"Black Women Don't Always Put Our Healthcare First": Facilitators and Barriers to Cervical Cancer Screening and Perceptions of Human Papillomavirus Self-Testing Among Church-Affiliated African American Women.

Background: African American women are at greater risk for cervical cancer incidence and mortality than White women. Up to 90% of cervical cancers are caused by human papillomavirus (HPVs) infections. The National Institutes of Health (NIH) co-developed HPV self-test kits to increase access to screening, which may be critical for underserved populations. Purpose/Research Design: This mixed methods study used the Theory of Planned Behavior to examine attitudes, barriers, facilitators, and intentions related to receipt of cervical cancer screening and perceptions of HPV self-testing among church-affiliated African American women. Study Sample/Data Collection: Participants (N = 35) aged 25-53 participated in focus groups and completed a survey. Results: Seventy-four percent of participants reported receipt of cervical cancer screening in the past 3 years. Healthcare providers and the church were supportive referents of screening. Past trauma and prioritizing children's healthcare needs were screening barriers. Concerns about HPV self-testing included proper test administration and result accuracy. Conclusions: Strategies to mitigate these concerns (e.g., delivering HPV self-test kits to the health department) are discussed.

Cognitive predictors of a performance-based measure of instrumental activities of daily living following stroke.

BACKGROUND: To inform cognitive interventions that target functional capacity for individuals who have survived stroke, an evaluation of predictors of daily functioning is necessary. The current literature is limited regarding identifying the associations between objective cognitive functioning and objective performance of Instrumental Activities of Daily Living (IADLs). OBJECTIVES: To investigate the relationship between objectively measured cognitive domains/executive functions and performance on an objective measure of IADLs following a stroke. METHODS: Cross-sectional examination of 52 participants who have survived strokes and completed assessments of immediate memory, visuospatial/constructional skills, language, attention, delayed memory, executive functions (i.e., inhibition and flexibility, concept-formation and problem-solving, abstract thinking, deductive thinking, and verbal abstraction), and a performance-based measure of IADLs (UCSD Performance-based Skills Assessment; UPSA). RESULTS: Results indicated significant correlations between the UPSA and immediate memory, visuospatial/constructional skills, language, delayed memory, and executive functions (i.e., concept formation and problem-solving, flexibility of thinking, and verbal abstraction). A hierarchical multiple regression, controlling for age, severity of stroke, side of stroke, and depressive symptoms and including the cognitive measures individually significantly associated with the UPSA, explained approximately 62% of the variance in overall UPSA performance. This regression demonstrated that only language significantly predicted UPSA total score, in the context of multiple variables. CONCLUSIONS: Cognitive functioning is significantly associated with IADL functioning post-stroke, and considering multiple domains of cognitive functioning together largely explains the performance of IADLs.

Predictors of instrumental activities of daily living in community-dwelling older adults.

Psychiatric mental health clinicians often rely on proxy and self-report evaluations to determine the cognitive function of older adults however, performance measures have greater accuracy and predictive ability for everyday function. This study tested physical and cognitive predictors of functional abilities in fifty-one community residing older adults. We administered a computerized battery of executive function tasks, a performance-based measure of instrumental activities of daily living (IADL), and three physical function measures (grip strength, 30-second Chair Stand Test, and 8-foot Up and Go). Regression models assessed the associations of three components of executive function (updating, shifting, and inhibition) with IADLs and physical functions. Updating was a significant predictor of the Medications and Financial DAFS scores and of grip strength. Shifting also predicted grip strength. In conclusion, different executive functions predict different domains of IADL functioning. Working memory was a robust predictor of IADL functioning in older adults, especially medication management skills.

What eye-tracking methods can reveal about the role of information format in decision-aid processing: an exploratory study.

