Discrepancies between self- and informant-ratings of functional abilities and objective cognition: predictors of bias in mild cognitive impairment.

OBJECTIVE: Self- and informant-ratings of functional abilities are used to diagnose mild cognitive impairment (MCI) and are commonly measured in clinical trials. Ratings are assumed to be accurate, yet they are subject to biases. Biases in self-ratings have been found in individuals with dementia who are older and more depressed and in caregivers with higher distress, burden, and education. This study aimed to extend prior findings using an objective approach to identify determinants of bias in ratings. METHOD: Participants were 118 individuals with MCI and their informants. Three discrepancy variables were generated including the discrepancies between (1) self- and informant-rated functional status, (2) informant-rated functional status and objective cognition (in those with MCI), and (3) self-rated functional status and objective cognition. These variables served as dependent variables in forward linear regression models, with demographics, stress, burden, depression, and self-efficacy as predictors. RESULTS: Informants with higher stress rated individuals with MCI as having worse functional abilities relative to objective cognition. Individuals with MCI with worse self-efficacy rated their functional abilities as being worse compared to objective cognition. Informant-ratings were worse than self-ratings for informants with higher stress and individuals with MCI with higher self-efficacy. CONCLUSION: This study highlights biases in subjective ratings of functional abilities in MCI. The risk for relative underreporting of functional abilities by individuals with higher stress levels aligns with previous research. Bias in individuals with MCI with higher self-efficacy may be due to anosognosia. Findings have implications for the use of subjective ratings for diagnostic purposes and as outcome measures.

Disentangling Visual Exploration Differences in Cognitive Impairment.

OBJECTIVE: Individuals with cognitive impairment (CI) exhibit different oculomotor functions and viewing behaviors. In this work we aimed to quantify the differences in these functions with CI severity, and assess general CI and specific cognitive functions related to visual exploration behaviors. METHODS: A validated passive viewing memory test with eyetracking was administered to 348 healthy controls and CI individuals. Spatiotemporal properties of the scanpath, the semantic category of the viewed regions, and other composite features were extracted from the estimated eyegaze locations on the corresponding pictures displayed during the test. These features were then used to characterize viewing patterns, classify cognitive impairment, and estimate scores in various neuropsychological tests using machine learning. RESULTS: Statistically significant differences in spatial, spatiotemporal, and semantic features were found between healthy controls and individuals with CI. The CI group spent more time gazing at the center of the image, looked at more regions of interest (ROI), transitioned less often between ROI yet in a more unpredictable manner, and exhibited different semantic preferences. A combination of these features achieved an area under the receiver-operator curve of 0.78 in differentiating CI individuals from controls. Statistically significant correlations were identified between actual and estimated CI scores and other neuropsychological tests. CONCLUSION: Evaluating visual exploration behaviors provided quantitative and systematic evidence of differences in CI individuals, leading to an improved approach for passive cognitive impairment screening. SIGNIFICANCE: The proposed passive, accessible, and scalable approach could help with earlier detection and a better understanding of cognitive impairment.

Comparison of performance on the oral versus written trail making test in patients with movement disorders.

The Oral Trail Making Test (O-TMT) was designed as a clinical analog of the written version (W-TMT). There is debate, however, about whether the measurement of processing speed and set shifting is equivalent between versions. Given the administration advantages of the O-TMT - especially for patients with motor impairments - we examined convergent validity with the W-TMT in patients with movement disorders. Fifty patients (n = 43 idiopathic Parkinson's disease [PD]) were evaluated in a movement disorders clinic. Patients averaged 71 years old (SD = 8.07 years), 16 years of education (SD = 2.30 years), and the majority were non-Hispanic White (n = 46) and male (n = 35). In addition to other neuropsychological measures, patients completed the O-TMT and the W-TMT, counterbalanced and separated by thirty-minutes. Part A scores on O-TMT and W-TMT were not significantly correlated. In contrast, Part B scores were strongly correlated, such that slower performances on O-TMT Part B corresponded with slower performances on W-TMT Part B. Discrepancy scores (Part B minus Part A completion times) were also strongly correlated, such that more time on O-TMT, indicative of slower set shifting speed, corresponded with more time on W-TMT. Better performances on both O-TMT B and W-TMT B were associated with better scores on measures of overall cognitive status, verbal learning, and both phonemic and semantic fluency. Part B of the O-TMT shows promise as an analog for Part B of the W-TMT when evaluating set shifting abilities in patients with movement disorders. Future research with diverse patient populations is recommended to establish generalizability.

