as estimated by Cronbach's α, was .83. Significant and strong Judgment score correlations with measures of general cognitive functioning and instrumental activities of daily living provided evidence of construct validity. Furthermore, participants who exhibited the capacity to consent to the evaluation performed significantly better on the Judgment subtest than did participants who did not exhibit consent capacity. Finally, Judgment scores predicted a significant proportion of variance in both instrumental and basic activities of daily living over and above the variance accounted for by scores on measures of general cognitive functioning and executive functioning. This study presents promising preliminary evidence of the incremental validity of Judgment subtest scores for predicting both basic and instrumental activities of daily living in an assisted-living sample.
The full text can be found at: The Clinical Neuropsychologist. 2013 Jul;27(5):827-39. doi: 10.1080/13854046.2013.786759. Epub 2013 Apr 9.
MacDougall, E.E. & Mansbach, W.E. (2013). The Judgment Test of the Neuropsychological Assessment Battery (NAB): Psychometric Considerations in an Assisted-Living Sample. The Clinical Neuropsychologist, 27(5):827-39. doi: 10.1080/13854046.2013.786759.
Ask the BCAT Faculty: Accuracy Concerns with the BIMS Assessment Screen
"I am a medical social worker in a skilled nursing facility. One of my tasks is to administer the Brief Instrument of Mental Status (BIMS) to all our residents. We don't find the BIMS very helpful, and the scores do not seem reliable. For example, we recently had a resident who had a perfect BIMS score, yet our rehab team finds her to have significant memory and other cognitive problems. Is this a common problem? Am I missing something?"
BCAT faculty response.....
Thank you for your questions. The BIMS is the cognitive screening tool mandated by MDS 3.0, the broad assessment system currently used in nursing homes. Federal and state governments have long recognized that cognitive assessment is a critical feature of person-centered care and clinical treatment planning. In all fairness to the BIMS, it was not designed as a complex assessment instrument and is not sensitive to many cognitive issues. Still, it is an improvement over previous nursing home assessments.
Your experience with the BIMS is not unusual. While it appears to be a technical improvement over earlier mandated cognitive assessment methods, it has some shortcomings. First and foremost, it is not designed to be sensitive to the full cognitive continuum and does not stage impairment levels. Second, the cut-scores differentiating those residents with and without cognitive impairments are based on the Modified Mini-Mental State Examination, a measure that appears to have poor sensitivity to mild cognitive impairment. Therefore, it could have a relatively high error rate. Third, memory is assessed using a simple word list (three words), with no story recall component. There is empirical support for inclusion of story recall items in cognitive screening instruments, especially for identifying patients with Mild Cognitive Impairment (MCI). Fourth, despite the fact that deficits in executive functions are common features of dementia, the BIMS used in MDS 3.0 does not assess executive capacities. Fifth, the BIMS was normed on a VA population in which approximately 95% of the sample was male. Most nursing homes have more females than males, and it is unclear if females would have different normative values.
The BCAT Research Center has just completed a study comparing the BCAT, BCAT- Short Form, and BIMS. One of the issues we investigated was the error rate of each test in properly identifying cognitive stages. Unfortunately, the BIMS was found to have an unacceptably high "false negative" rate. That is, it tended to classify residents as cognitively "normal" when in fact they had cognitive impairment. This may be the situation the medical social worker wrote us about.
Both the BCAT and BCAT-SF performed well in predicting cognitive categories. While MDS 3.0 does not require facilities to use the BCAT or BCAT-SF, we recommend them for accurate assessment and appropriate person-centered care. As for our recent research comparing cognitive instruments, we will send out a notice when the study is available for publication.
Empathy & Age
One common definition of empathy is the propensity to “experience perspectives and feelings more congruent with another’s situation than with [one’s] own” (Decety & Lamm, 2006). Quite a lot of research has investigated empathy in people younger than 65, but relatively little has focused on older adults. Ed O’Brien and his colleagues recently compared self-reported empathy in three large cross-sectional samples of American adults aged 18-90.
Key study features:
- Over 72,000 subjects participated across the three samples
- Participants completed the Interpersonal Reactivity Index (Davis, 1983), which measures “empathic concern” and “perspective taking.”
- In all three samples, empathy conformed to an inverse-U-shaped curve: Middle-aged adults reported higher empathy than both young adults and older adults.
- Another finding was that women reported more empathy than men.
To learn more about this study, see the Journals of Gerontology: Series B (March, 2013).
Pay Attention to Mis-Attention
These questions were asked by a recreation therapist who works in a BCAT certified facility.
Question - "I understand that one reason why it is dangerous to drive and talk on the cell phone at the same time is that the two activities (driving and talking on the cell) make us inefficient at both. Why can't we do two things at the same time efficiently? Also, how do we get better at it?"
The BCAT faculty response:
Answer - While it is comforting to believe that we are good at multi-tasking, it is more accurate to say that we tend to switch attention back and forth, from one task to another. Attention or "attentional capacity" is rather limited, and might best be described in zero-sum terms. When attention is directed to one task, say driving, it is diverted from another, say talking on the cell phone. We simply can't devote 100% of our attention to two tasks at the same time.
If you want to improve your attentional skills, you will likely be more successful trying to increase your total attentional resources, rather than just trying to get better at dividing your attention. This way, you have more total attentional capacity to draw from. That being said, here is a tip on efficient "divided attention." It is easier to do two very different types of tasks at the same time than two similar ones. For example, it is easier to divide attention between eating dinner and watching TV, than it is to read the newspaper and carry on a conversation. This is partly because in the case of the former, you are tapping into two very different areas of the brain, while in the latter, you are not. So, the more dissimilar the tasks (and the more simple), the more successful the divided attention.
Ask the BCAT Faculty
This series is created to answer specific and frequently asked questions from professionals in the field or who do research. The questions we address in the series are selected from the large volume of inquiries we receive each week. Generally, the BCAT faculty addresses one question per month.
A healthcare provider writes:
"I am working with a patient who has started doing cross word puzzles and Sudoku everyday. Would you say that this qualifies as brain fitness training? Are there necessary conditions for cognitive exercises to qualify as brain training?"
BCAT faculty response:
"Brain fitness" has become an enormous and growing industry. Some products have sound science behind them, while others simply do not. From our perspective, cognitive exercises are more likely to have an actual positive impact on cognitive processing if they meet the following criteria.
- The exercises should engage core neural circuits, such as those associated with memory, executive functions, and attentional capacity (the "cognitive task manager" domains, for example). If they don’t, probability of success is much lower. At the very least, the exercises should require sustained attention and concentration.
- The exercises should be moderately difficult--hard enough to really work the neural circuit, but not so challenging that failure is frequent. Also, the exercises should be increasingly difficult over time. Once mastery is obtained at one level, it is time to go to the next level.
- The exercises should be frequent. One guideline is 15-20 minutes per day, three to five times a week. We emphasize frequency over duration of each exercise session. Three challenging 15-minute sessions per week may be more effective than one long session.
