The aging brain: risk factors and interventions for long term brain health in women.

PURPOSE OF REVIEW: Poor cognitive aging and dementia pose a significant public health burden, and women face unique risks compared to men. Recent research highlights the role of genetics, menopause, chronic disease, and lifestyle in risk and resilience in women's cognitive aging. This work suggests avenues for clinical action at midlife that may change the course of brain health in aging. RECENT FINDINGS: Studies indicate women's risk for poor cognitive aging relates in part to hormone changes at menopause, a time when memory, brain structure and function, and Alzheimer's pathology may be observed in women and not men. Medical and lifestyle risks including diabetes, hypertension, and low physical activity also contribute to women's unique risks. At the same time, literature on resilience suggests women may benefit from lifestyle and chronic disease intervention, possibly more than men. Current studies emphasize the importance of interacting genetic and lifestyle risks, and effects of social determinants of health. SUMMARY: Women have greater risk than men for poor cognitive aging; however, by treating the whole person, including genetics, lifestyle, and social environment, clinicians have an opportunity to support healthy cognitive aging in women and reduce the future public health burden of dementia.

Feasibility and safety of a rapid-access transient ischemic attack clinic.

BACKGROUND: In the United States, patients with transient ischemic attacks (TIAs) are commonly admitted to the hospital despite evidence that low-risk TIA patients achieve improved outcomes at lower costs at specialized rapid-access TIA clinics (RATCs). LOCAL PROBLEM: All patients experiencing TIAs at a hospital system in the Pacific Northwest were being admitted to the hospital. This project aimed to implement an RATC to relocate care for low-risk TIA patients, showing feasibility and safety. METHODS: Following implementation of the RATC, a retrospective chart review was performed. Outcomes included days to RATC; days to magnetic resonance imaging (MRI); final diagnosis; stroke-related admissions and deaths within 90 days of the RATC visit. INTERVENTIONS: From 2016 to 2018, implementation of an RATC included patient triage tools; multidisciplinary collaboration between departments; a direct scheduling pathway; and emphasis on stroke prevention. RESULTS: Ninety-nine patients were evaluated in the RATC, 69% (69/99) were referred from the emergency department. Sixty-six percent of patients were seen in the TIA clinic in 2 days or less, 19% at 3 days, and 15% at 4 days or more. Mean days to TIA clinic was 2.5 days (SD 2.4). Mean days (SD) to MRI was 2.1 days (SD 2.3). Forty-eight percent (48/99) had a final diagnosis of probable TIA, followed by 32% (32/99) who had other diagnoses; 15% (15/99) migraine variant; 4% (4/99) with stroke. Two percent (2/99) of patients had a stroke-related admission within 90 days, another 2% (2/99) died of non-stroke-related causes within 90 days of the RATC visit. CONCLUSIONS: Utilization of RATCs is feasible and safe. Nurse practitioners are integral in delivering this innovative, cost-effective model of care.

UW Project ECHO-Dementia: Implementation of a virtual clinic and telementoring program to improve dementia diagnosis and treatment in rural and under-resourced primary care settings.

BACKGROUND: Primary care providers are on the front lines of dementia care and frequently the first point of contact for individuals and families concerned about changes in memory and thinking. In addition to the challenges of managing complex medical comorbidities, primary care providers in rural or lower-resource settings often lack access to specialists, interdisciplinary teams or other programs and services to aid in diagnosis and care of individuals with mild cognitive impairment and dementia. The current project extends an existing technology-based hub and spoke model virtual clinic, Project ECHO (Extension for Community Healthcare Outcomes, University of New Mexico), to improve diagnosis and care of dementia in primary care. METHOD: The current project is an extension of work related to the Washington State Plan for Alzheimer's Disease and Other Dementias with implementation supported by legislative funding. The program includes an interdisciplinary expert panel ("hub") meeting with participants ("spokes") including primary and allied health care providers from healthcare systems, group practices, and solo practitioners. The twice-monthly virtual clinic sessions include a brief didactic followed by case-based learning in an "all-teach, all-learn" format emphasizing expertise and experience of spoke sites as well as the hub. Participants are provided with resources discussed during the clinic session, ongoing opportunities for consultation, and free continuing education credits. RESULTS: Launching amid the COVID-19 pandemic, the program has provided over 250 hours of education to more than 50 providers across 20 unique sites. Post session surveys indicate that the program is well-received with 2 in 3 providers indicating that they will change their practice based on learning. Surveys also demonstrate significant increases in both knowledge and confidence in dementia-specific diagnosis and care. CONCLUSION: The success of the current project demonstrates both the feasibility and benefit of leveraging technology to deliver dementia-related education to primary care providers in rural and under-resourced settings. While initially hampered by disruptions in care due to the COVID-19 pandemic, increased technological proficiency on the provider and systems level has appeared to be a benefit in terms of resources and comfort participating in a virtual education program to scale Dementia Capable Care in Primary Care.

Beyond the amygdala: Linguistic threat modulates peri-sylvian semantic access cortices.

