Mild behavioral impairment as a predictor of cognitive functioning in older adults.

OBJECTIVE: To assess the influence of mild behavioral impairment (MBI) on the cognitive performance of older adults who are cognitively healthy or have mild cognitive impairment (MCI). METHODS: Secondary data analysis of a sample (n = 497) of older adults from the Florida Alzheimer's Disease Research Center who were either cognitively healthy (n = 285) or diagnosed with MCI (n = 212). Over half of the sample (n = 255) met the operationalized diagnostic criteria for MBI. Cognitive domains of executive function, attention, short-term memory, and episodic memory were assessed using a battery of neuropsychological tests. RESULTS: Older adults with MBI performed worse on tasks of executive function, attention, and episodic memory compared to those without MBI. A significant interaction revealed that persons with MBI and MCI performed worse on tasks of episodic memory compared to individuals with only MCI, but no significant differences were found in performance in cognitively healthy older adults with or without MBI on this cognitive domain. As expected, cognitively healthy older adults performed better than individuals with MCI on every domain of cognition. CONCLUSIONS: The present study found evidence that independent of cognitive status, individuals with MBI performed worse on tests of executive function, attention, and episodic memory than individuals without MBI. Additionally, those with MCI and MBI perform significantly worse on episodic memory tasks than individuals with only MCI. These results provide support for a unique cognitive phenotype associated with MBI and highlight the necessity for assessing both cognitive and behavioral symptoms.

Neuropsychiatric symptoms as a distinguishing factor between memory diagnoses.

OBJECTIVES: To determine whether neuropsychiatric symptoms (NPS) are able to differentiate those with mild cognitive impairment (MCI) and dementia from persons who are cognitively healthy. METHODS: Multinomial and binary logistic regressions were used to assess secondary data of a sample (n = 613) of older adults with NPS. Analyses evaluated the ability to differentiate between diagnoses, as well as the influence of these symptoms for individuals with amnestic MCI (MCI-A), non-amnestic MCI (MCI-NA), and dementia compared with those who are cognitively healthy. RESULTS: Persons with MCI were more likely to have anxiety, apathy, and appetite changes compared with cognitively healthy individuals. Persons with dementia were more likely to have aberrant motor behaviors, anxiety, apathy, appetite changes, and delusions compared with those who were cognitively healthy. Individuals with any type of cognitive impairment were more likely to have anxiety, apathy, appetite changes, and delusions. Specifically, anxiety, apathy, appetite changes, and disinhibition were predictors of MCI-A; agitation and apathy were predictors of MCI-NA; and aberrant motor behaviors, anxiety, apathy, appetite changes, and delusions were predictors of dementia. Finally, nighttime behavior disorders were less likely in individuals with dementia. CONCLUSIONS: The present study's results demonstrate that specific NPS are differentially represented among types of cognitive impairment and establish the predictive value for one of these cognitive impairment diagnoses.

Verbal fluency patterns in mild cognitive impairment and Alzheimer's disease.

BACKGROUND/AIMS: Verbal fluency patterns can assist in differential diagnosis during neuropsychological assessment and identify individuals at risk for developing Alzheimer's disease (AD). While evidence suggests that subjects with AD perform worse on category fluency than letter fluency tasks, the pattern in mild cognitive impairment (MCI) is less well known. METHODS: Performance on the Controlled Oral Word Association Test (COWAT) and Animal fluency was compared in control, amnestic MCI, non-amnestic MCI, and AD groups. The sample included 136 participants matched for age, education, and gender. RESULTS: Both MCI groups performed similarly with a category > letter fluency pattern rather than a category < letter fluency pattern typically observed in AD. The pattern in MCI, albeit relatively more impaired than in controls, was more similar to healthy controls who exhibited a category > letter fluency pattern. CONCLUSION: MCI using a category < letter fluency pattern may not represent AD; however, future research requires longitudinal studies of pattern analysis.

Impact of Mild Behavioral Impairment on Longitudinal Changes in Cognition.