OBJECTIVE: Decision tools can assist patients and families in making informed choices about treatment options. However, information format can influence understanding of treatment options and subsequent treatment decisions, so it is critical to identify formats that support clear and accurate communication. METHOD: Forty-five older adults made a hypothetical treatment decision about rt-PA therapy for stroke while viewing risk information presented in one of three graph formats (bar, stacked bar, or iconic array). We investigated decisional uncertainty, study time and memory accuracy as a function of graph format. Eye tracking methods explored format-related differences in graph processing. RESULTS: Decisional uncertainty was higher after studying the bar graph, compared to the stacked bar or iconic graph. The bar graph was also associated with poorer memory and longer overall study time. Eye-tracking indicated that graph information was processed in a different order and to a different extent for the three graph types. CONCLUSION: Understanding how people process information in decision aids is critical for clear communication with decision-makers. PATIENT IMPLICATIONS: Format has been shown to impact information processing, and eye-tracking may be a useful tool to understand these format differences and their implications, and to guide the design of decision aids to optimize communication.

Computer-Based Executive Function Training for Combat Veterans With PTSD: A Pilot Clinical Trial Assessing Feasibility and Predictors of Dropout.

Background: While evidence-based PTSD treatments are often efficacious, 20-50% of individuals continue to experience significant symptoms following treatment. Further, these treatments do not directly target associated neuropsychological deficits. Here, we describe the methods and feasibility for computer-based executive function training (EFT), a potential alternative or adjunctive PTSD treatment. Methods: Male combat veterans with full or partial PTSD (n = 20) and combat-exposed controls (used for normative comparison; n = 20) completed clinical, neuropsychological and functional neuroimaging assessments. Those with PTSD were assigned to EFT (n = 13) or placebo training (word games; n = 7) at home for 6 weeks, followed by repeat assessment. Baseline predictors of treatment completion were explored using logistic regressions. Individual feedback and changes in clinical symptoms, neuropsychological function, and neural activation patterns are described. Results: Dropout rates for EFT and placebo training were 38.5 and 57.1%, respectively. Baseline clinical severity and brain activation (i.e., prefrontal-insula-amygdala networks) during an emotional anticipation task were predictive of treatment completion. Decreases in clinical symptoms were observed following treatment in both groups. EFT participants improved on training tasks but not on traditional neuropsychological assessments. All training completers indicated liking EFT, and indicated they would engage in EFT (alone or as adjunctive treatment) if offered. Conclusion: Results provide an initial framework to explore the feasibility of placebo-controlled, computerized, home-based executive function training (EFT) on psychological and neuropsychological function and brain activation in combat veterans with PTSD. Clinical severity and neural reactivity to emotional stimuli may indicate which veterans will complete home-based computerized interventions. While EFT may serve as a potential alternative or adjunctive PTSD treatment, further research is warranted to address compliance and determine whether EFT may benefit functioning above and beyond placebo interventions.

Multitasking in older adults with type 2 diabetes: A cross-sectional analysis.

BACKGROUND AND PURPOSE: Deficits in the ability to multitask contribute to gait abnormalities and falls in many at-risk populations. However, it is unclear whether older adults with type 2 diabetes mellitus (DM) also demonstrate impairments in multitasking. The purpose of this study was to compare multitasking performance in cognitively intact older adults with and without DM and explore its relationship to measures of gait and functional ability. METHODS: We performed a cross-sectional analysis of 40 individuals aged 60 and older with type 2 DM and a matched group of 40 cognitively intact older adults without DM. Multitasking was examined via the ambulatory Walking and Remembering Test (WART) and seated Pursuit Rotor Test (PRT). Self-selected normal and fast walking speed and stride length variability were quantitatively measured, and self-reported functional ability was assessed via the Late Life Function and Disability Index (LLFDI). RESULTS: Participants with DM walked slower and took more steps off path when multitasking during the WART. No between-group differences in multitasking performance were observed on the PRT. Multitasking performance demonstrated little correlation with gait and functional ability in either group. DISCUSSION AND CONCLUSIONS: Older adults with DM appear to perform poorly on an ambulatory measure of multitasking. However, we analyzed a relatively small, homogenous sample of older adults with and without type 2 DM and factors such as peripheral neuropathy and the use of multiple comparisons complicate interpretation of the data. Future research should explore the interactions between multitasking and safety, fall risk, and function in this vulnerable population. Clinicians should recognize that an array of factors may contribute to gait and physical dysfunction in older adults with type 2 diabetes, and be prepared to assess and intervene appropriately.

