A neuropsychologically based employment intervention for women with multiple sclerosis: A quasi-randomized controlled trial.

OBJECTIVE: Job loss is common in multiple sclerosis (MS) and frequently associated with depression, fatigue, and cognitive dysfunction. Identifying these modifiable risk factors and providing "at-risk" women with a neuropsychologically-based intervention may improve employment outcomes. Our study seeks to investigate the utility of a neuropsychologically-based intervention with varying levels of treatment and follow-up, and evaluate treatment and employment outcomes among groups. METHOD: In this longitudinal, quasi-randomized controlled trial, employed women with MS meeting criteria on screening measures were considered "at-risk" for job instability and randomized to one of two neuropsychological testing interventions (standard-care group received testing and phone feedback of results and recommendations; experimental group received testing and in-person feedback with subsequent care-coordinator calls from a nurse to help coordinate recommendation completion). Participants who did not meet criteria were considered "low-risk" and only followed over time. RESULTS: 56 women in the treatment groups (standard-care = 23; experimental = 33) and 63 women in the follow-only group were analyzed at 1 year. Rates of decreased employment were similar between standard-care (17.4%) and experimental (21.2%) groups (OR = .782, 95% CI .200-3.057). However, the experimental group completed significantly more treatment recommendations, t(53) = -3.237, p = .002. Rates of decreased employment were also similar between the "low-risk" (17.5%) and "at-risk" groups (19.6%), (OR = .721, 95% CI .285-1.826). CONCLUSION: Employment outcomes were similar at 1 year between treatment groups receiving differing levels of a neuropsychologically-based intervention, however treatment adherence significantly improved in the experimental group. Treatment groups also had similar employment outcomes as compared to a "low-risk," no intervention group, suggesting that engaging in either neuropsychological intervention may have impacted job stability.

A neuropsychologically-based intervention with increased follow-up support for employed women with multiple sclerosis: a pilot randomized controlled trial.

OBJECTIVE: To evaluate feasibility and acceptability of a neuropsychologically-based vocational intervention with increased follow-up support for women with multiple sclerosis. DESIGN: Single-blinded parallel-group randomized controlled trial with 12-month follow-up. SETTING: Tertiary-care multiple sclerosis center. PARTICIPANTS: Forty-nine employed women with multiple sclerosis meeting criteria on measures of cognitive dysfunction (Symbol Digit Modalities Test), fatigue (Fatigue Severity Scale), and/or depression (Beck Depression Inventory/Patient Health Questionnaire). INTERVENTIONS: Participants received either neuropsychological testing and phone feedback regarding findings and tailored recommendations (standard-care treatment), or testing, in-person feedback, and two calls from a care-coordinator (experimental treatment). MEASURES: Feasibility measures included enrollment and attrition rates, and compliance to recommendations at 12-months between groups. Acceptability was evaluated by participants' report of benefit from interventions. Secondary analyses included evaluation of symptom changes (cognition, fatigue, depression) from baseline to 12-months. RESULTS: Of 49 women meeting screening measure thresholds, 44 were randomized to treatment groups (attrition: standard-care = 8, experimental = 6), and 30 completed the study (standard-care = 14, experimental = 16). Recommendation adherence rates did not significantly differ between standard-care and experimental groups (31% vs 49%). However, 16/16 experimental participants at least partially completed given recommendations as compared to 8/14 in the standard-care group. Participants across groups (97%) reported benefit from participation. No significant differences in symptom outcomes between groups at 12-months. CONCLUSION: In-person feedback and care-coordinator calls were feasible and acceptable additions to a neuropsychological intervention and may serve to increase recommendation adherence. Given high drop-out rate, particularly prior to testing, future research may explore avenues to improve completion rates and maximize benefits of such interventions.

Is the Montreal cognitive assessment culturally valid in a diverse geriatric primary care setting? Lessons from the Bronx.

BACKGROUND: Efficacy and validity of the MoCA for cognitive screening in ethnoculturally and linguistically diverse settings is unclear. We sought to examine the utility and discriminative validity of the Spanish and English MoCA versions to identify cognitive impairment among diverse community-dwelling older adults. METHODS: Participants aged ≥65 with cognitive concerns attending outpatient primary care in Bronx, NY, were recruited. MoCA and neuropsychological measures were administered in Spanish or English, and a neuropsychologist determined cognitive status (normal with subjective cognitive concerns [SCC], mild cognitive impairment [MCI], and dementia). One-way ANOVA compared cognitive statuses. ROC analyses identified optimal MoCA cutpoints for discriminating possible cognitive impairment. RESULTS: There were 231 participants, with mean age 73, 72% women, 43% Hispanic; 39% Black/African American; 113 (49%) completed testing in English and 118 (51%) in Spanish. Overall MoCA mean was 17.7 (SD = 4.3). Neuropsychological assessment identified 90 as cognitively normal/SCC, average MoCA 19.9 (SD = 4.1), 133 with MCI, average MoCA 16.6 (SD = 3.7), and 8 with dementia, average MoCA 10.6 (SD = 3.1). Mean English MoCA average was 18.6 (SD = 4.1) versus Spanish 16.7 (SD = 4.3). The published cutpoint ≤23 for MCI yielded a high false-positive rate (79%). ROC analyses identified ≤18.5 as the score to identify MCI or dementia using the English MoCA (65% sensitivity; 77% specificity) and ≤16.5 for the Spanish MoCA (64% sensitivity;73% specificity) in this sample of older adults with cognitive concerns. CONCLUSIONS: Current MoCA cutpoints were inappropriately high in a culturally/linguistically diverse urban setting, leading to a high false-positive rate. Lower Spanish and English MoCA cutpoints may improve diagnostic accuracy for identifying cognitive impairment in this group, highlighting the need for the creation and validation of accurate cognitive screeners for ethnoculturally and linguistically diverse older adults.

Role of Cognitive Frailty in Older Adults With Cardiovascular Disease.

As the older adult population expands, an increasing number of patients affected by geriatric syndromes are seen by cardiovascular clinicians. One such syndrome that has been associated with poor outcomes is cognitive frailty: the simultaneous presence of cognitive impairment, without evidence of dementia, and physical frailty, which results in decreased cognitive reserve. Driven by common pathophysiologic underpinnings (eg, inflammation and neurohormonal dysregulation), cardiovascular disease, cognitive impairment, and frailty also share the following risk factors: hypertension, diabetes, obesity, sedentary behavior, and tobacco use. Cardiovascular disease has been associated with the onset and progression of cognitive frailty, which may be reversible in early stages, making it essential for clinicians to diagnose the condition in a timely manner and prescribe appropriate interventions. Additional research is required to elucidate the mechanisms underlying the development of cognitive frailty, establish preventive and therapeutic strategies to address the needs of older patients with cardiovascular disease at risk for cognitive frailty, and ultimately facilitate targeted intervention studies.