Assessing subjective cognitive decline in older adults attending primary health care centers: what question should be asked?

INTRODUCTION: Subjective Cognitive Decline (SCD) refers to a self-perceived experience of decreased cognitive function without objective signs of cognitive impairment in neuropsychological tests or daily living activities. Despite the abundance of instruments addressing SCD, there is no consensus on the methods to be used. Our study is founded on 11 questions selected due to their recurrence in most instruments. The objective was to determine which one of these questions could be used as a simple screening tool. METHODS: 189 participants aged 65 and over selected from Primary Care centers in Santiago de Chile responded to these 11 questions and were evaluated with the MiniMental State Examination (MMSE), the Free and Cued Selective Reminding Test (FCSRT), the Pfeffer functional scale, and the Geriatric Depression Scale (GDS). An Item ResponseTheory (IRT) method was performed to assess the contribution of each of the 11 questions to the SCD latent trait and its discrimination ability. RESULTS: Based on the results of the exploratory factor analysis showing very high/low saturation of several questions on the factors, and the high residual correlation between some questions, the IRT methods led to select one question ("Do you feel like your memory has become worse?") which revealed to be the most contributive and discriminant. Participants who answered yes had a higher GDS score. There was no association with MMSE, FCSRT, and Pfeffer scores. CONCLUSION: The question "Do you feel like your memory has become worse?" may be a good proxy of SCD and could be included in routine medical checkups.

Health trajectories of elderly living in French senior housing: a longitudinal perspective.

Senior housing for older adults could be an alternative or a transitional care model between home care and nursing home care. Using two longitudinal cohorts of community dwellers aged 65 years or older, we compared risks of mortality and of nursing homes admission between older adults who did or did not move to senior housing over time. In the 3C study (n = 2104, 17 years of follow-up), 143 (6.8%) participants moved into a senior housing during the follow-up. This move was associated with a lower risk of mortality (hazard ratio (HR): 0.64; 95% confidence interval (CI) 0.46-0.77) and a higher risk of nursing home admissions (HR: 1.54 (1.10-2.15)). The risks of hospitalizations (HR: 0.54 (0.40-0.73)) and falls (HR: 0.63 (0.50-0.79)) were lower. In the PAQUID study (n = 3777, 27 years of follow-up), 161 (4.3%) participants moved into a senior housing. This move was also associated with a lower mortality risk (HR: 0.72 (0.58-0.88)) and a higher risk of nursing home admissions (HR: 1.39 (1.05-1.86)). Our results showing lower risks of mortality suggest that senior housing may be a relevant model for vulnerable older adults.

Psychometric properties of the Perceived Social Support Questionnaire (PSSQ), a new measure of perceived social support among older adults.

OBJECTIVE: Based on literature and available questionnaires, the present study aimed at creating and validating the Perceived Social Support Questionnaire (PSSQ): a 4-item scale assessing the perceived social support in older adults. Normative scores were also computed. METHODS: Three hundred and two participants (mean age 87.68) selected from ongoing population-based studies completed a phone interview. Among these, 247 completed a second interview 4 months later allowing assessing the questionnaire fidelity over time. RESULTS: The factor analysis evidenced two dimensions: availability of social support and satisfaction with it. Both dimensions had a satisfactory internal consistency but weak intraclass correlation coefficient. Univariate analyses revealed that age, number of calls per week and living environment marginally associated with the availability score. The satisfaction score was associated with perceived health status, sadness, depressive mood, feeling of loneliness, anxiety, and the perception of social support during the pandemic context. The norms computed were stratified on age. CONCLUSIONS: The PSSQ is a short and easy-to-administer tool allowing assessing perceived social support in older population. Despite a weak fidelity that could actually be explained by changes in perceived social support over time, the questionnaire revealed good psychometric qualities and validity.

The "Alzheimer Village": Assessment of Alzheimer's disease representations in the general population: A cross sectional phone survey.

