Neural signature of everyday function in older adults at-risk of cognitive impairment

Assessment of everyday activities are central to the diagnosis of pre-dementia and dementia. Yet, little is known about the brain substrates and processes that contribute to everyday functional impairment, particularly during early stages of cognitive decline. We investigated everyday function using a complex gait task in normal older adults stratified by risk of cognitive impairment. We applied a novel EEG approach, which combines electroencephalographic with 3D-body tracking technology to measure brain-gait dynamics with millisecond precision while participants are in motion. Twenty-six participants (mean age = 74.9 years) with cognitive and everyday functional profiles within the normal range for their age and sex were ranked for risk of cognitive impairment. We used the Montreal Cognitive Assessment battery, a global index of cognition with a range from 0 to 30, to classify individuals as being at higher (22-26) and lower risk (27+). Individuals walking on a treadmill were exposed to visual perturbation designed to destabilize gait. Assuming that brain changes precede behavioral decline, we predicted that older adults increase step width to gain stability, yet the underlying neural signatures would be different for lower versus higher risk individuals. When pooling across risk groups, we found that step width increased and fronto-parietal activation shifted from transient, during swing phases, to sustained across the gait cycle during visually perturbed input. As predicted, step width increased in both groups but underlying neural signatures were different. Fronto-medial theta (3-7Hz) power of gait-related brain oscillations were increased in higher risk individuals during both perturbed and unperturbed inputs. On the other hand, left central gyri beta (13-28Hz) power was decreased in lower risk individuals, specifically during visually perturbed input. Finally, relating MoCA scores to spectral power pooled across fronto-parietal regions, we found associations between increased theta power and worse MoCA scores and between decreased beta power and better MoCA scores. Able-bodied older adults at-risk of cognitive impairment are characterized by unique neural signatures of mobility. Stronger reliance on frontomedial theta activation in at-risk individuals may reflect higher-order compensatory responses for deterioration of basic sensorimotor processes. Region and spectral-specific signatures of mobility may provide brain targets for early intervention against everyday functional decline.

Increasing Access to Task-Oriented Community-Based Exercise Programs Through Healthcare-Community Partnerships to Improve Function Post-Stroke: Feasibility of a 2-Group Randomized Controlled Trial Protocol

BackgroundObjectives were to describe the feasibility of a protocol for evaluating a community-based exercise program incorporating a healthcare-community partnership (CBEP-HCP) compared to a waitlist control group on improving everyday function among people post-stroke.MethodsA pilot 2-group randomized controlled trial was conducted in three cities in Ontario, Canada. Adults (≥ 18 years) living at home for ≥ 3 months post-stroke, and able to walk ≥ 10 metres without physical assistance were stratified by site and gait speed and randomly assigned to an exercise program or waitlist control group. Trained fitness instructors delivered a 1-hour, group exercise class, involving repetitive and progressive practice of balance/mobility tasks relevant to everyday function (e.g., sit-to-stand, walking, step-ups) twice a week for 12 weeks. The waitlist group was offered the exercise program at 10 months. Blinded assessors conducted evaluations at 3, 6 and 10 months post-baseline. Sensitivity to change of two measures of everyday function (Subjective Index of Physical and Social Outcome (SIPSO) and Nottingham Extended Activities of Daily Living (NEADL)) was compared. Qualitative interviews were conducted separately with 13 participants and 9 caregivers post-intervention. Quantitative and qualitative results were triangulated.ResultsThirty-three people with stroke were randomized to the intervention (n = 16) or waitlist group (n = 17); 68% of available caregivers agreed to participate. Recruitment rates were 2.4, 1.2, and 1.1 participants/month across sites and highest in the largest urban centre. Participants preferred a familiar healthcare professional to refer them to the study. Participants described a 10- or 12-month wait as too long and two people in the waitlist group withdrew for this reason. The exercise program was implemented per protocol across sites. Attendance was lowest (63% and 71% in the intervention and waitlist group, respectively) at 10-month evaluations. Participants described inclement weather, availability of transportation, and long commutes as barriers to attending evaluations and exercise classes. The SIPSO physical scale but not the NEADL detected change in the intervention group. Quantitative and qualitative results suggested an immediate effect of the intervention on balance, balance self-efficacy, everyday function (dressing, cooking), and overall health.ConclusionChallenges with recruitment, attendance, and retention will inform protocol revisions for a future trial.Trial Registration: ClinicalTrials.gov, NCT03122626. Registered April 17, 2017 - Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03122626

A randomised control trial of the effects of home-based online attention training and working memory training on cognition and everyday function in a community stroke sample.

Cognitive difficulties are common following stroke and can have widespread impacts on everyday functioning. Technological advances offer the possibility of individualised cognitive training for patients at home, potentially providing a low-cost, low-intensity adjunct to rehabilitation services. Using this approach, we have previously demonstrated post-training improvements in attention and everyday functioning in fronto-parietal stroke patients. Here we examine whether these benefits are observed more broadly in a community stroke sample. Patients were randomised to either 4 weeks of online adaptive attention training (SAT), working memory training (WMT) or waitlist (WL). Cognitive and everyday function measures were collected before and after intervention, and after 3months. During training, weekly measures of patients' subjective functioning were collected. The training was well received and compliance good. No differences in standardised cognitive tests were observed for either intervention relative to controls. However, on patient reported outcomes, SAT participants showed greater levels of improvement in everyday functioning than WMT or WL participants. In line with our previous work, everyday functioning improvements were greatest for patients with spatial impairments and those who received SAT training. Whether attention training can be recommended for stroke survivors depends on whether cognitive test performance or everyday functioning is considered more relevant.

