Galit Yogev-Seligmann

The Role of Executive Function and Attention in Gait

Until recently, gait was generally viewed as a largely automated motor task, requiring minimal higher‐level cognitive input. Increasing evidence, however, links alterations in executive function and attention to gait disturbances. This review discusses the role of executive function and attention in healthy walking and gait disorders while summarizing the relevant, recent literature. We describe the variety of gait disorders that may be associated with different aspects of executive function, and discuss the changes occurring in executive function as a result of aging and disease as well the potential impact of these changes on gait. The attentional demands of gait are often tested using dual tasking methodologies. Relevant studies in healthy adults and patients are presented, as are the possible mechanisms responsible for the deterioration of gait during dual tasking. Lastly, we suggest how assessments of executive function and attention could be applied in the clinical setting as part of the process of identifying and understanding gait disorders and fall risk.

How Does Explicit Prioritization Alter Walking During Dual-Task Performance? Effects of Age and Sex on Gait Speed and Variability

Background Previous studies have demonstrated that the performance of a secondary task during walking alters gait. Objective This study investigated the effects of task prioritization on walking in young and older adults to evaluate the “default” prioritization scheme used, the flexibility to alter prioritization and cortical resources allocated to gait and a secondary cognitive task, and any age-associated changes in these abilities. Design A cross-sectional study that explicitly altered the focus of attention was used to investigate the effects of prioritization in young and older adults who were healthy. Methods Gait speed and gait variability were evaluated in young adults (n=40) and older adults (n=17) who were healthy, both during usual walking and under 3 dual-task conditions: (1) no specific prioritization instructions, (2) prioritization of gait, and (3) prioritization of the cognitive task. Results Young adults significantly increased gait speed in the gait prioritization condition compared with gait speed in the no-instruction condition; a similar tendency was seen in the older adults. Gait speed was reduced when priority was given to the cognitive task in both age groups; however, this effect was less dramatic in the older adults. In the young adults, prioritization of gait tended to have different effects on gait speed among both men and women. In the older adults, but not in the young adults, all dual-task conditions produced increased gait variability, whereas prioritization did not alter this gait feature. Limitations The sample size and the relative homogeneity of the older adults could be considered as possible limitations of the study. Conclusions Even among young adults, the effects of secondary, cognitive tasks on gait speed are strongly influenced by prioritization. This finding was less significant in the older adults, suggesting that there is an age-associated decline in the ability to flexibly allocate attention to gait. Somewhat surprisingly, when prioritization was not explicitly instructed, gait speed in both young and older adults most closely resembled that of the condition when they were instructed to focus attention on the cognitive task.

The interplay between gait, falls and cognition: can cognitive therapy reduce fall risk?

In this article, we briefly summarize the incidence and significant consequences of falls among older adults, the insufficient effectiveness of commonly used multifactorial interventions and the evidence linking falls and cognitive function. Recent pharmacologic and nonpharmacologic studies that evaluated the effects of cognitive therapy on fall risk are reviewed. The results of this article illustrate the potential utility of multiple, diverse forms of cognitive therapy for reducing fall risk. The article also indicates that large-scale, randomized controlled trials are warranted and that additional research is needed to better understand the pathophysiologic mechanisms underlying the interplay between human mobility, fall risk and cognitive function. Nonetheless, we suggest that multimodality interventions that combine motor and cognitive therapy should, eventually, be incorporated into clinical practice to enable older adults and patients to move safer and with a reduced fall risk.

Do we always prioritize balance when walking? Towards an integrated model of task prioritization

Previous studies suggest that strategies such as “posture first” are implicitly employed to regulate safety when healthy adults walk while simultaneously performing another task, whereas “posture second” may be inappropriately applied in the presence of neurological disease. However, recent understandings raise questions about the traditional resource allocation concept during walking while dual tasking. We propose a task prioritization model of walking while dual tasking that integrates motor and cognitive capabilities, focusing on postural reserve, hazard estimation, and other individual intrinsic factors. The proposed prioritization model provides a theoretical foundation for future studies and a framework for the development of interventions designed to reduce the profound negative impacts of dual tasking on gait and fall risk in patients with neurological diseases.

