The evolution of a relevant nosological concept reflects changes in the distinction between what is recognized and defined as normal and pathologic. Attention is directed to the rationale and value of detecting subclinical aging-related modifications in cognitive performance. The position that different kinds of dementias may have precedents in etiological-specific kinds of early or mild cognitive impairments (MCI) supports targeting people earlier for study of these subclinical symptoms. Because heterogeneous disorders can be expected to have multiple patterns of (...) cognitive and behavioral changes, useful conceptual nosologies should be flexible. Yet clinical research primarily restricts its focus to a single pathway where MCI leads to Alzheimer's disease (AD), and uses selective recruitment, washout screenings, repeated trialing of similar compounds, and other methods that bank the published evidence in favor of the existing therapies and their modest efficacy. This focus on AD recursively colors MCI, not as a flexible "human kind" in need of more careful research, but like AD, as an essential "natural kind." Early determination of MCI targets a potential pharmaceutical market of a quarter to a half of the population over sixty-five and the individual experiencing cognitive decline in its early stages is aware and sensitive to their surroundings, to a linked sociodegeneration with neurodegeneration. This paper examines how classifying people changes both the classifier and the subject of classification. The potential for conflict of interest is raised regarding what new causal knowledge and techniques for ascertainment are selected. Reading evidence from epidemiology, neurology, and clinical studies through science studies and bioethics lenses, we explore the possibility of a pluralistic model of cognitive impairment nosology where biological/pathologic processes respond and interrelate with a normal healthy state. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mild Cognitive Impairment:Where Does It Go From Here?John Bond (bio) and Lynne Corner (bio)Keywordsbiomedicalization, dementia, mild cognitive impairment, subjectivityThe joy of formal interdisciplinary discussion of this kind is the way that ideas presented through the gaze of social scientists stimulate such exciting thoughts and responses from other disciplines such as philosophy and psychology. We would like to thank Sabat and Thornton for their supportive and (...) provocative reactions to our paper. In the spirit of their responses, it is not our intention to respond to their thoughts directly; rather, we take the opportunity to theorize sociologically about this new category of psychiatry that has come to be known simply as mild cognitive impairment (MCI). In reviewing the responses of Sabat and Thornton, three thoughts emerged. First, together we have covered ontologic, epistemologic, methodologic, and theoretical questions about MCI, but none of us has posed basic political questions, such as: Why has MCI emerged as a new psychiatric label at this particular time? Second, this discussion brings together social scientists with a psychologist and a philosopher, but important constituents are missing. Consequently we are missing "insider" views on the importance of MCI to clinical practice. Third, this discussion highlights for us even more acutely the central question: Is MCI a real entity? In the following, we reflect on the first of these because our response also addresses the third. We first revisit the "evidence" about the importance of MCI for clinical practice.The notion of MCI as the transitional state between normal aging and Alzheimer's disease and other dementias has existed in a number of guises for many years, with benign senescent forgetfulness (Kral 1962) being the forerunner of a number of other terms, including questionable dementia, incipient dementia, isolated memory impairment, mild neurocognitive decline, age-associated memory impairment, age-associated cognitive decline, and cognitive-impairment-not-demented (Geda et al. 2004). Given that psychiatric labels implying the existence of MCI have been part of the practice landscape for over forty years, it is perhaps not surprising that its reinvention in the form of MCI has not, it appears, raised much attention outside specialist centers in North America and Europe. The reaction from grassroots clinical practice has been similar in intensity to their subdued reaction to the antipsychiatry movement in the 1960s. But for specialist clinics like the Mayo Clinic in Rochester, Minnesota, it has been an expanding [End Page 29] industry with numerous published papers, international conference presentations, and research funding opportunities.MCI can be distinguished from similar diagnostic categories that preceded its appearance in 1991. A key diagnostic criteria is the requirement for a subjective memory complaint by the person subsequently diagnosed as having MCI. Other diagnostic criteria include normal general cognitive function, normal activities of daily living, and memory being impaired for age, but not being demented (Petersen et al. 1999; Petersen and Morris 2003). To our knowledge, the idea of subjectivity being an important diagnostic criterion, as opposed to a means of identifying signs and symptoms, is a first in medical science. We know of no other medical category or diagnosis where subjectivity plays such a significant role, other than perhaps severe health phobias. Broadly speaking, two kinds of clinical evidence for MCI exist: first, that originating from studies (some quite small) applying the diagnostic criteria in specialist clinic populations; and, second, that found in large population studies. The main distinction between these two sets of evidence is that one is based on selected clinic populations and the other on unselected community populations. Most studies conclude that people whose memory is impaired for their age, as measured by similar cognitive tests such as the Mini-Mental State Examination, show decline in cognition that often leads to Alzheimer's disease and other kinds of dementia in the future. This finding is not remarkable given that it has long been known that age is a predictor of cognitive impairment. However, the population studies suggest a lower conversion rate than those for specialist clinics (Ritchie, Artero, and Touchon 2001).Petersen (2005) provides a robust defense as to why MCI might be a useful category in research and also indicates the potential benefits of treating MCI... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mild Cognitive Impairment Is RelevantRonald C. Petersen (bio)Keywordsaging, Alzheimer’s disease, dementia, mild cognitive impairment, pharmaceutical industryGraham and Ritchie (2006) have contributed a scholarly document that implores us to reexamine nosological categories and certain diagnostic outcomes. They have chosen mild cognitive impairment (MCI) as the target of their scrutiny and have raised several interesting issues. I would like to comment on their approach and (...) suggest that MCI is a useful clinical entity that does serve a practical function and hopefully will lead to a better quality of life for aging persons.There are several clarifications concerning the construct of MCI that need to be emphasized. Graham and Ritchie have asserted that all persons with MCI eventually evolve to Alzheimer's disease (AD) and have claimed that this is the inevitable outcome of the disorder. Although it is true that many of the early studies on MCI focused on the amnestic subtype as a precursor to AD (Bennett et al. 2002; Ganguli, Dodge, Shen, and DeKosky 2004; Lopez et al. 2003; Petersen et al. 1999), subsequent work has expanded the construct to include prodromal forms of other disorders (Petersen 2004; Winblad et al. 2004). As such, the construct of MCI has become flexible in recent years to account for alternative types of intermediate cognitive impairment.The authors state that MCI addresses those individuals speculated to have an inevitable dementia. Certainly, we do not presume that dementia is inevitable in the aging process; rather, we posit that if certain criteria are fulfilled in persons who are aging, the likelihood of a person progressing to a certain type of dementia is quite high. As such, this is an important precondition about which to learn, because interventional strategies may be available.Graham and Ritchie argue that some cognitive changes with aging are "normal" and trying to classify these individuals as "abnormal" is performing a disservice to much of the aging population. We draw an important distinction between the cognitive changes of normal aging, as they are recognized to exist, and what we feel constitutes the pathologic changes of MCI. We believe that the abnormal cognitive function found in MCI has a high probability of progressing to a greater degree of cognitive dysfunction in a relatively short period of time and these behavioral changes are accompanied by pathologic brain changes that are manifested on magnetic resonance imaging scans, positron emission tomography scans, cerebrospinal fluid biomarkers, and autopsy studies (Hampel et al. 2004; Jack et al. 1999; Markesbery et al. [End Page 45] 2006; Petersen et al. 2006). This type of progression is in contradistinction to other individuals who are experiencing cognitive changes of normal aging. These individuals do not progress rapidly to greater degrees of impairment and autopsy studies reveal that their brains do not harbor the pathologic changes found in the MCI population (Knopman et al. 2003).The cognitive and behavioral changes accompanying persons with MCI are devastating and cannot be ascribed to "senility" or "He is just getting old." It is a mistake to imply that by labeling people with a condition such as MCI we are doing them a disservice. Most of these individuals are seeking medical attention for their perceived difficulties. Consequently, addressing these concerns and educating the individuals on the implications of their symptoms are important services. Although we may not have adequate therapies at present, this does not imply that we should ignore the symptoms.We cannot treat many conditions at present, yet we do not avoid the opportunity to characterize the condition and make a diagnosis. Even if this were part of the aging process, this does not mean that we should ignore the disability and refuse to treat it. Most individuals develop an inflexibility of their optical lenses as they age, yet corrective lenses of one type or another are believed to be extremely beneficial at alleviating this disability associated with the aging phenomenon. No one would argue that it is inappropriate to treat this condition because it is "just a part of aging."It should be noted that I have stressed the situation in which individuals are seeking medical attention for their cognitive concerns. It is quite a different situation if an... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mild Cognitive Impairment:What's in a Name?Steven R. Sabat (bio)Keywordslabeling, mild cognitive impairment, recall memory, selfhood, stereotype threatCorner and Bond (2006) raise a number of important conceptual issues related to the problems involved in defining mild cognitive impairment (MCI), differentiating it from normal aging, the definition of normal aging itself, and ethical issues surrounding the possible adverse effects of a diagnosis of MCI on (...) the individuals thus described. It would seem that portentous ramifications are involved and that clarifying the conceptual issues would be of great value, not only to researchers but also to the ever-growing population of elderly people. In what follows, I address some of these issues further.Problems of Definition and MeasurementOne of the problems that the authors discuss at the outset of their article concerns what methods are appropriate for detecting those with MCI: "Neuropsychological tests alone do not discriminate between normal aged-related memory loss and MCI or dementia and clinical judgment remains central to diagnosis" (Corner and Bond 2006, 5). Of course, to be able to discriminate between normal aged-related memory problems and MCI, we must first be able to define the former. What exactly is normal? As the authors correctly point out, the term has different meanings, one being normative (usual), another being nonpathologic. Is it normal (usual) for some sort of breakdown to occur in brain systems as a function of increased age? If so, is there a threshold age below which the very same physiologic breakdown is unusual? Would such a threshold age, if one existed, be the same for everyone, regardless of genotype and the cumulative interactive effects of nutrition, health, and stress-related factors over a period of decades? In effect, is some sort of memory impairment part of the natural (usual) process of aging for some people at particular ages rather than for others? And exactly what does it mean to be mildly impaired in the cognitive domain?Hogan and McKeith (2001) presented a working group's definition characterizing MCI such that people who complain about memory problems and who also provide objective evidence of such problems, yet who simultaneously display "normal general cognitive function and intact activities of daily living" (Hogan and McKeith 2001, 1131), should be identified and followed. Here again, however, we confront the problem of defining "normal general cognitive function" as well as "normal activities of daily living." Can one have normal general cognitive function without normal memory function? If so, what exactly constitutes [End Page 13] general cognitive function and on what conceptual or theoretical basis is such a definition valid? Furthermore, what sort of memory function are we talking about? Memory can be said to involve a number of stages: encoding, storage, and retrieval. Retrieval can be of the explicit type (conscious recall or recognition of specific information) with which people with Alzheimer's disease (AD) often reveal deficits or of the implicit type (a change in behavior as a result of previous experience of which the person may have no conscious recollection) as demonstrated in people with AD (Knopman and Nissen 1987). That is, people with AD can display deficits in explicit memory functions without similar deficits simultaneously in implicit memory functions.A partial answer to the question about memory loss in MCI may be found in the use of the Mini-Mental State Examination (MMSE; Folstein, Folstein, and McHugh 1975), originally intended to be used as a screening device, but employed more and more frequently as an outcome measure to assess cognitive decline as well as the efficacy of drug treatments. Although the examination purports to test orientation, registration, attention, calculation, recall, language (naming, repeating, reading, writing, three-stage command), and construction, a task analysis reveals that the test is not quite as "global" in the cognitive domain as it is purported to be. For example, ten of the maximum thirty points on the examination are earned for "orientation" in time and place. Yet, all of the questions in this section of the test require intact recall of the relevant information. For example, if a person is asked, "What day of the week is this?" and replies "I don't know," the... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mild Cognitive Impairment:Kinds, Ethics, and Market ForcesStephen Ticehurst (bio)KeywordsAlzheimer’s disease, dementia, human kinds, mild cognitive impairment, natural kindsIn their article, Graham and Ritchie (2006) robustly confront the term mild cognitive impairment (MCI). They contrast a "real" diagnosis of Alzheimer's disease (AD) with a potentially spurious human invention called MCI. They argue we should not push MCI and AD too close together, lest MCI (...) catch too much of the reflected reality it does not deserve. I agree with their purpose, but suspect their argument is not as clear cut as we might hope.Classification is fundamental to the human activity called science. It is reflected also in the way we allocate and refine words. Classification allows us to determine the usefulness of terms, to share meaning, and hopefully to predict. MCI is an attempt at classification in this manner.The first problem is the clarity of definition. Graham and Ritchie imply that others see MCI as a precursor to dementia. At times they fall prey to this belief themselves. But is this what MCI claims? This link to AD and its recursive coloring of MCI is central to their argument. It seems that many hope that MCI is a term for "at risk of dementia." This confusion hampers much of the debate. The current operationally defined nosological criteria specify MCI is not dementia. This means that MCI can not be dementia without changing the criteria for one or both. At present, the evidence does not support this. Those people with MCI who will go on to develop dementia cannot reliably be distinguished from those who have a defective memory for other reasons. In the meantime, the link between MCI and dementia of various types is a valid area for investigation. Graham and Ritchie should have more confidence that usefulness can be determined by science and that this will triumph in the end.Modern psychiatry is very keen to believe it is naturalistic. Everything can be measured and will soon be explained by physical laws. However, Graham and Ritchie point to the intrusion of human concepts and values that may be shaping the way we measure the natural world. They invoke the term human kind to differentiate this activity from natural kinds. Psychiatry has always struggled to connect its diagnoses to naturalistic ideas of pathology and etiology. It could be argued that psychiatric nosology has always been susceptible to the creations of humans. Another modern invention—early psychosis—has parallels with the MCI story. But as the Rorschach test shows, most of us continue to see shapes in what really [End Page 53] is only an inkblot. If the shape is something we really want to see, expect, or have been trained to look for, so much the better. A definable precursor state to dementia (or schizophrenia) would make us all happy, not just those insatiable shareholders. However, the earlier in the unfolding of degenerative dementia we go, the less reliable and valid are our clinical diagnoses.Graham and Ritchie say MCI is a human kind, unlike Alzheimer's disease, which is an essential natural kind. The authors argue that the purported relationship between MCI and AD feed back in a loop to give MCI a natural kind standing that it does not yet deserve. They examine the underlying social processes that support this firming of an as yet insubstantial concept. These include the desire for patients and their doctors to have hope and pharmaceutical companies to have markets and profits. They invoke a mythical authorized person who can determine a diagnosis as a newly formed kind after a common act of recognition. Using kind in this context appears to refer to a thing rather than a term. But it is the term that is being socially validated, not the thing. AD is a more socially validated term than MCI, but its relationship with reality remains humanly constructed.Does the invocation of kinds aid this argument? A kind is not really what it appears. A kind is a term to describe a concept that humans hold about the world. Therefore, dividing kinds into various types, such as natural, human, and practical, betrays the inevitable human... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mild Cognitive Impairment:Which Kind Is It?Andy Hamilton (bio)Keywordshuman kinds, mild cognitive impairment, multiple personality disorder, practical kinds, social constructionThere is much stimulating material in the Graham and Ritchie's paper (2006), concerning not just disease-classification but also the ethics of diagnosis. My concern is with the way in which they adduce Ian Hacking's views in the philosophy of science in support of their own. The authors (...) quote with approval his "dynamic nominalism" and its influence on Zachar's concept of "practical kinds." Hacking's view, as the authors quote it, is that "People classified in a certain way tend to conform to or grow into the ways that they are described; but they also evolve in their own ways, so that the classifications and descriptions have to be constantly revised" (1995, 21). The act of classifying changes both the classifier and the subject of classification, resulting in facts and categories that are both socially created and real. Hacking calls this "the looping effect of human kinds," and comments that "Multiple personality [disorder] is an almost too perfect illustration of this feedback effect" (1995, 21). The authors comment that Zachar (2000) builds on Hacking's position, discarding essentialist notions of classification that are limited to inherent biological properties, and turning instead to "practical kinds—nonarbitrary cultural artifacts intended to meet pragmatic needs (e.g. therapeutic, predictive prognostic, labeling effects, and physiology)" (Graham and Ritchie 2006, 36). Practical kinds, they believe, offer a way out of the clinical approach focused on mild cognitive impairment (MCI) as a precursor to, or mild form of, Alzheimer's disease. The inclination of the authors, as I read them, is to treat MCI as a practical or human kind, and not, like Alzheimer's disease, as a natural kind.My concern is whether the "looping effect of human kinds" can be transferred to the case of MCI from Hacking's original case study in Rewriting the Soul, multiple personality disorder (MPD). Hacking wished there to undermine the traditional debate over whether MPD is a "social or psychiatric artifact." He claims, correctly I think, that the presupposition behind the question "Is MPD a real disorder as opposed to a product of social circumstances?" should be rejected. The fact that a disorder is a product of social circumstances does not make it less real (1995, 12). On the looping of human kinds, Hacking comments that "The concept of child abuse [implicated in MPD] may itself be so made and molded by attempts at knowledge and intervention, and social reaction to these studies, that there is no stable object, child abuse, to have knowledge about." This is a "no fact of the matter" response, and it [End Page 51] is based on the recognition of conceptual change. He later adds that child abuse "is a real evil, and it was so before the concept was constructed. It was nevertheless constructed. Neither reality nor construction should be in question" (1995, 61, 68). However, Hacking's conclusions about the reality of MPD express only a muted skepticism. Utilitarian skeptics approach this question by asking, "What is the most effective treatment?" Hacking writes that "in their hearts [such skeptics] suspect that the outcome of multiple therapy [therapy that condones or even encourages the development of multiples in the patient] is a type of false consciousness" (1995, 267). The skeptics about MPD are making a moral judgment, he believes; but on whether that moral judgment is correct, he is silent, although the suspicion must be that he agrees with it.How do these considerations apply to the case of MCI? Graham and Ritchie rightly note that classifying a subject as suffering from MCI, and informing them of the diagnosis, will affect them adversely—it will cause suffering not least because there is at present no cure. However, it must surely be conceded that any disease at all—physical or mental—is a social entity insofar as it involves behavioral ascriptions to the subject concerning their incapacity. The authors also note the vested interests—especially from the pharmaceutical industry—in developing a diagnostic category of MCI. These interests are present in the development of any significant diagnostic... (shrink)