- The exercises should be varied and continual. By varied, we mean that one should not always do the same exercise, but should perform a variety of exercises that work different neural circuits. By continual, we mean that positive gains in cognition may not endure without ongoing exercise. You either move forward or you move backward. Cognition is a dynamic, not a static process.
- While not a criterion per se, exercises that are enjoyable are more likely to be completed. Go for the fun ones!
So, to answer the question as to whether a specific cognitive exercise qualifies as "brain training," determine if it meets these criteria.
For more information about brain fitness and the more clinically focused "brain rehabilitation," visit the BCAT Brain Rehabilitation page on our website here.
If you would like the BCAT faculty to address your question, please write us at: email@example.com
BCAT Certification Through e-Learning
We are happy to announce that healthcare professionals who are interested in using the BCAT Test System can become certified through our online course beginning May 15, 2013. This is a three-hour e-learning program that focuses on all five of The BCAT System tests. Successful completion of this Certified BCAT Test System Administrator course will be required in order to use the BCAT, BCAT-Short Form, WIPE Depression Screen, Kitchen Picture Test of Judgment (KPT), and the BCIS (for severe cognitive impairment). For many healthcare disciplines, continuing education credits for this three-hour course will be available. More information will soon be available on the BCAT University page.
Impact of GED Education on Incident IADLs
For years, research has demonstrated that education matters when it comes to predicting morbidity, mortality, and functional disability. Those with less than a high school education are at higher risk for each. Given the increasing number of people who obtain the General Educational Development (GED) diploma, it may prove helpful to understand whether the GED is predictive of functional disability. In a recently published article by Liu and colleagues (The Gerontologist, April, 2013), findings are presented from research investigating whether adults 50 years and older with GEDs have increased risk for incident instrumental activities of daily living (IADLs) as compared with high school graduates.
Key study findings:
- Survey data
- 9426 subjects from the Health and Retirement Study
- HS degree holders had lower risks for incident IADLs
- No significant differences were found between GED holders and respondents without HS degrees in terms of developing IADL disabilities
The “Take-away” – While GEDs may be seen as equivalent to high school diplomas, in terms of functions status (IADLs), they are not. In fact, GED holders more resemble persons without HS credentials than they do HS graduates in terms of functional disabilities.
The Association between Depression and Mortality
An impressive body of research shows that depressive symptoms are associated with increased mortality among older adults. However, most of these studies have been conducted with American and European samples. There is much less data available for Asian elderly.
Teng et al. (2013) recently investigated whether depressive symptoms are associated with increased mortality for Asian older adults. Using data form the Survey of Health and Living Status of the Elderly in Taiwan, a cohort of 2416 men and women aged 65 and older were followed up to eight years. Depressive symptoms were assessed by the 10-item CESDS.
Primary findings: Depressive symptoms were associated with “all-cause” mortality in men, but not women. Among those without chronic diseases (without diabetes, lung disease, cancer, or cognitive impairment), depressive symptoms were associated with mortality after eight years follow-up. However, no significant association between depressive symptoms and mortality was found for participants with chronic diseases. Thus, depressive symptoms may be an independent risk factor for mortality among Asian elderly in general, but particularly for elderly men and those without chronic disease.
The entire study can be found in the journal, Aging and Mental Health, Volume 17, Issue 8, 2013, 470-478.
Comparing Major Depression & Subthreshold Depression
From the standpoint of risk management and treatment interventions, there is a tendency to think about depression in binary terms - one is depressed or one is not. This is an unfortunate and inaccurate perspective, as there is ample evidence that depression is continuum-based. It is more accurate to think about depression in terms of "major" depression and subthreshold depression. The latter refers to depressive symptoms that are serious, but don't meet the formal criteria of major depression.
Mi Jin Lee and colleagues were interested in comparing older adults who had major depression with those who had subthreshold depression. Specifically they investigated whether there were differences in specific symptomology and associative factors in their community long-term care sample.
Method: Participants were age 60, derived from a baseline survey of a longitudinal study (315 non-depressed, 74 MD, and 221 SD). The Diagnostic Interview Schedule was used to establish diagnoses of major depression (MD), the Center for Epidemiological Studies Depression Scale (CES-D) was used to establish diagnoses of subthreshold depression (SD), and other self-report measures were selected to explore potential associative factors of demographics, comorbidity, social support, and stressors.
Results: (1) No differences in CES-D identified symptoms occurred between the two groups. (2) MD and SD were both associated with lower education, poorer social support, more severe medical conditions, and higher stress when compared to non-depressed older adults. (3) Younger age and being female were associated solely with MD. (4) Worse perceived health and more trouble affording food were associated solely with SD. (5) The only associative factor significantly different between MD and SD was age. MD subjects were more likely to be younger than those with SD.
Conclusion: Should one only focus on older adults who meet criteria for MD, many depressed persons (who have subthreshold depression), who also face multiple comorbidities, high levels of stress and social isolation, and substantial depressive symptoms, would go undiagnosed and untreated.
You can read more about this study in: Aging & Mental Health Volume 17, Issue 4, 2013, pages 461- 469.
Available online: 11 Apr 2013
30-Day Rehospitalizations & Post-Acute Nurse Retention
After acute hospitalization, many older adults with complex medical conditions are directly discharged to skilled nursing facilities for post-acute or long-term care. Approximately one fourth of these Medicare skilled nursing home transfers will be readmitted to hospitals within 30 days. It has been estimated that 28-40% of these could have been prevented with higher quality post-acute nursing home care. Previous research has linked nursing home quality to licensed nurse retention. To better understand whether nurse retention is associated with 30-day rehospitalizations, Kali Thomas and her colleagues investigated the possible association between the two.
Key study features:
- The used archival data from 681 Florida nursing homes
- They found that licensed nurse retention in nursing homes was significantly related to the 30-day hospital readmission rate
- Higher retention was associated with few readmissions
This study is published in The Gerontologist, 53(3), 211-221.
Time Discrimination in Traumatic Brain Injury Patients
Time management skills are required for most daily activities. While the traumatic brain injury (TBI) literature is full of indications that TBI patients suffer from cognitive impairments, few studies have looked at time management skills. Mioni, Stablum, and Cantagallo (JCEN, 2012) designed a study to assess temporal abilities in TBI patients using a time discrimination task.
Twenty-seven TBI patients (ages = 18–60 years) and 27 controls (ages = 20–60 years) were asked to discriminate between two time intervals presented sequentially. Participants were also asked to perform two tasks to assess attention, speed-of-processing (the Stroop task), and working memory (the n-back task) abilities.
Primary finding: The TBI patients were less accurate than the controls on the time discrimination task and showed greater time-order error effects.
Cognitive Processing Speed in Persons with Multiple Sclerosis
Patients, families, and practitioners have observed that Multiple Sclerosis (MS) patients can experience delays in cognitive processing speed (CPS). In an attempt to understand underlying factors that may contribute to these delays, Sandroff and Motl published their research findings in a recent edition of the Journal of Clinical and Experimental Neuropsychology (2012).