In this study, healthy volunteers were scanned using functional magnetic resonance imaging (fMRI) to investigate the neural systems involved in processing the threatening content conveyed via visually presented "threat words." The neural responses elicited by these words were compared to those elicited by matched neutral control words. The results demonstrate that linguistic threat, when presented in written form, can selectively engage areas of lateral temporal and inferior frontal cortex, distinct from the core language areas implicated in aphasia. Additionally, linguistic threat modulates neural activity in visceral/emotional systems (amygdala, parahippocampal gyrus and periaqueductal gray), and at earlier stages of the visual-linguistic processing stream involved in visual word form representations (ventral occipitotemporal cortex). We propose a model whereby limbic activation modulates activity at multiple nodes along the visual-linguistic-semantic processing stream, including a perisylvian "semantic access network" involved in decoding word meaning, suggesting a dynamic interplay between feedforward and feedback processes.

Altered threat and safety neural processing linked to persecutory delusions in schizophrenia: a two-task fMRI study.

Persecutory delusions are a clinically important symptom in schizophrenia associated with social avoidance and increased violence. Few studies have investigated the neurobiology of persecutory delusions, which is a prerequisite for developing novel treatments. The aim of this two-paradigm functional magnetic resonance imaging (fMRI) study is to characterize social "real world" and linguistic threat brain activations linked to persecutory delusions in schizophrenia (n=26) using instructed-fear/safety and emotional word paradigms. Instructed-fear/safety activations correlated to persecutory delusion severity demonstrated significant increased lateral orbitofrontal cortex and visual association cortex activations for the instructed-fear vs. safety and instructed-fear vs. baseline contrasts; decreased lateral orbitofrontal cortex and ventral occipital-temporal cortex activations were observed for the instructed-safety stimuli vs. baseline contrast. The salience network also showed divergent fear and safety cued activations correlated to persecutory delusions. Emotional word paradigm analyses showed positive correlations between persecutory delusion severity and left-lateralized linguistic and hippocampal-parahippocampal activations for the threat vs. neutral word contrast. Visual word form area activations correlated positively with persecutory delusions for both threat and neutral word vs. baseline contrasts. This study links persecutory delusions to enhanced neural processing of threatening stimuli and decreased processing of safety cues, and helps elucidate systems-level activations associated with persecutory delusions in schizophrenia.

Neuroimaging of frontal-limbic dysfunction in schizophrenia and epilepsy-related psychosis: toward a convergent neurobiology.

Psychosis is a devastating, prevalent condition considered to involve dysfunction of frontal and medial temporal limbic brain regions as key nodes in distributed brain networks involved in emotional regulation. The psychoses of epilepsy represent an important, though understudied, model relevant to understanding the pathophysiology of psychosis in general. In this review, we (1) discuss the classification of epilepsy-related psychoses and relevant neuroimaging and other studies; (2) review structural and functional neuroimaging studies of schizophrenia focusing on evidence of frontal-limbic dysfunction; (3) report our laboratory's PET, fMRI, and electrophysiological findings; (4) describe a theoretical framework in which frontal hypoactivity and intermittent medial temporal hyperactivity play a critical role in the etiopathology of psychosis both associated and unassociated with epilepsy; and (5) suggest avenues for future research.

Communicative hand gestures and object-directed hand movements activated the mirror neuron system.

Humans produce hand movements to manipulate objects, but also make hand movements to convey socially relevant information to one another. The mirror neuron system (MNS) is activated during the observation and execution of actions. Previous neuroimaging experiments have identified the inferior parietal lobule (IPL) and frontal operculum as parts of the human MNS. Although experiments have suggested that object-directed hand movements drive the MNS, it is not clear whether communicative hand gestures that do not involve an object are effective stimuli for the MNS. Furthermore, it is unknown whether there is differential activation in the MNS for communicative hand gestures and object-directed hand movements. Here we report the results of a functional magnetic resonance imaging (fMRI) experiment in which participants viewed, imitated and produced communicative hand gestures and object-directed hand movements. The observation and execution of both types of hand movements activated the MNS to a similar degree. These results demonstrate that the MNS is involved in the observation and execution of both communicative hand gestures and object-direct hand movements.

Cognitive performance and autonomic reactivity in abstinent drug abusers and nonusers.

In this study the authors compared the performance of abstinent drug abusers (n = 21) and nonuser control participants (n = 20) in neurocognitive and emotional functions by use of the Rogers Decision Making Task, Gambling Task, Emotional Stroop, impulsivity continuous performance task (CPT), and vigilance CPT. Skin conductance (SC) and heart rate (HR) monitoring was synchronized with task performance. Groups showed similar performance for vigilance, impulsivity, and emotional interference; however, drug abusers showed stronger SC responses. Drug abusers performed more poorly on the Gambling and Rogers Decision Making Tasks. When making risky decisions, drug abusers showed significantly less increase in SC activity than controls and exhibited lower HRs throughout performance on all tasks. In conclusion, complex tasks involving decision making, sensitivity to consequences, and emotional regulation discriminated between drug abusers and controls.