Interprofessional education in the clinical learning environment: a mixed-methods evaluation of a longitudinal experience in the primary care setting.

Team collaboration in our healthcare workforce is necessary to effectively address multifaceted medical and social needs, especially for those impacted by systemic inequities. Effective interprofessional practice and education models including curricula are needed to prepare a practice ready healthcare workforce for team collaboration. Most healthcare trainee interprofessional experiences take place episodically in classroom settings. However, creating a culture that supports team-based learning and interprofessional clinical practice requires teaching skills (e.g., communication, collaboration, shared decision-making, coordination of care) longitudinally in the clinical setting. A weekly interprofessional clinic for patients/clients with chronic health conditions was organized in three primary care practices. Trainees from nutrition, social work, medicine, and physician assistant programs worked with supervising clinicians from each field. Surveys, interviews, and focus groups assessed the effects of interprofessional education and training in the primary care setting. Results show the longitudinal experiential IPE program significantly improved knowledge, attitudes, skills, and values addressing key interprofessional competencies. Qualitative results complement survey data and highlight key themes addressing patient-centered care and team dynamics. These findings demonstrate the importance of longitudinal, immersive team-based interprofessional training in the clinical learning environment.

Investigating age-related changes in anterior and posterior neural activity throughout the information processing stream.

Event-related potential (ERP) and other functional imaging studies often demonstrate age-related increases in anterior neural activity and decreases in posterior activity while subjects carry out task demands. It remains unclear whether this "anterior shift" is limited to late cognitive operations like those indexed by the P3 component, or is evident during other stages of information processing. The temporal resolution of ERPs provided an opportunity to address this issue. Temporospatial principal component analysis (PCA) was used to identify underlying components that may be obscured by overlapping ERP waveforms. ERPs were measured during a visual oddball task in 26 young, 26 middle-aged, and 29 old subjects who were well-matched for IQ, executive function, education, and task performance. PCA identified six anterior factors peaking between ∼140 ms and 810 ms, and four posterior factors peaking between ∼300 ms and 810 ms. There was an age-related increase in the amplitude of anterior factors between ∼200 and 500 ms, and an age-associated decrease in amplitude of posterior factors after ∼500 ms. The increase in anterior processing began as early as middle-age, was sustained throughout old age, and appeared to be linear in nature. These results suggest that age-associated increases in anterior activity occur after early sensory processing has taken place, and are most prominent during a period in which attention is being marshaled to evaluate a stimulus. In contrast, age-related decreases in posterior activity manifest during operations involved in stimulus categorization, post-decision monitoring, and preparation for an upcoming event.

The impact of executive capacity and age on mechanisms underlying multidimensional feature selection.

This study examined the role of executive capacity (EC) and aging in multidimensional feature selection. ERPs were recorded from healthy young and old adults of either high or average EC based on neuropsychological testing. Participants completed a color selective attention task in which they responded to target letter-forms in a specified color (attend condition) while ignoring letter-forms in a different color (ignore condition). Two selection negativity (SN) components were computed: the SN(Color) (attend-ignore), indexing early color selection, and the SN(Letter) (targets-standards), indexing early letter-form selection. High EC subjects exhibited self-terminating feature selection; the processing of one feature type was reduced if information from the other feature type suggested the stimulus did not contain the task-relevant feature. In contrast, average EC subjects exhaustively selected all features of a stimulus. The self-terminating approach was associated with better task accuracy. Higher EC was also linked to stronger early selection of target letter-forms, but did not modulate the seemingly less demanding task of color selection. Mechanisms utilized for multidimensional feature selection appear to be consistent across the lifespan, although there was age-related slowing of processing speed for early selection of letter features. We conclude that EC is a critical determinant of how multidimensional feature processing is carried out.

Age-related differences in early novelty processing: using PCA to parse the overlapping anterior P2 and N2 components.

Previous work demonstrated age-associated increases in the anterior P2 and age-related decreases in the anterior N2 in response to novel stimuli. Principal component analysis (PCA) was used to determine if the inverse relationship between these components was due to their temporal and spatial overlap. PCA revealed an early anterior P2, sensitive to task relevance, and a late anterior P2, responsive to novelty, both exhibiting age-related amplitude increases. A PCA factor representing the anterior N2, sensitive to novelty, exhibited age-related amplitude decreases. The late P2 and N2 to novels inversely correlated. Larger late P2 amplitude to novels was associated with better behavioral performance. Age-related differences in the anterior P2 and N2 to novel stimuli likely represent age-associated changes in independent cognitive operations. Enhanced anterior P2 activity (indexing augmentation in motivational salience) may be a compensatory mechanism for diminished anterior N2 activity (indexing reduced ability of older adults to process ambiguous representations).

Age-related decline in differentiated neural responses to rare target versus frequent standard stimuli.