The lifetime prevalence of major depressive disorder in adolescents is reported to be as high as 20%; thus, MDD constitutes a significant social and public health burden. MDD is often associated with nonsuicidal self-injury behavior, but the contributing factors including cognitive function have not been investigated in detail. To this end, the present study evaluated cognitive impairment and psychosocial factors in associated with MDD with NSSI behavior. Eighteen and 21 drug-naïve patients with first-episode MDD with or without (...) NSSI and 24 healthy control subjects were enrolled in the study. The Hamilton Anxiety Scale, Hamilton Depression Scale, Adolescent Self-injury Questionnaire, Beck Scale for Suicide Ideation–Chinese Version, Shame Scale for Middle School Students, Sensation Seeking Scale and Childhood Trauma Questionnaire were used to assess depression-related behaviors, and event-related potentials were recorded as a measure of cognitive function. The latency of the N1, N2, P3a, P3b, and P50 components of ERPs at the Cz electrode point; P50 amplitude and P50 inhibition showed significant differences between the 3 groups. CTQ scores also differed across three groups, and the NSSI– and NSSI+ groups showed significant differences in scores on the Shame Scale for Middle School Students. Thus, cognitive function was impaired in adolescents with MDD with NSSI behavior, which was mainly manifested as memory decline, attention and executive function deficits, and low anti-interference ability. We also found that childhood abuse, lack of social support, and a sense of shame contributed to NSSI behavior. These findings provide insight into the risk factors for MDD with NSSI behavior, which can help mental health workers more effectively diagnose and treat these patients. (shrink)

