Early Detection of Amyloid-Related Changes in Memory among Cognitively Unimpaired Older Adults with Daily Digital Testing.

OBJECTIVE: This study was undertaken to determine whether assessing learning over days reveals Alzheimer disease (AD) biomarker-related declines in memory consolidation that are otherwise undetectable with single time point assessments. METHODS: Thirty-six (21.9%) cognitively unimpaired older adults (aged 60-91 years) were classified with elevated ß-amyloid (Aß+) and 128 (78%) were Aß- using positron emission tomography with 11C Pittsburgh compound B. Participants completed the multiday Boston Remote Assessment for Neurocognitive Health (BRANCH) for 12 min/day on personal devices (ie, smartphones, laptops), which captures the trajectory of daily learning of the same content on 3 repeated tests (Digit Signs, Groceries-Prices, Face-Name). Learning is computed as a composite of accuracy across all 3 measures. Participants also completed standard in-clinic cognitive tests as part of the Preclinical Alzheimer's Cognitive Composite (PACC-5), with 123 participants undergoing PACC-5 follow-up after 1.07 (standard deviation = 0.25) years. RESULTS: At the cross-section, there were no statistically significant differences in performance between Aß+/- participants on any standard in-clinic cognitive tests (eg, PACC-5) or on day 1 of multiday BRANCH. Aß+ participants exhibited diminished 7-day learning curves on multiday BRANCH after 4 days of testing relative to Aß- participants (Cohen d = 0.49, 95% confidence interval = 0.10-0.87). Diminished learning curves were associated with greater annual PACC-5 decline (r = 0.54, p < 0.001). INTERPRETATION: Very early Aß-related memory declines can be revealed by assessing learning over days, suggesting that failures in memory consolidation predate other conventional amnestic deficits in AD. Repeated digital memory assessments, increasingly feasible and uniquely able to assess memory consolidation over short time periods, have the potential to be transformative for detecting the earliest cognitive changes in preclinical AD. ANN NEUROL 2024;95:507-517.

Smartphone-Based Neuropsychological Assessment in Parkinson's Disease: Feasibility, Validity, and Contextually Driven Variability in Cognition.

OBJECTIVES: The prevalence of neurodegenerative disorders demands methods of accessible assessment that reliably captures cognition in daily life contexts. We investigated the feasibility of smartphone cognitive assessment in people with Parkinson's disease (PD), who may have cognitive impairment in addition to motor-related problems that limit attending in-person clinics. We examined how daily-life factors predicted smartphone cognitive performance and examined the convergent validity of smartphone assessment with traditional neuropsychological tests. METHODS: Twenty-seven nondemented individuals with mild-moderate PD attended one in-lab session and responded to smartphone notifications over 10 days. The smartphone app queried participants 5x/day about their location, mood, alertness, exercise, and medication state and administered mobile games of working memory and executive function. RESULTS: Response rate to prompts was high, demonstrating feasibility of the approach. Between-subject reliability was high on both cognitive games. Within-subject variability was higher for working memory than executive function. Strong convergent validity was seen between traditional tests and smartphone working memory but not executive function, reflecting the latter's ceiling effects. Participants performed better on mobile working memory tasks when at home and after recent exercise. Less self-reported daytime sleepiness and lower PD symptom burden predicted a stronger association between later time of day and higher smartphone test performance. CONCLUSIONS: These findings support feasibility and validity of repeat smartphone assessments of cognition and provide preliminary evidence of the effects of context on cognitive variability in PD. Further development of this accessible assessment method could increase sensitivity and specificity regarding daily cognitive dysfunction for PD and other clinical populations.

Parsing social motivation: development and validation of a self-report measure of social effort.