Introduction: In most countries, the societal view of Alzheimer's disease (AD) is very negative. The initiatives that are part of the so-called "dementia-friendly approach" aim not only at promoting well-being and dignity of persons suffering from AD but also improving the way they are regarded and their inclusion in society. Unfortunately, scarce research has been conducted to assess whether such goals can be achieved. In France, the experimental Alzheimer Village in Dax is designed as a dementia-friendly community. Due to the recent opening (2020) and the strong local media coverage of this project, a survey has been designed to determine whether the representations of AD have been impacted by such a project. Methods: The survey was conducted before and after the opening of the Alzheimer Village in the city of Dax (hosting the village) and surrounding areas, and in a control city with similar socio-demographics. The analyses intend to compare different dimensions of the representations and attitudes toward AD in the general population. Results: A total of 423 persons living in the Alzheimer Village city (37.4% were men) and 415 persons living in the control city (40.2% were men) were interviewed, resulting in 838 complete questionnaires. The main results report significantly lower rating in the perception of loss of identity (ß = -0.57, P = .014) and in the feeling of disgust for persons with AD (ß = -0.61, P = .008) in the city hosting the village after the opening of the Alzheimer Village. No significant changes were seen in the control city sample. Discussion: While societal representations of AD are very robust and difficult to change, this study suggests a modest but significant evolution of representations of AD in the surrounding areas of the Alzheimer Village. Highlights: The French Alzheimer Village is one of the very few ones in the world.This is the first study assessing the impact of an Alzheimer Village on disease representations.After the opening of the village, attitudes toward Alzheimer's disease have changed.

Routinization: risk factor or marker of adjustment to negative health issues?

OBJECTIVES: Routinization reflects how older people cope with the health problems. It remains to be seen whether it should be considered as a risk factor of negative health outcomes, or rather, a mechanism of adjustment to health issues: mortality, institutionalization, dementia, disability, cognitive decline, depression and subjective health. METHODS: From longitudinal data of two large-scale French epidemiological studies, the study sample consists of 961 participants aged 77 years on average, living at home and with no neurocognitive disorder. The relationship between the level of routines measured by the Preferences for Routines Scale-Short form and the adverse health outcomes are studied considering the level of routines at baseline and in time-dependent using Cox proportional hazards models and Latent process mixed models. RESULTS: After adjustment for sociodemographic variables, the routinization score at baseline is not associated with any health outcomes while the routinization score as a time-dependent variable is significantly associated with an increased risk of dementia (hazard ratios (HR) = 1.08, 95% confidence intervals (CI) = 1.02-1.15, p = 0.016) and institutionalization (HR = 1.18, 95% CI = 1.03-1.36, p = 0.019), greater global cognitive decline (ß = -0.02, p = 0.001) and depressive symptoms (ß = 0.02, p = 0.023) and a decrease in subjective health (ß = 0.02, p = 0.008). CONCLUSIONS: The level of routines measured at a given time is not associated with long-term prediction of negative health outcomes, while in time-dependent, it reveals to be a significant predictor. It should be seen as a marker of adjustment process.

Longitudinal Study of Cognitive Decline before and after the COVID-19 Pandemic: Evidence from the PA-COVID Survey.

INTRODUCTION: Even though several studies reported good resilience capacities in older adults in the first period of the coronavirus disease 2019 (COVID-19) pandemic, in the long run, social isolation induced by the protective measures adopted by most countries may negatively impact cognitive functioning. Taking the advantage of measures collected up to 15 years before the pandemic in participants followed up in epidemiological studies, we compared cognitive decline before and after the start of the pandemic. METHODS: PA-COVID is a phone survey designed in the framework of ongoing population-based studies (PAQUID, 3-City, Approche Multidisciplinaire Intégrée cohorts). Data on social functioning and mental health were collected in participants aged 80 years and older during the pandemic. Prior to the pandemic, the participants followed up in the prospective studies completed the Mini-Mental State Examination. During the PA-COVID survey, they underwent the Telephone Interview for Cognitive Status. A score was computed with the 11 items shared by the 2 tests. Our analysis was carried out in the participants for whom a cognitive measure was available up to 15 years before the pandemic and during the pandemic (n = 263). RESULTS: Compared to the slow decline of the cognitive subscore observed during the 15 years preceding the pandemic, mixed models showed an acceleration of decline after the start of the pandemic (ß = -0.289, p value <0.001). CONCLUSIONS: With a design allowing comparing cognitive trajectory before and after the pandemic, this is the first study reporting an accelerated decline in older adults. Future COVID research in older adults will need to pay special attention to cognitive outcomes.

Trajectory of Quality of Life Before and After Entering a Nursing Home: A Longitudinal Study.

