Racial and ethnic differences in the relationship between financial worry and white matter hyperintensities in Latinx, non-Latinx Black, and non-Latinx White older adults.

Socioeconomic status (SES) is associated with white matter hyperintensities (WMHs) and contributes to racial and ethnic health disparities. However, traditional measures of SES may not accurately represent individual financial circumstances among non-Latinx Black and Latinx older adults due to longstanding structural inequities. This study examined associations between multiple SES indicators (education, income, subjective financial worry) and WMHs across non-Latinx Black, Latinx, and non-Latinx White older adults in the Washington Heights-Inwood Columbia Aging Project (N = 662). Latinx participants reported the lowest SES and greatest financial worry, while Black participants evidenced the most WMHs. Greater financial worry was associated with higher WMHs volume above and beyond education and income, which were not associated with WMHs. However, this association was only evident among Latinx older adults. These results provide evidence for the minority poverty hypothesis and highlight the need for systemic socioeconomic interventions to alleviate brain health disparities in older adulthood.

Longitudinal associations between racial discrimination and hippocampal and white matter hyperintensity volumes among older Black adults.

RATIONALE: Non-Hispanic Black older adults are at higher risk of Alzheimer's disease and related dementias (ADRD) than non-Hispanic Whites, which reflects racial disparities in both brain and cognitive health. Discrimination may contribute to these disparities, but much of the research on discrimination and ADRD outcomes is cross-sectional and/or does not disaggregate experiences of discrimination by attribution. Focusing specifically on racial discrimination and considering longitudinal brain outcomes may advance our understanding of the role of discrimination in explaining disproportionate rates of ADRD among non-Hispanic Black older adults. METHODS: In total, 221 non-Hispanic Black participants in the Washington Heights-Inwood Columbia Aging Project completed multiple measures of discrimination at one time point and structural magnetic resonance imaging (MRI) scans at two time points. Everyday discrimination and lifetime discrimination were operationalized first as aggregate experiences of discrimination (regardless of identity attributions) and then as racial discrimination per se. MRI outcomes included hippocampal and white matter hyperintensity (WMH) volumes. Latent difference score models estimated associations between the discrimination measures and each MRI outcome over four years. RESULTS: Aggregate discrimination (regardless of attributions) was not associated with either outcome. Lifetime racial discrimination was associated with lower initial hippocampal volume. Everyday racial discrimination was associated with faster accumulation of WMH over time. CONCLUSIONS: Racial discrimination may be detrimental for brain aging among non-Hispanic Black older adults, which may contribute to their disproportionate dementia burden. Disaggregating discrimination by attribution may clarify research on racial inequalities in brain and cognitive aging, as racial discrimination appears to be particularly toxic.

Financial decision-making and self-awareness for financial decision-making is associated with white matter integrity in older adults.

Financial decision-making (FDM) and awareness of the integrity of one's FDM abilities (or financial awareness) are both critical for preventing financial mistakes. We examined the white matter correlates of these constructs and hypothesized that the tracts connecting the temporal-frontal regions would be most strongly correlated with both FDM and financial awareness. Overall, 49 healthy older adults were included in the FDM analysis and 44 in the financial awareness analyses. The Objective Financial Competency Assessment Inventory was used to measure FDM. Financial awareness was measured by integrating metacognitive ratings into this inventory and was calculated as the degree of overconfidence or underconfidence. Diffusion tensor imaging data were processed with Tracts Constrained by Underlying Anatomy distributed as part of the FreeSurfer analytic suite, which produced average measures of fractional anisotropy and mean diffusivity in 18 white matter tracts along with the overall tract average. As expected, FDM showed the strongest negative associations with average mean diffusivity measure of the superior longitudinal fasciculus -temporal (SLFT; r = -.360, p = .011) and -parietal (r = -.351, p = .014) tracts. After adjusting for FDM, only the association between financial awareness and average mean diffusivity measure of the right SLFT (r = .310, p = .046) was significant. Overlapping white matter tracts were involved in both FDM and financial awareness. More importantly, these preliminary findings reinforce emerging literature on a unique role of right hemisphere temporal connections in supporting financial awareness.

Self-awareness for financial decision making abilities is linked to right temporal cortical thickness in older adults.