Disentangling visual exploration differences in cognitive impairment.

Objective: Compared to individuals without cognitive impairment (CI), those with CI exhibit differences in both basic oculomotor functions and complex viewing behaviors. However, the characteristics of the differences and how those differences relate to various cognitive functions have not been widely explored. In this work we aimed to quantify those differences and assess general cognitive impairment and specific cognitive functions. Methods: A validated passive viewing memory test with eyetracking was administered to 348 healthy controls and CI individuals. Spatial, temporal, semantic, and other composite features were extracted from the estimated eye-gaze locations on the corresponding pictures displayed during the test. These features were then used to characterize viewing patterns, classify cognitive impairment, and estimate scores in various neuropsychological tests using machine learning. Results: Statistically significant differences in spatial, spatiotemporal, and semantic features were found between healthy controls and individuals with CI. CI group spent more time gazing at the center of the image, looked at more regions of interest (ROI), transitioned less often between ROI yet in a more unpredictable manner, and had different semantic preferences. A combination of these features achieved an area under the receiver-operator curve of 0.78 in differentiating CI individuals from controls. Statistically significant correlations were identified between actual and estimated MoCA scores and other neuropsychological tests. Conclusion: Evaluating visual exploration behaviors provided quantitative and systematic evidence of differences in CI individuals, leading to an improved approach for passive cognitive impairment screening. Significance: The proposed passive, accessible, and scalable approach could help with earlier detection and a better understanding of cognitive impairment.

Knowledge About COVID-19 Symptoms, Transmission, and Prevention: The Relationship With Cognitive Status in Older Adults.

Objective: Advanced age poses an increased risk for cognitive impairment, and therefore, poor knowledge regarding the risks associated with COVID-19 may confer vulnerability. We administered a COVID-19 Knowledge Questionnaire to older persons to evaluate the association between knowledge regarding public health recommendations, and cognitive status as measured by the Montreal Cognitive Assessment (MoCA). Method: Ninety-nine participants completed a 22-item questionnaire about COVID-19 symptoms, risks, and protective strategies, and they also completed the MoCA. Associations between knowledge and cognitive status were examined via Spearman correlations. Results: The mean (SD) age of participants was 72.6 (7.6) years, and MoCA scores averaged 23.4 (4.5) points. Higher MoCA total scores were significantly (p < .001) correlated with a greater number of correct questionnaire responses. Higher Orientation and Memory Index scores were moderately associated with an increased number of correct responses (p < .001), with the Executive Index exhibiting a significant albeit weaker association. MoCA Index scores assessing attention, language, and visuospatial functioning were not significantly associated with COVID-19 knowledge. Conclusions: Given the rapid transmission rate of the SARS CoV-2 infections, COVID knowledge lapses will likely have deleterious repercussions. Public health messages should ensure effective acquisition and retention of COVID specific information, especially in cognitively compromised older adults.

Automated analysis of facial emotions in subjects with cognitive impairment.

