The effects of individual music therapy in nursing home residents with dementia to improve general well-being: study protocol of a randomized controlled trial.

BACKGROUND: Dementia is often associated with Neuropsychiatric Symptoms (NPS) such as agitation, depression, hallucinations, anxiety, that can cause distress for the resident with dementia in long-term care settings and can impose emotional burden on the environment. NPS are often treated with psychotropic drugs, which, however, frequently cause side effects. Alternatively, non-pharmacological interventions can improve well-being and maintain an optimal quality of life (QoL) of those living with dementia. Other QoL related outcomes, such as pain, discomfort and sleep disruption are relevant outcomes in music trials as well. Music therapy is a non-pharmacological intervention that can reduce NPS and improve well-being, and its associated symptoms in dementia. METHODS: The research will be conducted at eight nursing home facilities of a health care organization in the Netherlands. A sample size of 30 in each group (experimental and control group) is required, totalling 60 residents increased to 80 when considering expected drop out to follow up. The participants in the intervention group receive 30 min of individual music therapy (MT) in their own room by a music therapist twice a week for 12 weeks. The participants in the control group will receive 30 min of individual attention in their own room by a volunteer twice a week for 12 weeks. Assessments will be done at baseline, 6 weeks and 12 weeks. An independent observer, blinded for the intervention or control condition, will assess directly observed well-being (primary outcome) and pain (secondary outcome) before and after the sessions. Nurses will assess other secondary outcomes unblinded, i.e., perceived quality of life and NPS, both assessed with validated scales. The sleep duration will be indirectly assessed by a wrist device called MotionWatch. Information about psychotropic drug use will be derived from electronic medical chart review. DISCUSSION: The main purpose of this study is to assess the effects of individual music therapy on directly observed well-being controlled for individual attention in nursing home residents with dementia with NPS. The outcomes refer to both short-term and long-term effects consistent with therapeutic goals of care for a longer term. We hope to overcome limitations of previous study designs such as not blinded designs and music facilitators that were not only music therapists but also occupational therapists and nurses. This study should lead to more focused recommendations for practice and further research into non-pharmacological interventions in dementia such as music therapy. TRIAL REGISTRATION: The trial is registered at the International Clinical Trials Registry Platform (ICTRP) search portal in the Netherlands Trial Registration number NL7708, registration date 04-05-2019.

An Individual Music Intervention for Adults With Intellectual Disabilities and Challenging Behavior: Protocol for a Randomized Controlled Trial.

BACKGROUND: Individuals with intellectual disabilities (ID) are more likely to have problems with executive functioning (EF) and challenging behavior (CB), which are negatively linked to well-being. Among clinical populations, music interventions have been shown to improve various outcome measures, such as CB and EF. Until now, no randomized controlled trials (RCTs) have been conducted to examine the effectiveness of an individual music intervention for adults with ID and CB. OBJECTIVE: The study aims to identify the effect and feasibility of an individual music intervention compared with care-as-usual for people with ID and CB. METHODS: In this study, a 2-group RCT with a pretest, posttest, and follow-up assessment after 8 weeks is presented. Participants of the music intervention condition will receive 16 individual music sessions within 8 to 10 weeks. The music intervention will be guided by a manual for music workers, in which every session will have a different focus (introduction, emotions, different EF, and end performance). Participants receiving care as usual will function as a control group. After the research is finished, they will be offered a budget, which they can spend on musical activities or musical instruments as they wish. Assessments will include caregiver rating scales and self-report questionnaires and tests, which will assess outcome measures of CB, well-being, depression, anxiety, self-esteem, and 4 domains of EF. A process evaluation will be conducted after the completion of the study, which entails the analysis of data on multiple aspects of the intervention and the study overall. RESULTS: Enrollment commenced in July 2021, and data collection ended in May 2023. A total of 97 participants were recruited, with 44 participants allocated to the intervention group and 53 allocated to the control group. Data will be analyzed after this protocol has been accepted for publication. CONCLUSIONS: Because there are currently no published RCTs of an individual music intervention for adults with ID and CB, this study will provide insight into the effectiveness and experiences of an individual music intervention for this target group. TRIAL REGISTRATION: International Clinical Trials Registry Platform NL8482; http://tinyurl.com/4565s5pd. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52497.

Effect of an 18-Month Walking Intervention on the Rest-Activity Rhythm of Older Adults With Mild-Moderate Dementia.