BACKGROUND: To examine cross-sectional differences and longitudinal changes in cognitive performance based on the presence of mild behavioral impairment (MBI) among older adults who are cognitively healthy or have mild cognitive impairment (MCI). METHODS: Secondary data analysis of participants (n = 17 291) who were cognitively healthy (n = 11 771) or diagnosed with MCI (n = 5 520) from the National Alzheimer's Coordinating Center database. Overall, 24.7% of the sample met the criteria for MBI. Cognition was examined through a neuropsychological battery that assessed attention, episodic memory, executive function, language, visuospatial ability, and processing speed. RESULTS: Older adults with MBI, regardless of whether they were cognitively healthy or diagnosed with MCI, performed significantly worse at baseline on tasks for attention, episodic memory, executive function, language, and processing speed and exhibited greater longitudinal declines on tasks of attention, episodic memory, language, and processing speed. Cognitively healthy older adults with MBI performed significantly worse than those who were cognitively healthy without MBI on tasks of visuospatial ability at baseline and on tasks of processing speed across time. Older adults with MCI and MBI performed significantly worse than those with only MCI on executive function at baseline and visuospatial ability and processing speed tasks across time. CONCLUSIONS: This study found evidence that MBI is related to poorer cognitive performance cross-sectionally and longitudinally. Additionally, those with MBI and MCI performed worse across multiple tasks of cognition both cross-sectionally and across time. These results provide support for MBI being uniquely associated with different aspects of cognition.

Evaluating the impact of dental care on housing intervention program outcomes among homeless veterans.

OBJECTIVES: In this retrospective longitudinal cohort study, we examined the impact of dental care on outcomes among homeless veterans discharged from a Department of Veterans Affairs (VA) transitional housing intervention program. METHODS: Our sample consisted of 9870 veterans who were admitted into a VA homeless intervention program during 2008 and 2009, 4482 of whom received dental care during treatment and 5388 of whom did not. Primary outcomes of interest were program completion, employment or stable financial status on discharge, and transition to permanent housing. We calculated descriptive statistics and compared the 2 study groups with respect to demographic characteristics, medical and psychiatric history (including alcohol and substance use), work and financial support, and treatment outcomes. RESULTS: Veterans who received dental care were 30% more likely than those who did not to complete the program, 14% more likely to be employed or financially stable, and 15% more likely to have obtained residential housing. CONCLUSIONS: Provision of dental care has a substantial positive impact on outcomes among homeless veterans participating in housing intervention programs. This suggests that homeless programs need to weigh the benefits and cost of dental care in program planning and implementation.

Suicidal behavior in a national sample of older homeless veterans.

OBJECTIVES: We examined self-reported suicidal behavior of older homeless veterans to establish frequencies and predictors of recent suicidal behaviors, and their impact on transitional housing interventions. METHODS: We analyzed the records of a national sample of 10,111 veterans who participated in a transition housing program over a 6-year period, ending in 2008. RESULTS: Approximately 12% of homeless veterans reported suicidal ideation before program admission; 3% reported a suicide attempt in the 30 days before program admission. Older homeless veterans exhibiting suicidal behavior had histories of high rates of psychiatric disorders and substance abuse. Regression analyses showed that self-report of depression was the primary correlate of suicidal behavior. Suicidal behavior before program entry did not predict intervention outcomes, such as program completion, housing outcome, and employment. CONCLUSIONS: Suicidal behavior was prevalent in older homeless veterans and was associated with a history of psychiatric disorder and substance abuse. Self-reported depression was associated with these behaviors at the time of housing intervention. Despite the association with poor mental health history, suicidal behavior in older homeless veterans did not impact outcomes of transitional housing interventions.

Cognitive change checklist: psychometric characteristics in community-dwelling older adults.

OBJECTIVE: To extend the psychometric study of the Cognitive Change Checklist (3CL) by examining the reliability, factor structure, and external correlates of 3CL informant and self-report ratings in community-dwelling adults. We also conducted receiver operating characteristic analyses examining rating scores from this normative sample with those of clinical samples. DESIGN: Scale reliability and validity study. SETTING: Community sites. PARTICIPANTS: Six hundred seventy-nine older adults. RESULTS: The pattern of scale relationships within and across versions, and the failure to find associations with age and education, were consistent with findings in clinic samples reported previously. Factor analysis replicated the four-factor structure of the informant ratings. All informant version scales significantly discriminated amnestic mild cognitive impairment cases and patients with mild dementia from normals. CONCLUSION: These findings provide support for the use of the checklist as a clinical tool to facilitate identification of cases of mild cognitive impairment and early dementia.

