Cognitive changes associated with mentally active lifestyle and structured cognitive programs: a 2-year longitudinal study.

Objectives: Mentally stimulating leisure activities and cognitive interventions are associated with delayed cognitive decline, although evidence has not been unequivocal, possibly due to differential contribution of the two types of activities. This study aimed to examine the respective contributions of mentally active lifestyle and structured cognitive programs on cognitive changes in older adults.Methods: This was a 2-year prospective cohort study of 1,793 healthy older adults. We recorded mentally active lifestyle and participation in cognitive program. Cognitive function was assessed using the Montreal Cognitive Assessment. Physical frailty was also screened for the potential effect on cognition.Results: Compared to the mentally inactive group, the mentally active group had better baseline cognitive functioning (standardized mean difference of 0.08, t = -3.8; p < 0.001), but both groups showed a mild cognitive decline over time (both p < 0.05). The mentally active group were less physical frail, more physical independent, and less depressed. Participation in structured cognitive programs was associated with cognition improvement, in older persons who had a mentally active or inactive lifestyle (standardized mean differences of 0.22 and 0.27, respectively; both p < 0.01), but these gains significantly diminished at year 2 in the latter group. Lower baseline cognitive function and higher level of physical frailty predicted greater cognitive gains from structured cognitive programs.Conclusion: Both a mentally active lifestyle and structured cognitive programs contributed to better cognition. Structured cognitive programs appeared to add on to the benefits of a mentally active lifestyle, and predicted cognitive changes regardless of lifestyle.

Validating a Cantonese short version of the Zarit Burden Interview (CZBI-Short) for dementia caregivers.

OBJECTIVES: The present study aimed to develop and validate a Cantonese short version of the Zarit Burden Interview (CZBI-Short) for Hong Kong Chinese dementia caregivers. METHODS: The 12-item Zarit Burden Interview (ZBI) was translated into spoken Cantonese and back-translated by two bilingual research assistants and face validated by a panel of experts. Five hundred Chinese dementia caregivers showing signs of stress reported their burden using the translated ZBI and rated their depressive symptoms, overall health, and care recipients' physical functioning and behavioral problems. The factor structure of the translated scale was identified using principal component analysis and confirmatory factor analysis; internal consistency and item-total correlations were assessed; and concurrent validity was tested by correlating the ZBI with depressive symptoms, self-rated health, and care recipients' physical functioning and behavioral problems. RESULTS: The principal component analysis resulted in 11 items loading on a three-factor model comprised role strain, self-criticism, and negative emotion, which accounted for 59% of the variance. The confirmatory factor analysis supported the three-factor model (CZBI-Short) that explained 61% of the total variance. Cronbach's alpha (0.84) and item-total correlations (rho = 0.39-0.71) indicated CZBI-Short had good reliability. CZBI-Short showed correlations with depressive symptoms (r = 0.50), self-rated health (r = -0.26) and care recipients' physical functioning (r = 0.18-0.26) and disruptive behaviors (r = 0.36). CONCLUSIONS: The 12-item CZBI-Short is a concise, reliable, and valid instrument to assess burden in Chinese dementia caregivers in clinical and social care settings.

Social support as a predictor of diet and exercise self-efficacy in patients with coronary artery disease.

OBJECTIVES: This study examined the role of social support and other factors in relation to exercise and diet self-efficacy in Chinese patients with coronary heart disease in Hong Kong. METHODS: A cross-sectional study was conducted on a convenience sample identified from two cardiac rehabilitation centers. Eighty-five participants joined the study. RESULTS: Both self-efficacy measures correlated with social support, in particular in the domains of emotional/informational support and positive social interactions. Stronger social support was independently associated with a higher level of exercise and diet self-efficacy. Patients with a higher body mass index had a lower level of exercise self-efficacy, whereas social drinkers had a lower level of diet self-efficacy. CONCLUSIONS: Our data supported an association between social support and self-efficacy. It was suggested that social companions would help patients get greater confidence in overcoming barriers to lifestyle modification. Further studies may investigate what type of social support contributes to improving the self-efficacy beliefs of patients.