Background: In the present study, we aimed to better investigate attention system profile of Parkinson's disease-Mild Cognitive Impairment patients and to determine if specific attentional deficits are associated with 123I-FP-CIT SPECT.Methods: A total of 44 de novo drug-naïve PD patients [ with normal cognition and 17 with MCI ], 23 MCI patients and 23 individuals with subjective cognitive impairment were recruited at the Clinical Neurology Unit of Santa Chiara hospital. They were assessed by a wide neuropsychological (...) battery, including Visual Search Test measuring selective attention. Performances among groups were compared by non-parametric tests. Further, Spearman's rank correlations were performed to explore the association between neuropsychological variables and 123I-FP-CIT SPECT data in PD subgroup.Results: PD-MCI patients performed worse on VST than patients with PD-NC, patients with MCI and individuals with SCI. The performance of PD-MCI patients on VST significantly correlated with caudate nucleus 123I-FP-CIT SPECT uptake, whereas a negative correlation between such test and 123I-FP-CIT SPECT uptake in the left putamen was found in PD-NC patients.Conclusions: We suggest that selective attention deficit might be a trigger of cognitive decay in de novo PD-MCI patients. The VST should be routinely used to detect attentional deficits in hospital clinical practice, in the light of its closely association with dopamine depletion of basal ganglia in mildly impaired PD patients. (shrink)