An investigation of PreMCI: subtypes and longitudinal outcomes.

BACKGROUND/AIMS: To investigate the clinical features and rates of progression of conditions that are not considered to be normal, but do not fulfill criteria for mild cognitive impairment (MCI). METHODS: We longitudinally evaluated 269 elderly subjects who did not meet formal criteria for MCI at baseline but had: (1) a clinical history suggesting MCI without neuropsychological deficits (PreMCI-Clinical); or (2) neuropsychological deficits on one or more memory measures in conjunction with a negative clinical examination (amnestic PreMCI-NP) or were normal on both neuropsychological and clinical examination. RESULTS: The rate of progression to MCI or dementia over an average of 2- to 3 years was 3.7% for no cognitive impairment subjects, whereas it was significantly greater for all PreMCI subtypes (22.0% for PreMCI-Clinical, 38.9% for amnestic PreMCI-NP subjects with two or more memory impairments). Among PreMCI subjects as a whole, lower baseline scores on object memory and category fluency tests were the best predictors of progression to MCI or dementia. Cardiovascular risk factors, Parkinsonian symptoms, and hippocampal atrophy were not associated with progression. CONCLUSION: Distinct PreMCI subtypes defined on the basis of clinical and neuropsychological evaluations were found to have distinct characteristics, but both subtypes demonstrated elevated risk for progression to MCI or dementia. Despite the lack of evidence of clinical impairment, subjects with neuropsychological deficits in two memory domains were particularly at increased risk for progression of their deficits.

Assessment of cognition in early dementia.

Better tools for assessing cognitive impairment in the early stages of Alzheimer's disease (AD) are required to enable diagnosis of the disease before substantial neurodegeneration has taken place and to allow detection of subtle changes in the early stages of progression of the disease. The National Institute on Aging and the Alzheimer's Association convened a meeting to discuss state of the art methods for cognitive assessment, including computerized batteries, as well as new approaches in the pipeline. Speakers described research using novel tests of object recognition, spatial navigation, attentional control, semantic memory, semantic interference, prospective memory, false memory and executive function as among the tools that could provide earlier identification of individuals with AD. In addition to early detection, there is a need for assessments that reflect real-world situations in order to better assess functional disability. It is especially important to develop assessment tools that are useful in ethnically, culturally and linguistically diverse populations as well as in individuals with neurodegenerative disease other than AD.

Defining mild cognitive impairment: impact of varying decision criteria on neuropsychological diagnostic frequencies and correlates.

OBJECTIVE: To examine the impact of varying decision criteria on neuropsychological diagnostic frequencies and on their correlates. DESIGN: Descriptive and correlational study. SETTING: Florida Alzheimer's Disease Research Center. PARTICIPANTS: A sample of 373 individuals with comprehensive baseline analyses participating in a longitudinal study of cognitive decline and early Alzheimer disease. MEASUREMENTS: Mild cognitive impairment (MCI) diagnoses were made on the basis of four sets of decision criteria created by crossing two approaches: varying the number of impaired test results required for a diagnosis within any domain (1 test versus 2) and varying the performance level required to determine impairment (1.5 or 2 standard deviations [SDs] below the normative mean) for any test. RESULTS: Under each criteria set, single-domain amnestic MCI was the most frequent MCI diagnosis. MCI global and subtype diagnosis frequencies were inversely related to the stringency of the criteria. The single test-1.5 SD criterion identified the largest number of cases as qualifying for an MCI diagnosis, and the two test-2.0 SD cutoff identified the fewest. Across all sets of criteria, the authors found significant positive associations between neuropsychological diagnoses and Clinical Dementia Rating score categories. Significant relationships between diagnoses and both apolipoprotein E (APOE) genotype and magnetic resonance imaging ratings of medial temporal atrophy (MTA) application were found only for the two test-1.5 SD and two test-2.0 SD cutoffs. CONCLUSION: MCI diagnosis frequencies are substantively affected by the stringency of the criteria, but the relative rankings of MCI subtype diagnoses are fairly consistent regardless of the stringency of the criteria. Significant associations of neuropsychological diagnoses with independent markers such as APOE genotype and MTA are only found with more stringent criteria, suggesting that a coherent network of associations reflecting cognitive decline occurs with more restrictive definitions for impairment.

