Adam Gerstenecker

Measuring mild cognitive impairment in patients with Parkinson's disease.

We examined the frequency of Parkinson disease with mild cognitive impairment (PD‐MCI) and its subtypes and the accuracy of 3 cognitive scales for detecting PD‐MCI using the new criteria for PD‐MCI proposed by the Movement Disorders Society. Nondemented patients with Parkinsons disease completed a clinical visit with the 3 screening tests followed 1 to 3 weeks later by neuropsychological testing. Of 139 patients, 46 met Level 2 Task Force criteria for PD‐MCI when impaired performance was based on comparisons with normative scores. Forty‐two patients (93%) had multi‐domain MCI. At the lowest cutoff levels that provided at least 80% sensitivity, specificity was 44% for the Montreal Cognitive Assessment and 33% for the Scales for Outcomes in Parkinsons Disease‐Cognition. The Mini‐Mental State Examination could not achieve 80% sensitivity at any cutoff score. At the highest cutoff levels that provided specificity of at least 80%, sensitivities were low (≤44%) for all tests. When decline from estimated premorbid levels was considered evidence of cognitive impairment, 110 of 139 patients were classified with PD‐MCI, and 103 (94%) had multi‐domain MCI. We observed dramatic differences in the proportion of patients who had PD‐MCI using the new Level 2 criteria, depending on whether or not decline from premorbid level of intellectual function was considered. Recommendations for methods of operationalizing decline from premorbid levels constitute an unmet need. Among the 3 screening tests examined, none of the instruments provided good combined sensitivity and specificity for PD‐MCI. Other tests recommended by the Task Force Level 1 criteria may represent better choices, and these should be the subject of future research.

Behavioral abnormalities in progressive supranuclear palsy.

Progressive supranuclear palsy (PSP) is a rare neurodegenerative disorder in which, classically, patients present with postural instability and falls, parkinsonism, and slowing of vertical saccades. PSP patients typically have deficits in cognitive functioning, difficulties with most daily activities, and present with notable behavioral disturbances-particularly apathy, impulsivity, and irritability. Using data from 154 patients meeting criteria for clinically probable PSP, domain and total scores of the Neuropsychiatric Inventory were examined and compared to demographics, disease severity, cognition, and motor features. Behavioral abnormalities were common in this cohort of PSP patients, with more than half experiencing apathy, depression, and sleeping problems, and approximately one third displaying agitation, irritability, disinhibition, and eating problems. Few clinical correlates of neuropsychiatric symptoms were observed in this cohort. Given the prevalence of neuropsychiatric symptoms in PSP, these patients are expected to be frequently seen by psychiatrists and other mental health professionals for symptom management and increased quality of life. Clinical trials are clearly needed to address the neuropsychiatric morbidity in these patients.

Executive Dysfunction Is the Primary Cognitive Impairment in Progressive Supranuclear Palsy

Cognitive difficulties appear to be a more prevalent clinical feature in progressive supranuclear palsy (PSP) than previously thought, and significant cognitive impairment is prevalent in a majority of patients PSP patients not considered clinically demented. The neurocognitive performance of 200 patients with PSP across multiple sites was examined with a variety of commonly used neuropsychological tests. Results indicate primary executive dysfunction (e.g., 74% impaired on the Frontal Assessment Battery, 55% impaired on Initiation/Perseveration subscale of the Dementia Rating Scale), with milder difficulties in memory, construction, and naming. These results have important clinical implications for providers following patients with PSP.

Mild cognitive impairment: a history and the state of current diagnostic criteria.

ABSTRACT Background: Mild cognitive impairment (MCI) is a diagnostic classification used to describe patients experiencing cognitive decline but without a corresponding impairment in daily functioning. Over the years, MCI diagnostic criteria have undergone major changes that correspond to advancements in research. Despite these advancements, current diagnostic criteria for MCI contain issues that are reflected in the research literature. Methods: A review of the available MCI literature was conducted with emphasis given to tracing MCI from its conceptual underpinnings to the most current diagnostic criteria. A clinical vignette is utilized to highlight some of the limitations of current MCI diagnostic criteria. Results: Issues are encountered when applying MCI diagnostic criteria due to poor standardization. Estimates of prevalence, incidence, and rates of conversion from MCI to dementia reflect these issues. Conclusions: MCI diagnostic criteria are in need of greater standardization. Recommendations for future research are provided that could potentially bring more uniformity to the diagnostic criteria for MCI and, therefore, more consistency to the research literature.

Interventions for Cognitive Deficits in Breast Cancer Survivors Treated With Chemotherapy.

Background: Cognitive deficits are distressing adverse effects of chemotherapy that have a negative effect on quality of life in breast cancer survivors (BCSs). Cognitive deficits in cancer survivors are a top research and clinical practice priority. Objective: The aims of this study were to describe cognitive deficits that occur after chemotherapy, describe deficits in BCSs treated with chemotherapy within a framework of cognitive reserve and neuroplasticity, and discuss cognitive interventions (ie, cognitive training interventions, compensatory strategies with cognitive training interventions, pharmacological interventions, and complementary and integrative medicine interventions). Methods: PubMed search yielded 21 intervention studies of cognitive deficits in BCSs. Results: Cognitive training interventions and compensatory strategies with cognitive training resulted in improvement of cognitive deficits. Methylphenidate did not result in cognitive improvement. Modafinil showed improvement in attention. Some complementary and integrative medicine interventions are promising. Conclusions: Cognitive training has been most beneficial. Effectiveness of pharmacologic and complementary and integrative medicine interventions has not yet been established. Implications for Practice: While limited evidence is available to guide clinical management of cognitive deficits in BCSs, validating patients’ symptom experience and evaluating co-occurring symptom clusters such as fatigue, sleep, and depression, are suggested.