ImportancePrevious studies of post-acute COVID-19 syndrome have focused on critical cases with severe disease. However, most cases are mild to moderate in disease severity.ObjectiveWe aimed to examine cognitive outcomes in cases of non-critical, mild-to-moderate COVID-19. Design, Setting, and Participants: In this cross-sectional study, we enrolled 72 adults aged 22 to 65 years in Central Texas who had non-critical, mild-to-moderate COVID-19 infection between 13 January 2021 and 20 April 2021.Main Outcomes and MeasuresWe remotely administered cognitive-behavioral testing to determine the (...) frequency of cognitive impairment and examine demographic, clinical, and psychosocial contributors to impairment.ResultsThe frequency of objective cognitive impairment was 40%. The largest number of participants showed impairment on a measure of executive functioning. Attention and processing speed was more impaired in males. Males endorsed lower adherence to social distancing guidelines, which was in turn associated with cognitive impairment across participants. Younger age was correlated with impairment but was also associated with racial/ethnic minority status and increased psychological symptoms. Moderate COVID-19 severity was associated with attention/processing speed impairment, increased pain, and higher number of COVID-19 symptoms.Conclusion and RelevanceMild or moderate COVID-19 infection may be associated with cognitive impairments, especially in the domain of executive functioning. A subgroup of younger individuals may be more vulnerable to cognitive and psychosocial effects of COVID-19.HighlightsQuestion: How frequent is cognitive impairment among non-critical, mild-to-moderate COVID-19 survivors?FindingsIn this cross-sectional study of 72 adults, 40% demonstrated cognitive impairment, particularly in executive function.MeaningNeurologic sequelae, such as cognitive impairment, may be common following COVID-19 infection. (shrink)

This paper examines the ethical conundrum between a hospital's ethos of relieving distress, investigation and treatment, and its concurrent duties under English law to administer tests of decision-making capacity and safeguarding protection where it believes the patient may lack this capacity. Delirium, characterised by a precipitous decline in mental functioning exhibiting the shared symptomology of recoverable depressive disorders and terminal dementia, is not uncommon after emergency admission of elderly patients into acute medical hospital wards. The use of functional capacity testing (...) as a benchmark for decision-making capacity for post-discharge residence has been criticised as outdated, conceptually floored, subjective, lacking central guidance, transparent process, and accountability. A study of patient experience demonstrates the potential for hospital misuse of capacity testing, the failure of functional testing to differentiate decision making capacity from the disability of partial cognitive impairment, and how hospital capacity processes can interact and amplify patient pathology thereby decreasing recovery prospects. Prioritisation of mental capacity obligations above thorough investigation of emergent mental pathology and relief of patient anguish, results in extended detention in medical wards lacking bespoke facilities. Further understanding of patient experience is needed to inform policy with interventions tailored to avoid harm and increase wellbeing. (shrink)

Most democratic countries either limit or deny altogether voting rights for people with cognitive impairments or mental health conditions. Against this weight of legal and practical exclusion, disability advocacy and developments in international human rights law increasingly push in the direction of full voting rights for people with cognitive impairments. Particularly influential has been the adoption by the UN of the Convention on the Rights of Persons with Disabilities in 2007. Article 29 declares that states must ‘ensure that (...) persons with disabilities can effectively and fully participate in political and public life on an equal basis with others, directly or through freely chosen representatives, including the right and opportunity for persons with disabilities to vote and be elected’. This article also argues for the right of all people to vote, including people with cognitive impairments, by adopting a uniquely strategic approach. Firstly, some of the strategic limitations of existing arguments in favour of extending the franchise are highlighted. Most such arguments are flawed because they run the risk of inviting disparaging philosophical commentary which compares disabled people to animals, or because they are based on implausible empirical claims, or because they inadvertently tie the case for voting rights for the disabled to other cases unlikely to ever enjoy widespread acceptance. This article, instead, justifies extending voting rights to all people with cognitive impairments based on a simple cost-benefit analysis that avoids all of these problems. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ambiguities of Mild Cognitive ImpairmentTim Thornton (bio)Keywordsclassification, disease, mild cognitive impairment, normative, valuesCorner and Bond's paper (2006) raises some key ethical questions about the classification and diagnosis of mild cognitive impairment (MCI). In this commentary, I wish to revise some of the general issues about the classification of mental disorder raised by this particular classificatory concept. The central issue raised is the connection (...) between the pathologic status of a condition and what I term the plain facts about the frequency and nature of its symptoms.There are a number of ethical questions raised by applying the label of MCI. Centrally, perhaps, is the concern, illustrated by the case vignettes, that a diagnosis carries negative repercussions that might outweigh the more narrowly medical advantages of an early diagnosis. But although that concern may be appropriate, such ethical complications are a danger of any psychiatric classification or diagnosis, even the most well grounded. Any psychiatric diagnosis can carry a danger of stigma, for example.What seems to make such ethical concerns more serious in this case—at least to a philosopher outsider—is the implicit further concern that MCI is not a real, objective, or, to use a more medical term, valid category or classification. If it is not valid, then any negative connotations of the diagnosis will not be outweighed by medical technological achievements. In other words, the further ethical issues are given much greater weight if the question of validity is not satisfactorily resolved.The question of the reality, objectivity, or validity of MCI can be divided into two issues:1. Is MCI a real, objective, or valid feature of psychological phenomenology?2. Is MCI a real, objective, or valid psychological illness, disease, or pathology?A condition might be a real, objective, or valid feature of psychological phenomenology without being a real illness. It might be some other aspect of human living. Szasz (1960) suggests that this is the case with mental illness (he might more properly say "so-called mental illness") as a whole. But, less controversially, the unusual ability to calculate, mentally and in a flash, the date of future Easter Sundays is a genuine feature of human living—some people possess the ability even if most do not—without either it, or its lack, being an illness. Being real as an illness is a very specific kind of being. It is this, I suggest, that raises difficulties in the case of MCI by contrast with the easier question of whether something is a genuine feature of human living in some other way. [End Page 21]From "normal" and "normative" to "correct" and "incorrect"Corner and Bond (2006) usefully suggest that the question of whether MCI is real is made more difficult by an ambiguity in the sense of the word normal. They suggest that although "physiologic and cognitive decline is assumed to be a normal experience" this still leaves "boundary problems" about "distinguishing normal aging from disease" (Corner and Bond 2006, 3–4). Thus, if the symptoms of MCI are continuous with the ordinary phenomena of physiologic and cognitive decline, then they might also be merely normal. But this does not settle the status of MCI because normal can mean either "normative, that is, usual; or it can mean nonpathologic" (Corner and Bond 2006, 4).On the assumption that MCI is at least continuous with phenomena that are normal, then its symptoms might be normal in the sense of usual but nevertheless pathologic: an inevitable illness. Or they might be usual and nonpathologic, that is, merely a feature of aging that, although regrettable, lacks the connotations of illness (e.g., the appropriateness, if not the possibility, of treatment). (In principle on the assumption in play—that the symptoms of MCI are normal—they might be unusual but nonpathologic akin, for example, to an improved ability to solve crosswords with age that might affect a small lucky proportion of the population. Perhaps such a crossword puzzler might be reassured by their doctor: "Well that is very unusual but there is no need to worry: it is not a symptom of any illness. You are perfectly normal.")Thus the question "Is MCI normal... (shrink)