Cross-validation of the Florida Cognitive Activities Scale (FCAS) in an Alzheimer's disease research center sample.

We conducted a cross-validation study of the Florida Cognitive Activities Scale (FCAS) in a sample of heterogeneously diagnosed elderly participants in the Florida Alzheimer's Disease Research Center. FCAS scales were found to be significantly correlated with neuropsychological measures and with ratings of medial temporal atrophy (MTA). The pattern of significant differences in FCAS scores among groups of normals, those with mild cognitive impairment, and early-stage Alzheimer disease cases suggests that the cognitive activities tapped by the FCAS are affected throughout disease progression in the same way as the neuropsychological performance measures. Notably, FCAS score differences among these groups were as large as they were for ratings of MTA. The accumulation of reliability and validity data indicates that the FCAS scales are sensitive measures of individual differences in cognitive activity and would serve as valid longitudinal measures of change in the study of aging, cognitive decline, and degenerative dementia.

Use of informants to identify mild cognitive impairment in older adults.

Extensive research supports the use of informant ratings in diagnosing dementia. In comparison, far fewer studies have examined the use of informant ratings in identifying mild cognitive impairment (MCI), a state that occurs as healthy older adults make the gradual transition to dementia. A review of available studies that have examined discrepancies between MCI patient and informant reports has for the most part demonstrated that informant ratings reveal greater loss of everyday functional ability and cognitive competency. Additionally, current findings support a significantly greater association of informant ratings with objective measures of patient cognitive performance and characteristics of underlying dementing processes. Structured measures used to examine the diagnostic efficacy of informant ratings in identifying cases of MCI are reviewed. Two recently developed instruments seem especially promising, but further validation efforts will be required before they can be considered to meet standards for clinical use.

The cognitive change checklist (3CL): cross-validation of a measure of change in everyday cognition.

OBJECTIVE: The recently developed cognitive change checklist (3CL) is comprised of four scales titled memory, executive, language, and remote recall. A previous study demonstrated that the checklist met criteria for reliability and validity in characterizing cases of mild cognitive impairment (MCI) and early dementia in a memory disorder clinic sample. In this study we examined further the reliability, validity, and efficacy of the 3CL in distinguishing among groups of normal individuals, those with cognitive complaints, amnestic and non-amnestic MCI cases, and early-stage demented individuals. DESIGN: Scale validation study. SETTING: Alzheimer's Disease Research Center PARTICIPANTS: One hundred and twenty-five individuals who completed extensive evaluations as part of a longitudinal study of cognitive change. RESULTS: Scale reliabilities were found to be well within guidelines to support their use in the clinical assessment of change in global and specific cognitive domains. The factor structure of the 3CL was found to be highly similar to that originally reported. Validation support was obtained from correlational analyses that showed significant scale relationships with neurocognitive measures and with MRI ratings of medial temporal atrophy. Informant 3CL scales were found to discriminate individuals with cognitive complaints but without clinical findings from those individuals with amnestic MCI or early dementia. CONCLUSION: Results extend the foundation of support for the use of the 3CL as a measure to facilitate identification of cases of MCI and early AD. Further examination of the diagnostic utility of the scale, and of its value in combination with cognitive screening measures, will also be required.

Measuring change in everyday cognition: development and initial validation of the cognitive change checklist (3CL).