Measuring learning potential in people with schizophrenia: A comparison of two tasks.

Learning potential measures utilize dynamic assessment methods to capture performance changes following training on a cognitive task. Learning potential has been explored in schizophrenia research as a predictor of functional outcome and there have been calls for psychometric development in this area. Because the majority of learning potential studies have utilized the Wisconsin Card Sorting Test (WCST), we extended this work using a novel measure, the Rey Osterrieth Complex Figure Test (ROCFT). This study had the following aims: 1) to examine relationships among different learning potential indices for two dynamic assessment tasks, 2) to examine the association between WCST and ROCFT learning potential measures, and 3) to address concurrent validity with a performance-based measure of functioning (Test of Grocery Shopping Skills; TOGSS). Eighty-one adults with schizophrenia or schizoaffective disorder completed WCST and ROCFT learning measures and the TOGSS. Results indicated the various learning potential computational indices are intercorrelated and, similar to other studies, we found support for regression residuals and post-test scores as optimal indices. Further, we found modest relationships between the two learning potential measures and the TOGSS. These findings suggest learning potential includes both general and task-specific constructs but future research is needed to further explore this question.

PTSD and cognitive symptoms relate to inhibition-related prefrontal activation and functional connectivity.

BACKGROUND: Posttraumatic stress disorder (PTSD) is associated with reduced executive functioning and verbal memory performance, as well as abnormal task-specific activity in prefrontal cortex (PFC) and anterior cingulate cortices (ACC). The current study examined how PTSD symptoms and neuropsychological performance in combat veterans relates to (1) medial PFC and ACC activity during cognitive inhibition, and (2) task-independent PFC functional connectivity. METHODS: Thirty-nine male combat veterans with varying levels of PTSD symptoms completed the multisource interference task during functional magnetic resonance imaging. Robust regression analyses were used to assess relationships between percent signal change (PSC: incongruent-congruent) and both PTSD severity and neuropsychological performance. Analyses were conducted voxel-wise and for PSC extracted from medial PFC and ACC regions of interest. Resting-state scans were available for veterans with PTSD. Regions identified via task-based analyses were used as seeds for resting-state connectivity analyses. RESULTS: Worse PTSD severity and neuropsychological performance related to less medial PFC and rostral ACC activity during interference processing, driven partly by increased activation to congruent trials. Worse PTSD severity related to reduced functional connectivity between these regions and bilateral, lateral PFC (Brodmann area 10). Worse neuropsychological performance related to reduced functional connectivity between these regions and the inferior frontal gyrus. CONCLUSIONS: PTSD and associated neuropsychological deficits may result from difficulties regulating medial PFC regions associated with "default mode," or self-referential processing. Further clarification of functional coupling deficits between default mode and executive control networks in PTSD may enhance understanding of neuropsychological and emotional symptoms and provide novel treatment targets.

Perspectives of People with Dementia About Meaningful Activities: A Synthesis.

Qualitative studies were synthesized to describe perspectives of people with dementia regarding meaningful activities. Themes of connectedness were identified using a meta-ethnography approach. The theme of being connected with self encompasses engagement for continuity, health promotion, and personal time. The theme of being connected with others includes being with others not to feel alone, doing an activity with others, and meaningful relationships. The theme of being connected with the environment encompasses being connected to one's familiar environment, community, and nature. This synthesis suggests that connectedness is an important motivation for engagement in daily activities. Findings indicate that identifying the underlying motivation for an individual with dementia to engage in different activities is important for matching a person with activities that will be satisfying. This review may inform the development of interventions for engaging people with dementia in meaningful, daily activities and creating connectedness to self, others, and the environment.