Everyday financial decision making and the awareness of the integrity of one's financial decision making abilities (or financial awareness) are both critical to study in older adults as they can help identify those at risk for making suboptimal financial decisions and prevent financial loss. In the current study, we examined the cognitive and cortical thickness correlates of financial decision making and financial awareness in 59 community-dwelling participants co-enrolled in a larger study (mean age=68.35 years (SD=5.5), mean education=15.91 (SD=2.36), 61% = women, 67% = White, 30% = Black participants). Data from standardized measures of financial decision making and cognition was investigated along with FreeSurfer (v. 5.3) derived thickness regions. Based on metacognitive frameworks, financial awareness was measured along with a well-validated measure of memory awareness. Results revealed that numeracy, executive functioning and vocabulary were associated with financial decision making, whereas in analysis adjusted for financial decision making, memory awareness relative to cognition was most strongly linked to financial awareness. No significant associations between thickness and financial decision making were found. However, both financial and memory awareness were associated with the same right-hemisphere temporal thickness regions underscoring the idea of a common substrate of awareness. Interestingly, our findings converge with the emerging work on financial exploitation in which the right sided temporal regions have been found to play a prominent role. Incorporating the contributing role of self-awareness in various models of financial exploitation will be an important consideration for future studies.

Association of Regional White Matter Hyperintensities With Longitudinal Alzheimer-Like Pattern of Neurodegeneration in Older Adults.

Importance: Small vessel cerebrovascular disease, visualized as white matter hyperintensities (WMH), is associated with cognitive decline and risk of clinical Alzheimer disease (AD). One way in which small vessel cerebrovascular disease could contribute to AD is through the promotion of neurodegeneration; the effect of small vessel cerebrovascular disease on neurodegeneration may differ across racial and ethnic groups. Objective: To examine whether WMH volume is associated with cortical thinning over time and subsequent memory functioning and whether the association between WMH volume and cortical thinning differs among racial and ethnic groups. Design, Setting, and Participants: This longitudinal community-based cohort study included older adults from northern Manhattan who were participants in the Washington Heights-Inwood Columbia Aging Project. Participants underwent two 3T magnetic resonance imaging (MRI) scans a mean of 4 years apart. Data were collected from March 2011 to January 2020. Exposures: Total and regional WMH volumes. Main Outcomes and Measures: The association of total and regional WMH volumes with cortical thinning over time was tested using general linear models in a vertexwise analysis. Cortical thinning was measured vertexwise by symmetrized percent change between 2 time points. The association of changes in cortical thickness with memory and whether this association differed by race and ethnicity was also analyzed. Delayed memory was a secondary outcome. Results: In 303 participants (mean [SD] age, 73.16 [5.19] years, 181 [60%] women, 96 [32%] non-Hispanic White, 113 [37%] Non-Hispanic Black, 94 [31%] Hispanic), baseline WMH volumes were associated with cortical thinning in medial temporal and frontal/parietal regions. Specifically, total WMH volume was associated with cortical thinning in the right caudal middle frontal cortex (P = .001) and paracentral cortex (P = .04), whereas parietal WMH volume was associated with atrophy in the left entorhinal cortex (P = .03) and right rostral middle frontal (P < .001), paracentral (P < .001), and pars triangularis (P = .02) cortices. Thinning of the right caudal middle frontal and left entorhinal cortices was related to lower scores on a memory test administered closest to the second MRI visit (right caudal middle frontal cortex: standardized ß = 0.129; unstandardized b = 0.335; 95% CI, 0.055 to 0.616; P = .01; left entorhinal cortex: ß = 0.119; b = 0.290; 95% CI, 0.018 to 0.563; P = .03). The association of total WMH with thinning in the right caudal middle frontal and right paracentral cortex was greater in non-Hispanic Black participants compared with White participants (right caudal middle frontal cortex: ß = -0.222; b = -0.059; 95% CI, -0.114 to -0.004; P = .03; right paracentral cortex: ß = -0.346; b = -0.155; 95% CI, -0.244 to -0.066; P = .001). The association of parietal WMH with cortical thinning of the right rostral middle frontal, right pars triangularis, and right paracentral cortices was also stronger among non-Hispanic Black participants compared with White participants (right rostral middle frontal cortex: ß = -0.252; b = -0.202; 95% CI, -0.349 to -0.055; P = .007; right pars triangularis cortex: ß = -0.327; b = -0.253; 95% CI, -0.393 to -0.113; P < .001; right paracentral cortex: ß = -0.263; b = -0.337; 95% CI, -0.567 to -0.107; P = .004). Conclusions and Relevance: In this study, small vessel cerebrovascular disease, operationalized as WMH, was associated with subsequent cortical atrophy in regions that overlap with typical AD neurodegeneration patterns, particularly among non-Hispanic Black older adults. Cerebrovascular disease may affect risk and progression of AD by promoting neurodegeneration and subsequent memory decline.