They designed a cross-sectional study examining associations among aerobic capacity, muscle strength, balance, and cognitive processing speed (CPS). 31 persons with multiple sclerosis (MS) and 31 matched controls participated. Participants completed neuropsychological tests and aerobic capacity (i.e., peak oxygen consumption), muscular strength (i.e., asymmetry between knee muscles), and balance (i.e., postural sway) assessments.
They found that aerobic capacity (r = .27), postural sway (r = −.40), and knee extensor asymmetry (r = −.25) were associated with CPS in those with MS and accounted for differences in CPS between MS and control groups. This was a cross-sectional study reporting correlational data (does not imply that these factors actually cause cognitive processing delay, but that they are associated with it). One implication of their findings is that aerobic, balance, and resistance training might be avenues for improving CPS in this population.
Social Support and Religious Attendance in Later Life
A considerable amount of research has documented that older adults are more at risk for loneliness and associated negative health consequences. Retirement, relocation, spousal and other deaths, and social migration can make social networks smaller. Some research suggests that one of the motivating factors in religious attendance (e.g., attending services, going to congregational events) is to either hold onto or increase social integration and support. Rote, Hill, and Ellison (2013) tested their model that social integration and social support are key mechanisms that link religious attendance and loneliness.
Key study features:
- They used data from the national Social Life, Health, and Aging Project (data from 2165 subjects were selected)
- Subjects were aged 57-85
- The researchers found that religious attendance was associated with higher levels of social integration and social support, and that social integration and social support were associated with lower levels of reported loneliness.
- They conclude that religious attendance may protect older adults against loneliness by integrating them into a larger and supportive social network.
For more information about this study, click here.
Programs that Locate Wandering Elders
Given an aging society and increased life expectancies, the incidents of “wandering” of older adults with cognitive deficits will increase. While there are several programs developed to locate wanderers, there is actually little research on how effective they may be in locating wanders, and whether they are significantly more effective than informal efforts. Gina Petonito and her colleagues address this and other issues in a recently published article in The Gerontologist (2013). They review three prominent programs: Safe Return, Project Lifesaver, and Silver Alert.
- Regarding Safe Return: The program was established in 1993 by the Alzheimer’s Association. AA partnered with MedicAlert. Funding comes from a one-time enrollment fee of approximately $50 and annual renewals of $25. It is a 24-hour national program maintaining a database of 145,000 registered individuals. Registrants wear an identifying bracelet of necklace. If a user is missing, caregivers call an emergency telephone number.
- Regarding Project Lifesaver: Targets people with “Alzheimer’s, Autism, Down Syndrome, dementia, and other related disorders.” Enrolled individuals wear a transmitter. Caregivers notify their local Project Lifesaver if a member is missing. The company partners with for-profit agencies that supply the locating equipment. Funding comes from donations, a Department of Justice grant, and individual enrollment (about $25).
- Regarding Silver Alert: Relies on integrating media, traffic signs, and law enforcement to inform the public of missing older adults who are cognitively impaired. The program also often broadcasts information about the missing person through television stations. The first program was established in 2006 in Georgia, and now at least 32 states have the program. There is a bill to nationalize the program. It is a free program based on the Amber Alert concept.
The researchers point out that it is unclear just how effective these programs are in locating cognitively impaired wanders. More research should be done to test them, and determine what features are most effective. They advocate that different categories of “missing” be established, differentiating among wandering, actually missing, and critical risk factors.
Reducing Hospital Readmissions by Improving Nurse Working Conditions
Can nursing work factors affect hospital readmission rates? Provisions in the Affordable Care Act increase hospitals’ financial accountability if readmissions occur too quickly after discharge. In an interesting study by McHugh and colleagues published in the journal Medical Care, there is support for the idea that improving nurses’ hospital work and staffing patterns may be effective in preventing readmissions.
Key study features:
- Data came from 412 California, New Jersey, and Pennsylvania hospital nurses surveys, as well as the American Hospital Association Annual Survey
- Hospitals with “good” working conditions (a factor of work environment, staffing patterns, nurse education) experienced reductions in 30-day readmissions for heart failure, heart attack, and pneumonia, compared with hospitals with poorer working conditions
- Highly educated nurses were associated with modest improvement in reduced readmissions for pneumonia, but not for heart conditions
- One implication is that hospitals might want to invest in improving work environment variables to reduce 30-day readmissions.
For more information on this study, click here.
"Social Slights" Among Older Adults
Social contacts and conversations are central to our well-being. While individuals differ as to how much they require, generally speaking, insufficient social stimulation has a negative impact on our psychological and somatic health. Previous research has shown that older adults might be less negatively impacted by “social slights” or exclusion from social interactions than younger adults. Why this may be the case is unclear. In an attempt to add to our understanding of this, Löckenhoff and her colleagues published their findings on social exclusion in The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences (2013).
- 40 younger adults (22-39) and 40 older adults (58-89) participated
- Participates played a version of “Cyberball,” in which they were progressively excluded
- Older adults were less likely than younger adults to respond negatively to mild levels of social exclusions
- However, both groups responded similarly to pronounced social exclusion
While not specifically addressed in this research, the generalizability of these findings to assisted-living and nursing facilities is interesting. Both types of facilities have complex social and residential dynamics. If it is the case that more pronounced social exclusion does negatively impact on well-being, facilities should be mindful in their design of activity programs to promote positive social interactions and reduce social exclusion.
Bilingualism and Delaying Onset of MCI
A number of recent studies demonstrate that bilingualism might delay the onset of dementia. It appears that this effect is associated with life-long bilingualism, not necessarily recent acquisition of a second language. Reporting their findings in the Journals of Gerontology (2012), Ossher and colleagues extended the question of delay to subjects with Mild Cognitive Impairment (MCI). More specifically, does bilingualism delay the onset of amnestic MCI or multi-domain MCI?
Details of the study:
- 111 subjects were recruited
- clinical evaluations were conducts by two neuropsychologists
- for amnestic MCI, bilingual subjects experienced a delay in onset compared with monolingual subjects
- bilingual amnestic MCI subjects were 4.5 years older than monolingual subjects at the time of diagnosis
- however, for multi-domain MCI, no bilingual delay was found
- the researchers contend that life-long bilingualism may serve a protective function for amnestic MCI
Single-domain MCI refers to the condition in which one primary cognitive domain is significantly impaired. This is typically memory, and referred to as amnestic MCI. In multi-domain MCI, more than one cognitive domain is impaired, but not to the degree to which a diagnosis of dementia can be accurately made.
Depression in Long-Term Care
Depression is common in long-term care settings. Unfortunately, it is often unrecognized. As a result many residents needlessly suffer from a disorder that is generally treatable. Publishing in the Journal of the American Medical Directors Association, Mugdha and Blazer reviewed this literature.
- Up to 35% of long-term care residents have depressive symptoms
- Physicians and nursing staff often fail to identify depression
- Less than 50% of the cases of depression were recognized by nursing staff
- Probable reasons for failure in identifying depression are that providers are not looking for depression, and depression is comorbid with other conditions
- It is important to identify depression since it often responds positively to treatment
Cross-cultural Caregiving: Results from a Hong Kong Study
Numerous studies have documented various "burden" syndromes associated with spousal caregivers. While most of these studies have focused on Western people, cross-cultural and ethnic studies of caregiving in other countries are increasing. A recent study of caregivers in Hong Kong is one interesting example.