Balance and gait of adults with very mild Alzheimer disease.

BACKGROUND AND PURPOSE: Studies have shown that adults with Alzheimer disease (AD) have gait and balance deficits; however, the focus has been on those with mild to severe disease. The purpose of this study was to determine whether balance and gait deficits are present in those with very mild AD. METHODS: Thirteen adults (72.9±4.7 years old) with very mild AD and 13 age-matched (72.6±4.6 years old) and sex-matched (10 males and 3 females) participants in a control group without AD performed balance and gait tests. All participants were living in the community and independent in community ambulation. RESULTS: Participants with very mild AD had shorter times in tandem stance with eyes open (P<0.001) and with eyes closed (P=0.007) compared with participants in the control group. Those with AD also took longer to complete the Timed "Up & Go" Test (P<0.001). Gait deficits were found for those with AD as demonstrated by slower velocities in the 10-m walk at a comfortable pace (P=0.029) and on an instrumented walkway (P<0.001). Stance times were longer for those with AD (P<0.001) and step length was shorter (P=0.001). There were no group differences in the 10-m walk at a fast pace. The gait velocity of participants in the control group was faster on the instrumented walkway than in the 10-m walk at a comfortable pace (P=0.031). In contrast, the gait velocity of those with AD was significantly slower on the instrumented walkway than in the 10-m walk at a comfortable pace (P=0.024). DISCUSSION: Balance and gait deficits may be present in those in the very early stages of AD. Novel surfaces may affect gait speed in those with very mild AD. Identifying mobility deficits early in the progression of AD may provide an opportunity for early physical therapy intervention, thus promoting continued functional independence. CONCLUSIONS: Adults in the very early stages of AD may show signs of balance and gait deficits. Recognition of these problems early with subsequent physical therapy may slow the progression of further balance and gait dysfunction.

Feasibility and efficacy of intensive cognitive training in early-stage Alzheimer's disease.

Cognitive training may be beneficial for individuals with Alzheimer's disease (AD); however, the effects are modest with little evidence of carryover. Prior studies included limited hours and low intensity of training. The purpose of this study was to test the feasibility and efficacy of many hours of intensive cognitive training with adults in the early stages of AD. Twenty-one adults with very mild or mild AD participated in cognitive training for 10 days over 2 weeks with 4 to 5 hours of training each day. Participants significantly improved in practiced computer-based tasks including those involving working memory, sustained attention, and switching attention. Outcome measures that improved included the Mini-Mental State Examination, letter fluency, and 3 of 5 Trail-Making Tests. Gains in outcome measures were maintained at 2- and 4-month follow-up. Adults in early-stage AD can participate in intensive cognitive training and make modest gains in both practiced and unpracticed cognitive tasks.

Adults with diabetic peripheral neuropathy exhibit impairments in multitasking and other executive functions.