OBJECTIVES: The objective of this longitudinal study was to compare the trajectory of subjective quality of life in 2 groups of older adults: those who entered a nursing home and those who remained living in the community with similar clinical conditions. METHOD: PAQUID is a prospective population-based study. It included, at baseline, 3777 community-dwelling participants aged 65 years and over. Participants were followed-up for up to 27 years. Among people living at home at baseline, 2 groups were compared: participants who entered a nursing home over a 20-year follow-up (n = 528) and those who remained community dwellers (n = 2273). We used latent process mixed models to estimate the relationship between mean trajectory of subjective quality of life and admission into a nursing home. We computed univariate and multivariate models taking into account potential confounders (age, gender, education, income, comorbidities, dementia, disability and depression). RESULTS: Nursing home placement was significantly associated with a drop in quality of life between the last visit before and after institutionalization. Nevertheless, we found no difference in quality of life trajectory after this initial drop. CONCLUSION: Older adults exhibit an acute drop in quality of life after nursing home admission, probably reflecting the associated psychological distress. Even though their quality of life does not go back to pre-admission levels, the residents do not show a steeper decline when compared to the "natural" evolution of quality of life in older adults living in the community, which suggests a relative adaptation to their new living conditions.

Older Adults and the COVID-19 Pandemic, What About the Oldest Old? The PACOVID Population-Based Survey.

Introduction: The literature draws a mitigated picture of the psychosocial effects of the lockdown in older adults. However, the studies conducted so far are mainly based on web surveys which may involve selection bias. The PACOVID survey relies on a population-based design and addresses the attitudes, psychological and social experiences of the oldest old regarding the pandemic and lockdown and their impact. Material and Methods: Cross-sectional phone survey involving 677 persons. Baseline report on attitudes, psychological, and social experiences of the oldest old, regarding the pandemic and lockdown measures. Results: The mean age was 87.53 (SD 5.19). About 46% were living alone during the lockdown. Concerning difficulties, "none" was the most frequent answer (35.6%). For questions addressing how often they had felt sad, depressed, or lonely (CESD-scale), the most frequent answers were "never/very rarely" (58.7, 76.6, 60.8%) and 27.1% had anxious symptomatology (STAI scale). Most (92.9%) felt socially supported. Engaging in leisure activities was the most frequent coping strategy, and for numerous participants the lockdown did not represent much of a change in terms of daily routine. A very good knowledge and awareness of COVID-19 and the safety measures was observed. Comparisons with measures collected before the pandemic showed low changes in subjective health and the CES-D questions. Discussion: With a methodological design limiting selection bias, our results claim for a weakened psychosocial impact even though the participants are concerned and aware of the pandemic issues. These results highlight the resources and resilience abilities of older persons including in advancing age.

Similarities in cognitive abilities in older couples: a study of mutual influences.

Objective: Similarities between spouses in cognitive functions have been mainly explained by the assortative mating phenomenon and the convergence for age and education. The mutual influence between spouses is another explanation particularly relevant in the elderly population. Today, it remains difficult to determine whether cognitive similarities exclusively result from the convergence effect or from the mutual influence. Using a novel methodology, the present study aimed to assess the impact of the marital relationship on cognitive similarities among elderly couples.Methods: 1723 couples from the Three-City Cohort Study were classified in two groups of couples with homogeneous and heterogeneous age and education. We also constituted two groups of pseudo-couples by a random association of individuals, with homogeneous and heterogeneous age and education. Dyadic analyses were conducted in the four groups, regarding the similarities in lexicosemantic abilities, executive functions, memory and global cognitive functioning.Results: Similarities were found on lexicosemantic abilities both in mate-assorted couples and in couples heterogeneous in age and education but no similarity was found in pseudo-couples.Discussion: Beyond the convergence effect, the fact that the spouses co-construct their lifestyles may contribute to cognitive similarities in the lexicosemantic domain.

Validation of Short Form of Preferences for Routines Scale: Norms in Older Adults.