Key features of this study:
- females were more often caregivers
- caregivers were on average two years younger than their care recipients, but suffered from the same number of chronic illnesses
- despite their age, caregivers provided more than 14 hours of care per day
- caregiving was a risk factor for depression, but becoming depressed was more associated with attitudes about role and self
- having social support resources did not predict depression
The researchers discuss conceptual issues inherent to this population. One of which is whether caregivers could be more at risk given Confucian ideology that emphasizes moral imperatives associated with roles in society.
For more information about this study, click here.
How Well do People Understand Alzheimer's Disease?
Dementia in general, and Alzheimer's disease in particular, represent major public health concerns. As such, how well do people understand them? A number of surveys have been conducted in the U.S., but fewer in other countries. In a recent study about Alzheimer's disease in Britain, Hudson and colleagues examined questions about the public's knowledge about AD.
Specific features of their research:
- 312 subjects participated by responding to a questionnaire about Alzheimer's disease.
- Subjects completed the Alzheimer's disease knowledge scale (ADKS).
- In general and regardless of age, education, and disease familiarity, participants demonstrated a good understanding of a number of AD features.
- However, knowledge gaps existed more meaningfully in these areas: the disease course, such as life expectancy and increased fall risk; conditions that can exacerbate cognitive decline in AD, such as inadequate nutrition; and conditions that can simulate AD symptoms, especially depression.
They conclude that educational campaigns are important in order to reduce negative disease impact.
For more information about this study, click here.
Executive Functions and Diabetes Self-Management
Diabetes is a growing public health burden in the U.S. and in many industrialized nations. Among older adults, Type II diabetes is on the rise. This age population also shares a high prevalence of cognitive impairment, especially in the executive functions. Therefore, the issue of whether impaired executive capacity is a risk factor for diabetes management is important to understand. In a recently published article in the journal, Aging and Mental Health (2012), Nguyen and colleagues reported their findings about whether compromised executive functions (They also looked at affective disorders, but these findings will not be reported in this review) are a risk factor for diabetic management.
About their study:
- 563 independently living rural older adults (age 60 and older) participated
- Three measures of executive functions were used: Animal Fluency, Brief Attention Test, and Digit Span Backward
- Blood glucose as measured by A1C was the main outcome measure
- Executive functions were significantly associated with A1C levels
- Poor executive functions were associated with high glucose levels, and stronger executive functions were associated with lower glucose levels
They conclude that low executive abilities are a potential barrier to self-care of managing glucose levels.
BCAT- Short Form (BCAT-SF) and Primary Care
In order to meet the rapidly expanding numbers of older adults with dementia and MCI, we will need effective and brief cognitive screening tools. In a recent survey of primary care specialists, doctors, and nurse practitioners reported that they believe that cognitive screening should be part of primary care assessments. However, given the number and complexity of health issues among their patients, time is at a premium, and often cognitive screening is not done. They advocate for screening tools that can be completed in less than five minutes. One screening tool that can be administered rapidly and that has robust psychometric properties is the BCAT – Short Form.
Some important features of the BCAT – Short Form (BCAT-SF):
- It can be administered in less than five minutes
- It consists of six items
- 21 possible points, with a “cut” score differentiating dementia from non-dementia
- Scores of 15 and below indicate dementia; scores of 16 and above indicate non-dementia
- It has an online scoring and interpretive system
- It is derived from the full BCAT, and contains items representing the three cognitive clusters: contextual memory, executive functions, and attentional capacity
- The BCAT-SF is predictive of ADLs and IADLs
- The development and validation study is published in the journal, Aging and Mental Health.
More information on the BCAT-SF can be found at www.thebcat.com
Depression and Cognitive Impairment Among Nursing Home Residents
Depression and cognitive impairment are common among nursing home residents. Effective treatment can depend on whether care providers accurately understand the level of depression in their residents. Studies have documented a "disconnect" between resident and staff ratings of resident depression, independent of cognitive functioning. This issue was investigated by Gail Towsley and her colleagues and reported in the journal, Aging and Mental Health (2012).
Key features of the study:
- 395 pairs of residents and nurses
- 28 nursing homes participated
- Average resident was white, female and had Mild Cognitive Impairment (MCI)
- Depression measured by interviewing both residents and nurses
- Depression measure used was the Cornell Scale for Depression in Dementia (CSDD)
- High discrepancy between resident and nurse ratings in resident depression
- Implications: importance in obtaining resident input when assessing depression, and educating staff in how best to assess depression (especially in residents with cognitive impairment).
For more information about the Cornell, click here.
Greater Cognitive Decline in Women than Men
Using a meta-analysis from 15 independent studies, Karen Irvine and her colleagues investigated the question of whether there are differences in cognitive decline between men and women with Alzheimer's disease. They found that in the five cognitive domains investigated, women deteriorated more rapidly than men.
One interesting aspect of gender differences in terms of cognitive processing is that differences seem to exist in normal children and adults — but in a different direction. It appears that Alzheimer's disease changes the balance, with women experiencing steeper or more rapid declines than men. In the Irvine study, this was found in both memory and verbal abilities. The second finding is striking because normal women often have stronger verbal skills.
Their study was published in the Journal of Clinical and Experimental Neuropsychology (2012). To review the study, click here.
Does Cognitive Function Predict Falls?
Not only can falls lead to physical and psychological traumas, they represent a significant risk factor for death among older adults. Therefore, predicting falls can create important opportunities for preventive interventions. In a recently published study, Chen, Peronto, and Edwards investigated, among other issues, whether cognitive function is (1) associated with falls, and (2) predicts falls.
509 community-dwelling older adults participated in the study. Measures of executive function, cognitive processing speed, psychomotor speed, and other known risk factors were administered. Key study results: (1) poor executive functions (based on the Trail Making Test) and slower psychomotor speed (Digit Symbol Test) were significantly associated with falls (This does not mean they cause falls.); (2) executive functions were not found to independently predict falls; (3) only medication use (4 or more), visual acuity, and psychomotor speed were predictors of falls.
Some additional considerations: The sample is community-based, and nursing and assisted living facility populations may have different fall predictions. Previous research has found executive functions to be a predictor of falls. While the number of medications was a significant predictor of falls, the researchers didn't look at specific medications that could increase fall likelihood (e.g., narcotics). Finally, the rate of falls in their sample was small, potentially impacting their findings.
Key implication - a simple measure of psychomotor speed may be a good and fast method for predicting falls in community-dwelling older adults.
Depression and MCI
Italian longitudinal study that investigated the comorbidity of MCI and depression, the researchers found depressive symptoms to be present in more than 63% of those with a diagnosis of MCI.
Some specifics of the study:
In the Italian Longitudinal Study on Aging, 2,963 individuals from 5,632 65- to 84-year-old subjects were evaluated at the 1st and 2nd survey, with a 3.5-year follow-up. Depressive symptoms were measured with the Geriatric Depression Scale.