The objective of this 18-month walking intervention was to evaluate the effect on rest-activity rhythm (RAR) for older adults with mild-to-moderate dementia (65.8% female; aged M = 82.4 [SD = 6.5]). The intervention group (n = 44) was intended to walk 30 min, five times per week for 18 months. The control group (n = 35) received sedentary activities or usual care. RAR was measured at baseline to after 18 months and five times in between actigraphy outcome variables (interdaily stability, intradaily variability, relative amplitude, activity 10 most active hours, and activity 5 least active hours). Hierarchical mixed model analyses revealed no significant intervention effects (with or without baseline confounders as covariate) on RAR. However, participants in the intervention group were able to significantly increase their daily life activity (activity 10 most active hours) from the onset of the preceding measurement, b = 0.10, t(239.32) = 2.36, p = .019. More research is warranted to study the effect of regular walks on older persons with dementia whose RAR is worst at baseline.

Observing videos of mastication in dementia: Results of a clustered randomised controlled trial.

OBJECTIVES: The aim of this study was to examine effects of the observation of video-recorded chewing in a daily setting on mixing ability, cognition, activities of daily living, depressive symptoms and quality of life of older adults with dementia. METHODS: A clustered randomised controlled trial was carried out with residents from 14 residential care facilities. n = 56 participants' data were analysed. An experimental group watched videos of people chewing, displayed on tablet-PCs during lunch, while a control group watched videos of nature and buildings. This was scheduled to take place 5 days a week for 12 weeks. A two-colour chewing gum test was used to measure mixing ability, neuropsychological tests for cognition and questionnaires for the other outcomes. Effects were examined via hierarchical linear mixed model analyses for T1-T3 (i.e. pre-, halfway and post-intervention). When a significant interaction effect was found, T4 (follow-up) was also included. RESULTS: The experimental (n = 27) and control (n = 28) groups differed on a few variables at baseline. A significant Time*Group interaction effect was found for the Mini-Mental State Examination only (b = 1.18, t(48.35) = 2.53, p = .015), in favour of the experimental group. A significant effect was also found, albeit smaller, when T4 was included. CONCLUSION: One potential reason for the intervention effect on cognition is activation of specific brain areas. Some challenges associated with conducting this intervention in a daily setting are presented. Further research is required before a well-considered decision can be made regarding any potential implementation. TRIAL REGISTRATION: Number: NTR5124. Date of registration: 30 March 2015, retrospectively registered (during participant inclusion).

Active music making and leisure activities for people with intellectual disabilities: A cluster randomized pilot study.

AIM: A pilot cluster randomized controlled trial was performed to evaluate the effects of a music group intervention and a leisure activities group intervention on well-being, self-esteem, social acceptance, challenging behaviour and three components of executive functions (inhibitory control, cognitive flexibility and visual working memory) of adults with intellectual disabilities (ID). METHOD: Twenty-nine participants living in four residential facilities for people with ID were randomized into a music or a leisure activities group intervention. Sixteen weekly sessions of one hour were performed with six to eight participants per group. Measurements were carried out at baseline, post-intervention and 11 weeks follow- up. Results were analysed with linear mixed models. RESULTS: The leisure activities group intervention improved more than the music group intervention on internalizing behaviour overall and on inhibitory control at post-intervention. However, further analyses showed that this improvement was only significant in one of the two leisure activities facilities. CONCLUSION: A leisure activities group intervention seems a promising intervention to improve internalizing behaviour and inhibitory control of younger adults with mild ID. Implications for the delivery of leisure activities group interventions and especially music group interventions are discussed. WHAT THIS PAPER ADDS: Involvement in leisure activities of people with ID is associated with better well-being, an improvement in social skills and a reduction in emotional and behavioural problems. Active music making, as a specific form of leisure activities, seems to improve well-being, social acceptance and challenging behaviour (CB) as well. Moreover, in different (non-clinical) groups a significant effect of active music making has been found on self-esteem and executive functioning (EF). So far, little attention has been paid to the possible positive effects of active music making on adults with ID. In the current paper, a randomized controlled trial (RCT) was conducted to compare the post-intervention and follow-up measurements with baseline measurements between a music group intervention and a leisure activities group intervention on well-being, self-esteem, social acceptance, CB and EF in adults with ID. Multilevel models were used to detect possible intervention effects of 16 weekly sessions. Overall, inhibitory control and internalizing behaviour improved more amongst the participants of the leisure activities group than amongst the participants of the music group. This was mainly the case for younger participants who had mild ID. These effects are discussed and recommendations regarding the improvement of a music intervention for people with ID are presented.