Age and Education Corrected Older Adult Normative Data for a Short Form Version of the Financial Capacity Instrument

Financial capacity is an instrumental activity of daily living (IADL) that comprises multiple abilities and is critical to independence and autonomy in older adults. Because of its cognitive complexity, financial capacity is often the first IADL to show decline in prodromal and clinical Alzheimers disease and related disorders. Despite its importance, few standardized assessment measures of financial capacity exist and there is little, if any, normative data available to evaluate financial skills in the elderly. The Financial Capacity Instrument-Short Form (FCI-SF) is a brief measure of financial skills designed to evaluate financial skills in older adults with cognitive impairment. In the current study, we present age- and education-adjusted normative data for FCI-SF variables in a sample of 1344 cognitively normal, community-dwelling older adults participating in the Mayo Clinic Study of Aging (MCSA) in Olmsted County, Minnesota. Individual FCI-SF raw scores were first converted to age-corrected scaled scores based on position within a cumulative frequency distribution and then grouped within 4 empirically supported and overlapping age ranges. These age-corrected scaled scores were then converted to age- and education-corrected scaled scores using the same methodology. This study has the potential to substantially enhance financial capacity evaluations of older adults through the introduction of age- and education-corrected normative data for the FCI-SF by allowing clinicians to: (a) compare an individuals performance to that of a sample of similar age and education peers, (b) interpret various aspects of financial capacity relative to a normative sample, and (c) make comparisons between these aspects. (PsycINFO Database Record

Both Financial and Cognitive Decline Predict Clinical Progression in MCI.

We investigated the roles of financial/functional and cognitive abilities in predicting clinical progression in patients with mild cognitive impairment (MCI). In a longitudinal sample of 51 patients with consensus conference diagnosed MCI likely due to Alzheimer disease (AD), two-year change scores were calculated for a performance measure of functional ability, cognitive variables, and 3 outcome measures used to track progression in neurological disorders. We examined patterns of financial and cognitive decline across the 2-year study period, and used these data and the 3 outcome variables to construct discrete predictor models of clinical progression in MCI. We found that both financial skills and cognitive abilities declined over the 2-year study period, were significantly associated with clinical progression, and contributed unique variance to all 3 predictor models. The resulting models accounted for 40% to 75% of variance in clinical progression across outcome variables. Taken together, our results indicate that changes in both cognitive abilities and higher order functional skills appear integral to understanding clinical progression in MCI likely due to AD. Specifically, declines in financial skills contribute unique variance to measures commonly used to track progression in neurological disorders associated with aging, and thus represent an important functional marker of clinical progression in prodromal AD.

Cognitive predictors of understanding treatment decisions in patients with newly diagnosed brain metastasis

Medical decision‐making capacity is a higher‐order functional skill that refers to a patients ability to make informed, sound decisions related to care and treatment. In a medical context, understanding is the most cognitively demanding consent standard and refers to a patients ability to comprehend information to the extent that informed decisions can be made.

Screening Instruments and Brief Batteries for Dementia

Publisher Summary This chapter reviews commonly used cognitive screening instruments and brief batteries for dementia. Cognitive impairment is the most frequent mental health syndrome affecting older adults and is a leading cause of disability, psychological distress, and health care expenditures. Dementia syndromes such as Alzheimers disease (AD) have grown in prevalence as advances in medical care have increased longevity. Early identification of cognitive impairment may also lead to empowerment of the cognitively impaired person and their family by giving them the opportunity to become more educated regarding the illness, which can lead to better decision-making and less stress. On the other hand, ruling out cognitive impairment can lead elders complaining of memory loss to look for other explanations. As dementia becomes more advanced, the purposes of brief batteries shift toward evaluating the impact of cognitive impairment on daily functioning, the need for environmental support to ensure safety, and a variety of clinical situations such as treatment and discharge planning. Although all instruments require evidence of clinical utility and validity, additional psychometric features may be emphasized depending upon the purpose of the assessment. Whereas instruments used for earlier detection of dementia syndromes require high levels of sensitivity, instruments used for the purpose of predicting functioning have greater requirements for predictive validity.

Functional impairment in progressive supranuclear palsy

Objective: The current study sought to describe the functional profiles of patients with early-stage progressive supranuclear palsy (PSP) in a large prospective, multisite study. Methods: Using data from 202 individuals meeting criteria for clinically definite or probable PSP, 3 functional scales were examined. Functional scores were then compared to measures of motor, cognition, and psychiatric symptoms. Results: Functional disability was high in early-stage PSP, with 100% of patients having less than perfect scores on all functional scales. Whereas functional scores tended not to be related to cognition or psychiatric symptoms, they were strongly related to motoric ratings. Conclusions: Both clinically and in research settings, the definition of functional intactness/impairment has important implications. Future studies should examine if functional impairment is this high in PSP or if new scales of functional abilities need to be developed for this condition.