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This chapter outlines some of the ways in which cognitive behavior therapy (CBT) for anxiety disorders and depression has been modified and adapted to the ageing older population. Aspects that are outlined include modifications to the process of conceptualization, which has been expanded to include relevant gerontological factors. The areas that should be incorporated into the assessment of older adults with anxiety and depression prior to starting therapy are delineated, with a focus on the characteristic features that color the presentation in the case of older adults. The changes that must be made in carrying out CBT for older adults with depression and anxiety disorders so that it is effective are described. This includes accommodations for cognitive changes and health-related difficulties as well as taking into consideration factors that are specific to the older population.
A wide variety of neurological conditions may present first to a psychiatrist and it is important to be aware of these in differential diagnosis. A careful history, examination and a broad differential diagnosis can help set up an appropriate management plan – with room to change if things change in unexpected ways. In this article we explore common ground shared by psychiatry and neurology and show how incorporation of neurological knowledge can improve the practice of psychiatry. Using four fictional case vignettes of altered mental status we explore important neurological differential diagnoses which could present to the Psychiatrist.
Dementia is a major cause of disability worldwide. About 25%-40% of patients with mild to moderate dementia are affected by sleep-awake cycle disturbances, including increased daytime sleepiness and insomnia. However, little is known about the specific impact of excessive daytime sleepiness on the cognitive decline of dementia patients.
To evaluate the impact of daytime sleepiness on the cognitive decline of dementia patients. Additionally, longitudinal associations with functional impairment and neuropsychiatric symptoms will be explored.
A longitudinal study will be conducted in a psychogeriatric consultation. Patients will be consecutively invited according to predefined eligibility criteria. Those aged ≥65 years, with dementia diagnosis or Mini-Mental State Examination (MMSE) <24, and with a knowledgeable caregiver, will be included. The exclusion criteria are: a caregiver <18 years, terminally ill, incapable to communicate or with a known diagnosis of insomnia, sleep related respiratory disorders, central hyperinsomnia, restless legs syndrome or sleep paralysis. Participants will undergo an assessment with a comprehensive protocol including: Montreal Cognitive Assessment (MoCA), Barthel and Lawton Index, Epworth Sleepiness Scale (ESS), Neuropsychiatric Inventory (NPI) and Global Deterioration Scale (GDS). Participants will be re-assessed 6 months after the initial evaluation. The Health Ethics Committee of Hospital Universitário de São João granted the study authorization (nº 260/2020).
Findings will be disseminated via publication in peer-reviewed journals and presentations at national and international scientific conferences.
This study will address key questions on the relation of daytime sleepiness and dementia outcomes, in order to undertake corrective and preventive non-pharmacological and pharmacological approaches.
The growth in the number of aged people in the population is considered a worldwide phenomenon, with direct consequences in health systems. The literature indicates an increase in the diagnosis of mental disorders and the use of psychotropic drugs for that population, as well as frequent complaints regarding to cognition.
To analyze the possible relationship between cognitive decline and use of psychiatric drugs in elderly with mental disorders, assisted by psychiatric outpatient clinics, city of Campo Grande, state of Mato Grosso do Sul, Brazil.
Quantitative, exploratory, descriptive and cross-sectional research, with 59 participants.Sociodemographic and clinical variables were collected through semi-structured clinical interviews and medical records. To screen for cognitive decline, the Mini Mental State Examination was used.
Majority of females, with a mean age of 66.75 ± 0.63 years, married, up to 8 years of completed studies and living with family members. The prevalence of depressive disorders was higher (52.54%), with selective serotonin reuptake inhibitor antidepressant use in 67.8%. Most were using 2 or more psychotropics the most prevalent combination being benzodiazepines and antidepressants. 52.5% of the elderly reported cognitive complaints and 45.8% presented Mini Mental scores, suggesting cognitive decline. It was associated with depressive disorders and the consumption of 2 or more psychotropics.
Although there is evidence that psychotropic drugs represent effective strategies for the treatment of mental disorders, the use for this group of elderly should be carefully analyzed, due to the predisposition or worsening of cognitive decline, with impairment to the quality of life of this population.
