Attitudes toward advance care planning among persons with dementia and their caregivers.

OBJECTIVES: To examine factors that influence decision-making, preferences, and plans related to advance care planning (ACP) and end-of-life care among persons with dementia and their caregivers, and examine how these may differ by race. DESIGN: Cross-sectional survey. SETTING: 13 geographically dispersed Alzheimer's Disease Centers across the United States. PARTICIPANTS: 431 racially diverse caregivers of persons with dementia. MEASUREMENTS: Survey on "Care Planning for Individuals with Dementia." RESULTS: The respondents were knowledgeable about dementia and hospice care, indicated the person with dementia would want comfort care at the end stage of illness, and reported high levels of both legal ACP (e.g., living will; 87%) and informal ACP discussions (79%) for the person with dementia. However, notable racial differences were present. Relative to white persons with dementia, African American persons with dementia were reported to have a lower preference for comfort care (81% vs. 58%) and lower rates of completion of legal ACP (89% vs. 73%). Racial differences in ACP and care preferences were also reflected in geographic differences. Additionally, African American study partners had a lower level of knowledge about dementia and reported a greater influence of religious/spiritual beliefs on the desired types of medical treatments. Notably, all respondents indicated that more information about the stages of dementia and end-of-life health care options would be helpful. CONCLUSIONS: Educational programs may be useful in reducing racial differences in attitudes towards ACP. These programs could focus on the clinical course of dementia and issues related to end-of-life care, including the importance of ACP.

Self-reported Lifestyle Activities in Relation to Longitudinal Cognitive Trajectories.

BACKGROUND: Few studies have examined the relationship between lifestyle activity engagement and cognitive trajectories among individuals who were cognitively normal at baseline. OBJECTIVE: To examine the relationship of current engagement in lifestyle activities to previous cognitive performance among individuals who were cognitively normal at baseline, and whether this relationship differed for individuals who subsequently developed mild cognitive impairment (MCI), or by APOE-4 genotype, age, and level of cognitive reserve. METHODS: Participants (N=189) were primarily middle-aged (M=56.6 y) at baseline and have been prospectively followed with annual assessments (M follow-up=14.3 y). Engagement in physical, cognitive, and social activities was measured by the CHAMPS activity questionnaire. Longitudinal cognitive performance was measured by a global composite score. RESULTS: Among individuals who progressed to MCI (n=27), higher lifestyle activity engagement was associated with less decline in prior cognitive performance. In contrast, among individuals who remained cognitively normal, lifestyle activity engagement was not associated with prior cognitive trajectories. These effects were largely independent of APOE-4 genotype, age, and cognitive reserve. CONCLUSIONS: Greater engagement in lifestyle activities may modify the rate of cognitive decline among those who develop symptoms of MCI, but these findings need to be confirmed in prospective studies.

Age-Dependent Association Between Cognitive Reserve Proxy and Longitudinal White Matter Microstructure in Older Adults.

Objective: This study examined the association of lifetime experiences, measured by a cognitive reserve (CR) composite score composed of years of education, literacy, and vocabulary measures, to level and rate of change in white matter microstructure, as assessed by diffusion tensor imaging (DTI) measures. We also examined whether the relationship between the proxy CR composite score and white matter microstructure was modified by participant age, APOE-ε4 genetic status, and level of vascular risk. Methods: A sample of 192 non-demented (n = 166 cognitively normal, n = 26 mild cognitive impairment) older adults [mean age = 70.17 (SD = 8.5) years] from the BIOCARD study underwent longitudinal DTI (mean follow-up = 2.5 years, max = 4.7 years). White matter microstructure was quantified by fractional anisotropy (FA) and radial diffusivity (RD) values in global white matter tracts and medial temporal lobe (MTL) white matter tracts. Results: Using longitudinal linear mixed effect models, we found that FA decreased over time and RD increased over time in both the global and MTL DTI composites, but the rate of change in these DTI measures was not related to level of CR. However, there were significant interactions between the CR composite score and age for global RD in the full sample, and for global FA, global RD, and MTL RD among those with normal cognition. These interactions indicated that among participants with a lower baseline age, higher CR composite scores were associated with higher FA and lower RD values, while among participants with higher age at baseline, higher CR composite scores were associated with lower FA and higher RD values. Furthermore, these relationships were not modified by APOE-ε4 genotype or level of vascular risk. Conclusion: The association between level of CR and DTI measures differs by age, suggesting a possible neuroprotective effect of CR among late middle-aged adults that shifts to a compensatory effect among older adults.

Computerized paired associate learning performance and imaging biomarkers in older adults without dementia.

This cross-sectional study examined whether performance on the computerized Paired Associate Learning (PAL) task from the Cambridge Neuropsychological Test Automated Battery is associated with amyloid positivity as measured by Positron Emission Tomography, regional volume composites as measured by Magnetic Resonance Imaging, and cognitive impairment. Participants from the BIOCARD Study (N = 73, including 62 cognitively normal and 11 with mild cognitive impairment; M age = 70 years) completed the PAL task, a comprehensive clinical and neuropsychological assessment, and neuroimaging as part of their annual study visit. In linear regressions covarying age, sex, years of education and diagnosis, higher PAL error scores were associated with amyloid positivity but not with medial temporal or cortical volume composites. By comparison, standard neuropsychological measures of episodic memory and global cognition were unrelated to amyloid positivity, but better performance on the verbal episodic memory measures was associated with larger cortical volume composites. Participants with mild cognitive impairment demonstrated worse cognitive performance on all of the cognitive measures, including the PAL task. These findings suggest that this computerized visual paired associate learning task may be more sensitive to amyloid positivity than standard neuropsychological tests, and may therefore be a promising tool for detecting amyloid positivity in non-demented participants.

Long-Term Effects of Cognitive Training on All-Cause Mortality in US Older Adults.

Objectives: Cognitive abilities have been implicated as predictors of mortality in older adults. This study examines the effects of cognitive training on mortality 20 years post-intervention. Methods: Data come from the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) randomized control trial (N = 2802). Participants were cognitively and physically healthy, community-dwelling adults aged 65 and older. Cox proportional hazard models were used to investigate (1) the association between baseline cognition and mortality risk and (2) the effect of ACTIVE cognitive training (memory, reasoning, and speed of processing) on mortality risk 20 years post-intervention. Results: Higher baseline cognition predicted lower mortality risk 20 years post-intervention. No significant effects of ACTIVE cognitive training in memory, reasoning, or speed of processing on mortality risk were observed. Discussion: More work is needed to identify cognitive training interventions that may lead to lower mortality risks in later adulthood.