OBJECTIVE: There is ample evidence to support an informant-based approach in screening efforts for the identification of cases of Mild Cognitive Impairment and early Alzheimer disease, but existing instruments are not maximally designed to capture recent changes in cognitive status of the types seen in these disorders. The authors describe the construction of a multiscale informant rating checklist (Cognitive Change Checklist; 3CL) designed to be sensitive to the earliest stages of cognitive decline associated with degenerative dementias. DESIGN: Scale development, reliability, and validity study. SETTING: Memory Disorder Clinics. PARTICIPANTS: Three hundred fifty-nine individuals are evaluated for a memory disorder. RESULTS: The analyses resulted in a 28-item informant rating checklist of cognitive change that is composed of four nonoverlapping scales titled Memory, Executive, Language, and Remote Recall. Scale reliabilities were found to be well within guidelines to support their use in the clinical assessment of change in global cognition and specific cognitive domains. Substantive support for the validity of the checklist was obtained from correlational analyses that showed significant scale relationships with neurocognitive measures, from the finding of differences in scale scores among diagnostic groups that paralleled that of the neurocognitive measures, and from examination of the sensitivity of the scales in receiver operating characteristic analyses. CONCLUSION: These findings provide support for the use of the checklist as a clinical tool to facilitate identification of cases of Mild Cognitive Impairment and early Alzheimer disease. Further examination of the diagnostic utility of the scale, and of its value in combination with cognitive screening measures, will also be required.

Severity of medial temporal atrophy and amnestic mild cognitive impairment: selecting type and number of memory tests.

OBJECTIVE: Medial temporal lobe atrophy (MTA) can be used as a biomarker of pathology that affects mechanisms of episodic memory. The authors compared the strength of this biomarker with performance on four memory measures and examined the influence of demographic factors including age, level of education, and primary language (English or Spanish). METHODS: The Hopkins Verbal Learning Test-revised, Fuld Object Memory Evaluation (FOME), delayed memory for a story passage, and delayed visual reproduction of the Wechsler Memory Scale-revised tests were administered to 281 subjects who were diagnosed as having no cognitive impairment, mild cognitive impairment (MCI), impaired non-MCI, or dementia. MTA scores were obtained from visual ratings of the hippocampus, entorhinal cortex, and perirhinal cortex on coronal magnetic resonance imaging scans using a magnetization-prepared rapid gradient echo protocol. RESULTS: Age was associated with scores on all memory measures and MTA. Level of educational attainment had no influence on FOME performance but had greater associations with scores on other memory measures. In regression models, FOME scores had the strongest relationship with MTA scores, accounting for 31% of the explained variability. Among subjects with MCI, an index representing the total number of memory tests that were impaired was also predictive of the severity of MTA scores. CONCLUSION: Among four common tests of memory, the FOME was highly associated with MTA, and it exhibited minimal influences of education. Impairment on more than one memory test was more predictive of MTA than impairment on a single memory test.

Suicidality and the Onset of Homelessness: Evidence for a Temporal Association From VHA Treatment Records.

OBJECTIVE: This study examined the temporal sequencing of a first-recorded episode of homelessness and treatment for suicidal ideation or attempt. METHODS: Data were from the U.S. Department of Veterans Affairs Corporate Data Warehouse and contained medical records of service use dates and associated ICD codes for care provided by the Veterans Health Administration. The analysis examined treatment for suicidality before and after a first record of homelessness ("onset") among 152,519 veterans. The second analysis examined the rate of treatment for suicidality among 156,288 veterans with any indication of homelessness. The third analysis examined the rate of homelessness among 145,770 veterans with indication of suicidality. RESULTS: Among newly homeless veterans, treatment for suicidality peaked just before onset of homelessness. Thirteen percent of homeless veterans had evidence of suicidality. Twenty-nine percent of veterans with evidence of suicidality appeared to have concurrent homelessness. CONCLUSIONS: Homelessness should be considered a primary risk factor for suicidality.

Externalizing pathology and the five-factor model: a meta-analysis of personality traits associated with antisocial personality disorder, substance use disorder, and their co-occurrence.

In this meta-analysis we examined Five-Factor Model of personality (FFM) characteristics of externalizing disorders. Two pathologies, Antisocial Personality Disorder (APD) and Substance Use Disorder (SUD), have significant levels of co-occurrence that may be due to shared personality traits. Results from 63 samples (N = 15,331) were analyzed in order to summarize and compare five-factor results for APD, SUD, and co-occurring APD/SUD. Shared and unique personality features were identified at both the domain and the facet level of the FFM. Moderation analyses indicated that sample source (clinical versus community) and diagnosis (psychopathy versus DSM-based APD) accounted for some of the variability at the domain level. Results are discussed with respect to personality and externalizing disorders.