One mechanism hypothesized to contribute to cognitive aging is the failure to recruit specialized neural modules and generate differentiated neural responses to various classes of stimuli. Here, ERPs were used to examine the extent to which target and standard stimulus types were processed differently by well-matched adults ages 19-99. Subjects responded to designated visual target letters under low and high load conditions. Temporospatial PCA was used to parse the P3b component, an index of categorization/memory updating. The P3b amplitude difference between targets and standards decreased substantially as a function of age. Dedifferentiation began in middle age, and continued into old-old age. The reduced differentiation of neural responses was driven by an age-related decline in the size of the P3b to targets and an age-related increase in the P3b to standards. Larger P3b amplitude to standards among older subjects was associated with higher executive capacity and better task performance. In summary, dedifferentiation begins relatively early in adulthood and progresses in a linear fashion throughout the lifespan. The age-related augmentation of the P3b to standards appears to reflect a compensatory mechanism that helps maintain task performance.

Does the age-related "anterior shift" of the P3 reflect an inability to habituate the novelty response?

Old adults often generate larger anterior neural responses than young adults when carrying out task requirements. A common finding in the ERP literature is an "anterior shift" of the P3b to targets. Utilizing principal component analysis (PCA), we recently demonstrated that rather than the P3b moving anteriorly, old adults generate a large P3a that temporally overlaps with their P3b. A dominant hypothesis for the age-related increase in anterior P3 is the failure to habituate the brain's novelty response to rare targets. We tested this hypothesis in young and old adults by comparing the amplitude of the PCA factor representing P3a to targets presented in the first versus last of eight blocks of a visual oddball task. If, unlike young adults, old adults are unable to habituate a novelty response, one would expect (1) the P3a amplitude to decrease between the first and last blocks for young, but not old subjects and (2) the difference in P3a amplitude between young and old subjects to be greater in the last than the first block. Our results indicate the amplitude of the P3a was larger in old adults than young adults. However, this effect was not modulated by block. These findings argue against the hypothesis that an age-related increase in the P3a to targets reflects an inability of old subjects to habituate a novelty response. An alternative hypothesis is that the augmented P3a indexes the increased utilization of frontal executive functions to provide compensatory scaffolding to carry out a task.

Investigating the age-related "anterior shift" in the scalp distribution of the P3b component using principal component analysis.

An age-related "anterior shift" in the distribution of the P3b is often reported. Temporospatial principal component analysis (PCA) was used to investigate the basis of this observation. ERPs were measured in young and old adults during a visual oddball task. PCA revealed two spatially distinct factors in both age groups, identified as the posterior P3b and anterior P3a. Young subjects generated a smaller P3a than P3b, while old subjects generated a P3a that did not differ in amplitude from their P3b. Rather than having a more anteriorly distributed P3b, old subjects produced a large, temporally overlapping P3a. The pattern of the age-related "anterior shift" in the P3 was similar for target and standard stimuli. The increase in the P3a in elderly adults may not represent a failure to habituate the novelty response, but may reflect greater reliance on executive control operations (P3a) to carry out the categorization/updating process (P3b).

Age-related differences in the automatic processing of single letters: implications for selective attention.

Older adults exhibit diminished ability to inhibit the processing of visual stimuli that are supposed to be ignored. The extent to which age-related changes in early visual processing contribute to impairments in selective attention remains to be determined. Here, 103 adults, 18-85 years of age, completed a color selective attention task in which they were asked to attend to a specified color and respond to designated target letters. An optimal approach would be to initially filter according to color and then process letter forms in the attend color to identify targets. An asymmetric N170 ERP component (larger amplitude over left posterior hemisphere sites) was used as a marker of the early automatic processing of letter forms. Young and middle-aged adults did not generate an asymmetric N170 component. In contrast, young-old and old-old adults produced a larger N170 over the left hemisphere. Furthermore, older adults generated a larger N170 to letter than nonletter stimuli over the left, but not right hemisphere. More asymmetric N170 responses predicted greater allocation of late selection resources to target letters in the ignore color, as indexed by P3b amplitude. These results suggest that unlike their younger counterparts, older adults automatically process stimuli as letters early in the selection process, when it would be more efficient to attend to color only. The inability to ignore letters early in the processing stream helps explain the age-related increase in subsequent processing of target letter forms presented in the ignore color.

The impact of visual acuity on age-related differences in neural markers of early visual processing.

The extent to which age-related differences in neural markers of visual processing are influenced by changes in visual acuity has not been systematically investigated. Studies often indicate that their subjects had normal or corrected-to-normal vision, but the assessment of visual acuity seems to most frequently be based only on self-report. Consistent with prior research, to be included in the current study, subjects had to report normal or corrected-to-normal vision. Additionally, visual acuity was formally tested using a Snellen eye chart. Event-related potentials (ERPs) were studied in young adults (18-32years old), young-old adults (65-79years old), and old-old adults (80+ years old) while they performed a visual processing task involving selective attention to color. Age-related differences in the latency and amplitude of ERP markers of early visual processing, the posterior P1 and N1 components, were examined. All results were then re-analyzed after controlling for visual acuity. We found that visual acuity declined as a function of age. Accounting for visual acuity had an impact on whether older and younger adults differed significantly in the size and latency of the posterior P1 and N1 components. After controlling for visual acuity, age-related increases in P1 and N1 latency did not remain significant, and older adults were found to have a larger P1 amplitude than young adults. Our results suggest that until the relationship between age-associated differences in visual acuity and early ERPs is clearly established, investigators should be cautious when interpreting the meaning of their findings. Self-reports about visual acuity may be inaccurate, necessitating formal measures. Additional investigation is needed to help establish guidelines for future research, especially of very old adults.