Aggressive Incidents by Incarcerated People With Psychiatric Illness and Their Relationship With Psychiatric Symptoms.

AIM: A prospective design was used to investigate the relationship of current psychiatric symptoms of incarcerated people with serious mental illness (SMI) and aggressive behavior on a penitentiary ward for crisis intervention. METHODS: One hundred sixty detainees with SMI, detained in a high-security penitentiary psychiatric facility, were screened every 2 weeks with the Brief Psychiatric Rating Scale-Extended (BPRS-E) by trained clinicians, to ensure that the data on psychiatric symptoms were up-to-date. Aggressive behavior was registered with the Staff Observation Aggression Scale-Revised. A binary logistic regression analysis was performed to examine the relationships between factor scores of the BPRS-E and aggressive behavior. RESULTS: Significant relationships between the BPRS-E factor hostility, antisocial traits, and aggressive incidents were found, but not between the positive symptoms or manic factor scores and aggressive incidents. DISCUSSION: Symptoms of SMI measured with the BPRS-E did not help to explain the occurrence of aggressive behavior. This is not in line with what is commonly found. The implication is that it can be expected that this population will display aggressive behavior but that symptoms do not help in predicting when this will occur. In addition, hostility and antisocial traits were related to aggressive behavior. For this specific population, an interactional approach might be more effective in the management of aggression than treatment of symptoms of SMI.

Prison and the brain.

Imprisonment is a common punishment in most countries. Goals of imprisonment are often not only retribution, but also prevention. Specific prevention aims to reduce the risk of reoffending of the imprisoned offender. The question is whether the goals of retribution and specific prevention contradict each other. Retribution is not only expressed in taking away ones freedom, but also in the prison environment itself. Prisoners live in a sober regime, with a minimal amount of autonomy. There are few cognitive challenges, meaningful social interaction is reduced significantly, and many prisoners are highly sedentary. In other words, prison can be viewed as an impoverished environment. In the last few decades, much knowledge has been gained on the influence of enriched versus impoverished environment on the brain. In this chapter, we discuss the influence of the impoverished prison environment on brain functions of prisoners, with an emphasis on self-regulation and executive functions, since these functions are (1) often impaired in offenders, (2) highly sensitive to environmental influences, and (3) crucial for successful resocialization. We conclude this chapter by discussing possibilities for and potential effects of enriching prison environments.

The effects of a moderate physical activity intervention on physical fitness and cognition in healthy elderly with low levels of physical activity: a randomized controlled trial.

BACKGROUND: Increasing physical activity is one of the most promising and challenging interventions to delay or prevent cognitive decline and dementia. METHODS: We conducted a randomized controlled trial to assess the effects of a physical activity intervention, aimed at increasing step count, in elderly with low levels of physical activity on measures of strength, balance, aerobic capacity, and cognition. Participants were assigned to 9 months of exercise counseling or active control. RESULTS: The intention-to-treat analyses show that the intervention, compared to control, increases the level of physical activity, but has no significant effect on physical fitness and cognition. Those who increased their physical activity with 35% or more show significant improvements in aerobic capacity, gait speed, verbal memory, executive functioning, and global cognition, compared to those who did not achieve a 35% increase. LIMITATIONS: The number of participants that achieved the intended improvement was lower than expected. CONCLUSION: Responder analyses suggest an improvement of physical fitness and cognition in those who achieved an increase in physical activity of at least 35%. TRIAL REGISTRATION: The trial protocol is registered at the Dutch Trial Register NL5675, August 1, 2016.

The long-term relation between physical activity and executive function in the Rotterdam Study.