Characteristics of the Florida cognitive activities scale in older African Americans.

Substantial research effort has recently focused on the potential protective effect of cognitively demanding activities on cognitive decline in late life. A significant methodological issue in this effort has been the lack of consistency in approaches to the operational measurement of cognitive activity. In this study, data in support of the reliability and construct validity of the recently developed Florida Cognitive Activities Scale (FCAS) in a sample of 223 African American older adults are provided. Consistent with the findings of the Schinka et al. study using a sample of Whites, the FCAS full scale showed a reasonably high level of internal consistency, small negative correlations with age and a measure of depressive symptomatology, and moderate positive correlations with years of education and neuropsychological measures of overall cognitive functioning, memory, and executive functioning. Even after controlling for the effects of age, education, and gender, the full scale score contributed significantly to the prediction of global cognitive functioning. The results of this study suggest that the FCAS is a reliable and valid measure of cognitive activities in older African Americans and provides additional, although not causative, evidence in support of the hypothesis of a protective effect of cognitive activity against cognitive decline regardless of ethnicity or race.

Mortality and Cause of Death in Younger Homeless Veterans.

OBJECTIVES: Increased mortality has been documented in older homeless veterans. This retrospective study examined mortality and cause of death in a cohort of young and middle-aged homeless veterans. METHODS: We examined US Department of Veterans Affairs records on homelessness and health care for 2000-2003 and identified 23 898 homeless living veterans and 65 198 non-homeless living veterans aged 30-54. We used National Death Index records to determine survival status. We compared survival rates and causes of death for the 2 groups during a 10-year follow-up period. RESULTS: A greater percentage of homeless veterans (3905/23 898, 16.3%) than non-homeless veterans (4143/65 198, 6.1%) died during the follow-up period, with a hazard ratio for risk of death of 2.9. The mean age at death (52.3 years) for homeless veterans was approximately 1 year younger than that of non-homeless veterans (53.2 years). Most deaths among homeless veterans (3431/3905, 87.9%) and non-homeless veterans (3725/4143, 89.9%) were attributed to 7 cause-of-death categories in the International Classification of Diseases, 10th Revision (cardiovascular system; neoplasm; external cause; digestive system; respiratory system; infectious disease; and endocrine, nutritional, and metabolic diseases). Death by violence was rare but was associated with a significantly higher risk among homeless veterans than among non-homeless veterans (suicide hazard ratio = 2.7; homicide hazard ratio = 7.6). CONCLUSIONS: Younger and middle-aged homeless veterans had higher mortality rates than those of their non-homeless veteran peers. Our results indicate that homelessness substantially increases mortality risk in veterans throughout the adult age range. Health assessment would be valuable for assessing the mortality risk among homeless veterans regardless of age.

Predictors of Mortality in Older Homeless Veterans.

OBJECTIVES: In this analysis of a cohort of older homeless veterans, we examined psychosocial, health, housing, and employment characteristics to identify predictors of mortality. METHOD: Our sample of 3,620 older veterans entered Veteran Affairs homeless programs in years 2000-2003. Fifteen variables from a structured interview described this sample and served as predictors. National Death Index data for years 2000-2011 were used to ascertain death. Survival table analyses were conducted to estimate and plot cumulative survival functions. To determine predictors and estimate hazard functions, Cox proportional hazards regression analysis was conducted. RESULTS: Five variables (presence of a serious health issue, hospitalization for alcohol abuse, alcohol dependency, unemployment for 3 years, and age 60+) were associated with increased risk of death; three (non-White, drug dependency, and dental problems) were associated with reduced risk. A risk score, based on total unit-weighted risk for all eight predictors, was used to identify three groups that were found to differ significantly in mortality. CONCLUSIONS: These analyses underline the jeopardy faced by older homeless veterans in terms of early death. We were able to identify several variables associated with mortality; more importantly, we were able to show that a risk score based on status for these variables was significantly related to survival.