High level of preferences for routines is an indicator of psychological vulnerability in older adults. However, the psychometric properties of the Preferences for Routines Scale (PRS) initially validated in a small selected sample of older adults revealed a low Cronbach's α (.50) in the general elderly population. The present study aims to improve the PRS using the data from the "AMI" and "PAQUID" population-based studies. Among 718 older persons, the most discriminative items are identified using item response theory methodology. A short form of the PRS (PRS-S) included five of the ten items of the original scale and showed improved internal consistency and test-retest reliability. The factors associated with the PRS-S are similar to those found in previous studies. Norms are provided according to gender and educational level. The reduction of the number of items tends to facilitate its administration and promote its use in both clinical and epidemiologic research contexts.

Influence of pre-admission factors on quality of life and adaptation in nursing home residents with dementia: the QOL-EHPAD study protocol.

BACKGROUND: In 2015 in France, 585,560 people were nursing home residents. A large body of studies has identified predictors of poor quality of life and poor adaptation in institution, mostly for residents without dementia. With 42 to 72% of these residents diagnosed with dementia, it is crucial to identify what factors prior to admission might have an impact on quality of life once the admission is finalized, in order to target specific domains of intervention, while the person still lives at home and after his/her admission. METHODS: QOL-EHPAD is a prospective, multi-centred, observational cohort study. At baseline, we will collect retrospective data on the life of 150 persons with dementia and their caregivers. These data will refer to the conditions of admission to a nursing home (emergency admission, involvement in the decision, admission from home or from the hospital) and to the 6 months prior to the admission of the person with dementia: sociodemographic and medical data, psychological tests, information on quality of life, satisfaction, behaviour, and nutrition. Similar data about life in the nursing home will be collected after 6 months, along with information on adaptation of the person with dementia to his/her new living environment. We will use univariate regression analyses followed by stepwise linear regression models to identify which factors pertaining to life at home are associated with quality of life and adaptation after 6 months. DISCUSSION: This study will provide data on the impact of institutionalization on quality of life and the determinants of a successful institutionalization in people with dementia. This could be helpful in setting up targeted interventions to prepare admission into a nursing home before the actual admission and to accompany both the caregiver and the person with dementia throughout this process.

Do Individual and Geographical Deprivation Have the Same Impact on the Risk of Dementia? A 25-Year Follow-up Study.

OBJECTIVES: To determine the impact of both individual psychosocioeconomic precariousness and geographical deprivation on risk of dementia in older adults followed-up for 25 years. METHOD: The sample consisted of 3,431 participants aged 65 years or over from the PAQUID cohort study. Individual psychosocioeconomic precariousness was measured computing eight economic and psychosocial indicators. Geographical deprivation was assessed by the FDep99 index, consisting of four community socioeconomic variables. For both measures, the fourth quartile of the distribution was considered as the more precarious or deprived category, while the first quartile was considered as the less precarious or deprived one. Clinical dementia diagnosis was assessed all along study follow-up. The association between individual psychosocioeconomic precariousness, geographical deprivation and risk of dementia was assessed using illness-death regression models adjusted for age, sex, depression, psychotropic drug consumption, comorbidities, disability, and body mass index, while accounting for death as a competing event. RESULTS: The risk of dementia was higher for the more psychosocioeconomic precarious participants (HR = 1.51; 95% CI: 1.24-1.84). No increased risk of dementia was found for those living in communities with high index of deprivation. DISCUSSION: Psychosocioeconomic precariousness, but not geographical deprivation, is associated with a higher risk of dementia.

Is Low Psychomotor Speed a Marker of Brain Vulnerability in Late Life? Digit Symbol Substitution Test in the Prediction of Alzheimer, Parkinson, Stroke, Disability, and Depression.