BACKGROUND: Research on the association between physical inactivity and cognitive decline and dementia is dominated by studies with short-term follow-up, that might be biased by reverse causality. OBJECTIVE: Investigate the long-term association between physical activity, cognition, and the rate of age-associated cognitive decline. METHODS: We investigated the association between late-life physical activity and executive functioning and rate of decline of executive abilities during follow-up of up to 16 years, in 3553 participants of the prospective Rotterdam Study cohort. Measurement took place in 1997-1999, 2002-2004, 2009-2011, and 2014-2015. RESULTS: At baseline (age ± 72 years), higher levels of physical activity were associated with higher levels of executive functioning (adjusted mean difference = 0.03, 95% CI: 0.00 ; 0.06, p = 0.03). This difference remained intact up to 16 years of follow-up. The level of physical activity at baseline was unrelated to the rate of decline of executive abilities over time, in the whole group (adjusted mean difference in changetime*physical activity = 0.00, 95% CI: -0.00 ; 0.01, p = 0.31). However, stratification by APOE genotype showed that the accelerated decline of executive abilities observed in those with the ApoE-ε4 allele might be attenuated by higher levels of physical activity in late adulthood (ApoE-ε4 carriers: Btime*physical activity = 0.01, 95% CI: 0.00 ; 0.01, p = 0.03). CONCLUSION: Higher levels of physical activity in late adulthood are related to higher levels of executive functioning, up to 16 years of follow-up. Accelerated decline of executive abilities observed in those with the ApoE-ε4 allele might be mitigated by higher levels of physical activity.

Brief report: Free-living physical activity levels and cognitive control in multi-problem young adults.

Previous studies indicate a positive association between physical activity and cognitive control in sedentary but healthy adults, yet not much is known about physical activity levels in multi-problem young adults. We examined the level of self-reported free-living physical activity (i.e., MET minutes per week) in an ecologically valid sample of young adults facing multiple problems, including unemployment, lack of education, frequent substance use, and history of delinquency. We compared cognitive control with an age- and sex-matched control sample. Additionally, the association between physical activity and cognitive control (i.e., response inhibition, error processing, interference effect) in the multi-problem group was examined. Physical activity and cognitive control were measured with the International Physical Activity Questionnaire-Long Form and three cognitive control experiments (i.e., Flanker, Go/NoGo, Stroop), respectively. With M = 4428 Metabolic Equivalents (METs), our multi-problem sample (n = 63) showed physical activity levels similar to the age- and sex-matched control sample from the general population (n = 62). The multi-problem young adults also showed impaired cognitive control indexed as decreased response inhibition and decreased Flanker correctness effect compared to their peers. We could not find an association between self-reported physical activity and cognitive control in the multi-problem sample. Due to the small sample size, results should be interpreted with caution. However, future dose-response studies could still use these results to further examine if within-individual increased physical activity may possibly lead to improved cognitive control in (already relatively active) multi-problem young adults.

Neural basis of affective touch and pain: A novel model suggests possible targets for pain amelioration.

Pain is one of the most common health problems and has a severe impact on quality of life. Yet, a suitable and efficient treatment is still not available for all patient populations suffering from pain. Interestingly, recent research shows that low threshold mechanosensory C-tactile (CT) fibres have a modulatory influence on pain. CT-fibres are activated by slow gentle stroking of the hairy skin, providing a pleasant sensation. Consequently, slow gentle stroking is known as affective touch. Currently, a clear overview of the way affective touch modulates pain, at a neural level, is missing. This review aims to present such an overview. To explain the interaction between affective touch and pain, first the neural basis of the affective touch system and the neural processing of pain will be described. To clarify these systems, a schematic illustration will be provided in every section. Hereafter, a novel model of interactions between affective touch and pain systems will be introduced. Finally, since affective touch might be suitable as a new treatment for chronic pain, possible clinical implications will be discussed.

Neutralizing a Springboard for Inflammation: Physical Activity to Control the Immune Network.

The severe consequences of the present Corona Virus Disease 2019 COVID-19 pandemic seem to be closely related to an already ongoing ('first') pandemic, directly associated with a sedentary lifestyle. It seems evident that the prognosis after infection is substantially worse for individuals suffering from, for example, (visceral) obesity, cardiovascular disease, and diabetes type 2. Consequently, it may be considered highly relevant to gain insight into the potential beneficial effects of exercise interventions to strengthen the immune system, particularly in high-risk populations. For this reason, the exercise protocols that are suggested to strengthen the immune system, which can be executed by all ages and almost all physical conditions, were reviewed and evaluated. Previously published protocols range from interrupting prolonged sitting, to regular low-to-moderate exercise activities, to high intensity, typically interval, sports formats. Reported positive effects on immune functioning appear to be induced either directly or via beneficial metabolic and/or psychological effects and become measurable after 3 weeks to 3 months. Based in these findings, it appeared possible to design an optimal exercise protocol to maximize effects on immune functioning that should be executable for all, even under restricted ('lockdown') circumstances.

