Facility-based and home-based multidomain interventions including cognitive training, exercise, diet, vascular risk management, and motivation for older adults: a randomized controlled feasibility trial.

We aimed to evaluate the feasibility of multidomain intervention (MI) tailored to the Korean context. In an outcome assessor-blinded, randomized controlled trial, participants without dementia and with one or more modifiable dementia risk factors, aged 60-79 years, were randomly assigned to the facility-based MI (FMI; n=51), the home-based MI (HMI; n=51), or the control group receiving general health advice (n=50). The 24-week intervention comprised vascular risk management, cognitive training, social activity, physical exercise, nutrition guidance, and motivational enhancement. The FMI participants performed all intervention programs at a facility three times a week. The HMI participants performed some programs at a facility once every 1-2 weeks and performed others at home. The primary outcome was feasibility measured through retention, adherence, and at least no differences from the control group in the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). In the FMI and HMI groups, the retention rates were 88.2% and 96.1%, and adherence to the intervention was 94.5% and 96.8%, respectively. The RBANS total scale index score improved significantly in the FMI (5.46 ± 7.50, P = 0.004) and HMI (5.50 ± 8.14, P = 0.004) groups compared to the control group (-0.74 ± 11.51). The FMI and HMI are feasible and there are indicators of efficacy.

The effect of severity of white matter hyperintensities on loss of functional independency in patients with mild cognitive impairment: A CREDOS-LTCI (clinical research center for dementia of South Korea-long term card insurance) study.

OBJECTIVE: By combining data from the Clinical Research Center for Dementia of South Korea(CREDOS) study and long-term care insurance(LTCI), we aimed to assess whether the severity of white matter hyperintensity(WMH) predicted functional decline in cases of amnestic mild cognitive impairment(MCI). METHODS: WMH was evaluated in 3,569 patients with amnestic MCI using the visual rating scale developed for the CREDOS study. The participants were classified as having amnestic MCI with minimal WMH change(aMCI), with moderate WMH change(maMCI) and with severe WMH change(saMCI) according to the severity of the WMH measurements. A Kaplan-Meier survival probability estimate was used to compute median time from the diagnosis of MCI to LTCI enrollment for the three MCI groups. The effect of various risk factors of LTCI enrollment was evaluated using Cox's proportional hazards model, adjusted for covariates. RESULTS: As compared with aMCI cases, maMCI and saMCI patients required help with daily activities of living at a younger age. The saMCI and maMCI patients had higher risk of LTCI enrollment as compared with that of the aMCI patients. Younger patients(≤ 65y) with MCI had a 3.201 times higher risk of early LTCI enrollment than older patients(> 65y) did. High clinical dementia rating score and female sex were also risk factors of early LTCI enrollment. CONCLUSIONS: WMH predicted the rate of global functional decline and loss of independence in patients with MCI. The findings support the use of neuroimaging of WMH, in conjunction with biomarkers, as a tool in predicting functional decline in patients with MCI.

Exposure to ambient fine particles and neuropsychiatric symptoms in cognitive disorder: A repeated measure analysis from the CREDOS (Clinical Research Center for Dementia of South Korea) study.

There is a growing concern that air pollution, especially those particles <2.5 µm (PM2.5), could increase the risk of cognitive impairment and mental disorders. However, the relationship between ambient PM2.5 and neuropsychiatric symptoms in people with cognitive impairment is still undetermined. This longitudinal study included 645 pairs of cognitively impaired subjects, who had not changed residence within Seoul, and their caregivers from the Clinical Research Center for Dementia of South Korea study cohort between September 2005 and June 2010 (1763 days). Neuropsychiatric symptoms were measured by the Korean version of the Neuropsychiatry Inventory, and caregiver burden was examined by the Neuropsychiatry Inventory Caregiver Distress Scale at the first and second visits at the outpatient clinic. District-specific PM2.5 concentrations were constructed over 1 month to 1 year prior to each visit. A log-linear regression using generalized estimating equations to account for repeated measures was used to assess the relationship between PM2.5 exposure and neuropsychiatric symptoms or caregiver burden. Aggravated neuropsychiatric symptoms were associated with exposure to high PM2.5 levels (adjusted percent change: 16.7% [95% confidence interval (CI), 5.0-29.7] per 8.3 µg/m3 increase in 1-month moving averages). Increased caregiver burden was associated with high PM2.5 exposures only in caregivers for patients with Alzheimer's disease (adjusted percent change: 29.0% [95% CI, 8.1-53.9] per 8.3 µg/m3 increase in 1-month moving averages). The present results indicate that PM2.5 exposure is associated with aggravated neuropsychiatric symptoms and increased caregiver burden in subjects with cognitive impairment. The findings in this study suggest that the role of air pollution deserves great consideration in the aging population with cognitive impairment.

The moderating effect of religiosity on caregiving burden and depressive symptoms in caregivers of patients with dementia.