BACKGROUND: Dementia, stroke, depression, and disability are frequent in late life and are major causes of quality of life disruption and family burden. Even though each of these disorders relies on specific pathogenic processes, a common clinical manifestation is psychomotor slowing. OBJECTIVE: We assessed the relevance of a simple marker of low psychomotor speed in predicting several brain outcomes: dementia, Alzheimer's disease (AD), Parkinson's disease (PD), stroke, depressive symptoms, and disability in activities of daily living (ADL) and instrumental ADL (IADL). METHODS: PAQUID is a population-based study involving 3,777 individuals aged 65 or older prospectively followed-up with repeated clinical evaluations. After 10 years, 437 participants developed dementia, 333 developed AD, 71 developed PD, 207 reported incident stroke, 404 developed disability in ADL, 994 in IADL, and 494 developed depressive symptomology. Psychomotor speed was measured with the digit symbol substitution test (DSST). Cox proportional hazards models controlled for several confounders assessed the risk of incident outcomes. RESULTS: Participants with low DSST performance had increased risk of incident all-type dementia (hazard ratio [HR] 3.41, p < 0.0001) and AD-type dementia (HR 3.18, p < 0.0001). Higher risk for PD (HR 2.98, p = 0.04), IADL (HR 1.82, p < 0.0001), ADL disability (HR 1.95, p = 0.001), depressive symptoms (HR 1.53, p = 0.03), and a statistical trend for stroke (HR 1.88, p = 0.09) was also found. CONCLUSION: Low psychomotor speed is associated with an increased risk of developing various brain outcomes: dementia, AD, PD, disability, depressive symptoms, and marginally stroke. Low psychomotor speed may be the consequence of a number of discrete cerebral abnormalities and could be considered as a marker of brain vulnerability. In clinical practice, a low score in DSST should be seen as a warning sign of possible negative evolution.

A comprehensive approach of the determinants of use of care in dementia: the Recaredem (recourse to care in dementia) cross-sectional study.

BACKGROUND: Given the rate of the undiagnosed cases of dementia and the consequences of inappropriate care, understanding the factors that explain the use of medical and health care in dementia is a critical concern. Our objective was to identify the psychosocial and medical determinants of use of care in dementia. METHODS: The study sample consisted of 308 participants: the persons with dementia (n = 99) selected from three French population-based cohorts (i.e. PAQUID, 3C, AMI), their family caregivers (primary, n = 96, and secondary, n = 51), and their general practitioners (n = 62). Use of care in dementia was considered according to two indicators: (1) recourse to secondary care, (2) number of community and health services used. RESULTS: Multiple logistic models including sociodemographics and psychosocial variables revealed that the determinants of nonuse of care are similar both for the recourse to secondary care and for the number of community and health services used: lack of education and the contribution of the people with dementia to the decisions regarding their own care and dementia care services in the community area. In addition, satisfaction of the primary caregiver with the services used by his/her relative is associated with non-recourse to secondary care. CONCLUSIONS: Taken together, these results highlight the predominant role of psychosocial factors in the use of care in dementia and the importance of addressing this issue through an integrative approach including psychological, social, medical, and family dimensions.

A Subjective Quality of Life Proxy for Older Adults in the PAQUID Cohort Study.

OBJECTIVES: Quality of life is regarded as a major outcome in epidemiologic research, especially in the older population. Nevertheless, some cohort studies lack a specific instrument to evaluate it. The aim of this study was to propose a subjective quality of life proxy using easily accessible items, available in most epidemiologic studies. METHOD: We used data from the PAQUID (Personnes Agées Quid) cohort study (1991-1992, France). A subjective quality of life proxy was created based on items on positive affects, subjective health, and life satisfaction. Logistic and linear regression models as well as Cox survival models were used to assess the association between the proxy score and depression, dependence, cognitive complaints, adverse life events, comorbidities, and death. Analyses were replicated in an independent cohort study, AMI (Approche Multidisciplinaire intégrée; 2007-2008, France). All models were adjusted for age, sex, Mini-Mental State Examination score, and place of residence. RESULTS: In the PAQUID sample (n = 2135), we found significant associations between the proxy score and the selected health outcomes. We found the same associations in the AMI cohort. CONCLUSION: This proxy might be useful when no gold standard for quality of life assessment is available or when in need of a short but reliable instrument that will not require extended administration time.

Death, Depression, Disability, and Dementia Associated With Self-reported Hearing Problems: A 25-Year Study.

Background: Hearing loss in older adults is suspected to play a role in social isolation, depression, disability, lower quality of life, and risk of dementia. Such suspected associations still need to be consolidated with additional research. With a particularly long follow-up, this study assessed the relationship between hearing status and four major adverse health events: death, dementia, depression, and disability. Methods: Prospective community-based study of 3,777 participants aged ≥65 followed up for 25 years. At baseline, 1,289 reported hearing problems and 2,290 reported no trouble. The risk of occurrence of the negative outcomes, including death, dementia, depressive symptoms, disability in activities of daily living (ADL), and instrumental ADL (IADL), was assessed with Cox proportional hazards models. Results: Adjusting for numerous confounders, an increased risk of disability and dementia was found for participants reporting hearing problems. An increased risk of depression was found in men reporting hearing problems. In additional exploratory analyses, such associations were not found in those participants using hearing aids. Mortality was not associated with self-reported hearing loss. Conclusions: Our study confirms the strong link between hearing status and the risk of disability, dementia, and depression. These results highlight the importance of assessing the consequences of treating hearing loss in elders in further studies.