A media intervention applying debunking versus non-debunking content to combat vaccine misinformation in elderly in the Netherlands: A digital randomised trial.

BACKGROUND: As several COVID-19 vaccines are rolled-out globally, it has become important to develop an effective strategy for vaccine acceptance, especially in high-risk groups, such as elderly. Vaccine misconception was declared by WHO as one of the top 10 health issues in 2019. Here we test the effectiveness of applying debunking to combat vaccine misinformation, and reduce vaccine hesitancy. METHODS: Participants were recruited via a daily news show on Dutch Television, targeted to elderly viewers. The study was conducted in 980 elderly citizens during the October 2020 National Influenza Vaccination Campaign. Borrowing from the recent literature in behavioural science and psychology we conducted a two-arm randomized blinded parallel study, in which participants were allocated to exposure to a video containing social norms, vaccine information plus debunking of vaccination myths (intervention group, n = 505) or a video only containing vaccine information plus social norm (control group, n = 475). Participants who viewed either of the video's and completed both a pre- and post-intervention survey on vaccination trust and knowledge, were included in the analysis. The main outcomes of this study were improvement on vaccine knowledge and awareness. FINDINGS: Participants were recruited from the 13th of October 2020 till the 16th of October 2020 and could immediately participate in the pre-intervention survey. Subsequently, eligible participants were randomly assigned to an interventional video and the follow-up survey, distributed through email on the 18th of October 2020, and available for participation till the 24th of October 2020. We found that exposure to the video with addition of debunking strategies on top of social norm modelling and information resulted in substantially stronger rejection of vaccination misconceptions, including the belief that: (1) vaccinations can cause Autism Spectrum Disorders; (2) vaccinations weaken the immune system; (3) influenza vaccination would hamper the COVID-19 vaccine efficacy. Additionally, we observed that exposure to debunking in the intervention resulted in enhanced trust in government. INTERPRETATION: Utilizing debunking in media campaigns on top of vaccine information and social norm modeling is an effective means to combat misinformation and distrust associated with vaccination in elderly, and could help maximize grounds for the acceptance of vaccines, including the COVID-19 vaccines. FUNDING: Dutch Influenza Foundation.

Plasma Brain-Derived Neurotropic Factor Levels Are Associated with Aging and Smoking But Not with Future Dementia in the Rotterdam Study.

BACKGROUND: Brain-derived neurotropic factor (BDNF) plays a vital role in neuronal survival and plasticity and facilitates long-term potentiation, essential for memory. Alterations in BDNF signaling have been associated with cognitive impairment, dementia, and Alzheimer's disease. Although peripheral BDNF levels are reduced in dementia patients, it is unclear whether changes in BDNF levels precede or follow dementia onset. OBJECTIVE: In the present study, we examined the association between BDNF plasma levels and dementia risk over a follow-up period of up to 16 years. METHODS: Plasma BDNF levels were assessed in 758 participants of the Rotterdam Study. Dementia was assessed from baseline (1997-1999) to follow-up until January 2016. Associations of plasma BDNF and incident dementia were assessed with Cox proportional hazards models, adjusted for age and sex. Associations between plasma BDNF and lifestyle and metabolic factors are investigated using linear regression. RESULTS: During a follow up of 3,286 person-years, 131 participants developed dementia, of whom 104 had Alzheimer's disease. We did not find an association between plasma BDNF and risk of dementia (adjusted hazard ratio 0.99; 95%CI 0.84-1.16). BDNF levels were positively associated with age (B = 0.003, SD = 0.001, p = 0.002), smoking (B = 0.08, SE = 0.01, p = < 0.001), and female sex (B = 0.03, SE = 0.01, p = 0.03), but not with physical activity level (B = -0.01, SE = 0.01, p = 0.06). CONCLUSION: The findings suggest that peripheral BDNF levels are not associated with an increased risk of dementia.

A Randomized Controlled Trial on the Effects of a 12-Week High- vs. Low-Intensity Exercise Intervention on Hippocampal Structure and Function in Healthy, Young Adults.