OBJECTIVES: This study explored whether religiosity/spirituality has a protective role against negative caregiving outcomes, in a large multicenter nationwide sample of caregivers of patients with dementia in South Korea. Additionally, this study was the first to examine whether religiosity/spirituality could affect caregiving outcomes according to the various religious affiliations of caregivers. METHODS: The study was conducted on a sample of 476 caregivers of patients with dementia participated in the Clinical Research Center for Dementia of South Korea (CREDOS). We examined the moderating effect of each of the three dimensions of religiosity/spirituality (organizational religious activity, ORA; non-organizational religious activity, NORA; intrinsic religiosity, IR) on the relationship between activities of daily living (ADL) of patients with dementia and caregiving burden and depressive symptoms of caregivers, using a series of hierarchical regression analyses. In addition, these analyses were conducted according to the religious affiliations of the caregivers. RESULTS: ORA, NORA, and IR of religiosity/spirituality alleviated the effect of ADL of patients on caregiving burden. ORA and IR moderated the relationship between ADL of patients and depressive symptoms of caregivers. These moderating effects of religiosity on caregiving outcomes were different according to various religious groups. CONCLUSION: We have identified religiosity/spirituality as a protective factor for caregivers of patients with dementia. The sub-dimensions of religiosity as moderators were different by religious affiliations of caregivers. Further studies are needed to investigate the specific religiosity-related factors which could positively impact the mental health of the caregivers of patients with dementia by religions.

Effect of Individual and District-level Socioeconomic Disparities on Cognitive Decline in Community-dwelling Elderly in Seoul.

This study was to investigate the effects of individual and district-level socioeconomic status (SES) on the development of cognitive impairment among the elderly. A 3-year retrospective observational analysis (2010-2013) was conducted which included 136,217 community-dwelling healthy elderly who participated in the Seoul Dementia Management Project. Cognitive impairment was defined as 1.5 standard deviations below the norms on the Mini-mental status examination. In the individual lower SES group, the cumulative incidence rate (CIR) of cognitive impairment was 8.7% (95% confidence interval [CI], 8.64-8.70), whereas the CIR in the individual higher SES group was 4.1% (95% CI, 4.08-4.10). The CIR for lower district-level SES was 4.7% (95% CI, 4.52-4.86), while that in the higher district-level SES was 4.3% (95% CI, 4.06-4.44). There were no additive or synergistic effects between individual and district-level SES. From this study, the individual SES contributed 1.9 times greater to the development of cognitive impairment than the district-level SES, which suggests that individual SES disparities could be considered as one of the important factors in public health related to cognitive impairment in the elderly.

Normative Study of the Literacy Independent Cognitive Assessment in Illiterate and Literate Elderly Koreans.

OBJECTIVE: The aim of this study was to provide normative data on the Literacy Independent Cognitive Assessment (LICA) and to explore the effects of age, education/literacy, and gender on the performance of this test. METHODS: Eight hundred and eighty-eight healthy elderly subjects, including 164 healthy illiterate subjects, participated in this study. None of the participants had serious medical, psychiatric, or neurological disorders including dementia. Bivariate linear regression analyses were performed to examine the effects of age, education/literacy, and sex on the score in each of the LICA cognitive tests. The normative scores for each age and education/literacy groups are presented. RESULTS: Bivariate linear regression analyses revealed that total score and all cognitive tests of the LICA were significantly influenced by both age and education/literacy. Younger and more-educated subjects outperformed older and illiterate or less-educated subjects, respectively, in all of the tests. The normative scores of LICA total score and subset score were presented according to age (60-64, 65-69, 70-74, 75-80, and ≥80 years) and educational levels (illiterate, and 0-3, 4-6, and ≥7 years of education). CONCLUSION: These results on demographic variables suggest that age and education should be taken into account when attempting to accurately interpret the results of the LICA cognitive subtests. These normative data will be useful for clinical interpretations of the LICA neuropsychological battery in illiterate and literate elderly Koreans. Similar normative studies and validations of the LICA involving different ethnic groups will help to enhance the dementia diagnosis of illiterate people of different ethnicities.

Literacy Independent Cognitive Assessment: Assessing Mild Cognitive Impairment in Older Adults with Low Literacy Skills.