Reliability and validity of the life functioning assessment inventory (L-FAI) for patients with psychosis.

PURPOSE: Functioning level is one of the major indicators of recovery in schizophrenia. It is important that the assessment of functioning is performed accurately. However, functioning evaluation is difficult due to the absence of specific anchor points in the widely used functioning assessment scales. We aimed to validate a new functioning scale, the life functioning assessment inventory (L-FAI), which assesses the functioning outcome of patients with psychosis in a more objective, and comprehensive manner. L-FAI assesses four life domains including work, social relationships, leisure, and homemaking. Specific and concrete anchor points are set in each of these domains. METHODS: The reliability and validity of L-FAI were assessed in 32 patients with psychosis. Opinions towards the scale were also obtained from experienced mental health professionals and members of a local advocacy group. RESULTS: Good inter-rater reliability (Cohen's kappa 0.67-0.97) and test-retest reliability (Cohen's kappa 0.67-0.86) were found. The scale has also been found to have good concurrent validity, correlating well with social and occupational functioning assessment scale (SOFAS) and role functioning scale (RFS) (Spearman's r 0.53-0.89). The scale was associated solely with negative symptoms (Spearman's r -0.48) but not with positive symptoms. CONCLUSIONS: L-FAI is suited for both clinical and research purposes in evaluating functioning level in patients with psychosis. More research is needed to replicate the current study with a larger sample size.

Collaborative community mental health and aged care services with peer support to prevent late-life depression: study protocol for a non-randomised controlled trial.

BACKGROUND: Late-life depression is common, modifiable, yet under-treated. Service silos and human resources shortage contribute to insufficient prevention and intervention. We describe an implementation research protocol of collaborative stepped care and peer support model that integrates community mental health and aged care services to address service fragmentation, using productive ageing and recovery principles to involve older people as peer supporters to address human resource issue. METHODS/DESIGN: This is a non-randomised controlled trial examining the effectiveness and cost-effectiveness of the "Jockey Club Holistic Support Project for Elderly Mental Wellness" (JC JoyAge) model versus care as usual (CAU) in community aged care and community mental health service units in 12 months. Older people aged 60 years and over with mild to moderate depressive symptoms or risk factors for developing depression will be included. JoyAge service users will receive group-based activities and psychoeducation, low-intensity psychotherapy, or high-intensity psychotherapy according to the stepped care protocol in addition to usual community mental health or aged care, with support from an older peer supporter. The primary clinical outcome, depressive symptoms, and secondary outcomes, self-harm risk, anxiety symptoms, and loneliness, will be measured with the Patient Health Questionnaire-9 (PHQ-9), Self-Harm Inventory, Generalized Anxiety Disorder 7-item scale (GAD-7), and UCLA Loneliness 3-item scale (UCLA-3) respectively. Cost-effectiveness analysis will assess health-related quality of life using the EQ-5D-5L and service utilisation using the Client Service Receipt Inventory (CSRI). We use multilevel linear mixed models to compare outcomes change between groups and calculate the incremental cost-effectiveness ratio in terms of quality-adjusted life years. DISCUSSION: This study will provide evidence about outcomes for older persons with mental health needs receiving collaborative stepped care service without silos and with trained young-old volunteers to support engagement, treatment, and transitions. Cost-effectiveness findings from this study will inform resource allocation in this under-treated population. TRIAL REGISTRATION: ClinicalTrials.gov NCT03593889. Registered on 20 July 2018.

Random number generation deficit in early schizophrenia.