BACKGROUND: Reduced efforts to form and maintain social bonds can exist in the context of a sufficient desire for social connection. Thus, social impairment common across many psychiatric conditions may often reflect failures in social effort exertion, despite normative levels of social liking and wanting. Although there are many questionnaires available that assess sociability, desire, or lack thereof for connection and perceived social support, there is no current self-report assessment of the behavioral outputs of social motivation. AIMS: We aimed to develop and validate a measure of the social effort in college students and the general population. METHODS: College students (n = 981) and a broader sample of adults via Amazon's Mechanical Turk (MTurk; n = 506) participated in the study. RESULTS: We identified two factors that represented content related to general social effort and social effort in adherence with social norms; we named the measure the Social Effort and Conscientiousness Scale (SEACS). Results suggest the SEACS is a reliable and valid measure of social effort. CONCLUSIONS: Lower scores on the SEACS were associated with symptoms of depression and anxiety, highlighting the scale's potential utility in clinical populations. We include a discussion of possible applications of the SEACS, including its further use and application in psychopathology research.

Amitriptyline Dose and Treatment Outcomes in Specialty Headache Practice: A Retrospective Cohort Study.

OBJECTIVE: To characterize treatment patterns and real world outcomes in headache patients treated with amitriptyline in an academic headache center. DESIGN AND METHODS: A retrospective chart review identified 178 patients in our center who were given a new prescription for amitriptyline in treatment of headache, and who were seen in follow-up within one year. Charts were reviewed to identify dosing patterns (initial and maximum dose) and persistence, patient-reported headache benefit, and reported side effects. Variables assessed in relation to medication use were comorbid psychiatric disease, headache characteristics, and prior use of a preventive medication. RESULTS: We followed patients for an average of 6.5 months. Initial and maximum prescribed amitriptyline doses were characterized as: "very low" (≤10 mg daily), "low" (11-25 mg daily), and "traditional" (≥25 mg daily). The initial dose of amitriptyline ranged from 2.5 to 50 mg daily, though most patients were started on a dose of 10 mg daily (112/178, 63%). Approximately 3/4 of the patients were found to have improvement (134/178) and 85% (129/151) were still taking amitriptyline at the last follow-up appointment. Maximum dosing ranged from 2.5 to 100 mg daily with most patients taking 10-25 mg (86/146, 58%). The most commonly reported adverse effect was daytime fatigue (17/151, 11%). There did not appear to be any effect from gender, ethnicity, race, diagnosis of sleep apnea, chronicity of migraine, presence of aura on our outcome measures. CONCLUSION: Our study supports the common clinical practice of using low doses of amitriptyline to treat chronic headache disorders and suggests that it was effective and well tolerated at doses lower than those used in many clinical trials. Use of low dosage amitriptyline may also improve medication persistence, an important clinical consideration in the management of this common and chronic condition. A subgroup of patients may experience a dramatic benefit from amitriptyline and this could warrant further investigation.

The evolution and geographic distribution of headache medicine fellowship programs and graduates: an observational study.

OBJECTIVES: We sought to assess the experiences, growth, and distribution of accredited headache medicine fellowships since accreditation began in 2007, and to examine the number and current practice locations of fellows graduated from those programs. BACKGROUND: There are no data on the distribution of headache fellowship programs and their graduates throughout the United States. METHODS: We surveyed directors of Headache Medicine fellowship programs accredited by the United Council of Neurologic Subspecialties as of April 1, 2014. We recorded the geographic locations of accredited programs and fellowship graduates and determined their distribution in relation to the overall and selected minority populations of US census divisions, regions, and states. RESULTS: In early 2014, there were 25 accredited Headache Medicine fellowship programs in the United States. Thirty-two (63%) US states lack a headache fellowship program and 24 (47%) do not have a practicing United Council for Neurologic Subspecialties fellowship graduate. Fifty-two of 96 fellows (54%) entered practice in the same state where they did their training. The northeastern United States has the best ratio of fellowship programs and graduates to population (0.28 and 0.35 per million inhabitants) and land area (6.38 and 8 per 100,000 square miles). The Pacific Northwest has the worst (0.05 and 0.02 fellowship programs and graduates per million inhabitants and 2.3 and 1.1 per 100,000 square miles). Fifty-five percent of the US Hispanic population lives in areas of the country with only 32% of practicing certified headache specialists, 28% of accredited fellowship programs, and which have attracted only 27% of fellowship graduates. Thirty-three percent of the US black population lives in areas with just 8% of fellowship programs and 27% of fellowship graduates. Fellowship directors report that funding for fellowship positions is an important challenge. CONCLUSIONS: The number of fellowship programs has increased dramatically since 2007, but their geographic distribution is uneven and so are the subsequent practice locations of fellow graduates. At present, the distribution of training programs and headache specialists is not well matched to the US population as a whole or to the location of important racial and ethnic minorities. Increasing the overall supply of headache specialists is important, but geographic inequalities in specialist distribution must also be addressed or disparities will increase.