A Training Program to Improve Gait While Dual Tasking in Patients With Parkinson's Disease: A Pilot Study

Impairments in the ability to perform another task while walking (ie, dual tasking [DT]) are associated with an increased risk of falling. Here we describe a program we developed specifically to improve DT performance while walking based on motor learning principles and task-specific training. We examined feasibility, potential efficacy, retention, and transfer to the performance of untrained tasks in a pilot study among 7 patients with Parkinsons disease (PD). Seven patients (Hoehn and Yahr stage, 2.1±0.2) were evaluated before, after, and 1 month after 4 weeks of DT training. Gait speed and gait variability were measured during usual walking and during 4 DT conditions. The 4-week program of one-on-one training included walking while performing several distinct cognitive tasks. Gait speed and gait variability during DT significantly improved. Improvements were also seen in the DT conditions that were not specifically trained and were retained 1 month after training. These initial findings support the feasibility of applying a task-specific DT gait training program for patients with PD and suggest that it positively affects DT gait, even in untrained tasks. The present results are also consistent with the possibility that DT gait training enhances divided attention abilities during walking.

The contribution of postural control and bilateral coordination to the impact of dual tasking on gait

The simultaneous performance of a cognitive task while walking typically alters the gait pattern. In some populations, these alterations have been associated with an increased risk of falls, motivating study of this response from the clinical perspective. The mechanisms responsible for these effects are not fully understood. The concurrent requirement to control upright posture and stepping, a bilaterally coordinated rhythmic task, may be the cause of this so-called dual-tasking effect. To evaluate this possibility, the present study was designed to isolate the individual contribution of these two demands by assessing the effects of cognitive loading on standing (i.e., postural control without bilateral coordination of stepping), cycling (i.e., bilateral coordination similar to stepping, but with minimal postural demands), and walking. We also investigated the effects of aging and parkinsonism on the performance of these three tasks in response to cognitive loading, also referred to as a dual task. Twenty-one healthy young adults, 15 healthy older adults, and 18 patients with Parkinson’s disease were assessed while walking, standing, and cycling, with and without an additional cognitive load. In the young adults, the performance on the two motor tasks that involved bilateral coordination deteriorated significantly in response to the dual task, while standing was not impacted. Similar results, although less robust, were observed among the healthy older adults. In contrast, among the patients with Parkinson’s disease, the dual-task costs, i.e., the impact of the simultaneously performed cognitive task on the gait pattern, were high in all motor tasks. These findings suggest that walking is especially vulnerable to cognitive loading, in part, because of the unique sensitivity of bilateral coordination of limb movements to the effects of dual tasking.

The Montreal Cognitive Assessment in Cognitively-Intact Elderly: A Case for Age-adjusted Cutoffs

The Montreal Cognitive Assessment (MoCA) is a widely used screening test for evaluation of mild cognitive impairment (MCI), with a single cutoff for all ages. We examined whether it is associated with age in a sample of cognitively-intact elderly (CIE). The average MoCA score was negatively correlated with age and was significantly higher for younger than older CIE. Additionally, 42% of the older elderly fell below the proposed MCI cutoff score, although all subjects were CIE. Thus, cognitive abilities captured by the MoCA test decrease with age, even in CIE. Therefore, cutoff scores by age for the MoCA are needed.