Socioeconomic and psychosocial mechanisms underlying racial/ethnic disparities in cognition among older adults.

Objective: Racial/ethnic disparities in cognitive aging are only partly attributable to socioeconomic indicators. Psychosocial factors, such as discrimination and perceived control, also differ across racial/ethnic groups, and emerging literature highlights their potential role in contributing to cognitive disparities in addition to socioeconomic status. Method: 1,463 older adults (51% Hispanic, 27% non-Hispanic Black, and 22% non-Hispanic White) in the Washington Heights-Inwood Columbia Aging Project completed cognitive and psychosocial measures, including a comprehensive neuropsychological battery, Everyday and Major Experiences of Lifetime Discrimination scales, and the Perceived Control scale. Mediation models quantified separate indirect effects of Black race and Hispanic ethnicity on global cognitive composite scores through education, income, discrimination, and external perceived control. Results: Educational attainment, income, and perceived control each mediated racial/ethnic disparities in global cognition. Socioeconomic indicators (i.e., lower education and lower income) explained approximately 50% of the Black-White and Hispanic-White disparities in global cognition, and more external perceived control explained an additional 5%-8%. Hispanics reported the lowest levels of discrimination, while non-Hispanic Blacks reported the highest levels. However, neither everyday nor major lifetime discrimination was associated with global cognition. Significant racial/ethnic disparities in global cognition remained after accounting for the included socioeconomic and psychosocial factors. Conclusions: This study suggests that psychosocial factors may explain racial/ethnic disparities in cognitive aging above and beyond socioeconomic indicators. More external perceived control, which could reflect chronic exposure to interpersonal and institutional marginalization, may be a particularly salient psychosocial risk factor for poorer cognitive aging among non-Hispanic Black and Hispanic older adults. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Education differentially contributes to cognitive reserve across racial/ethnic groups.

INTRODUCTION: We examined whether educational attainment differentially contributes to cognitive reserve (CR) across race/ethnicity. METHODS: A total of 1553 non-Hispanic Whites (Whites), non-Hispanic Blacks (Blacks), and Hispanics in the Washington Heights-Inwood Columbia Aging Project (WHICAP) completed structural magnetic resonance imaging. Mixture growth curve modeling was used to examine whether the effect of brain integrity indicators (hippocampal volume, cortical thickness, and white matter hyperintensity [WMH] volumes) on memory and language trajectories was modified by education across racial/ethnic groups. RESULTS: Higher educational attainment attenuated the negative impact of WMH burden on memory (ß = -0.03; 99% CI: -0.071, -0.002) and language decline (ß = -0.024; 99% CI:- 0.044, -0.004), as well as the impact of cortical thinning on level of language performance for Whites, but not for Blacks or Hispanics. DISCUSSION: Educational attainment does not contribute to CR similarly across racial/ethnic groups.

Assessment of Leisure Time Physical Activity and Brain Health in a Multiethnic Cohort of Older Adults.