Capturing learning curves with the multiday Boston Remote Assessment of Neurocognitive Health (BRANCH): Feasibility, reliability, and validity.

OBJECTIVE: Unsupervised remote digital cognitive assessment makes frequent testing feasible and allows for measurement of learning over repeated evaluations on participants' own devices. This provides the opportunity to derive individual multiday learning curve scores over short intervals. Here, we report feasibility, reliability, and validity, of a 7-day cognitive battery from the Boston Remote Assessment for Neurocognitive Health (Multiday BRANCH), an unsupervised web-based assessment. METHOD: Multiday BRANCH was administered remotely to 181 cognitively unimpaired older adults using their own electronic devices. For 7 consecutive days, participants completed three tests with associative memory components (Face-Name, Groceries-Prices, Digit Signs), using the same stimuli, to capture multiday learning curves for each test. We assessed the feasibility of capturing learning curves across the 7 days. Additionally, we examined the reliability and associations of learning curves with demographics, and traditional cognitive and subjective report measures. RESULTS: Multiday BRANCH was feasible with 96% of participants completing all study assessments; there were no differences dependent on type of device used (t = 0.71, p = .48) or time of day completed (t = -0.08, p = .94). Psychometric properties of the learning curves were sound including good test-retest reliability of individuals' curves (intraclass correlation = 0.94). Learning curves were positively correlated with in-person cognitive tests and subjective report of cognitive complaints. CONCLUSIONS: Multiday BRANCH is a feasible, reliable, and valid cognitive measure that may be useful for identifying subtle changes in learning and memory processes in older adults. In the future, we will determine whether Multiday BRANCH is predictive of the presence of preclinical Alzheimer's disease. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Choosing wisely in headache medicine: the American Headache Society's list of five things physicians and patients should question.

In an effort to draw attention to tests and procedures associated with low-value care in headache medicine, the American Headache Society (AHS) joined the Choosing Wisely initiative of the American Board of Internal Medicine Foundation. The AHS president appointed an ad hoc "Choosing Wisely" task force of the AHS. The committee surveyed AHS members to develop a candidate list of items for the AHS "Top 5" list of low-value care in headache medicine. Through a process of literature review and consensus, the final list of five items was chosen. Draft recommendations went through several rounds of revision and a process of outside review. The AHS Board of Directors approved the final list of "Five Things." The five recommendations approved by the AHS Board of Directors are: (1) don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine; (2) don't perform computed tomography imaging for headache when magnetic resonance imaging is available, except in emergency settings; (3) don't recommend surgical deactivation of migraine trigger points outside of a clinical trial; (4) don't prescribe opioid- or butalbital-containing medications as a first-line treatment for recurrent headache disorders; and (5) don't recommend prolonged or frequent use of over-the-counter pain medications for headache. We recommend that headache medicine specialists and other physicians who evaluate and treat headache disorders should use this list when discussing care with patients.

Temporarily Withdrawn: Choosing Wisely in Headache Medicine: The American Headache Society's List of Five Things Physicians and Patients Should Question.

This paper has been temporarily withdrawn and is currently under embargo. The full text of the paper will be available on Thursday, November 21, 2013, and can be accessed at that time here: http://onlinelibrary.wiley.com/doi/10.1111/head.12233/abstract.

Recent contributions to the field of subjective cognitive decline in aging: A literature review.