Altered Topology in Information Processing of a Narrated Story in Older Adults with Mild Cognitive Impairment

The ability to store, integrate, and manipulate information declines with aging. These changes occur earlier, faster, and to a greater degree as a result of neurodegeneration. One of the most common and early characteristics of cognitive decline is difficulty with comprehension of information. The neural mechanisms underlying this breakdown of information processing are poorly understood. Using functional MRI and natural stimuli (e.g., stories), we mapped the neural mechanisms by which the human brain accumulates and processes information with increasing duration and complexity in participants with amnestic mild cognitive impairment (aMCI) and healthy older adults. To explore the mechanisms of information processing, we measured the reliability of brain responses elicited by listening to different versions of a narrated story created by segmenting the story into words, sentences, and paragraphs and then scrambling the segments. Comparing healthy older adults and participants with aMCI revealed that in both groups, all types of stimuli similarly recruited primary auditory areas. However, prominent differences between groups were found at the level of processing long and complex stimuli. In healthy older adults, parietal and frontal regions demonstrated highly synchronized responses in both the paragraph and full story conditions, as has been previously reported in young adults. Participants with aMCI, however, exhibited a robust functional shift of long time scale processing to the pre- and post-central sulci. Our results suggest that participants with aMCI experienced a functional shift of higher order auditory information processing, possibly reflecting a functional response to concurrent or impending neuronal or synaptic loss. This observation might assist in understanding mechanisms of cognitive decline in aMCI.

Abnormal neural hierarchy in processing of verbal information in patients with schizophrenia

Previous research indicates abnormal comprehension of verbal information in patients with schizophrenia. Yet the neural mechanism underlying the breakdown of verbal information processing in schizophrenia is poorly understood. Imaging studies in healthy populations have shown a network of brain areas involved in hierarchical processing of verbal information over time. Here, we identified critical aspects of this hierarchy, examining patients with schizophrenia. Using functional magnetic resonance imaging, we examined various levels of information comprehension elicited by naturally presented verbal stimuli; from a set of randomly shuffled words to an intact story. Specifically, patients with first episode schizophrenia (N = 15), their non-manifesting siblings (N = 14) and healthy controls (N = 15) listened to a narrated story and randomly scrambled versions of it. To quantify the degree of dissimilarity between the groups, we adopted an inter-subject correlation (inter-SC) approach, which estimates differences in synchronization of neural responses within and between groups. The temporal topography found in healthy and siblings groups were consistent with our previous findings – high synchronization in responses from early sensory toward high order perceptual and cognitive areas. In patients with schizophrenia, stimuli with short and intermediate temporal scales evoked a typical pattern of reliable responses, whereas story condition (long temporal scale) revealed robust and widespread disruption of the inter-SCs. In addition, the more similar the neural activity of patients with schizophrenia was to the average response in the healthy group, the less severe the positive symptoms of the patients. Our findings suggest that system-level neural indication of abnormal verbal information processing in schizophrenia reflects disease manifestations.

EPA-0414 – Breakdown of temporal hierarchy in neural processing of natural information: evidence from schizophrenia

Introduction The capacity to accumulate information over time is crucial to our functioning in an ever-changing world. Recently, in healthy subjects, we showed that brain uses a distributed and hierarchical network of brain areas to process information over time. Specifically, we revealed hierarchy of information processing over time from early sensory areas toward high order perceptual and cognitive areas. Here, we investigate this issue in first-episode schizophrenia patients. Objectives Previous studies posited that schizophrenia is the result of impairment of hierarchical temporal processing by the brain, claiming for impairment in use of context while being processing information. The hierarchical temporal deficit is a fundamental trait that may be a better target for the study of etiology and pathophysiology of the disease. Aims We intended to map, in schizophrenia patients, the topographical organization of temporal scales using an ecologically relevant auditory stimulus - a real-life story. In addition, we assumed that studying healthy siblings, who are at high-risk for cognitive dysfunctions, will enable to determine functional neuromarkers of predisposition to disorder. Methods The fMRI data were analyzed using inter-subject correlation approach. The time-courses within each brain area in schizophrenia patients were estimated against healthy controls and unaffected siblings of the patients. Results Among patients, we observed impaired hierarchy with processing intact in low level but disturbed in high level. The sibling group showed an intermediate effect. Conclusions Better understanding of the underlying neural circuit involved in information processing in schizophrenia patients may assist in early identification of functional neuromarkers for the disease.