Differences in expressing facial emotions are broadly observed in people with cognitive impairment. However, these differences have been difficult to objectively quantify and systematically evaluate among people with cognitive impairment across disease etiologies and severity. Therefore, a computer vision-based deep learning model for facial emotion recognition trained on 400.000 faces was utilized to analyze facial emotions expressed during a passive viewing memory test. In addition, this study was conducted on a large number of individuals (n = 493), including healthy controls and individuals with cognitive impairment due to diverse underlying etiologies and across different disease stages. Diagnoses included subjective cognitive impairment, Mild Cognitive Impairment (MCI) due to AD, MCI due to other etiologies, dementia due to Alzheimer's diseases (AD), and dementia due to other etiologies (e.g., Vascular Dementia, Frontotemporal Dementia, Lewy Body Dementia, etc.). The Montreal Cognitive Assessment (MoCA) was used to evaluate cognitive performance across all participants. A participant with a score of less than or equal to 24 was considered cognitively impaired (CI). Compared to cognitively unimpaired (CU) participants, CI participants expressed significantly less positive emotions, more negative emotions, and higher facial expressiveness during the test. In addition, classification analysis revealed that facial emotions expressed during the test allowed effective differentiation of CI from CU participants, largely independent of sex, race, age, education level, mood, and eye movements (derived from an eye-tracking-based digital biomarker for cognitive impairment). No screening methods reliably differentiated the underlying etiology of the cognitive impairment. The findings provide quantitative and comprehensive evidence that the expression of facial emotions is significantly different in people with cognitive impairment, and suggests this may be a useful tool for passive screening of cognitive impairment.

Olfactory Dysfunction in Neurodevelopmental Disorders: A Meta-analytic Review of Autism Spectrum Disorders, Attention Deficit/Hyperactivity Disorder and Obsessive-Compulsive Disorder.

Olfactory dysfunction is recognized in neurodevelopmental disorders and may serve as an early indicator of global dysfunction. The present meta-analysis measures olfaction effect sizes in attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorders (ASDs), and obsessive-compulsive disorder (OCD). Meta-analysis included 320 ADHD, 346 ASD, and 208 OCD individuals as compared to 910 controls. Olfactory performance deficits were small-to-moderate and heterogeneous (d = - 0.42, 95% CI = - 0.59 < δ < - 0.25). Meta-analytic results indicate that olfactory dysfunction is evident in individuals with ASD and OCD, with small-to-negligible effects in ADHD. These findings imply olfactory dysfunction is related to clinical phenotype in ASD and OCD, but not ADHD, and warrant inclusion in clinical assessment and evaluation of certain neurodevelopmental disorders.

The Relationship Between Multiple Sclerosis Symptom Severity Measures and Performance on Driving Variability Metrics in a Virtual Reality Simulator.

OBJECTIVE: Driving ability can be compromised in individuals with multiple sclerosis (MS); however, the progressive nature of multiple sclerosis makes it difficult for clinicians to assess when performance on functional tasks, such as driving, has started to decline. The aim of the study was to evaluate the relationship between two measures of multiple sclerosis severity, the Expanded Disability Status Scale and the Multiple Sclerosis Functional Composite, and minor driving errors in a virtual reality driving simulator. DESIGN: Symptom severity was measured in 31 active drivers with multiple sclerosis using the Expanded Disability Status Scale and Multiple Sclerosis Functional Composite. Driving performance was measured using a standardized virtual reality driving simulator route. Executive functioning, a cognitive function commonly related to driving, was evaluated using the Trail Making Test B. RESULTS: Greater impairment on the Multiple Sclerosis Functional Composite was related to increased difficulty maintaining lane positioning (r = -0.49, P = 0.01) and poorer executive functioning (r = -0.52, P < 0.01). In contrast, the Expanded Disability Status Scale was not related to either measure. CONCLUSIONS: These findings suggest that poorer performance on the Multiple Sclerosis Functional Composite, and not the Expanded Disability Status Scale, may indicate vulnerability to minor driving errors as an early sign of driving compromise. The use of screening tools, such as the Multiple Sclerosis Functional Composite, could help clinicians identify increased driving risk and consider comprehensive driving evaluations earlier, before a major driving violation or accident occurs. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe the relationship between symptom severity and driving performance in a virtual reality driving simulator, and how the relationship may vary based on which symptom severity measure is used; (2) Identify nuanced differences between two commonly used multiple sclerosis (MS) symptom severity measures when assessing functional abilities such as driving; and (3) Utilize symptom severity screeners that can assist in monitoring symptom progression and assessing whether further driving evaluation is needed. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Older Adult Normative Data for the Sniffin' Sticks Odor Identification Test.