Subjective cognitive decline (SCD) is defined as self-experienced, persistent concerns of decline in cognitive capacity in the context of normal performance on objective cognitive measures. Although SCD was initially thought to represent the "worried well," these concerns can be linked to subtle brain changes prior to changes in objective cognitive performance and, therefore, in some individuals, SCD may represent the early stages of an underlying neurodegenerative disease process (e.g., Alzheimer's disease). The field of SCD research has expanded rapidly over the years, and this review aims to provide an update on new advances in, and contributions to, the field of SCD in key areas and themes identified by researchers in this field as particularly important and impactful. First, we highlight recent studies examining sociodemographic and genetic risk factors for SCD, including explorations of SCD across racial and ethnic minoritized groups, and examinations of sex and gender considerations. Next, we review new findings on relationships between SCD and in vivo markers of pathophysiology, utilizing neuroimaging and biofluid data, as well as associations between SCD and objective cognitive tests and neuropsychiatric measures. Finally, we summarize recent work on interventions for SCD and areas of future growth in the field of SCD.

Cognition in Context: Understanding the Everyday Predictors of Cognitive Performance in a New Era of Measurement.

BACKGROUND: Research suggests that variability in attention and working memory scores, as seen across time points, may be a sensitive indicator of impairment compared with a singular score at one point in time. Given that fluctuation in cognitive performance is a meaningful metric of real-world function and trajectory, it is valuable to understand the internal state-based and environmental factors that could be driving these fluctuations in performance. OBJECTIVE: In this viewpoint, we argue for the use of repeated mobile assessment as a way to better understand how context shapes moment-to-moment cognitive performance. To elucidate potential factors that give rise to intraindividual variability, we highlight existing literature that has linked both internal and external modifying variables to a number of cognitive domains. We identify ways in which these variables could be measured using mobile assessment to capture them in ecologically meaningful settings (ie, in daily life). Finally, we describe a number of studies that have already begun to use mobile assessment to measure changes in real time cognitive performance in people's daily environments and the ways in which this burgeoning methodology may continue to advance the field. METHODS: This paper describes selected literature on contextual factors that examined how experimentally induced or self-reported contextual variables (ie, affect, motivation, time of day, environmental noise, physical activity, and social activity) related to tests of cognitive performance. We also selected papers that used mobile assessment of cognition; these papers were chosen for their use of high-frequency time-series measurement of cognition using a mobile device. RESULTS: Upon review of the relevant literature, it is evident that contextual factors have the potential to meaningfully impact cognitive performance when measured in laboratory and daily life environments. Although this research has shed light on the question of what gives rise to real-life variability in cognitive function (eg, affect and activity), many of the studies were limited by traditional methods of data collection (eg, involving retrospective recall). Furthermore, cognition has often been measured in one domain or in one age group, which does not allow us to extrapolate results to other cognitive domains and across the life span. On the basis of the literature reviewed, mobile assessment of cognition shows high levels of feasibility and validity and could be a useful method for capturing individual cognitive variability in real-world contexts via passive and active measures. CONCLUSIONS: We propose that, through the use of mobile assessment, there is an opportunity to combine multiple sources of contextual and cognitive data. These data have the potential to provide individualized digital signatures that could improve diagnostic precision and lead to meaningful clinical outcomes in a wide range of psychiatric and neurological disorders.

Predictors of self-perceived stigma in Parkinson's disease.