Mild Cognitive Impairment (MCI) is a diagnostic category indicating cognitive impairment which does not meet diagnostic criteria for dementia such as Alzheimer’s disease. There are public health concerns about Alzheimer’s disease (AD) prompting intervention strategies to respond to predictions about the impacts of ageing populations and cognitive decline. This relationship between MCI and AD rests on three interrelated principles, namely, that a relationship exists between AD and MCI, that MCI progresses to AD, and that there (...) is a reliable system of classification of MCI. However, there are also several ethical issues and problems arising in the AD/MCI relationship. These include early diagnosis and interventions, the effects on people with MCI, and the newer neuroimaging and neuropharmacological approaches used in diagnosis and treatment. All these issues pose questions about the principles of MCI in relation to AD, with implications for how MCI is understood, diagnosed, treated, and experienced by patients. This article analyses four challenging areas for neuroethics: the definition and diagnosis of MCI; MCI in relation to AD; clinical implications of MCI for ethical disclosure, diagnosis, and treatment; and the research implications of MCI. The significant connections between these areas are often overlooked, together with uncertainties overall. Patients, healthcare systems and society are best served by informed clinicians, academics and researchers. After 35 years, the store of MCI knowledge is expanding and evolving. (shrink)

Start Exercising Your Brain Now: 201 Word and Number Exercises to Challenge Your Memory, Reasoning, Visual-Spatial Skills, Vocabulary, and More! Keep your brain active, even with MCI. For adults with Mild Cognitive Impairment, brain exercises are the best way to stay sharp and delay the onset of dementia. That’s why cognitive specialist Dr. Tonia Vojtkofsky tailored this fun workbook specifically for people with MCI. It’s the first of its kind! Find a word that meets the definition and (...) contains the letters “CAN” Truthful; straightforward; frank A brown nut with an edible kernel A cylinder black of wax with a wick Pick the one statement that is correct: UWYVX V is right of X. W is right of V. V is between U and Y. Y is right of W. Find and complete the pattern: 5, 8, 12, 17, 23, _____, _____, _____, _____. 14, 56, 224, 896, _____, _____, _____, _____. 5, 15, 30, 90, 180 _____, _____, _____, _____. Plus: Complete the word, image recall, determine the order, matching, true or false, logic problems, decode using clues, trivia, discover the pattern, word mazes, and math games. “The idea for the book originated from my need to provide appropriate brain exercises for my clients who have MCI. All of the brain-exercise books on the market today are for people with no cognitive impairment and therefore were too hard for my clients. I knew that I had to provide something for this underserved population.”—Dr. Tonia Vojtkofsky. (shrink)

Parkinson's disease has long been perceived as a pure motor disorder, partly due to its initial description by James Parkinson, who suggested that "senses and intellect remain intact", and partly due to the fact that patients with PD did not survive long, before effective treatment became available. As the survival time of patients with Parkinson's disease has substantially increased due to modern treatment, it has become apparent that cognitive deficits and dementia are also frequent features, especially in elderly patients. (...) With the progression of the disease and age, dementia develops in a substantial number of patients and constitutes a major therapeutic challenge. Dementia has thus increasingly been the focus of research and practice in recent years and a large body of knowledge has been accumulated. Despite these developments there has been no single volume dedicated to this topic. This book provides an extensive overview of the current status of knowledge pertaining to cognitive impairment and dementia associated with Parkinson's disease, intended as a reference book for general neurologists, neurology residents and also those with a special interest in movement disorders. In this edited volume experts in the field describe in detail all aspects of cognitive impairment and dementia in Parkinson's disease, including epidemiology, spectrum of clinical features, pathology, neurochemistry and genetics, findings in auxiliary investigations, relation to other neurodegenerative disorders, diagnostic process and management, and rounded up by discussion of future research directions and expectations. The text is complemented and enriched with tables, figures and heavily referenced to encompass all relevant literature. (shrink)

Elucidating distinct morphological atrophy patterns of Alzheimer’s disease and its prodromal stage, namely, mild cognitive impairment helps to improve early diagnosis and medical intervention of AD. On that account, we aimed to obtain distinct patterns of voxel-wise morphological atrophy and its further perturbation on structural covariance network in AD and MCI compared with healthy controls. T1-weighted anatomical images of matched AD, MCI, and HCs were included in this study. Gray matter volume was obtained using voxel-based morphometry and compared (...) among three groups. In addition, structural covariance network of identified brain regions exhibiting morphological difference was constructed and compared between pairs of three groups. Thus, patients with AD have a reduced hippocampal volume and an increased rate of atrophy compared with MCI and HCs. MCI exhibited a decreased trend in bilateral hippocampal volume compared with HCs and the accelerated right hippocampal atrophy rate than HCs. In AD, the hippocampus further exhibited increased structural covariance connected to reward related brain regions, including the anterior cingulate cortex, the putamen, the caudate, and the insula compared with HCs. In addition, the patients with AD exhibited increased structural covariance of left hippocampus with the bilateral insula, the inferior frontal gyrus, the superior temporal gyrus, and the cerebellum than MCI. These results reveal distinct patterns of morphological atrophy in AD and MCI, providing new insights into pathology of AD. (shrink)