Random number generation with a written response mode provides a potentially appealing marker for executive processes. Impaired performance on written random number generation tasks has been reported in chronic schizophrenic patients. However, no study has investigated whether such a deficit occurs in early schizophrenia and whether its profile and severity are similar to those in patients with chronic illness. This study investigated the ability to generate random numbers in patients with early schizophrenia (n = 44) and a healthy control group (n = 48). Patients were less able to maintain several production strategies and generated more stereotyped response sequences, whereas their abilities to identify randomness with an even-handed treatment of digits and to monitor the equality of occurrence of single digits appeared to remain intact. These results provide evidence that some aspects of the deficits in random number generation among chronic schizophrenic patients are also present at early psychotic episode, while some other aspects are relatively less affected in the early years.

The relationship between insomnia symptoms and frailty in community-dwelling older persons: a path analysis.

BACKGROUND: The relationship between sleep and frailty in older age is complex. Most previous studies focused on sleep duration, while insomnia, a common sleep problem in older adults, has not been adequately examined and the factors implicated in its association with frailty were under-explored. METHODS: A community-based sample of 345 prefrail and frail older adults were recruited and completed the measures on insomnia symptoms (Pittsburgh Sleep Quality Index) and frailty status (FRAIL Scale). The relationship between insomnia symptoms and frailty, with potential mediators including physical performance (Short Physical Performance Battery), depression (Patient Health Questionnaire-9), and level of physical activity (Physical Activity Scale for the Elderly), were tested in path analysis adjusting for age, gender, body mass index and sleep medications. RESULTS: The prevalence of sleep-onset insomnia was higher in frail participants than their prefrail counterparts (48% vs. 34%, aOR = 1.73; 95% CI 1.09, 2.76; p = 0.02), but there was no significant difference in the prevalence of sleep-maintenance insomnia (61% vs. 54%). The association between sleep-onset insomnia and frailty was explained by reduced physical performance (standardized coefficient = 0.11; 95% BCa CI [0.002, 0.233]), but not depression and level of physical activity. Sleep-maintenance insomnia was not associated with frailty. CONCLUSIONS: Insomnia symptoms are prevalent in frail and prefrail older adults. Sleep-onset insomnia is associated with poorer physical performance, which is further linked to a higher risk for frailty in older persons. The findings highlight the importance of timely assessing and managing insomnia among older adults at risk of frailty.

Effectiveness of a Two-Tier Family-Oriented Intervention in Enhancing the Family Functioning and Care Capacity of the Family Caregivers of Stroke Survivors: Protocol for a Randomized Controlled Trial.

BACKGROUND: Stroke has profound impacts on families. Often, family members, including stroke survivors and the person who takes up the role of the primary caregiver, would encounter demands on finances, rehabilitation arrangement, and even conflicts. Hence, a family-oriented intervention is expected to enable families to rebuild internal and external resources to achieve optimal rehabilitation and community reintegration. OBJECTIVE: This study aims to describe a design of a two-tier family-oriented care management intervention for enhancing the family functioning and care capacity of the caregivers of stroke survivors. METHODS: The two-tier care management intervention was guided by a standardized protocol conducted by trained professional care managers (first tier) with the support of trained volunteers (second tier), which lasted for 8-12 weeks. Participants were recruited through collaborating hospitals according to inclusion and exclusion criteria. In order to examine the effectiveness and cost-effectiveness of the two-tier care management intervention, a two-arm randomization multicenter study was designed, including an active comparison group, which was guided by a standardized protocol conducted by trained volunteers. Dyadic participants, including both stroke survivors and their primary caregivers for both groups, were invited to participate in a questionnaire survey using standardized and purposefully developed measures 3 times: before the intervention, immediately after the intervention, and 2 months after the intervention. The primary outcome was family functioning measured by the Family Role Performance Scale and Family Assessment Device-General Functioning Scale. The secondary outcomes included caregiving burden, depressive symptoms, care management strategies, and the incremental cost-effectiveness ratio. RESULTS: Recruitment began in January 2017 and was completed at the end of April 2019. Data collection was completed at the end of March 2020. As of March 2020, enrollment has been completed (n=264 stroke caregivers). A total of 200 participants completed the baseline questionnaires. We aim to publish the results by mid-2021. CONCLUSIONS: This study successfully developed a two-tier care management protocol that aims to enhance the family functioning of the caregivers of stroke survivors. Guided by a standardized protocol, this family-oriented two-tier intervention protocol was found to be feasible among Chinese families. TRIAL REGISTRATION: ClinicalTrials.gov NCT03034330; https://ichgcp.net/clinical-trials-registry/NCT03034330. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/16703.