Importance: Results from longitudinal studies suggest that regular leisure time physical activity (LTPA) is associated with reduced risk of dementia or Alzheimer disease. Data on the association between LTPA and brain magnetic resonance imaging (MRI) measures remain scarce and inconsistent. Objective: To examine the association of LTPA and MRI-assessed brain aging measures in a multiethnic elderly population. Design, Setting, and Participants: This cross-sectional study included 1443 older (≥65 years) adults without dementia who were participants of the Washington/Hamilton Heights-Inwood Columbia Aging Project study. LTPA, from self-reported questionnaire, was calculated as metabolic equivalent of energy expenditure. Both moderate to vigorous LTPA, assessed as meeting Physical Activity Guidelines for Americans (≥150 minutes/week) or not, and light-intensity LTPA were also examined. Exposures: LTPA. Main Outcomes and Measures: Primary outcomes included total brain volume (TBV), cortical thickness, and white matter hyperintensity volume, all derived from MRI scans with established methods and adjusted for intracranial volume when necessary. We examined the association of LTPA with these imaging markers using regression models adjusted for demographic, clinical, and vascular risk factors. Results: The 1443 participants of the study had a mean (SD) age of 77.2 (6.4) years; 921 (63.8%) were women; 27.0%, 34.4%, and 36.3% were non-Hispanic White, non-Hispanic African American, and Hispanic individuals, respectively; and 27.3% carried the apolipoprotein E (APOE) ɛ4 allele. Compared with the LTPA of nonactive older adults, those with the most LTPA had larger (in cm3) TBV (ß [SE], 13.17 [4.42] cm3; P = .003; P for trend = .006) and greater cortical thickness (ß [SE], 0.016 [0.008] mm; P = .05; P for trend = .03). The effect size comparing the highest LTPA level with the nonactive group was equivalent to approximately 3 to 4 years of aging (ß for 1 year older, -3.06 and -0.005 for TBV and cortical thickness, respectively). A dose-response association was found and even the lowest LTPA level had benefits (eg, TBV: ß [SE], 9.03 [4.26] cm3; P = .03) compared with the nonactive group. Meeting Physical Activity Guidelines for Americans (TBV: ß [SE], 18.82 [5.14] cm3; P < .001) and light-intensity LTPA (TBV: ß [SE], 9.26 [4.29] cm3; P = .03) were also associated with larger brain measures. The association between LTPA and TBV was moderated by race/ethnicity, sex, and APOE status, but generally existed in all subgroups. The results remained similar after excluding participants with mild cognitive impairment. Conclusions and Relevance: In this study, more physical activity was associated with larger brain volume in older adults. Longitudinal studies are warranted to explore the potential role of physical activity in brain health among older individuals.

Education Moderates the Relation Between APOE ɛ4 and Memory in Nondemented Non-Hispanic Black Older Adults.

BACKGROUND: The APOEɛ4 allele is a well-known risk factor for Alzheimer's disease (AD). Previous research argues that higher education helps to preserve cognition in older adults with AD pathology because of its key role in cognitive reserve and resilience. OBJECTIVE: To test if higher educational level buffers the effect of APOEɛ4 on cognition among older non-Hispanic Blacks. METHODS: Participants were 849 non-demented older non-Hispanic Blacks (38.3% APOEɛ4+), who underwent a comprehensive neuropsychological evaluation. Multiple linear regression models tested the relationship between APOEɛ4 status and twelve cognitive measures with education (up to high school and beyond high school) as a moderator. RESULTS: Education buffered the effects of the APOEɛ4 allele, such that there was no impact of APOEɛ4 status on word-list memory retention and working memory among participants with more than a high school degree. This pattern was not observed for ten other cognitive measures of verbal and visual episodic memory, semantic memory, executive function, and processing speed-although a similar trend was observed for switching ability in executive functioning. The buffering effect of education was stronger among women than men. CONCLUSION: Our findings suggest that genetic effects on late-life cognition may be modified by environmental factors such as educational attainment. These results are consistent with the framework of cognitive reserve such that engaging in cognitively enriching activities and acquiring skills and knowledge with more years of education may increase the capacity to maintain cognitive function despite high genetic risk for impairment.

Medicare Expenditure Correlates of Atrophy and Cerebrovascular Disease in Older Adults.