BackgroundSocial cognitive impairments adversely affect social functioning in patients with schizophrenia. Although pharmacological interventions have been suggested to provide some benefits on social cognition, little information is available on the comparative efficacy of pharmacotherapy. Thus, the aim of this planned systematic review and network meta-analysis is to perform a quantitative comparison of the effects of various psychotropic drugs, including supplements, on social cognition disturbances of schizophrenia.MethodsThe literature search will be carried out using the PubMed, Embase, Cochrane Central Register of (...) Controlled Trials, PsycINFO, ClinicalTrials.gov, and International Clinical Trials Registry Platform databases from inception onward. Randomized controlled trials that examined the efficacy of drugs in social cognitive disturbances will be included, based on the most recent studies and the broader literature than previously searched. This protocol defines a priori the methods that will be used for study selection, data collection, quality assessment, and statistical syntheses.DiscussionThe findings this work are expected to help promote the development of better therapeutics of social cognitive impairments in schizophrenia and related psychiatric conditions.Systematic Review Registration[www.crd.york.ac.uk/prospero], identifier [CRD42021293224]. (shrink)

Although a large body of literature exists propounding the importance of space in aged care and care of the older person with dementia, there is, however, only limited exploration of the ‘acute care space’ as a particular type of space with archetypal constraints that maybe unfavourable to older people with cognitive impairment and nurses wanting to provide care that is person‐centred. In this article, we explore concepts of space and examine the implications of these for the delivery of (...) care to older people who are cognitively impaired. Our exploration is grounded in theorisations of space offered by key geographers and phenomenologists, but also draws on how space has been constructed within the nursing literature that refers specifically to acute care. We argue that space, once created, can be created and that nursing has a significant role to play in the process of its recreation in the pursuit of care that is person‐centred. We conclude by introducing an alternative logic of space aimed at promoting the creation of more salutogenic spaces that invokes a sense of sanctuary, safeness, and inclusion, all of which are essential if the care provided to the older person with cognitive impairment is apposite to their needs. The concept of ‘person‐centred space’ helps to crystallize the relationship between space and person‐centred care and implies more intentional manipulation of space that is more conducive to caring and healing. Significantly, it marks a return to Nightingale's wisdom, that is, to put the person in the best possible conditions for nature to act upon them. (shrink)

Relationships are central to enacting person‐centred care of the older person with cognitive impairment. A fuller understanding of relationships and the role they play facilitating wellness and preserving personhood is critical if we are to unleash the productive potential of nursing research and person‐centred care. In this article, we target the acute care setting because much of the work about relationships and older people with cognitive impairment has tended to focus on relationships in long‐term care. The (...) acute care setting is characterized by archetypal constraints which differentiate it from long‐term care, in terms of acuity and haste, task‐orientated work patterns and influence from “the rule of medicine,” all of which can privilege particular types of relating. In this article, we drew on existing conceptualizations of relationships from theory and practice by tapping in to the intellectual resources provided by nurse researchers, the philosophy of Martin Buber and ANT scholars. This involved recounting two examples of dyadic and networked relationships which were re‐interpreted using two complementary theoretical approaches to provide deeper and more comprehensive conceptualizations of these relationships. By re‐presenting key tenets from the work of key scholars on the topic relationships, we hope to hasten socialization of these ideas into nursing into the acute care setting. First, by enabling nurses to reflect on how they might work toward cultivating relationships that are more salutogenic and consistent with the preservation of personhood. Second, by stimulating two distinct but related lines of research enquiry which focus on dyadic and networked relationships with the older person with cognitive impairment in the acute care setting. We also hope to reconcile the schism that has emerged in the literature between preferred approaches to care of the older person with cognitive impairment, that is person‐centred care versus relationship‐centred care by arguing that these are complementary rather than mutually exclusive and can be brought together in one theoretical framework acknowledging personhood as relational in essence. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reifying Relevance in Mild Cognitive Impairment:An Appeal for Care and CautionJanice E. Graham (bio) and Karen Ritchie (bio)KeywordsAlzheimer’s disease, construction, dementia, market forces, mild cognitive impairmentWe thank the reviewers for their thoughtful comments that probe shadowy areas in our argument, and we welcome this opportunity to elucidate our position. First, we are not repudiating the natural and social facts of pathologic brain degeneration and the physical (...) and cognitive impairments that manifest in people affected by dementia disorders. We are, however, questioning the epistemology, politics, and persistence by some to harden the construct of mild cognitive impairment (MCI) prematurely as a "natural" precursor to dementia. We suggested insufficiencies in viewing MCI as prodromal to Alzheimer's disease (AD; Graham and Ritchie 2006, 36), and pointed to evidence for the prognostic irrelevance of some MCI subcategories (35). The commentators have read our manuscript as suggesting that AD and MCI are different kinds, and that a diagnosis of AD is more "real" than that of MCI. But AD is also fraught with classification issues, as we describe in the section of our paper that deals with consensus committees, published practice guidelines, and the determination of treatment efficacy. Like MCI, AD is a heterogeneous condition, but unlike MCI, AD is a constructed practical kind that does some "work" beyond essentialist (neural degeneration, brain atrophy) claims. Its criteria identify people with well-defined dementia symptoms and multiple cognitive and functional impairments who are in need of, and benefit from, support. Even with these criteria, however, there have been great attempts to achieve definitional accuracy in dementia diagnoses. Practical refinements to the differential diagnosis of dementia based on solid research evidence have made way for more specific recognitions of vascular dementias, dementia of the Lewy body type, and other subtypes beyond AD. So AD too has been subject to more careful, more cautious operationalization in recent years, with research supporting multiple factors and the comorbidity of several types (kinds) of dementia in any one individual.Our paper takes up concerns that are not resolved for dementia and suggests that the nascent category of MCI is still so insufficiently defined as to be ambiguous, and as such, is in danger of identifying individuals with what will be, and has [End Page 57] already been, linked to a debilitating and deeply stigmatizing and fatal disorder (AD). We are not contesting the reality that some people begin to display early signs of cognitive loss, nor are we suggesting that symptoms be ignored; as researchers, we stand behind the careful tracking of symptoms and signs in patients and research participants as an essential clinical and research practice. In a era where the public has been made wary of the potentially fatal effects of new treatments whose more careful scrutiny in specific populations would have saved lives (e.g., Fontanarosa, Rennie, and DeAngelis 2004; Psaty and Furberg 2005), and made all the more popular by what Kramer coined "diagnostic bracket creep" (1993, 15), we are questioning the drivers and value of a premature diagnostic classification whose definitional accuracy is neither sufficient nor effective for specific identification of individuals.That matters of fact are constructed does not take away from their natural fact. Some people have subjective reports or show objective evidence of cognitive decline while having preserved activities of daily living—the construction of this evidence indicates they are not normal and they are not demented. Based on such evidence, where then does the balance of probability for MCI lie? A multidisciplinary international group of experts gathered in Stockholm in 2003 to discuss MCI concepts (Winblad et al. 2004). They acknowledged that the heterogeneous etiology of MCI contributes to "some confusion concerning the specific boundaries of the condition", stating that this "not normal, not demented" condition is nonetheless "useful both clinically and as a research entity" (p. 241). Importantly, they concluded that MCI needs "better definition" (p. 246). It was at this stage that we first wrote our manuscript, and in the subsequent two years we have eagerly awaited new studies, and the recognition of flexible, practical subtypes to evolve.We state "that MCI cannot be considered to be a separate clinical entity" (Graham and... (shrink)