Benzodiazepines (BZDs) and related drugs (BZRDs) are widely used to reduce agitation, anxiety and sleep disturbances in the elderly, despite concerns raised about their modest efficacy for such indications and risk of severe adverse effects, including acute consequences on cognition. Recently, some studies have also raised concerns about the long-term effect of BZDs, suggesting their association with an increased risk of cognitive decline and dementia.
To review published synthesis studies on the risk of dementia development due to BZDs/BZRDs use.
An electronic search was conducted in PubMed. Meta-analysis, systematic and non-systematic reviews examining the association between BZDs/BZRDs and subsequent dementia were included. No language nor publication date restrictions were applied. Search results other than synthesis studies were excluded. Studies were screened for relevance based on predefined inclusion and exclusion criteria.
Overall, 246 results were obtained. After initial screening, nine studies were included. From these, three were systematic reviews with meta-analysis of observational studies (cohort and/or case-control), one was a systematic review from observational studies and five were non-systematic reviews. Most studies found an association between BZDs/BZRDs and subsequent dementia, with meta-analysis studies reporting an increased risk (OR) between 1,38 and 1,78, even after controlling for protopathic bias. However, difficulties in establishing a causal relationship are reported due to the considerable clinical and methodological heterogeneity of the primary studies.
Most studies suggest an association between the use of BZDs/BZRDs and dementia risk, highlighting that their prescription should be cautious, prevented or reduced to attenuate this risk.
Anxiety Disorders (AnxDs) are highly prevalent in middle-aged and older individuals and are putative factors that might interfere with normal aging, by affecting cognitive functioning and neuroprogression.
This study aims to assess whether current AnxD in middle-aged and older subjects are associated with 1) lower neuropsychological performance, 2) shorter telomere length/lower plasmatic Amyloid-Beta, and 3) brain connectivity alterations, compared to subjects without lifetime psychiatric disorders (HCs).
This is an ongoing multicentric cross-sectional study. We collected preliminary data on neuropsychological performance through a standardized battery, in 60 outpatients with current AnxDs (DSM-5 criteria), 24 with psychopharmacological treatments (AnxDs+) and 36 without (AnxDs-), compared to 76 HCs, all aged 50-75 years. This study was supported by Fondazione Cariplo, grant n° 2014:0664.
AnxDs- patients showed poorer performance in the language domain, namely in semantic fluency (p=0.04), compared to HCs. No other significant differences were found between groups. Within the patients’ group, we found that a greater burden of psychiatric disorders or medical diseases, current use of benzodiazepines, or unhealthy lifestyle had significant detrimental effects on cognition, whereas current use of antidepressants, pharmacological treatments for medical conditions, and higher levels of physical activity exhibited the opposite effects.
We found only limited difference in cognitive performance between patients and controls. However, our preliminary results show that multiple factors influence cognitive performance in individuals with AnxDs, making these aspect important to monitor in clinical practice. So far, our results are provisional and further analyses in the final sample may provide more reliable conclusions.
Schizophrenia spectrum disorders (SSD) are characterized by heterogeneity. Cognitive decline, due to recent research results, appears to be a core symptom of schizophrenia. Dimensional approach of SSDs allows the separate assessment of each psychotic symptom, as well as cognitive functioning. Thus, correlations among them and their alterations, between baseline and follow up examination, can be estimated.
The objective of this study is to correlate observed alterations in cognitive performance in patients diagnosed with schizophrenia spectrum disorders, compared with baseline measurement, with alterations in severity of psychotic symptoms.
85 Patients diagnosed with schizophrenia spectrum disorders, attended in the Outpatient Department of Early Intervention in Psychosis of University of Thessaly, Greece and its affiliated psychiatric clinics, were evaluated the last 24 months, using the CRDPSS (Clinician-Rated Dimensions of Psychosis Symptoms Severity) measure and the validated greek version of the MoCA test. 37 of them had a follow up evaluation. The relationship between the two new categorical variables [dMoCA (positive- negative) and dmCRDPSS7 (positive-negative)] was assessed with x² test.
Alterations in cognitive function, as assessed with MoCA scale and dMoCA variable, were inversely correlated with the alteration in mean severity of other dimensions of psychosis symptoms (dmCRDPSS7), x²(1, N = 37) = 9.4891, p = .0021.