Background/Study Context: Magnetic resonance imaging (MRI) markers of cerebrovascular disease and atrophy are common in older adults and are associated with cognitive and medical burden. However, the extent to which they are related to health care expenditures has not been examined. We studied whether increased Medicare expenditures were associated with brain markers of atrophy and cerebrovascular disease in older adults. METHODS: A subset of participants (n = 592; mean age = 80 years; 66% women) from the Washington Heights Inwood Columbia Aging Project (WHICAP), a community-based observational study of aging in upper Manhattan, received high-resolution MRI and had Medicare expenditure data on file. We examined the relationship of common markers of cerebrovascular disease (i.e., white matter hyperintensities and presence of infarcts) and atrophy (i.e., whole brain and hippocampal volume) with Medicare expenditure data averaged over a 10-year period. Main outcome measures were (a) mean Medicare payment per year across the 10-year interval; (b) mean payment for outpatient care per year; and (c) mean payment for inpatient care per year of visit. In addition, we calculated the ratio of mean inpatient spending to mean outpatient spending as well as the ratio of mean inpatient spending to mean total Medicare spending. RESULTS: Increased Medicare spending was associated with higher white matter hyperintensity volume, presence of cerebral infarcts, and smaller total brain volume. When examining specific components of Medicare expenditures, we found that inpatient spending was strongly associated with white matter hyperintensity volume and that increased ratios of inpatient to outpatient and inpatient to total spending were associated with infarcts. CONCLUSION: Medicare costs are related to common markers of "silent" cerebrovascular disease and atrophy.

Racial Disparities in Cognitive Performance in Mid- and Late Adulthood: Analyses of Two Cohort Studies.

OBJECTIVES: To examine whether the attenuation of racial disparities observed in physical health outcomes at older ages can be extended to cognitive outcomes in mid- and late-life samples. DESIGN: Cross-sectional associations between race and cognitive functioning were examined as a function of age. SETTING: The National Survey of Midlife Development in the United States (MIDUS) and the Washington Heights-Inwood Columbia Aging Project (WHICAP). PARTICIPANTS: Non-Hispanic African American or white individuals aged 40 and older (MIDUS; n = 3875, 10.5% African American) and non-Hispanic African American or white individuals aged 65 and older without a diagnosis of dementia (WHICAP; n = 2,729, 53.8% African American). MEASUREMENTS: Composite scores of executive functioning and episodic memory. RESULTS: Independent of main effects of age, birth cohort, sex, education, and chronic health conditions, significant interactions between age and race indicated that racial disparities in episodic memory and executive functioning were larger at younger than older age in both samples. CONCLUSION: Attenuation of racial inequalities in older age can be extended to cognitive outcomes, which probably reflects selective survival. Research on cognitive disparities or on race-specific causes of cognitive outcomes in old age must incorporate corrections for selective survival if the goal is to identify causal predictors of cognitive outcomes rather than merely statistical predictors.

Higher education is an age-independent predictor of white matter integrity and cognitive control in late adolescence.

Socioeconomic status is an important predictor of cognitive development and academic achievement. Late adolescence provides a unique opportunity to study how the attainment of socioeconomic status (in the form of years of education) relates to cognitive and neural development, during a time when age-related cognitive and neural development is ongoing. During late adolescence it is possible to disambiguate age- and education-related effects on the development of these processes. Here we assessed the degree to which higher educational attainment was related to performance on a cognitive control task, controlling for age. We then used diffusion tensor imaging (DTI) to assess the degree to which white matter microstructure might mediate this relationship. When covarying age, significant associations were found between educational attainment and fractional anisotropy (FA) in the superior longitudinal fasciculus (SLF) and cingulum bundle (CB). Further, when covarying age, FA in these regions was associated with cognitive control. Finally, mediation analyses revealed that the age-independent association between educational attainment and cognitive control was completely accounted for by FA in these regions. The uncinate fasciculus, a late-myelinated control region not implicated in cognitive control, did not mediate this effect.

Quantitative approaches for assessment of white matter hyperintensities in elderly populations.

White matter hyperintensities (WMH) are areas of increased signal on T2-weighted magnetic resonance imaging (MRI), including fluid attenuated inverse recovery sequences. Total and regional WMH burden (i.e., volume or severity) has been associated with myriad cognitive, neurological, and psychiatric conditions among older adults. In the current report, we illustrate two approaches to quantify periventricular, deep, and total WMH and examine their reliability and criterion validity among 28 elderly patients enrolled in a depression treatment trial. The first approach, an operator-driven quantitative approach, involves visual inspection of individual MRI scans and manual labeling using a three-step series of procedures. The second approach, a fully automated quantitative approach, uses a processing stream that involves image segmentation, voxel intensity thresholding, and seed growing to label WMH and calculate their volume automatically. There was good agreement in WMH quantification between the two approaches (Cronbach's alpha values from 0.835 to 0.968). Further, severity of WMH was significantly associated with worse depression and increased age, and these associations did not differ significantly between the two quantification approaches. We provide evidence for good reliability and criterion validity for two approaches for WMH volume determination. The operator-driven approach may be better suited for smaller studies with highly trained raters, whereas the fully automated quantitative approach may be more appropriate for larger, high-throughput studies.