Older Adults' Perceptions of Age-friendliness in Hong Kong.

BACKGROUND AND OBJECTIVES: There is little understanding about how rapid urban development has affected the extent to which communities are able to optimize health and participation opportunities for older adults in Hong Kong. Our objective was to examine what older residents perceive to be the shortcomings of their communities in meeting their psychosocial and physical needs as they age. RESEARCH DESIGN AND METHODS: In reference to the WHO Age-Friendly Cities Project Methodology: Vancouver Protocol, we conducted nine focus groups comprising 65 participants for an Age-Friendly City baseline assessment in two districts in Hong Kong, China. Participants were asked to share their views on their respective district of residence, and identify aspects of the city they found unfriendly. Data generated from interviews were analyzed using thematic analysis. RESULTS: Five of the following key themes were identified: the failure of public transportation to cater to the needs of older adults; a lack of public space for recreation and socializing; diminishing human interactions in welfare services; physical and financial challenges relating to housing; and workplace discrimination against older adults. DISCUSSION AND IMPLICATIONS: These findings underscore the importance of prioritizing the social welfare of older adults in building a more inclusive and age-friendly city. They also highlight the difficulties in fostering an inclusive environment while ensuring efficiency and profit maximization.

Early-Stage Negative Symptom Trajectories and Relationships With 13-Year Outcomes in First-Episode Nonaffective Psychosis.

Negative symptoms are a key treatment target in early psychosis intervention. There is a paucity of research examining longitudinal course of negative symptoms across the initial years of treatment for first-episode psychosis using individual-based trajectory analysis. No study has been conducted investigating differential relationships of early-stage negative symptom trajectories with long-term distal outcomes. This study examined patterns and baseline predictors of negative symptom trajectories over the first 3 years of treatment in 138 patients aged 18-55 years presenting with first-episode nonaffective psychosis, using latent class growth analysis based on symptom ratings measured at 4 different time points (baseline, 1, 2, and 3 years). We further explored prospective relationships of identified trajectory classes with functional and negative symptom outcomes at 13-year follow-up. Our results revealed 3 distinct negative symptom trajectories including minimal-stable (59.6%), mild-stable (29.4%), and high-increasing (11.0%) trajectories. Poorer premorbid adjustment, more severe global cognitive impairment, and depressive symptoms at baseline were found to predict high-increasing trajectory. Among 3 trajectory classes, patients in high-increasing trajectory had the worst functional and negative symptom outcomes at 13-year follow-up, with post hoc analyses demonstrating significant outcome differences between high-increasing and minimal-stable trajectories. Our findings thus affirm a heterogeneous course of negative symptoms in first-episode psychosis and indicate that early-stage negative symptom trajectories are critically associated with long-term outcomes. Patients displaying persistently high negative symptom levels in the initial 3 years of treatment may represent a specific subgroup who necessitates an extended period of early intervention specifically targeting at negative symptoms to promote early functional recovery.

Clinical and social correlates of duration of untreated psychosis among adult-onset psychosis in Hong Kong Chinese: the JCEP study.