BACKGROUND AND PURPOSE: Diabetic peripheral neuropathy (DPN) contributes to functional impairment, and there is growing evidence that neuropsychological factors also influence physical function. We compared cognitive and executive function in adults with DPN with an age-matched comparison group, and examined the relationships between DPN, executive function, and physical function. METHODS: Twenty subjects with DPN and 20 comparison subjects were assessed. Diabetic peripheral neuropathy was quantified via the Michigan Neuropathy Screening Instrument and nerve conduction velocity testing. Subjects were administered Beck's Depression Inventory, the Mini-Mental Status Examination, and the Timed Up and Go (TUG) test. Each participant also completed a battery of 7 executive function tasks, including the Cognitive Timed Up and Go (cTUG) test, in which a concurrent mental subtraction task was added to the standard TUG test. RESULTS: The DPN group demonstrated poorer letter fluency (34.2 ± 11.6 words vs 46.2 ± 12.2 words; P = 0.001), category fluency (47.0 ± 8.1 words vs 56.3 ± 8.5 words; P = 0.003), and Rey-Osterrieth scores (25.9 ± 4.3 points vs 31.7 ± 2.4 points; P < 0.001), and took longer to complete both the TUG (10.3 ± 2.8 seconds vs 5.9 ± 1.0 seconds; P < 0.001) and cTUG (13.0 ± 5.8 seconds vs 6.9 ± 1.6 seconds; P < 0.001). Poorer global cognitive performance and greater depression symptoms were significantly related to each other (r = -0.46; P = 0.04) and to slower TUG times (r = -0.53; P = 0.02; and r = 0.54; P = 0.02, respectively). DISCUSSION AND CONCLUSIONS: Verbal, visuospatial, and multitasking measures of executive function may be impaired in adults with DPN. Future research should examine how these and other cognitive and psychological factors, such as depression, affect physical function in this population.

Health-related quality of life and physical, mental, and cognitive disabilities among nursing home residents in Jordan.

PURPOSE: To describe the physical, cognitive, psychological, and medical status of nursing home residents in Jordan. We also investigated the perceived health-related quality of life of this population. METHODS: A sample of 221 nursing home residents in Jordan was recruited to participate in this study. Demographic variables and medical history were collected. In addition, all participants were assessed using health-related quality of life items (HRQOL), mini-mental state examination (MMSE), Geriatric Depression Scale (GDS), Tinetti assessment battery for gait and balance (TAB), and disability of arm, shoulder, and hand assessment (DASH). RESULTS: TAB and DASH scores were related to the following HRQOL items: self-reported general health status, the need for personal care, the need for help from others in handling routine needs, the number of days of pain, feeling sad, depressed, worried, and not getting enough sleep, and the number of days feeling very healthy and full of energy. MMSE scores were related to self-reported need for personal care, the need for help from others in handling daily routine needs, and the number of days feeling pain, sad, worried, and depressed. GDS scores were related to self-reported general health status, the need for personal care, the need for help from others for handling daily routine needs, the number of pain, sad, worried, and not getting enough sleep days, and the number of days feeling healthy and full of energy. CONCLUSIONS: This study revealed a substantial impact of physical, cognitive, and psychological disabilities on HRQOL of nursing home residents in Jordan.

Processing speed mediates gender differences in memory in schizophrenia.

The primary aim of this study was to examine whether processing speed mediates the association between gender and episodic memory in schizophrenia. Participants were 51 female and 51 male outpatients comparable on demographic, clinical, and cognitive variables. Memory tests included both verbal and visual measures. Both groups scored below the normative mean of the memory and processing speed tests, except that females performed slightly above the mean on face recognition. Females outperformed males on verbal memory, visual recognition, and processing speed. Mediation regression analyses showed processing speed mediated immediate and delayed recall for both verbal and visual memory measures. Thus processing speed appears to be a critical variable for understanding cognitive deficits in schizophrenia and may be an important target for cognitive rehabilitation.

Learning to ignore distracters.

Eye tracking has indicated that older and young adults process distracters similarly when reading single sentences. The present study extended this approach by presenting short paragraphs, sentence by sentence. Eye tracking measures included reading times per word, and the duration of the first fixation and total fixations to the distracters and target words. Comprehension was tested following each paragraph, and recognition of distracters and target words was assessed. The results indicated that young adults were able to learn to ignore the distracters as they read through the paragraphs, whereas older adults were less successful at learning to ignore the distracters.

Executive function and type 2 diabetes: putting the pieces together.