Among the 2,963 participants, 139 prevalent MCI cases were diagnosed. 63.3% of them had depressive symptoms. During the 3.5-year follow-up, estimated incidence of depressive symptoms was 29.6 per 100 person-years.
The Risk of Dementia for Spouses Caring for Demented Partners
One of the better known studies that has investigated the effects of having a spouse with dementia on one’s own risk for incident dementia comes from the large, longitudinal Cache County Aging Health and Memory project. Maria Norton and numerous collaborating researchers reported their findings in 2010. Specific details of their study:
Methodology - Population-based study of incident dementia in spouses of persons with dementia.
Setting - Rural county in northern Utah.
Participants - 2,442 subjects (1,221 married couples) aged 65 and older.
Results - Spouses living with a demented partner experienced had a six-fold increase in risk of incident dementia compared to subjects whose spouses were dementia free.
Conclusion - Stress associated with dementia caregiving may exert substantial risk for the development of dementia in spousal caregivers.
Racial Differences in Caregiver Symptomatology & Medication Use
While it is clear that dementia caregivers are more likely to be depressed than same age non-caregivers, differences among racial groups in terms of symptoms and psychotropic treatment is less well understood.
Thorpe and colleagues shed some light on possible racial differences. Their research investigated African-American and white caregivers of older adults with dementia. Specifically they examined relationships between race and psychotropic drug use (antidepressant, antianxiety, sedative/hypnotic agents) in informal caregivers with symptoms of depression who provide care for elderly relatives with progressive dementia. Data was obtained and analyzed from two thousand thirty-two African-American and white female caregivers of elderly male veterans diagnosed with probable Alzheimer's disease or vascular dementia.
Depressive symptoms were measured using a modified version of the Center for Epidemiological Studies Depression Scale. Antidepressant, antianxiety, and sedative/hypnotic agents were indexed using the Veterans Affairs medication classification system.
They found that among the entire caregiver sample with depressive symptoms, 19% used antidepressants, 23% antianxiety agents, and 2% sedative/hypnotics. However, African-American caregivers with depressive symptoms were significantly less likely than whites with depressive symptoms to be using antidepressants and antianxiety medications. One can argue that both racial groups underutilize medications when depressed. However, this appears to be particularly so for African-American.
Physically Simulated Sport Play and Cognitive Function
Ever wonder if the physically simulated video games (think Wii Tennis as an example) on the market could enhance cognitive functioning in older adults? Maillot, Perrot, and Hartly investigated this question and recently published their findings in the journal, Psychology and Aging (2012, Vol. 27). They note that there is ample evidence that physical exercise can have a positive benefit on cognitive processing in older adults. Could video games that require movement also have positive cognitive affects?
Thirty-two independently living older adults participated in the study. Sixteen were randomly assigned to the experiment group (receiving physically simulated video games training – Wii games) and the remaining sixteen were assigned to the control group (no Wii training). Based on a pre-post design, using neuropsychological instruments to measure cognitive performance, the researchers found:
- Participants in the experiment group did better on the Wii games at post-testing as compared to the control group.
- Participants in the experimental group improved in two cognitive areas – executive control and processing speed, compared to the control group.
- No group difference were found in visuospatial abilities.
- The possible affect of the video games on memory was not investigated.
The researchers conclude that these types of videos can improve some areas of cognitive functioning. As a compliment or alternative to conventional exercising, video games that utilize physically simulated sport play have advantages for older adults. For example, they can be facility- or home-based, they can mitigate against environmental barriers to exercises, they allow choice among activities, and can be fun.
There are limitations to this study. Two of them are: They used a homogeneous small sample size that limits generalization of the findings. They made no comparisons to sedentary video games.
Hearing Loss and Dementia
Dr. Lin and colleagues, as part of the Baltimore Longitudinal Study of Aging, published their findings about a possible direct link between hearing loss and dementia for some older adults.
Below, we highlight important features of their study:
- Their objective was to determine whether hearing loss is associated with dementia, especially Alzheimer's disease.
- This was a prospective study of 639 subjects who underwent audiometric testing and were dementia-free.
- During a median follow-up of almost 12 years, subjects found to have dementia had substantially more severe hearing loss than non-demented subjects.
- They controlled for other possible causative variables.
- They concluded that hearing loss is independently associated with incident dementia.
- It is unclear if hearing loss is a marker for early-stage dementia or is instead a risk factor for dementia.
Brain Reserve and SuperAgers
Gradual decline in brain mass and in memory is a normal part of aging. Whereas most normal older adults maintain absolute memory skills into very late life, forgetfulness and lapses in attention are a common feature of aging. However, some older adults, the so-called SuperAgers, don't seem to experience cognitive decline. It appears that they have brains that are more resistant to both normal cortical atrophy and dementia.
Theresa Harrison and her colleagues looked at the relationship between brain size and cognitive abilities. While their sample size is small, their findings are very interesting. 12 SuperAgers (over 80 years of age with no memory deficits) were compared to 10 age controls and 14 middle-aged controls. They compared performances on cognitive testing and neuroimaging. They found that whole-brain thickness in the SuperAgers was no less than that found in the middle-agers. That is, cortical volume did not decline with age. The researchers show a positive correlation between cortical brain volume and memory performance.
MCI and Everyday Functioning
Previous research has demonstrated that people with Mild Cognitive Impairment (MCI) often have more difficulties completing everyday tasks (instrumental activities of daily living) than do people with normal cognitive functioning. Much of this research measured "everyday" functioning in artificial environments or through proxy (reports from others) assessments. Fewer studies have used direct measurement of everyday task performance. In a recently published article in the journal, Neuropsychology, Maureen Schmitter-Edgecombe and colleagues compared everyday task performance of 38 MCI subjects with 38 matched normal subjects. They focused on whether the MCI patients would perform as well as the control group on directly observable daily tasks. They found that the MCI group required more time to complete daily tasks and showed poorer task performance. One explanation for the performance differences was that MCI subjects had poorer memory which compromised their ability to keep track of multiple task goals.
The Stroop Test and Detecting Dementia
Functional MRI (fMRI) studies show that Stroop tasks activate the prefrontal cortex. This is not surprising given that Stroop tasks involve selective attention, sustained focus, set-shifting, and mental control (i.e., maintaining focus on one of two competing demands)—cognitive skills that are largely frontal lobe-associated. The frontal lobes are typically compromised in diseases such as Alzheimer's. So, one important question is whether a Stroop test is sensitive to early detection of Alzheimer's disease.
Hutchison, Balota, & Duchek investigated this hypothesis and published their results in the journal Psychology and Aging (Sep, 2010). Using a Stroop procedure, the researchers compared performances across young adults, older adults, and persons with "very mild" dementia. Their results (based on error rates) indicate that the Stroop procedure can discriminate between cognitively normal adults and those with mild dementia. That is, it can be used as an early detection screening tool for dementia. Furthermore, its discriminatory power was greater than other cognitive tests investigated. Younger adults and older adults also performed significantly different on this instrument.