AIM: Understanding factors that contribute to treatment delay would inform early detection and intervention strategies in psychotic disorders. However, existing data were mixed and primarily conducted among early-onset young patients. We examined duration of untreated psychosis (DUP) and its clinical and sociodemographic correlates in a large cohort of adult-onset patients with psychosis. METHODS: A total of 360 patients with first-onset psychosis aged 26-55 years were recruited consecutively as part of a controlled study of an early psychosis intervention service in Hong Kong Chinese. Demographic, sociodemographic and clinical characteristics relating to DUP were assessed within 4 months of onset. RESULTS: The population had a mean onset age of 36.6 years (SD = 8.7). The mean and median DUP were 515 days (SD = 1091) and 93 days (inter-quartile range from 20 to 382.3), respectively. Multivariate regression analysis suggested that insidious mode of onset, hospitalization, a diagnosis of schizophrenia, poorer insight and younger age at onset significantly prolonged DUP. DUP was not related to premorbid functioning, family involvement during help seeking and living alone. CONCLUSIONS: The initial period of untreated psychosis is determined by multiple factors. Whether family involvement is considered a kind of social support in shortening or prolonging DUP needs further examination. Local early intervention program for psychosis should take reference from these findings when formulating personalized plans to reduce delay.

Correlates of insight with symptomatology and executive function in patients with first-episode schizophrenia-spectrum disorder: a longitudinal perspective.

The present study aimed to examine the relationships of insight with symptomatology and executive function, both cross-sectionally and longitudinally in patients with first-episode schizophrenia-spectrum disorders. Ninety-two medication-naïve patients were recruited and 71 completed the assessments. Insight, symptoms and executive function were assessed at baseline, 6 months and 1 year. Insight was measured with the abridged version of Scale of Unawareness of Mental Disorder (SUMD). Symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS). Executive function was measured with the Modified Wisconsin Card Sorting Test (MCST). The most significant improvement of insight and symptomatology was found over the first 6 months, whereas the perseverative errors of MCST were significantly improved between 6 and 12 months. Differential correlations of perseverative errors of the MCST and PANSS scores with SUMD were found at different time points. This suggests the involvement of different mechanisms in insight deficit at different stages of the illness. The baseline MCST perseverative errors were correlated significantly with the SUMD total score at 6 months and the change of SUMD scores over the first 6 months. Although the variance explained was small, it suggests better set-shifting capacity facilitates the improvement of insight at an early stage of the illness.

Prospective relationship between duration of untreated psychosis and 13-year clinical outcome: a first-episode psychosis study.

BACKGROUND: The adverse effects of a long duration of untreated psychosis (DUP) have been explored in numerous short-term studies. These studies support the development of early interventions that reduce treatment delay and promote recovery. However, the enduring impact of DUP is largely unknown, partly due to the paucity of prospective long-term studies. Although the DUP-outcome relationship is commonly assumed to be linear, the threshold effect has not been adequately examined. OBJECTIVE: To explore the relationship between DUP and long-term symptomatic remission. METHODS: This was a prospective study of a cohort of 153 first-episode psychosis patients in Hong Kong at the 13-year follow-up. The patients were categorized into short (≤30days), medium (31-180days) and long (>180days) DUP groups. RESULTS: The long-term outcome was ascertained in 73% of the patients. Nearly half of the patients (47%) fulfilled the criteria for symptomatic remission. The short DUP group experienced a significantly higher remission rate over the course of the illness. The odds of long-term symptomatic remission was significantly reduced in the medium DUP (by 89%) and long DUP (by 85%) groups compared with the short DUP group. Further analysis showed that DUP had a specific impact on negative symptom remission. CONCLUSION: The findings support the threshold theory that DUP longer than 30days adversely impacts the long-term outcome. The present study is one of the few studies that confirmed the enduring impact of DUP on long-term outcomes based on well-defined criteria and adequate statistical adjustment.

The relationship of early premorbid adjustment with negative symptoms and cognitive functions in first-episode schizophrenia: a prospective three-year follow-up study.