OBJECTIVE: Comprehensive neuropsychological tests are important in the diagnosis and follow-up of patients with MCI; however, most were developed without consideration of illiteracy. We developed the Literacy Independent Cognitive Assessment (LICA) as a comprehensive neuropsychological assessment battery applicable to older adults who are either literate or illiterate. This study aimed to assess the reliability and validity of the LICA for diagnosis of MCI. METHODS: Normal controls (n=634) and patients with MCI (n=128) were recruited from 13 centers were included in this study. Participants were divided into illiterate or literate groups, based on their performance on a brief reading and writing test. The LICA, Korean Mini-Mental State Examination (K-MMSE), and Seoul Neuropsychological Screening Battery (SNSB) were administered. RESULTS: Total LICA scores distinguished MCI patients from controls (p<0.001). They were closely and positively correlated to the K-MMSE scores (r=0.632, p<0.001) but negatively correlated to clinical dementia rating (CDR) (r=-0.358, p<0.001) and CDR sum of boxes (r=-0.339, p<0.001). Area under the receiver operating characteristic curve for patients with MCI by total LICA score was 0.827 (0.783-0.870), superior to that presented by the K-MMSE. For the classification of MCI subtypes, inter-method reliability of LICA with the SNSB was good (κ 0.773; 0.679-0.867, p<0.001). CONCLUSION: The results of this study show that the LICA may be reliably used to distinguish MCI patients from cognitively intact adults, to identify MCI subtypes and monitor progression toward dementia, regardless of illiteracy.

Reliability and validity of the short form of the literacy-independent cognitive assessment in the elderly.

BACKGROUND AND PURPOSE: The Literacy-Independent Cognitive Assessment (LICA) has been developed for a diagnosis of dementia and is a useful neuropsychological test battery for illiterate populations as well as literate populations. The objective of this study was to develop the short form of the LICA (S-LICA) and to evaluate the reliability and validity of the S-LICA. METHODS: The subtests of the S-LICA were selected based on the factor analysis and validation study results of the LICA. Patients with dementia (n=101) and normal elderly controls (n=185) participated in this study. RESULTS: Cronbach's coefficient alpha of the S-LICA was 0.92 for illiterate subjects and 0.94 for literate subjects, and the item-total correlation ranged from 0.63 to 0.81 (p<.01).The test-retest reliability of the S-LICA total score was high (r=0.94, p<.001), and the subtests had high test-retest reliabilities (r=0.68-0.87, p<.01). The correlation between the K-MMSE and S-LICA total scores were substantial in both the illiterate subjects (r=0.837, p<.001) and the literate subjects(r=0.802, p<.001). The correlation between the S-LICA and LICA was very high (r=0.989, p<.001). The area under the curve of the receiver operating characteristic was 0.999 for the literate subjects and 0.985 for the illiterate subjects. The sensitivity and specificity of the S-LICA for a diagnosis of dementia were 97% and 96% at the cutoff point of 72 for the literate subjects, and 96% and 93% at the cutoff point of 68 for the illiterate subjects, respectively. CONCLUSIONS: Our results indicate that the S-LICA is a reliable and valid instrument for quick evaluation of patients with dementia in both illiterate and literate elderly populations.

Validation of the Literacy Independent Cognitive Assessment.

BACKGROUND: Low education and illiteracy are associated with an increased risk of dementia. This study aimed to develop a neuropsychological test battery applicable to both illiterate and literate elderly and to assess its reliability and validity for a diagnosis of dementia. METHODS: We developed the Literacy Independent Cognitive Assessment (LICA), which consists of 13 subtests assessing memory, language, visuoconstruction, executive function, attention and calculation. We investigated its reliability and validity on 152 patients with dementia, 66 with mild cognitive impairment and 639 normal controls. RESULTS: The subtests were found to be applicable to most of the illiterate normal controls (97.3%) and were found to have high inter-rater reliabilities (r = 0.85-1.00, p < 0.001) and moderate to high test-retest reliabilities (r = 0.50-0.86, p < 0.001). The LICA performed well in discriminating participants across Clinical Dementia Rating stages and showed excellent internal consistency and good concurrent validity with the Korean Mini-mental State Examination in both literate and illiterate participants. The area under the curve of the receiver operating characteristic was 0.985 in each of the two literacy groups. Sensitivity and specificity of the LICA to make a diagnosis of dementia was 91.9% and 91.8% at the cutoff point of 186.0 in the literate subjects and 96.2% and 91.1% at the cutoff point of 154.5 in the illiterate subjects. The battery was factored into two separate factors consisting of verbal memory tests and tests for other cognitive domains. CONCLUSION: The LICA is a valid and reliable instrument for a diagnosis of dementia in both illiterate and literate elderly.

Validation of the Korean version of the Syndrom Kurztest (SKT): a short test for the assessment of memory and attention.

The Syndrom Kurztest SKT is a brief neuropsychological test battery that consists of nine subtests and defines two independent factors of memory and attention deficit. The aim of this study was to validate the Korean version of the SKT. The reliability of each subtest among three parallel Forms (A, B and C) of the Korean version was high (r = 0.46-0.95). The SKT had good concurrent validity with the Mini-Mental State Examination (r = -0.83, p < 0.001). Factor analysis confirmed the presence of two primary factors, memory and attention. The overall similarities of the factor structures for the Korean data and those for the data from Germany and the USA provide evidence of the transcultural stability of the SKT.