Our data suggest that alterations in cognitive performance may predict an inverse effect in the severity of psychotic symptoms. Periodic follow up of cognitive functioning in patients diagnosed with schizophrenia spectrum disorders is suggested, since it can be interpreted in clinically useful information considering relapse.
The Maintain Your Brain (MYB) trial is one of the largest internet-delivered multidomain randomised controlled trial designed to target modifiable risk factors for dementia. It comprises four intervention modules: physical activity, nutrition, mental health and cognitive training. This paper explains the MYB Nutrition Module, which is a fully online intervention promoting the adoption of the ‘traditional’ Mediterranean Diet (MedDiet) pattern for those participants reporting dietary intake that does not indicate adherence to a Mediterranean-type cuisine or those who have chronic diseases/risk factors for dementia known to benefit from this type of diet. Participants who were eligible for the Nutrition Module were assigned to one of the three diet streams: Main, Malnutrition and Alcohol group, according to their medical history and adherence to the MedDiet at baseline. A short dietary questionnaire was administered weekly during the first 10 weeks and then monthly during the 3-year follow-up to monitor whether participants adopted or maintained the MedDiet pattern during the intervention. As the Nutrition Module is a fully online intervention, resources that promoted self-efficacy, self-management and process of change were important elements to be included in the module development. The Nutrition Module is unique in that it is able to individualise the dietary advice according to both the medical and dietary history of each participant; the results from this unique intervention will contribute substantively to the evidence that links the Mediterranean-type diet with cognitive function and the prevention of dementia and will increase our understanding of the benefits of a MedDiet in a Western country.
In diagnosing dementia, estimating premorbid functioning is critical for accurate detection of the presence and severity of cognitive decline. However, which assessments of premorbid intelligence are most suitable for use in clinical practice is not well established. Here, we systematically evaluate the validity of instruments for measuring premorbid intelligence in people living with dementia.
Design and setting:
In this systematic review, electronic databases (EMBASE, PsycINFO, MEDLINE, CINAHL, and AMED) were searched to identify studies reporting on objective measures of premorbid intelligence in dementia. Participants from included studies were recruited from local communities and clinical settings.
A total of 1082 patients with dementia and 2587 healthy controls were included in the review.
The literature search resulted in 13 eligible studies describing 19 different instruments. The majority of instruments (n = 14) consisted of language-based measures, with versions of the National Adult Reading Test (NART) being most commonly investigated.
Preliminary evidence suggested comparable performance of patients with mild dementia and healthy controls on word reading tasks in English, Portuguese, Swedish, and Japanese. In moderate dementia, however, the performance was significantly impaired on most verbal tasks. There was a lack of reliability and validity testing of available instruments, with only one of the included studies reporting psychometric properties within the patient group.
The results demonstrate that there is a wide range of tools available for estimating premorbid intelligence in dementia, with cautious support for the potential of word reading tasks across different languages in individuals with mild dementia. However, the review highlights the urgent need for extensive assessments of the psychometric properties of these tasks in dementia. We propose that further longitudinal research and assessments of nonverbal measures are necessary to validate these instruments and enhance diagnostic procedures for people living with dementia worldwide.
Previous studies indicate that occupation might affect cognitive functioning in late life. As people in low- and middle-income countries often have to work until late life, we sought to investigate if there are cognitive benefits to working later into life and whether cognitive function deteriorates after exiting the labour force. We analysed longitudinal data from the Mexican Health and Aging Study (MHAS), a nationally representative sample of Mexican adults age 50+ (N = 7,375), that assessed cognitive functioning by verbal learning, delayed recall and visual scanning. Analyses were carried out using mixed-effects modelling corrected for the influence of gender, instrumental activities of daily living, diabetes, stroke, hypertension, depression, income and marital status. Results suggest that working actively, compared to exiting the workforce, was associated with cognitive performance only in context with occupation. Domestic workers had a faster decline in verbal learning (b = −0.02, p = 0.020) and delayed recall (b = −0.02, p = 0.036) if they continued working actively and people working in administration (b = 0.03, p = 0.007), sales (b = 0.02, p = 0.044) and educators (b = 0.03, p = 0.049) had a slower decline in visual scanning if they continued working in old age. Our findings indicate that continued participation in the labour force in old age does not necessarily come with cognitive benefits. Whether or not working actively in later life protects or even harms cognitive functioning is likely to depend on the type of job.