Driving with Dementia
The realities of both voluntary and forced driving "retirement" are complex, and can have profound psychological and practical ramifications. At least two states, Maryland and California, have addressed driving safety issues for older adults to determine if unique standards should be applied to this population. Other states have either begun their own investigations or are reviewing research in this area. Whether most or all states will adopt separate driving evaluation standards, the following facts are pertinent to understanding this important national conversation. The information mostly comes from the National Highway Safety Administration 2009 dataset.
- There are approximately 28 million Americans 70 years of age or older. Approximately 78% of them are licensed drivers. This does not mean that they all actually drive.
- Older drivers tend to drive fewer miles per year, but keep their licenses longer and drive more miles collectively as a result.
- As a group, older drivers appear to be involved in fewer fatal crashes than in previous years, but still are the second highest at-risk age category for fatal crashes (after teens).
- While older drivers have relatively low crashes per capital, they have high rates of crashes per miles driven.
- The rate of fatalities relative to crashes is highest among older adults. This is likely primarily due to the frailer health status of older drivers as compared with younger drivers.
- Physical, cognitive, and visual deficits can play a major role in crashes for older adults.
- More than half of of the States require older drives to have more frequent driving renewals.
Homebound Older Adults and Telehealth
Homebound older adults represent an isolated and at-risk group for poor health and high medical costs. This population often does not receive preventive or adequate routine healthcare. Hence, alternative interventions such as Telehealth may prove effective for homebound older adults. Dr. Zvi Gellis and colleagues (see The Gerontologist, August 2012) investigated health outcomes for heart, respiratory, and associated mental health using a Telehealth intervention. In a randomized controlled trial, 51 older adults were treated for heart disease or COPD with Telehealth procedures. The Telehealth patients reported greater improvement in general health and depressive symptoms than did patients in the control group (patients receiving usual care). Furthermore, the control group had more visits to the emergency department than the Telehealth group. The researchers concluded that Telehealth may represent an efficient and effective intervention strategy for homebound older adults.
Behavioral Activation with Bereaved Older Adults
Over the past decade, there has been increasing interest in a specific cognitive-behavior therapy called, Behavioral Activation. Sometimes referred to as a "third generation" behavioral therapy, BA places emphasis on behavior over cognition. It aims to increase reinforcing activities, decrease avoidance behaviors, and bring about positive changes in thoughts, mood, and everyday living. BA has been commonly applied to problems of mood (depression, anxiety), and more recently to depressed and anxious older adults. In a newly published review, Holland & Diliberto (Clinical Gerontologist, July-September 2012) discuss positive applications of BA to bereaved older adults.
Benefits of BA for older adults include:
- Since the focus is on behavior, not cognition, patients with memory impairment can still benefit.
- Many older adults are resistive to "talk therapy." BA is brief and action-oriented, and many older adults are more comfortable with this approach.
- BA utilizes activities that are/were pleasurable for the patient, facilitating acceptance of the strategies.
- BA effectively targets "avoidance behaviors" that tend to keep patients depressed or anxious.
- BA is a good alternative and/or compliment to medications.
Naturally when we think of Olympic athletes, we picture late teenagers and young adults as Olympians. However, not all Olympic athletes fit into this age range. Below are some interesting facts about some of the oldest Olympians.
- The oldest male Olympian was Oscar Swahn of Sweden. He was 72 years, 281 days old when he competed at the 1920 Olympics in shooting.
- In 1936, Arthur von Pongracz of Austria also competed in Dressage at age 72, becoming one of the oldest competitors at the Olympics.
- In Beijing 2008, equestrian rider Hiroshi Hoketsu became the oldest Japanese Olympic representative at age 67. Hoketsu will be 71 when he competes in the London Olympics.
- Louis, Count du Douet de Graville (69 years, 95 days), competed in Equestrian in the 1900 Olympics. He is the oldest male gold medalist.
- The oldest woman to compete in the Olympics was British rider Lorna Johnstone, who participated in Equestrian at the 1972 Olympic Games. She was 70 years and 5 days old.
- In 1908, British archery winner Sybil "Queenie" Newall became the oldest woman ever to win an Olympic gold medal, she was aged 53 years, 275 days.
Competitiveness Across the Life Span
We live in a competitive society. Access to societal opportunities- jobs, entry exams, public office, college, social clubs- is regulated through competition. A common life span theory about competitive preferences predicts gradual decline as we age. However, a recently published study challenges this view. Some highlights from the research of Mayr, Wozniak, Davidson, Kuhns, & Harbaugh, published in the journal, Psychology and Aging (June 2012), are:
- competitive preference increased across the life span
- competitive preference peaked around age fifty
- across all age categories, men had stronger competitive preferences
- 543 subjects, age range was 25-74
- a definition of competitive preference was defined by a hypothetical financial risk test
- limitations: actual risk aversion was not studied, subjects older than 74 were not included, the competitive preference test was not a real-world situation
Marital Satisfaction in the Later Years
Studies have reported that marital quality seems to increase in later adulthood. Researchers have commented on the U-shaped curve whereby marital satisfaction appears highest in the early and late years of marital life, and lowest in the middle years. In a study just published in The Journals of Gerontology, Li & Fung report a similar finding and offer other insights.
These researchers assessed partner discrepancies and marital quality. They were primarily interested in how older married couples close the gap between ideal and perceived marriage quality in order to feel marital satisfaction. They found that husbands adjusted their expectations of their partners, and this likely produced higher marital satisfaction. This is consistent with life-span theory. Wives reported fairly consistent marital satisfaction ratings and may not have needed to make cognitive adjustments in the later years.
Telephone-Based CBT Caregiver Therapy
Epidemiologic studies indicate that there are more than five million adults in the United States with Alzheimer's disease. This figure will more than double over the next few decades. At the same time, the number of caregivers will also rapidly increase. Because African Americans with dementia are particularly likely to have informal (family and friends) caregivers, the question of caregiver burnout is a critical issue. Caregivers of all ethnicities are at increased risk for psychological, behavioral, and medical problems. A recent study was published that looked at the possible benefit of telephone-based cognitive-behavioral therapy for improving psychological functioning for African American caregivers.
Some highlights of their study, which can be found in the journal, Rehabilitation Psychology, vol. 57, follow below. The primary authors are Robert Glueckauf and W. Shuford Davis.
- pilot study based on telehealth technology
- small sample (14 participants)
- caregiver burden measured by Subjective Burden subscale of the CAI, Assistance Support subscale of the ISEL
- results show that the telephone-based treatment improved depression and subjective burden
- study limitations: very small sample, subject selection bias
American Coffee Consumption
There is little doubt that Americans like their coffee. More than 50% of adults drink coffee daily.