Do neuropsychological tests have the same meaning in Spanish speakers as they do in English speakers?

OBJECTIVE: The purpose of this study was to examine whether neuropsychological tests translated into Spanish measure the same cognitive constructs as the original English versions. METHOD: Older adult participants (N = 2,664), who did not exhibit dementia from the Washington Heights Inwood Columbia Aging Project (WHICAP), a community-based cohort from northern Manhattan, were evaluated with a comprehensive neuropsychological battery. The study cohort includes both English (n = 1,800) and Spanish speakers (n = 864) evaluated in their language of preference. Invariance analyses were conducted across language groups on a structural equation model comprising four neuropsychological factors (memory, language, visual-spatial ability, and processing speed). RESULTS: The results of the analyses indicated that the four-factor model exhibited partial measurement invariance, demonstrated by invariant factor structure and factor loadings but nonequivalent observed score intercepts. CONCLUSION: The finding of invariant factor structure and factor loadings provides empirical evidence to support the implicit assumption that scores on neuropsychological tests are measuring equivalent psychological traits across these two language groups. At the structural level, the model exhibited invariant factor variances and covariances.

A comprehensive assessment of gray and white matter volumes and their relationship to outcome and severity in schizophrenia.

Preliminary data suggest an association of posterior cortical gray matter reduction with poor outcome in schizophrenia. We made a systematic MRI assessment of regional gray and white matter volumes, parcellated into 40 Brodmann's areas, in 104 patients with schizophrenia (51 with good outcomes, 53 with poor outcomes) and 41 normal comparison subjects, and investigated correlations of regional morphometry with outcome and severity of the illness. Schizophrenia patients displayed differential reductions in frontal and to a lesser degree temporal gray matter volumes in both hemispheres, most pronounced in the frontal pole and lateral temporal cortex. White matter volumes in schizophrenia patients were bilaterally increased, primarily in the frontal, parietal, and isolated temporal regions, with volume reductions confined to anterior cingulate gyrus. In patients with schizophrenia as a group, higher illness severity was associated with reduced temporal gray matter volumes and expanded frontal white matter volumes in both hemispheres. In comparison to good-outcome group, patients with poor outcomes had lower temporal, occipital, and to a lesser degree parietal gray matter volumes in both hemispheres and temporal, parietal, occipital, and posterior cingulate white matter volumes in the right hemisphere. While gray matter deficits in the granular cortex were observed in all schizophrenia patients, agranular cortical deficits in the left hemisphere were peculiar to patients with poor outcomes. These results provide support for frontotemporal gray matter reduction and frontoparietal white matter expansion in schizophrenia. Poor outcome is associated with more posterior distribution (posteriorization) of both gray and white matter changes, and with preferential impairment in the unimodal visual and paralimbic cortical regions.

Frequency of subclinical heart disease in elderly persons with dementia.

The authors compared the frequency of structural and functional heart abnormalities assessed using transthoracic echocardiography among persons with Alzheimer's disease, vascular dementia, stroke, and healthy control subjects. Compared with controls, patients with Alzheimer's disease were more likely to have aortic valve thickening, aortic valve regurgitation, left ventricular wall motion abnormalities, left ventricular hypertrophy, and reduced ejection fraction. Persons with vascular dementia were more likely to have aortic valve regurgitation, but mitral valve thickening and tricuspid valve regurgitation were also more frequent. In the absence of dementia, persons with stroke differed from controls by more frequent mitral valve calcifications. With the increasing prevalence of Alzheimer's disease and vascular dementia, clinicians have to be more attentive to the presence of structural heart disease and its complications in persons with these conditions.

MRI assessment of gray and white matter distribution in Brodmann's areas of the cortex in patients with schizophrenia with good and poor outcomes.