This study compared the level of education and tests from multiple cognitive domains as proxies for cognitive reserve.
The participants were educationally, ethnically, and cognitively diverse older adults enrolled in a longitudinal aging study. We examined independent and interactive effects of education, baseline cognitive scores, and MRI measures of cortical gray matter change on longitudinal cognitive change.
Baseline episodic memory was related to cognitive decline independent of brain and demographic variables and moderated (weakened) the impact of gray matter change. Education moderated (strengthened) the gray matter change effect. Non-memory cognitive measures did not incrementally explain cognitive decline or moderate gray matter change effects.
Episodic memory showed strong construct validity as a measure of cognitive reserve. Education effects on cognitive decline were dependent upon the rate of atrophy, indicating education effectively measures cognitive reserve only when atrophy rate is low. Results indicate that episodic memory has clinical utility as a predictor of future cognitive decline and better represents the neural basis of cognitive reserve than other cognitive abilities or static proxies like education.
Cigarette smoking is associated with worse cognition and decreased cortical volume and thickness in healthy cohorts. Chronic cigarette smoking is prevalent in schizophrenia spectrum disorders (SSD), but the effects of smoking status on the brain and cognition in SSD are not clear. This study aimed to understand whether cognitive performance and brain morphology differed between smoking and non-smoking individuals with SSD compared to healthy controls.
Data were obtained from the Australian Schizophrenia Research Bank. Cognitive functioning was measured in 299 controls and 455 SSD patients. Cortical volume, thickness and surface area data were analysed from T1-weighted structural scans obtained in a subset of the sample (n = 82 controls, n = 201 SSD). Associations between smoking status (cigarette smoker/non-smoker), cognition and brain morphology were tested using analyses of covariance, including diagnosis as a moderator.
No smoking by diagnosis interactions were evident, and no significant differences were revealed between smokers and non-smokers across any of the variables measured, with the exception of a significantly thinner left posterior cingulate in smokers compared to non-smokers. Several main effects of smoking in the cognitive, volume and thickness analyses were initially significant but did not survive false discovery rate (FDR) correction.
Despite the general absence of significant FDR-corrected findings, trend-level effects suggest the possibility that subtle smoking-related effects exist but were not uncovered due to low statistical power. An investigation of this topic is encouraged to confirm and expand on our findings.
Healthy dietary patterns may protect against age-related cognitive decline, but results of studies have been inconsistent and few have had extensive longitudinal follow-up with comprehensive cognitive testing. The aim of the present study was to determine associations of dietary patterns with trajectories of global- and domain-specific cognitive change over a 12-year period. Data from 863 community-dwelling, dementia-free participants from the Lothian Birth Cohort 1936 study of ageing completed a FFQ at baseline (aged 70 years) and underwent cognitive testing at baseline, and at the ages of 73, 76, 79 and 82 years. Composite cognitive scores were constructed for four cognitive domains (visuospatial ability, processing speed, memory and verbal ability) and global cognitive function. A Mediterranean-style pattern and a traditional pattern were derived using principal component analysis of self-reported dietary intakes. In fully adjusted latent growth curve models, higher baseline adherence to the Mediterranean-style dietary pattern (β = 0·056, P = 0·009) and lower baseline adherence to the traditional dietary pattern (β = −0·087, P < 0·001) were cross-sectionally associated with better verbal ability. A slightly steeper decline in verbal ability over 12 years was observed in those with higher Mediterranean-style diet scores at baseline (β = −0·003, P = 0·008). All other associations were non-significant. Our findings in this well-characterised Scottish cohort indicate that adherence to a healthy Mediterranean-style diet is associated cross-sectionally with better verbal (crystallised) ability, with the converse being true for the traditional diet. A healthier baseline diet did not predict a reduced risk of global- or domain-specific cognitive decline.
Expertise bears a great importance in several realms of human intellectual activity. The topic has been addressed in depth in the model domain of chess, with a central focus in the evaluation of the premises posited from the deliberate practice approach, which advocates for expert performance being dependent on practice. A considerable and consistent body of evidence suggests, however, that deliberate practice alone is unable to explain the individual variability in chess expertise. This chapter addresses this controversy by framing these findings in the more extensive nature versus nurture debate. The chapter also explores the cognitive decline in human intellectual activity, which appears to occur in a lesser extent in the chess domain. Two interrelated factors may be highly protective of the cognitive decline in chess: the level of expertise attained, and the tournament activity.