Some interesting facts about coffee consumption:
- While more than 50% of adults drink coffee daily, another 30% drink coffee occasionally
- In a recent survey by the American Coffee Association, 83% of consumers reported brewing their previous day's coffee at home
- Coffee consumption in the U.S. ranks eighth in the world
- Coffee consumption in 2012 is trending 7% over 2011 levels
- The average consumer drinks three cups a day
- The U.S. coffee market is nearly 20 billion dollars per year
- The average coffee cup size is nine ounces
- 35% of coffee drinkers prefer their coffee black
- 65% of coffee consumption takes place during breakfast hours
- Seattle has 10 times more coffee stores per 100,000 residents than the United States has overall
- The United States imports more than $4 billion dollars of coffee each year
Air Travel for Older Adults with Dementia
While commercial air travel is one of the safest means of transportation, it may not be for older adults with dementia. The human body undergoes physiological and psychological changes at high altitudes (22,500 feet above sea level) that can contribute to emotional distress and Delirium. James Low and Daniel Chan present a good review of the possible impact of air travel for older people in general in their article, Air Travel in Older People, Age and Ageing, (2002). Geri Hall, focusing specifically on people with dementia, compiled travel guidelines in article entitled, Travel Guidelines for People with Dementing Illness.
Can Adults Learn Second Languages?
Can adults learn second languages? Iverson and colleagues have conducted a body of research addressing this and related questions. This subject and whether foreign language exercises can be used as brain fitness are addressed in this week's BCAT blog. Read an abstract of one of the Iverson studies below:
Applied Psycholinguistics, page 1 of 16, 2011 doi:10.1017/S0142716411000300
Auditory training for experienced and inexperienced second-language learners: Native French speakers learning English vowels
PAUL IVERSON, MELANIE PINET, and BRONWEN G. EVANS
University College London
Received: January 14, 2009 Accepted for publication: October 24, 2010
ADDRESS FOR CORRESPONDENCE: Paul Iverson, Division of Psychology and Language Sciences, University College London, Chandler House, 2 Wakefield Street, London WC1N 1PF, UK. E-mail: firstname.lastname@example.org
ABSTRACT: This study examined whether high-variability auditory training on natural speech can benefit ex- perienced second-language English speakers who already are exposed to natural variability in their daily use of English. The subjects were native French speakers who had learned English in school; experienced listeners were tested in England and the less experienced listeners were tested in France. Both groups were given eight sessions of high-variability phonetic training for English vowels, and were given a battery of perception and production tests to evaluate their improvement. The results demonstrated that both groups learned to similar degrees, suggesting that training provides a type of learning that is distinct from that obtained in more naturalistic situations.
Positive Synergy between Cognitive & Physical Exercise
As reviewed in a recent BCAT blog, Yonas Geda and colleagues at the Mayo Clinic examined the relationship between computer use, physical exercise, and mild cognitive impairment. One issue they investigated was whether the combination of computer and physical activity was more positively associated with reductions in memory deficits than either one individually. In their study sample, 926 non-demented persons, aged 70-93, completed self-report questionnaires. Participants answered questions about their physical exercise, computer use, and caloric intake. Adjusting for age, sex, education, and medical issues (including depression), they found that participants who engaged in both moderate exercise and computer use had significantly decreased the likelihood of having MCI. The study did have some limitations. Participants were not given specific cognitive exercises to complete, so there was variability in what "computer use" actually meant. Similarly, definitions of physical activity of moderate intensity were not strictly defined. Finally, the data was based on self-reports, and was not independently corroborated by others. For more information about the study, go to Mayo Clinic Proceedings.
Tobacco & Activity as Predictors of Cognitive Change
The fact that the global population is aging, particularly in industrialized nations, is common knowledge. The world and particularly the U.S., is confronted with an ever increasing number of people with dementia. In industrialized countries it is estimated that dementia will overtake coronary heart disease as the number one cause of disability among older adults. In the U.S. healthcare costs for persons with dementia are three times higher than for those without dementia. Against this backdrop the issues associated with prevention in general and identification of protective factors of cognitive decline associated with dementia, are keys to improved health and lower healthcare costs. Ada Lo and colleagues recently published a review of existing research on tobacco, alcohol, adiposity (excessive body weight), and activities as predictors of cognitive change in older adults. Two of these "risk factors" are described here. With respect to tobacco use and activity level, the following findings are reported: (1) smoking in general increased memory decline (smokers versus non-smokers by history), but did not affect language skills nor visuospatial skills; (2) activity (active lifestyle) – physically, cognitively, and socially – seems to have protective cognitive effects and may enhance overall quality of life; (3) cognitive and physical activity appear more protective of cognitive functioning than pure social activities. Some noteworthy limitations of the research: only studies published in English were reviewed, there are limitations in comparing studies with heterogeneous methodologies, and definitions of "cognitive" domains varied across the studies reviewed. Despite these limitations, this meta-analysis points to promising lifestyle influences on cognitive functioning and dementia in the older years of life.
Transitions in Primary Caregiver: Gender Differences
Families are the "first line of defense" in providing community-based primary caregiving for older adults with cognitive and physical disabilities. But first line is often not the last line. When do caregivers throw in the towel and transition their loved ones to another caregiving situation (e.g., nursing home)? Susan Allen and her colleagues investigated this issue and looked at caregiver characteristics associated with care transitions of community-dwelling older adults. In their longitudinal study, data from 2,990 older adults (aged 70 and over) were analyzed. Over a two year period, more than half of the subjects experienced some sort of transition. The researchers also reported that females tended to hold onto primary caregiver roles longer than males. Hence, if you look at caregiver transition from a risk perspective, disabled older women cared for by either a husband or son are more at risk for transition to another informal caregiver or formal (e.g., nursing home) provider. The authors speculate as to why there are gender differences in caregiver transition. The article (May, 2012) was published in The Journals of Gerontology, 67B, 362-371.
Spanish version of the Geriatric Depression Scale
Most of the depression screening tools for elderly patients are either exclusively written in English or when translated, have not been normed in other languages. In a recently published article in International Psychogeriatrics (April, 2012), reliability and validity findings are presented for a Spanish version of the Geriatric Depression Scale. In this study, the targeted population was older adults (55 and older) with mild-moderate dementia. There is evidence that the GDS is not warranted for severely demented patients since it relies upon self-report responses. Severely demented patients were not included in this study. 96 community-dwelling older adults completed a battery of instruments including the GDS-15 and GDS-5, the Cornell Scale for Depression in Dementia (CSDD), a list of self-reported chronic health issues, MMSE, a functional status instrument (Barthel Index), a generic quality of life scale (WHOQOL-BREF), and sociodemographic information. This study was conducted in Spain. The study provides evidence that the GDS-15 and GDS-5 have reasonable reliability and validity as screening measures for a Spanish speaking population with mild to moderate dementia. There are several caveats to consider. One should be careful about generalizing to patients with more severe dementia. Also, the MMSE is a questionable instrument when used as the primary indicator of dementia, especially for persons with mild severity. Studies show that the sensitivity of the MMSE is questionable for people with Mild Cognitive Impairment (MCI) and mild dementia. Finally, depression should not be diagnosed solely on the basis of the GDS or any screening tool alone.