Are poor set-shifting and central coherence associated with everyday function in anorexia nervosa? A systematic review

Background There is increasing interest in associations between cognitive impairments and clinical symptoms in Anorexia Nervosa (AN), however, the relationship with everyday function is unclear. The current review synthesizes existing data regarding associations between scores on tests of set-shifting and central coherence and functional outcome measures for individuals with AN. Method A systematic electronic database search yielded 13 studies which included participants with current or lifetime AN where scores on a neuropsychological test of set-shifting or central coherence were directly or indirectly compared to a functional outcome measure. Results Associations between set-shifting and central coherence performance measures and functional outcomes were limited in number and noted only in adult or mixed-age cohorts. Associations were noted at subscale level, suggesting they are specific in nature. In younger cohorts, assessments of executive functioning in everyday life appear sensitive to cognitive-behavioral flexibility issues. Conclusions Associations between cognitive performance and functional outcome have not been as systematically assessed in AN as in other psychiatric disorders. Key factors to address in future research include: (a) the use of function measures which are sensitive to both the level of impairment, and specific rather than general impairments (b) the ecological validity of measures, (c) the task impurity problem, especially in regard to cognitive flexibility assessment, and (d) the need to measure both cognitive deficits and strengths, because tests of specific cognitive processes may underestimate the ability to function in daily life due to compensatory strategies.

ActiviDaily: Turning Apathy Into Action in Neurodegenerative Disease

Impairment of goal-directed behavior (GDB), often labeled apathy, is a common behavioral symptom in dementia. ActiviDaily is a novel mobile app that engages both patients and caregivers to increase GDB to improve everyday function. ActiviDaily targets key components of GDB (motivation, planning and initiation) and individualizes patient goals. Pilot testing in twelve patient/caregiver dyads occurred over 4 weeks of app use. Measures of behavior, everyday functioning, and psychological distress were assessed in a pre-post design. Goal Attainment Scaling (GAS) was used to establish individualized goals and measure progress on a standard scale. GAS showed that 79% of participants’ goals were met at or above expectations. Caregiver depression and stress were significantly reduced. There was also a reduction in ratings of patient apathy. ActiviDaily is an innovative intervention that individualizes treatment of apathy and has the potential to increase independence in day-to-day life and decrease caregiver burden.

Decline in Everyday Functioning in MCI and Dementia

Performance of everyday activities requires the coordination of a variety of complex cognitive processes; thus, as cognition changes over time, so too does the ability to perform everyday activities. This chapter will review the extant literature on everyday functioning in healthy aging, mild cognitive impairment (MCI), and dementia from a neuropsychological perspective. The chapter first briefly reviews the various terms used to denote everyday functioning and associated difficulties/impairment. It also discusses the strengths and weaknesses of the methodological approaches to everyday function assessment. Next, the chapter reviews reports of associations between overall level of cognitive function and the ability to perform everyday tasks. Studies mapping the relations between specific cognitive processes and everyday functioning also are reviewed. The authors include a discussion of neuropsychological models (e.g., resource theory, omission–commission model) that have been proposed to account for the observed relations between cognition and everyday function. Finally, the authors make suggestions for future research on everyday functioning in older adults.

BEHAVIORAL INTERVENTIONS FOR COGNITION AND EVERYDAY FUNCTION: A SYSTEMATIC REVIEW

Behavioral interventions to improve cognitive function in older adults are widespread and can vary from theatre classes to cognitive training programs targeting one domain. However, the effectiveness in maintaining different cognitive domains varies greatly both across and within intervention types. To date, no systematic reviews have synthesized findings across more than a few types of interventions (e.g., cognitive vs. exercise). This systematic review examined nine types of behavioral interventions and the respective transfer to 18 cognitive domains and everyday function. The 2017 search yielded 75 unique eligible articles comprising of educational, theatre, mindfulness, cognitive, exercise, video game, and combination interventions. In general, there was limited evidence of consistent transfer from behavioral interventions to untrained cognitive domains. Few studies examined education, theatre, mindfulness, or video game interventions, leaving inconclusive results about their effect on cognitive function. Nine studies evaluated transfer to everyday function and found that both process- and strategy-based cognitive training conferred benefits up to 10 years posttest. These results suggest that while there is weak-to-moderate evidence of far transfer from behavioral interventions to untrained cognitive domains, it may be more important to examine far transfer to measures more indicative of older adult everyday life. Furthermore, it highlights the necessity to continue long-term follow-up. While there were notable limitations of the extant literature, including inconsistent use of terms such as active control or inadequate intervention description, there were strengths such as the recent implementation of factorial designs. Implications for future research and practice will be discussed.