Description of general practitioners' practices when suspecting cognitive impairment. Recourse to care in dementia (Recaredem) study.

OBJECTIVE: General practitioners (GPs) play a major role in the assessment of dementia but it is still unrecognized in primary care and its management is heterogeneous. Our objective is to describe the usual practices, and their determinants, of French GPs in this field. METHODS: GPs' characteristics and practices when facing cognitive decline were collected through a telephone interview and a postal questionnaire. A descriptive analysis of all study variables was conducted. The study of quantitative explanatory variables was done by testing the equality of means and the choice of qualitative variables was based on the chi-square independence test or Fischer test. RESULTS: Hundred two GPs completed the study. GPs were in majority men, working in urban areas. Mean age was 54.4 years old. GPs' feeling of confidence and self-perception of follow-up of national recommendations is linked with their practices. Performing a clinical interview to assess cognitive impairment is linked with good communication skills. GPs feel less confident to give information about resources for dementia. The main reason alleged for underdiagnosis is the limited effectiveness of drug therapy. CONCLUSIONS: This study underlines the importance of GPs' feeling of confidence when managing cognitively impaired patients with dementia, and the need of increasing training in the field of dementia, which could improve the awareness of GPs about diagnosis and available resources.

Occupational social and mental stimulation and cognitive decline with advancing age.

Objective: this study investigates the role of social and mental occupational characteristics in cognitive decline after retirement. Methods: the study included 1,048 subjects aged ≥65 years from the Three City cohort. Participants were evaluated at home at the initial visit and at 2-year intervals for a period of 12 years. The study includes detailed assessments of cognition, health and information about the subjects' main occupation. The four cognitive tests have been grouped into one latent factor. Three independent raters specialised in employment were asked to evaluate the level of social and intellectual stimulation for each occupation, which was then rated as low, medium and high. Results: after controlling for potential confounding factors, no association was found between higher levels of social stimulation at work and baseline cognition (medium score, P = 0.440; high score, P = 0.700) as compared with a low level. While cognitive trajectories were initially similar between high and medium levels of social stimulation compared with that of a low level, with advancing age this association diverged whereby more social stimulation during work years was related to accelerated cognitive decline that further grew in magnitude with older age. For mental stimulation, differences were only observed at baseline, with greater levels of mental stimulation during work years being associated with better cognitive performance (medium score, ß = 0.573, P = 0.015; and high score, ß = 0.510; P = 0.090) compared with a low level of mental stimulation. Conclusion: workers retiring from occupations characterised by high levels of social stimulation may be at risk of accelerated cognitive decline with advancing age.

Comparing the predictive value of three definitions of frailty: Results from the Three-City study.

BACKGROUND: Despite several attempts to reach a single definition of frailty, no consensus has been reached. The definitions previously published have tried to prove its utility in predicting negative health outcomes. The objective of the present study is to compare the predictive value of 3 different frailty instruments, for selected outcomes. METHODS: The study sample includes 1278 participants of the Three-City study, a French prospective population-based study, assessed for frailty using Fried's phenotype criteria, Rockwood's Frailty Index and Tilburg Frailty Indicator. To assess the risk of mortality, incident disability, falls, institutionalization and hospitalization for a follow up period of 12 years, Cox proportional hazard models with delayed entry have been used. The area under the time-dependent ROC curve has been used to estimate and compare the ability of the three instruments of frailty to predict the previous adverse outcomes at 12 years. RESULTS: Five hundred ninety four participants were identified as non-robust with Fried's criteria; 169 with Rockwood's FI and 303 with TFI. The three scales consistently identified 91 participants as non-robust and 574 as robust. Rockwood's FI was a statistically significant predictor of mortality, incident disability and falls, and a strong predictor of hospitalization. CONCLUSION: In the absence of a "gold standard" definition of frailty, a debate on what measures and how to include them is open. A clue may be that one should select the appropriate definition according to the to-be predicted outcome, the setting and the underlying etiology of frailty.