OBJECTIVE: The burden of PD extends beyond physical limitations and includes significant psychosocial adjustments as individuals undergo changes to their self-perception and how others perceive them. There is limited quantitative evidence of the factors that contribute to self-perceived stigma, which we addressed in the present study. METHODS: In 362 individuals with PD (157 women, 205 men), self-perceived stigma was measured by the four-item stigma subscale of the Parkinson's Disease Questionnaire (PDQ-39). Hierarchical linear modeling was used to assess predictors of stigma including demographics (age, gender) and disease characteristics: duration, stage (Hoehn & Yahr Scale), motor severity (Unified Parkinson's Disease Rating Scale, UPDRS, Part 3), activities of daily living (UPDRS Part 2), and depression (Geriatric Depression Scale). Predictor variables were chosen based on their significant correlations with the stigma subscale. Further analyses were conducted for men and women separately. RESULTS: For the total sample, the full model accounted for 14% of the variance in stigma perception (p < .001). Younger age and higher depression scores were the only significant predictors (both p < .001). This pattern was also seen for the men in the sample. For the women, only depression was a significant predictor. Depression mediated the relation between stigma and activities of daily living. CONCLUSIONS: Younger age (men) and depression (men and women) were the primary predictors of self-perceived stigma in PD. Disease characteristics (motor and ADL) did not contribute to stigma perception. Depression is a potential treatment target for self-perceived stigma in PD.

Migraine Pain Location and Measures of Healthcare Use and Distress: An Observational Study.

Introduction: Lateralized pain is a core diagnostic feature of migraine. In previous research, left-sided spinal pain was more frequent and associated with greater emotional distress and healthcare use than right-sided pain. We hypothesized therefore that patients with left-sided head pain might experience higher levels of distress or healthcare use than those with right-sided or bilateral pain. Methods: Medical record information was extracted for 477 randomly selected patients with migraine seen in 2011 in a tertiary headache clinic. This included demographic data, pain location, handedness, comorbid psychiatric diagnoses, medical and emergency department visits, and use of selected headache medications. Results and Discussion: Two hundred twenty-eight of four hundred seventy-seven (47.8%) patients reported lateralized pain, of which 107 (47.9%) patients were right sided compared with 65 (28.5%) left-sided patients (p=0.001), while 56 (24.5%) reported unilateral pain with no side predominance. Contrary to expectations, with the exception of self-reported posttraumatic stress disorder, there were no statistically significant differences between left and right in measures of psychiatric distress, emergency department visits, or healthcare use. Conclusion: Although unilateral pain location can be helpful in making a migraine diagnosis, it does not appear to have additional clinical implications. Additionally, its absence does not rule out a diagnosis of migraine since more than half of migraineurs have bilateral head pain.

Headache in Patients With Pituitary Lesions: A Longitudinal Cohort Study.

BACKGROUND: Headache is a presenting feature in 37% to 70% of patients with pituitary tumor. Other pituitary lesions may also present with headache, and together these lesions account for about 20% of all primary brain lesions. Although pituitary lesions have been associated with headache, the exact nature of the relationship remains undefined. It is not always clear whether the presenting headache is an unrelated primary headache, a lesion-induced aggravation of a preexisting primary headache, or a separate secondary headache related to the lesion. OBJECTIVE: To characterize headache in patients referred to a multidisciplinary neuroendocrine clinic with suspected pituitary lesions and to assess changes in headache in those who underwent surgery. METHODS: We used a self-administered survey of headache characteristics completed by patients upon presentation and after any pituitary surgical procedure. RESULTS: One hundred thirty-three participants completed the preoperative questionnaire (response rate of 99%). The overall prevalence of headache was 63%. Compared to patients without headache, the group with headache was more likely to be female (P = .001), younger (P = .001), and to have had a prior headache diagnosis (P < .001). Seventy-two percent of patients reported headache localized to the anterior region of the head. Fifty-one patients with headache underwent transsphenoidal pituitary surgery. Headache was not associated with increased odds of having surgery (odds ratio, 0.90). At 3 months, 81% of surgically treated patients with headache who completed the postoperative questionnaire (21/26) reported improvement or resolution of headaches. No patient who completed the postoperative questionnaire (44/84) reported new or worsened headache. CONCLUSION: Frequent, disabling headaches are common in patients with pituitary lesions referred for neuroendocrine consultation, especially in younger females with a preexisting headache disorder. Surgery in this group was associated with headache improvement or resolution in the majority and was not found to cause or worsen headaches. Suggestions for revision of the International Classification of Headache Disorders diagnostic criteria pertaining to pituitary disorders are supported by these findings.