Alzheimer’s disease (AD) studies are increasingly targeting earlier (pre)clinical populations, in which the expected degree of observable cognitive decline over a certain time interval is reduced as compared to the dementia stage. Consequently, endpoints to capture early cognitive changes require refinement. We aimed to determine the sensitivity to decline of widely applied neuropsychological tests at different clinical stages of AD as outlined in the National Institute on Aging – Alzheimer’s Association (NIA-AA) research framework.
Amyloid-positive individuals (as determined by positron emission tomography or cerebrospinal fluid) with longitudinal neuropsychological assessments available were included from four well-defined study cohorts and subsequently classified among the NIA-AA stages. For each stage, we investigated the sensitivity to decline of 17 individual neuropsychological tests using linear mixed models.
1103 participants (age = 70.54 ± 8.7, 47% female) were included: n = 120 Stage 1, n = 206 Stage 2, n = 467 Stage 3 and n = 309 Stage 4. Neuropsychological tests were differentially sensitive to decline across stages. For example, Category Fluency captured significant 1-year decline as early as Stage 1 (β = −.58, p < .001). Word List Delayed Recall (β = −.22, p < .05) and Trail Making Test (β = 6.2, p < .05) became sensitive to 1-year decline in Stage 2, whereas the Mini-Mental State Examination did not capture 1-year decline until Stage 3 (β = −1.13, p < .001) and 4 (β = −2.23, p < .001).
We demonstrated that commonly used neuropsychological tests differ in their ability to capture decline depending on clinical stage within the AD continuum (preclinical to dementia). This implies that stage-specific cognitive endpoints are needed to accurately assess disease progression and increase the chance of successful treatment evaluation in AD.
To estimate the prevalence of unmet needs for assistance among middle-aged and older adults with subjective cognitive decline (SCD) in the US and to evaluate whether unmet needs were associated with health-related quality of life (HRQOL).
US – 50 states, District of Columbia, and Puerto Rico
Community-dwelling adults aged 45 years and older who completed the Cognitive Decline module on the 2015-–2018 Behavioral Risk Factor Surveillance System reported experiencing SCD and always, usually, or sometimes needed assistance with day-to-day activities because of SCD (n = 6,568).
We defined SCD as confusion or memory loss that was happening more often or getting worse over the past 12 months. Respondents with SCD were considered to have an unmet need for assistance if they sometimes, rarely, or never got the help they needed with day-to-day activities. We measured three domains of HRQOL: (1) mental (frequent mental distress, ≥14 days of poor mental health in the past 30 days), (2) physical (frequent physical distress, ≥14 days of poor physical health in the past 30 days), and (3) social (SCD always, usually, or sometimes interfered with the ability to work, volunteer, or engage in social activities outside the home). We used log-binomial regression models to estimate prevalence ratios (PRs). All estimates were weighted.
In total, 40.2% of people who needed SCD-related assistance reported an unmet need. Among respondents without depression, an unmet need was associated with a higher prevalence of frequent mental distress (PR = 1.55, 95% CI: 1.12–2.13, p = 0.007). Frequent physical distress and social limitations did not differ between people with met and unmet needs.
Middle-aged and older adults with SCD-related needs for assistance frequently did not have those needs met, which could negatively impact their mental health. Interventions to identify and meet the unmet needs among people with SCD may improve HRQOL.
Post-diagnostic psychosocial interventions could play an important role in supporting people with mild dementia remain independent. The Promoting Independence in Dementia (PRIDE) intervention was developed to address this.
The mixed methods non-randomized, pre-post feasibility study occurred across England. Facilitators were recruited from the voluntary sector and memory services. Participants and their supporters took part in the three-session intervention. Outcome measures were collected at baseline and follow-up. To evaluate acceptability, focus groups and interviews were conducted with a subsample of participants and facilitators.