Executive Functions, Parkinson's Disease, & Activity Participation
Parkinson's disease (PD) is one of the most common movement disorders, affecting 1% of people older than 60 years of age. This is approximately 1 million Americans. PD is about 1.5 times more common in men than in women, and it becomes more common as one ages. The motor manifestations receive the most attention clinically, as PD is most noted as one of the movement disorders. However, individuals with PD, who are not demented, commonly have some cognitive concerns. One such example is executive function. In a recently published study by Foster and Hershey (2012), the relevance of executive functions in PD (without dementia) to instrumental, leisure, and social participation is reported. 24 persons with PD (no dementia) and 30 age-matched control volunteers participated. Executive function was assessed by administration of the Dys-executive Questionnaire. Complex activity participation was assessed by administration of the Activity Card Sort. This instrument consists of photographic cards depicting complex activities that fall into four domains: IADL, low physical-demand leisure activities, high-demand leisure activities, and social activities. Key study results: (1) individuals with PD (no dementia) had mild executive deficits; (2) these deficits were associated with reduced participation in IADL, leisure, and social activities. One could conclude that individuals with PD are at risk for problems in independent living (IADL) and well-being (leisure and social activities), due to cognitive deficits unrelated to their physical problems. Therefore from a treatment perspective, cognitive evaluation of PD patients is important.
Acute Bipolar I Presentation Across the Life Span
The literature on bipolar disorder across the life span reports few definitive conclusions, and quite a few conflicting ones. For example, it is not clear whether acute presentation of bipolar symptoms is similar for younger and older adult patients. For those who have life-long bipolar disorder, do psychotic and affective symptoms change as one ages? Some studies suggest that age is indeed a factor, while others arrive at the opposite conclusion. In a recent study published in the Journal of Geriatric Psychiatry and Neurology, Al Jurdi and colleagues recruited bipolar I patients between the ages of 20-59 (younger group) and 60 and older (older group), comparing their symptom profiles. No statistically significant differences were found in terms of psychotic features, mood elevation (mania and hypomania), and irritability. Furthermore, no statistically significant differences emerged between the two groups in terms of acute depression symptoms. In this study, age was not a differentiating factor in symptom presentation.
Donepezil (Aricept) and Memantine (Namenda) for Moderate-to-Severe AD
Most studies evaluating the efficacy of memory enhancers have focused on patients with mild-to-moderate Alzheimer's disease. In a recently published article in the New England Journal of Medicine, Howard et al. (March, 2012) investigated the treatment benefits of donepezil and memantine for patients with moderate-to-severe dementia. 295 community-dwelling patients who had been treated with donepezil for at least three months participated in the study. Outcome measures for cognition and function were, respectively, the standardized MMSE and the Bristol Activities of Daily Living Scale. The researchers had three objectives: (1) to test whether over a period of 52 weeks continuation of donepezil, as compared with discontinuation of this drug, would be associated with better cognition and function; (2) to test whether memantine treatment, as compared with placebo, would be associated with better cognition and function; and (3) to test whether combining donepezil and memantine would provide additive benefits. Results: (1) patients who continued with donepezil had better cognition and function scores than those who discontinued the drug; (2) patients who were assigned to receive memantine did better with cognition and function scores than those who were assigned placebo; and (3) there was no additive benefit in terms of cognition and function for using both drugs simultaneously. One should interpret these results with caution. The improvements in cognition and function associated with both drugs were small relative to the overall size of the decline in cognition and function. Furthermore the MMSE is a poor outcome measure for assessing change in cognition.
Prospective Memory and TBI
Prospective memory refers to our ability to remember to carry out intended actions in the future. Examples include remembering to take medications, pay bills, go to appointments, and manage a variety of instrumental activities of daily living (IADL). This differs from retrospective memory, which is more concerned with recalling events or details previously learned. Much of the time, these two memory features work in a complimentary fashion. In order to carry out an intended action, one has to be attentive and aware of when to perform an action (prospective), and at the same time, recall what action to perform (retrospective). There is a good deal of research looking at the impact of traumatic brain injury (TBI) on memory, especially retrospective memory. In a recently published article, Shital Pavawalla and colleagues looked at the relationship between TBI and prospective memory. They compared the prospective memory performances of 17 TBI and 17 "normal" control participants. The study findings support the view that TBI negatively effects prospective memory. TBI participants had significantly more difficulties recruiting the attentional skills necessary to carry out intended actions. One implication of this research is that attentional skills are critical to remembering to complete an intended action. Another is that individuals who have experienced a TBI may be at heightened safety risk and vulnerable to IADL failures. Furthermore, clinicians should be mindful in their evaluations of TBI patients to assess prospective and more traditional memory abilities. Readers should keep in mind that the study results are based on a small number of participants. The researchers did not differentiate among different types of TBI, nor did they track possible recovery of prospective memory over time.
Psychological & Physical Effects of Spousal Caregiving of MCI Patients
Recently published in the Journals of Gerontology, Jyoti Savla and colleagues reported on the psychological impact on care partners taking care of spouses with mild cognitive impairment (MCI). In their study, 30 spousal care partners participated in a diary study on behavioral problems associated with MCI, reporting on daily stressors and strains. They also provided saliva samples in order to record cortisol levels associated with stress. Key findings included: (1) care partners reported higher levels of negative affect when behavioral problems occurred toward the end of the day; (2) some MCI patients demonstrated a version of "sun-downing," not so different from what is often observed in demented patients; (3) on days in which behavioral problems were relatively high, cortisol levels in care partners were higher at the beginning of the day, remained higher, and receded at a lower rate. Normally, cortisol levels are highest in the morning and lowest at night. The study adds evidence to our understanding that caregiving places the caregiver at risk for both psychological and physiological symptoms.
Insulin Spray may Slow or Reverse Early Signs of Alzheimer's Disease
In a recently published article in the Archives of Neurology, Dr. Suzanne Craft and her colleagues report their findings that the administration of intranasal insulin may have a therapeutic benefit for adults with Mild Cognitive Impairment (MCI) or Alzheimer's disease (AD). Building on previous studies that found that low brain levels of insulin – the main hormone that turns sugar in the bloodstream into energy for cells – could contribute to Alzheimer's disease, the researchers recruited 104 adults, 64 of whom had amnestic MCI and 40 of whom were diagnosed with mild to moderate AD, to participate in their study. Participants received 20 IU of insulin or 40 IU of insulin for four months. One of the primary outcome measures used to track changes or improvement in memory was Story Recall. Participants who received the 20 IU dose showed improvement in Delayed Story Recall. Interesting, participants who received the 40 IU dose did not show improvement in this outcome measure. Studies investigating the possible benefits of intranasal insulin are at a preliminary stage, and insulin is not recognized as a viable treatment for cognitive disorders. It is not yet clear exactly why insulin could be beneficial for preserving and possibly enhancing memory. It is interesting to note that brain insulin receptors are densely localized in the hippocampus, which is a center for making new memories.
Intranasal Insulin Therapy for Alzheimer Disease and Amnestic Mild Cognitive Impairment: ...Craft et al.Arch Neurol.2011; 0: 20112331-10.