Premorbid adjustment is an important prognostic factor of schizophrenia. The relationships between sub-components of premorbid adjustment and outcomes on symptoms and cognition in first-episode schizophrenia were under-studied. In the current study, we prospectively followed up 93 patients aged 18-55 years presenting with first-episode schizophrenia-spectrum disorder. Psychopathological and cognitive assessments were conducted at baseline, clinical stabilization, 12, 24 and 36 months. Premorbid adjustment was sub-divided into discrete functional domains, developmental stages and premorbid-course types based on ratings of the Premorbid Adjustment Scale (PAS). The study focused on early developmental stages to minimize contamination by prodromal symptoms. Results indicated that gender differences in premorbid functioning were primarily related to early-adolescence adjustment and academic domain. Social domain was more strongly related to negative symptoms, while academic domain was more consistently linked to cognitive outcome (Wisconsin Card Sorting test and verbal fluency). Patients with stable-poor premorbid course had more severe negative symptoms and cognitive impairment. In conclusion, in a Chinese cohort of first-episode schizophrenia-spectrum disorder, sub-components of early premorbid adjustment were shown to be differentially related to clinical and cognitive measures. The results highlighted the importance of applying a more refined delineation of premorbid functioning in studying illness outcome.

Duration of untreated psychosis: relationship with baseline characteristics and three-year outcome in first-episode psychosis.

Duration of untreated psychosis (DUP) has been considered as one of the few potentially malleable prognostic factors in psychotic illness. The literature demonstrated that prolonged DUP predicted the level of positive symptoms, but its relationships with negative symptoms and functional outcome were less clear-cut. Thus far, most first-episode studies have been conducted in western countries. Yet, it is known that illness outcome might be modified by socio-cultural factors. In this study, we aimed to examine the impact of DUP on baseline characteristics, clinical and vocational outcomes over 3 years in 700 Chinese young people who presented with first-episode psychosis to a specialized early intervention service in Hong Kong. Our results showed that prolonged DUP was associated with male sex, younger age of onset, schizophrenia-spectrum diagnosis, insidious development of psychosis, fewer baseline positive symptoms and less likelihood of hospitalization at intake. Regression analyses revealed that prolonged DUP was significantly predictive of outcome on positive symptoms, recovery and sustained full-time employment in our first-episode psychosis cohort. Taken together, our study provided further supportive evidence regarding the prognostic value of DUP on illness outcome. Additionally, it suggested that an adverse impact of treatment delay for psychosis may likely be applied across regions of various ethno-cultural backgrounds.

Longitudinal changes in semantic categorization performance after symptomatic remission from first-episode psychosis: a 3-year follow-up study.

Semantic categorization abnormalities have been observed in schizophrenia, but studies have rarely focused on the longitudinal trajectory. In this study, we consider semantic performance and the relationship with symptomatic changes during recovery from a first-episode of schizophrenia over a period of 3 years. Thirty-seven first-episode patients with schizophrenia were compared to thirty-seven matched controls in a categorization task. Patients were assessed at first episode, after clinical stabilization, and annually for the subsequent 3 years. In the task, participants indicated whether a word belonged to a given category. Each category contained words of varying degrees of semantic relatedness: typical, atypical, borderline, related-but-outside, and unrelated. Reaction times and proportion of 'yes' responses were analyzed. At first assessment, semantic categorization abnormalities were observed in first-episode patients. Patients assigned more semantically-dissimilar words to the categories than controls. As patients stabilized from acute states, their semantic categorization performance improved and then remained stable throughout the entire follow up period of 3 years. Interestingly, semantic performance deficits, particularly a diminished typicality effect, correlated with negative symptoms in the initial episode, but not at stabilization when symptoms subsided. No significant associations between positive and negative symptoms, or pre-defined categorization measures were identified. The data demonstrated semantic memory abnormalities in first-episode schizophrenia. However, an improvement of semantic categorization performance was observed in stabilized schizophrenia patients. Overall, the data are suggestive of a state effect in semantic abnormalities rather than a trait effect. The correlation between degree of impairment and symptoms may explain previous inconsistent findings.