OBJECTIVE: High-resolution magnetic resonance imaging (MRI) was used to compare cortical gray and white matter and CSF volumes in schizophrenia patients with poor outcomes, schizophrenia patients with good outcomes, and healthy comparison subjects. METHOD: T(1)-weighted, 1.2-mm-thick MR images were acquired for 37 patients with schizophrenia and 37 healthy, age- and sex-matched comparison subjects. The patients were assigned to subgroups with poor outcomes (N=13) and good outcomes (N=24) on the basis of clinical characteristics. Poor-outcome patients were those who were continuously hospitalized or completely dependent on others for basic needs, were unemployed, and had severe negative symptoms and severe formal thought disorder. The MR images were reoriented to standard position parallel to the anterior commissure-posterior commissure line and segmented into CSF, gray matter, and white matter tissue types. The tissue types were assigned to Brodmann's areas by using the Perry postmortem histological atlas, and tissue-type volumes in the three subject groups were compared. RESULTS: Compared to the healthy subjects, the overall patient group had a significantly smaller mean cortical gray matter volume and significantly larger mean CSF volume, especially in the frontal lobe and left temporal lobe. The smaller frontal lobe volume in schizophrenia was confirmed for unadjusted volumes and for volumes with adjustment for whole brain volumes. Compared to patients with good outcomes, patients with poor outcomes (Kraepelinian schizophrenia) had significantly smaller gray matter volumes in the temporal and occipital lobes, but no difference between groups was found for total frontal lobe volume. Only 21% of the healthy subjects had volumes 0.5 standard deviations below the mean for healthy subjects in any area of the frontal or temporal lobes, compared with 62% of poor-outcome patients. CONCLUSIONS: Poor outcome in patients with schizophrenia may be associated with a more posterior distribution (posteriorization) of gray matter deficits across widely distributed cortical regions.

Cognitive burden and excess Lewy-body pathology in the Lewy-body variant of Alzheimer disease.

OBJECTIVES: Authors compared the degrees of cognitive deficit among individuals with Alzheimer disease (AD), the Lewy-body variant of AD (LBV), and "pure" dementia with Lewy bodies (DLB); and compared cortical Lewy body (LB) counts in LBV versus DLB and neuritic plaque and neurofibrillary tangle severity in LBV versus AD. METHODS: Authors examined brain specimens from consecutive autopsies of elderly nursing home subjects. Numbers and densities of plaques, Lewy bodies, and tangle severity were determined in multiple cortical regions, and demographic and clinical variables were compared among the three groups. RESULTS: The three groups did not differ in demographic or clinical variables. The LBV group was significantly more impaired than the other groups. Cortical LB counts were significantly higher in LBV than in DLB. There was no evidence of increased plaque or tangle severity in LBV than in AD. CONCLUSION: The co-occurrence of AD and LB pathology is associated with higher numbers of LBs and more severe dementia than when classical AD or LB lesions occur alone.

Longitudinal assessment of patient dependence in Alzheimer disease.

BACKGROUND: The Dependence Scale measures the amount of assistance patients with dementia require in performing daily activities. Validity and reliability of this scale have been demonstrated, but the progression throughout long periods in patients with Alzheimer disease (AD) has not previously been examined. OBJECTIVE: To determine the longitudinal course of patient dependence in a cohort of prospectively followed AD patients. METHODS: Two hundred thirty AD patients enrolled in the Predictors Study were followed up prospectively at 6-month intervals for an average of 6.5 visits. The Dependence Scale was administered to a caregiver, and patients were assessed with the modified Mini-Mental State Examination (mMMSE) and the Blessed Dementia Rating Scale. Dependence level and the additive sum of the Dependence Scale items were considered for analysis. RESULTS: Generalized estimating equations to regression analyses were used to determine that both Dependence Scale scores and dependence level significantly decline with time. By covarying mMMSE scores and self-care deficits factor scores of the Blessed Dementia Rating Scale, generalized estimating equations analysis also demonstrated that change in patient dependence was independent of global cognitive decline and other measures of activities of daily living, respectively. CONCLUSIONS: This study shows the validity of the Dependence Scale and demonstrated that dependency in AD significantly declines with time independent of global cognition and other self-care deficits. The scale is a valuable instrument for outcomes research, efficacy trials, and behavioral research in AD.