Physical exercise affects hippocampal structure and function, but the underlying neural mechanisms and the effects of exercise intensity remain incompletely understood. Therefore, we undertook a comprehensive, multi-modal 3T and 7T MRI randomized controlled trial (Netherlands Trial Register - NL5847) in which we randomized 52 young, non-athletic volunteers to a 12-week low- or high-intensity exercise program. Using state-of-the-art methods, we investigated changes in hippocampal volume, as well as changes in vasculature, neuro-metabolites, and peripheral growth factors as potential underpinnings. Cardiorespiratory fitness improved over time (p < 0.001), but no interaction with exercise intensity was found (p = 0.48). Accordingly, we did not observe significant interactions between exercise condition and time on MRI measures (all p > 0.06). However, we found a significant decrease in right hippocampal volume (p < 0.01), an increase in left hippocampal glutathione (p < 0.01), and a decrease of left hippocampal cerebral blood volume (p = 0.01) over time, regardless of exercise condition. Additional exploratory analyses showed that changes in brain-derived neurotrophic factor (p = 0.01), insulin-like growth-factor (p = 0.03), and dorsal anterior cingulate cortex N-acetyl-aspartate levels (p = 0.01) were positively associated with cardiorespiratory fitness changes. Furthermore, a trend toward a positive association of fitness and gray-matter cerebral blood flow (p = 0.06) was found. Our results do not provide evidence for differential effects between high-intensity (aerobic) and low-intensity (toning) exercise on hippocampal structure and function in young adults. However, we show small but significant effects of exercise on hippocampal volume, neurometabolism and vasculature across exercise conditions. Moreover, our exploratory results suggest that exercise might not specifically only benefit hippocampal structure and function, but rather has a more widespread effect. These findings suggest that, in agreement with previous MRI studies demonstrating moderate to strong effects in elderly and diseased populations, but none to only mild effects in young healthy cohorts, the benefits of exercise on the studied brain measures may be age-dependent and restorative rather than stimulatory. Our study highlights the importance of a multi-modal, whole-brain approach to assess macroscopic and microscopic changes underlying exercise-induced brain changes, to better understand the role of exercise as a potential non-pharmacological intervention.

The impact of pain on the course of ADL functioning in patients with dementia.

BACKGROUND: Understanding if and how pain influences activities of daily living (ADL) in dementia is essential to improving pain management and ADL functioning. This study examined the relationship between the course of pain and change in ADL functioning, both generally and regarding specific ADL functions. METHODS: Participants were Dutch nursing home residents (n = 229) with advanced dementia. ADL functioning was assessed with the Katz ADL scale, and pain with the Dutch version of the Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC-D). Changes of PACSLAC-D and Katz ADL scores were computed based on the difference in scores between baseline, 3-month and 6-month follow-up. Multivariate linear regression models were used to assess the relationships between change in pain score, change in total ADL score and specific ADL item scores during follow-up. RESULTS: At baseline, residents had a median ADL score of 18 (interquartile range 13-22, range 6-24) and 48% of the residents were in pain (PACSLAC-D ≥ 4). Residents with pain were more ADL dependent than residents without pain. A change in pain score within the first 3 months was a significant predictor for a decline in ADL functioning over the 6-month follow-up (B = 0.10, SE = 0.05, P = 0.045), and specifically, a decline on the items 'transferring' over the 6-month follow-up and 'feeding' during the first 3 months of follow-up. CONCLUSIONS: Pain is associated with ADL functioning cross-sectionally, and a change in pain score predicts a decline in ADL functioning, independent of dementia severity. Awareness of (changes in) ADL activities is clearly important and might result in both improved recognition of pain and improved pain management.

Cognitive reserve relates to executive functioning in the old-old.

Cognitive reserve (CR) is known to reduce or even protect against the negative effects of aging on cognitive functioning. Nonetheless, little is known about how CR influences the relationship between different cognitive abilities and age in the old-old. The goal of the present study was, therefore, to test the hypothesis whether, in the old-old, CR still modifies the relationship between age and cognitive functioning. Eighty-three adults (aged 71-94) without mild cognitive impairment or dementia residing in residential care facilities completed a detailed neuropsychological test battery. CR was estimated using a combination of educational attainment and an estimation of verbal intelligence. Moderation analyses revealed a significant effect for fluency and a trend for flexibility, showing that the negative relationship between age and cognitive performance is reduced as the level of CR increases. These results demonstrate that CR still influences the relationship between age and executive functions in adults of advanced age.