BackgroundChronic kidney disease is a significant cause of global deaths. Those who progress to end-stage kidney disease often commence dialysis as a life-extending treatment. For cognitively impaired patients, the decision as to whether they commence dialysis will fall to someone else. This scoping review was conducted to map existing literature pertaining to how decisions about dialysis are and should be made with, for, and on behalf of adult patients who lack decision-making capacity. In doing so, it forms the basis of (...) a larger body of work that is exploring how these decisions ought to be made.MethodsTo identify relevant papers, searches were conducted on Ovid MEDLINE(R), Embase, PsychINFO, The Cochrane Library, and Web of Science. Inclusion criteria were then applied, requiring that papers: report on empirical studies about how decisions about dialysis are made and/or discuss how decisions about dialysis should be made with, for, and on behalf of adult patients who lack decision-making capacity; be published from 1961 onwards; and be published in English. This resulted in 27 papers eligible for inclusion.ResultsOf note, the majority of papers originated in the United States. There was wide variation across the included papers. Extracted data were grouped under the following themes: involving various parties (patient involvement, family dominance, and wider communication); objectivity about care options (including difficulties with family detachment); cultural sensitivity; medical versus non-medical factors; managing nonadherent patients; and the role and prevalence of substituted judgement. The literature shows that there is inconsistency in the principles and processes surrounding decisions made about dialysis with, for, and on behalf of adult patients who lack decision-making capacity.ConclusionsThis scoping review demonstrates that there is significant variation in both the practice and theory of dialysis decision making with, for, and on behalf of cognitively impaired adult patients. Complexity arises in considering who should get a say, how influential their say should be in a decision, and what factors are most relevant to the decision. A lack of up-to-date literature exploring this issue is highlighted, with this scoping review providing a useful groundwork from which further research can be undertaken. (shrink)

Key commentators on person‐centred care have described it as a “new ethic of care” which they link inextricably to notions of individual autonomy, action, change and improvement. Two key points are addressed in this article. The first is that few discussions about ethics and person‐centred are underscored by any particular ethical theory. The second point is that despite the espoused benefits of person‐centred care, delivery within the acute care setting remains largely aspirational. Choices nurses make about their practice tend to (...) comply more often with prevailing norms than those championed by person‐centred care. We draw on elements of work by moral philosopher Løgstrup and Foucault to provide insight into nurses’ ethical conduct and ask why nurses would want to act otherwise, when what they think and do is viewed as normal, or think and act otherwise if doing so is seen within the organization as transgressive? To address these more specific questions, we discuss them in relation to the following constructs: the ethical demand, sovereign expressions of life and parrhêsia. We conclude by arguing that a ethical theoretical framework enables nurses to increase their perceptibility and appreciation of the ethical demand particularly those emanating from incommensurability between organizational norms and the norms invoked by person‐centred care. We argue that nurses’ responses to the ethical demand by way of parrhêsia can be an important feature of intra‐organizational reflexivity and its transformation towards the delivery care that is more person‐centred, particularly for older people with cognitive impairment. We conclude the article by highlighting the implications of this for nursing education and research. (shrink)

The aim of this analysis was to examine the concept of time to rejuvenate and extend existing narratives of time within the nursing literature. In particular, we hope to promote a new trajectory in nursing research and practice which focuses on time and person‐centred care, specifically of older people with cognitive impairment hospitalized in the acute care setting. We consider the explanatory power of concepts such as clock time, process time, fast care, slow care and time debt for (...) elucidating the relationship between ‘good care’ and ‘time use’. We conclude by offering two additional concepts of time, plurotemporality and person‐centred time (PCT) which we propose will help advance of nursing knowledge and practice. Nurse clinicians and researchers can use these alternative concepts of time to explore and describe different temporal structures that honour the patient's values and preferences using experiential, observation‐based nursing research approaches. (shrink)

Introduction Limited treatments for Mild Cognitive Impairment (MCI) highlight the need to explore innovations including Deep Brain Stimulation (DBS), with patient perspectives key to ethical protocol development.Methods Seven MCI patients and four care partners were interviewed (Feb 2023–Jan 2024) about daily MCI challenges, desired treatment outcomes, and views on DBS. Thematic analysis following COREQ guidelines identified key themes.Results DBS was a novel concept for all (7/7), and most expressed interest (6/7) despite concerns about invasiveness (6/7) and preference to (...) exhaust medications first (4/7). Care partners (4/4) shared concerns about invasiveness and emphasized proven efficacy. Key deciding factors included the involved procedural risk (6/7), desired significant outcomes (6/7), and prior testing for MCI (7/7). Most participants (6/7) were hesitant to be the first to try DBS, while one was willing.Conclusion Patient and care partner insights on DBS for MCI are crucial for balancing innovation with ethical, patient-centered research. (shrink)

Background:Smart Aging is a serious game (SG) platform that generates a 3D virtual reality environment in which users perform a set of screening tasks designed to allow evaluation of global cognition. Each task replicates activities of daily living performed in a familiar environment. The main goal of the present study was to ascertain whether Smart Aging could differentiate between different types and levels of cognitive impairment in patients with neurodegenerative disease.Methods:Ninety-one subjects (mean age = 70.29 ± 7.70 years)—healthy (...) older adults (HCs,n= 23), patients with single-domain amnesic mild cognitive impairment (aMCI,n= 23), patients with single-domain executive Parkinson's disease MCI (PD-MCI,n= 20), and patients with mild Alzheimer's disease (mild AD,n= 25)—were enrolled in the study. All participants underwent cognitive evaluations performed using both traditional neuropsychological assessment tools, including the Mini-Mental State Examination (MMSE), Montreal Overall Cognitive Assessment (MoCA), and the Smart Aging platform. We analyzed global scores on Smart Aging indices (i.e., accuracy, time, distance) as well as the Smart Aging total score, looking for differences between the four groups.Results:The findings revealed significant between-group differences in all the Smart Aging indices: accuracy (p< 0.001), time (p< 0.001), distance (p< 0.001), and total Smart Aging score (p< 0.001). The HCs outperformed the mild AD, aMCI, and PD-MCI patients in terms of accuracy, time, distance, and Smart Aging total score. In addition, the mild AD group was outperformed both by the HCs and by the aMCI and PD-MCI patients on accuracy and distance. No significant differences were found between aMCI and PD-MCI patients. Finally, the Smart Aging scores significantly correlated with the results of the neuropsychological assessments used.Conclusion:These findings, although preliminary due to the small sample size, suggest the validity of Smart Aging as a screening tool for the detection of cognitive impairment in patients with neurodegenerative diseases. (shrink)