OBJECTIVE: The current study establishes normative Sniffin' Sticks Odor Identification Test (SS-OIT) scores for cognitively intact older adults. METHOD: Two hundred and twenty-six cognitively normal older adults were identified as eligible for the current study (Mean Age = 70.49 years; 71.7% female). Important demographic covariates were identified using step-wise regression, and a normative regression equation was developed. RESULTS: Analyses of the effects of demographic variables (including age, education, and sex) on SS-OIT performance revealed that age was the only significant predictor, b = -0.07, SEb = .01, p < .01. A final regression equation was determined and normative data are reported in 5-year increments for a number of percentile ranks. CONCLUSIONS: Normative performance on the SS-OIT for adults over the age of 50 was established in a large and demographically diverse sample. These data are needed in order for clinicians to be able to include olfactory testing, a sensitive marker of neurodegeneration, in their assessment armamentarium.

The telephone effect: Overcoming initiation deficits in two settings.

PURPOSE: Disorders of motivation substantially impair an individual's ability to communicate with their families, therapists, and doctors. One method of overcoming initiation deficits is by utilizing the telephone effect, which is the ability for individuals with severe motivation deficits to communicate more readily when speaking on a telephone. However, little is available in the extant literature on how this effect works or how best to integrate this into patient care. This article aims to provide the first report of a proposed mechanism underlying the telephone effect and the first published procedures for eliciting this effect. DESIGN: This is largely a review article that also contains descriptions of clinical procedures for eliciting the telephone effect with 2 patient populations: acute inpatients following brain injury and dementia residents. A case vignette is also provided. RESULTS: We propose that the telephone effect is the result of an interaction between the patient and environment, and occurs because of Gibson's (1979) law of affordances. The use of this theory provides an explanation of the behaviors often observed when attempting to elicit this effect (i.e., disruption of the effect when using a cellular phone). Moreover, we argue that this can, and does, apply to social interactions as well. CONCLUSIONS/IMPLICATIONS: The telephone effect is an understudied phenomenon that provides a means of improving care for individuals with disorders of motivation. Future directions include systematic research into the telephone effect and further investigation of the mechanism underlying this effect. (PsycINFO Database Record

Driving after brain injury: Does dual-task modality matter?

BACKGROUND: Virtual reality technology allows neuropsychologists to examine complex, real-world behaviors with high ecological validity and can provide an understanding of the impact of demanding dual-tasks on driving performance. OBJECTIVE: We hypothesized that a task imposing high cognitive and physical demands (coin-sorting) would result in the greatest reduction in driving maintenance performance. METHODS: Twenty participants with acquired brain injury and 28 healthy controls were included in the current study. All participants were licensed and drove regularly. Participants completed two standardized VRDS drives: (1) a baseline drive with no distractions, and (2) the same route with three, counterbalanced dual-tasks representing differing demands. RESULTS: A series of 3 (Task)×2 (Group) ANOVAs revealed that the ABI group tended to go slower than the HC group in the presence of a dual-task, F (1, 111) = 6.24, p = 0.01. Importantly, the ABI group also showed greater variability in speed, F (1, 110) = 10.97, p < 0.01, and lane position, F (1, 108) = 7.81, p < 0.01, an effect driven by dual-tasks with both a cognitive and motor demand. CONCLUSIONS: These results indicate that long-term driving difficulties following ABI are subtle and likely due to reduced cognitive resources.