The devastating impact of type 2 diabetes mellitus (DM) on vascular, renal, retinal, and peripheral nerve functions has been well documented. However, there is also evidence that older adults with this disease exhibit impairments in the planning, coordinating, sequencing, and monitoring of cognitive operations, collectively known as executive function. Although poorly understood, disturbances in executive function, particularly within the dimension of time sharing, may contribute to the gait abnormalities and increased risk for falls, functional impairments, and disabilities associated with type 2 DM. However, the relationships between executive function and functional abilities remain poorly understood in this population. Current neuropsychological research regarding the concept of executive function is presented here as a framework upon which to examine the integrity of this critical cognitive entity in adults with type 2 DM. The pathophysiological mechanisms thought to underlie diabetes-related executive dysfunction are explored, and the possible contributions of executive deficits to impairments in gait and function observed in older people with type 2 DM are summarized. Finally, a brief discussion of dual-task assessment and intervention strategies that may facilitate the care and rehabilitation of the growing population of patients with type 2 DM is provided.

Understanding verbal fluency in healthy aging, Alzheimer's disease, and Parkinson's disease.

OBJECTIVE: Verbal fluency measures are frequently part of batteries designed to assess executive function (EF), but are also used to assess semantic processing ability or word knowledge. The goal of the present study was to identify the cognitive components underlying fluency performance. METHOD: Healthy young and older adults, adults with Parkinson's disease, and adults with Alzheimer's disease performed letter, category, and action fluency tests. Performance was assessed in terms of number of items generated, clustering, and the time course of output. A series of neuropsychological assessments were also administered to index verbal ability, working memory, EF, and processing speed as correlates of fluency performance. RESULTS: Findings indicated that regardless of the particular performance measure, young adults performed the best and adults with Alzheimer's disease performed most poorly, with healthy older adults and adults with Parkinson's disease performing at intermediate levels. The exception was the action fluency task, where adults with Parkinson's disease performed most poorly. The time course of fluency performance was characterized in terms of slope and intercept parameters and related to neuropsychological constructs. Speed of processing was found to be the best predictor of performance, rather than the efficiency of EF or semantic knowledge. CONCLUSIONS: Together, these findings demonstrate that the pattern of fluency performance looks generally the same regardless of how performance is measured. In addition, the primary role of processing speed in performance suggests that the use of fluency tasks as measures of EF or verbal ability warrants reexamination.

The association between verbal memory, processing speed, negative symptoms and functional capacity in schizophrenia.

The aim of this paper is to explore the links among verbal memory, processing speed, negative symptoms, and functional capacity, using structural equation modeling techniques. Model A is a multiple regression model with cognitive and symptom variables as predictors and functional capacity as the latent outcome variable. Model B consists of three two mediator models that assess the ability of each variable to mediate the effect of the other variable on outcome conditional on the inclusion of the other mediator in the model. Ninety-eight community-dwelling patients with schizophrenia (mean age=35.8years, S.D.=10.1) participated in the study. Results indicate that verbal memory, processing speed and negative symptoms significantly contributed to functional status. Verbal memory was at least partially mediated by processing speed in its effect on outcome, while the impact of processing speed on outcome was mediated by both verbal memory and negative symptoms. The influence of negative symptoms on functional capacity was partially mediated by processing speed. These findings enrich our understanding of the direct and indirect effects of these three interrelated variables and provide a basis for the development of intervention strategies.

Simulator driving performance predicts accident reports five years later.

L. Hoffman, J. M. McDowd, P. Atchley, and R. A. Dubinsky (2005) reported that visual and attentional impairment (measured by the Useful Field of View test and DriverScan) and performance in a low-fidelity driving simulator did not predict self-reported accidents in the previous 3 years. The present study applied these data to predict accidents occurring within a subsequent 5-year period (N = 114 older adults, 75% retention rate). Multivariate path models revealed that accidents in which the driver was at least partially at fault were significantly more likely in persons who had shown impaired simulator performance. These results suggest that even low-fidelity driving simulators may be useful in predicting real-world outcomes.