Contextual challenges to delivery including national research governance changes, affected recruitment of study sites. Thirty-four dyads consented, with 14 facilitators providing the intervention. Dyads took part in at least two sessions (79%), and 73% in all three. Outcome measures were completed by 79% without difficulty, with minimal missing data. No significant changes were found on pre and post assessments. Post hoc analysis found moderate effect size improvements for self-management (SMAS instrument) in people with dementia (d = 0.41) and quality of life (EQ5D measure) in carers (d = 0.40). Qualitative data indicated that dyads found PRIDE acceptable, as did intervention facilitators.
The three-session intervention was well accepted by participant-dyads and intervention facilitators. A randomized controlled trial of PRIDE would need to carefully consider recruitment potential across geographically varied settings and site stratification according to knowledge of contextual factors, such as the diversity of post-diagnostic services across the country. Letting sites themselves be responsible for identifying suitable intervention facilitators was successful. The self-report measures showed potential to be included in the main trial.
Falls are a growing concern in seniors (≥65 yrs). Cognitive impairment (CI) and vestibular impairment (VI) increase fall risk. The aim of this study is to assess the prevalence of CI and VI in seniors experiencing falls.
Participants (≥65 yrs) with falls were recruited from Falls Prevention Programs (FPPs) and a Memory Clinic (MC). CI was assessed using the Montreal Cognitive Assessment at FPPs. VI was assessed at an MC and FFPs using the Head Impulse- (video + bedside), Headshake-, Dix-Hallpike test, and test of sensory interaction in balance. Questionnaires included Dizziness Handicap Inventory (DHI) and Activities-specific Balance Confidence Scale (ABC).
Of 41 participants (29 FPPs, 12 MC); mean age was 80.1 ± 7.1 years, and 58.5% were female. Overall, 82.9% had VI. At FPPs, 76.0% had CI, and 72.3% had CI + VI. Bilateral vestibular hypofunction (BVH) was more common than unilateral vestibular hypofunction (UVH) (70.6% vs. 29.4%); p = 0.016. Dizziness Handicap (DHI) was not different between those with a VI (23.5 ± 23.9) versus without VI [PVI + no impairment] (10.0 ± 15.4); p = 0.160. Balance confidence (ABC) was lowest in VI but not significantly different between those with a VI (63.4 ± 27.3) versus without VI [PVI + no impairment] (85.0 ± 16.5); p = 0.053.
VI and CI are prevalent in seniors experiencing falls. For seniors with history of falls, both cognitive and vestibular functions should be considered in the assessment and subsequent treatment. Screening enables earlier detection, targeted interventions, and prevention, reducing the clinical and financial impact.
Existing research suggests walnut intake may be associated with better cognitive function in older adults, yet few studies utilise longitudinal data from observational studies of ageing populations. Our objective was to estimate the association between whole walnut intake and cognitive change in a representative sample of older Americans.
Secondary analysis of the Health and Retirement Study and Health Care and Nutrition Study. Walnut consumption was defined as a categorical measure (none, low intake (0·01–0·08 1 oz. servings per day) and moderate intake (>0·08 1 oz. servings per day)) and cognitive function was measured using the Telephone Interview for Cognitive Status. Latent growth modelling estimated the association between walnut consumption and trajectories of cognitive status over a 4-year observational period. Sensitivity analyses assessing non-random dropout and Monte Carlo power analyses were conducted to contextualise results.
A sample of 3632 US adults aged 65 years and older.
Those reporting any walnut consumption had greater cognitive scores at baseline than those not consuming walnuts (low walnut consumption, b = 1·53, se = 0·21, P < 0·001; moderate walnut consumption, b = 2·22, se = 0·27, P < 0·001), but walnut consumption was not associated with cognitive change. Walnut consumption was positively associated with socioeconomic status and health behaviours as well as intake of nutrients identified to have neuroprotective benefits.
We identified an association between walnut consumption and cognitive function in older adults, although we did not find that walnut consumption was protective against age-related cognitive decline.
Over the past two hundred years the average global life expectancy has increased from just over thirty years of age to well over seventy years of age. There are many reasons for this ranging from the eradication of certain diseases, life style changes and improvements in public health. As people have lived longer, so they have worked longer, and this is reflected in the changing demographic of the workforce. However, notwithstanding this increase in life expectancy the aging process can takes in toll in terms of cognitive and functional decline which may have an impact on the ability of the older person to perform satisfactorily in the workplace. Where this involves physicians and surgeons there is obvious concern for patient safety.