In his paper, “The Relevance of Rawls’ Principle of Justice for Research on Cognitively Impaired Patients” (Theoretical Medicine and Bioethics 23 (2002):45–53), Giovanni Maio has developed a thought-provoking argument for the permissibility of non-therapeutic research on cognitively impaired patients. Maio argues that his conclusion follows from the acceptance of John Rawls’s principles of justice, specifically, Rawls’s “liberty principle” Maio has misinterpreted Rawls’s “libertyprinciple” – correctly interpreted it does notsupport non-therapeutic research on cognitivelyimpaired patients. Three other ‘Rawlsian’ arguments are suggested by (...) Maio’s discussion –two “self-respect” arguments and a “presumed consent” argument – but none of them are convincing. However, an alternative argument developed from Rawls’s discussion of “justice in health care” in his most recent book, Justice as Fairness: A Restatement, may justify certain kinds of non-therapeutic research on some cognitively impaired patients in special circumstances. We should not expect anything more permissive from a liberal theory of justice. (shrink)

This article presents a reflexive account by way of a critical interpretive review of the literature pertaining to falls of older people with cognitive impairment who have been hospitalised in an acute care setting. A key aim of this review was to use thematic analysis and problematisation to challenge assumptions underpinning the current falls literature and to bring into consideration alternate foci of research and new approaches to falls research. An innovative approach is used to generate descriptive and (...) interpretive summaries of the literature which are presented graphically to reveal the prevailing themes and assumptions within. It is argued that currently, falls research in the context of cognitive impairment is constrained by scientism. Meta‐paradigmatic approaches, which have the potential to provide a better understanding of why falls may or may not occur among this particular subgroup of older people, are proposed as an alternative. (shrink)

Meeting the needs of individuals who experience vulnerability due to cognitive impairment presents significant challenges to caregivers. Primary caregiver responsibility is often relegated to professionals in hospitals or long-term care facilities, while proxy decision-making responsibility lies with families. The complex relationship among patients, professional caregivers, and families may be further complicated by the relative cognitive capacity of different patients. While some experience diminished cognitive capacity to such an extent that they cannot make any informed voluntary decisions, (...) others may be able to express global preferences and participate more actively in rehabilitative efforts. With reference to Catholic social teaching, I briefly establish the intrinsic dignity of human persons who experience cognitive impairment and then analyze how the web of relationships and responsibilities among patients, professional caregivers, families, and communities ought to be defined. Finally, I consider how these relationships may be optimized to enhance participation in mutually reinforced caregiving and decision making. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Alzheimer's Disease, Mild Cognitive Impairment, and the Biology of Intrinsic AgingThomas B. L. Kirkwood (bio)Keywordsaging, Alzheimer’s disease, genetic mutation, mild cognitive impairment, telomereThe article by Gaines and Whitehouse (2006) raises key questions about the uncertain relationship between (i) the intrinsic, "normal" aging process, and (ii) the clinicopathologic states represented by the labels of Alzheimer's disease (AD) and mild cognitive impairment (MCI). This short (...) commentary offers a perspective on this debate that is drawn from a consideration of underlying biological mechanisms.Because age is unquestionably the greatest single risk factor associated with AD and MCI, I begin by asking what we know about the intrinsic processes of aging. The central feature of current understanding of intrinsic aging is that it consists of the gradual, lifelong accumulation of a wide variety of molecular and cellular faults that begins very early in life and eventually leads to overt functional impairments resulting in age-related frailty, disability, and disease (Kirkwood 2005). This is an essentially bottom-up process. A strong consensus has emerged in recent years that there is no active program for aging and that there are no genetic factors that have evolved specifically to cause aging or age-related diseases. Unquestionably, there are genes that influence susceptibility to disease and even length of life, but these genes are genes for maintenance and repair functions, not for aging. It is the limitation in the past evolutionary pressure to invest in greater longevity than was required, within an environment where life was usually truncated by hazards such as starvation, injury, or infection, that means that our maintenance systems—good as they are—are insufficient to keep us going indefinitely. Added to this is the idea that there are probably also genes that program processes that are good for the young organism, but which may in later life have harmful effects. Processes like inflammation and apoptosis, which are seen to occur extensively in aged tissues, including brain, surely evolved to help cope with infection and cellular damage arising earlier in life. That they are called into play in aged tissues is a direct, but secondary, consequence of accumulated damage.With this general framework to understand the intrinsic biology of aging, let us now ask what we might expect a priori for the aging of an organ such [End Page 79] as the brain. Although we cannot pretend complete ignorance of how the brain actually does age, our enquiry can be based entirely on data from other organ systems, so we can develop our predictions about brain aging without prejudice.Aging begins very early during human development, faults accumulating from the first stages of embryonic development. Each time a cell divides, each of the daughter cells is likely to acquire a few new mutations. We know this from the estimates for the error rate in DNA replication and the size of the human genome. It is confirmed by direct evidence that at individual gene loci where mutations have been measured, mutation frequency increases with age (Morley 1998; Vijg 2000). In addition to replication errors, DNA is damaged on a daily basis to a very considerable degree by agents such as reactive oxygen species (free radicals), which are formed as byproducts of normal cellular metabolism. Although most of this damage is corrected by repair, the repair mechanisms themselves are not error free and additional mutations accumulate through this route. If a mutation is lethal to the cell, the cell dies and thus the mutation is eliminated. However, the majority of mutations are nonlethal, either because the mutation is recessive and the cell carries an intact gene copy on the other chromosome, because the gene is not currently required, or because the mutation produces only a delayed deleterious effect. Examples of genes that produce delayed deleterious effects include the genes responsible for familial AD. It is interesting to reflect that on statistical grounds alone, it is almost certain that each of us carries a randomly determined fraction of cells in our brains that bear amyloid precursor protein or presenilin mutations associated with AD. We also carry a heterogeneous array of random mutations that compromise essential cell maintenance functions. How many such... (shrink)

The COVID-19 pandemic is putting the NHS under unprecedented pressure, requiring clinicians to make uncomfortable decisions they would not ordinarily face. These decisions revolve primarily around intensive care and whether a patient should undergo invasive ventilation. Certain vulnerable populations have featured in the media as falling victim to an increasingly utilitarian response to the pandemic—primarily those of advanced years or with serious existing health conditions. Another vulnerable population potentially at risk is those who lack the capacity to make their own (...) care decisions. Owing to the pandemic, there are increased practical and normative challenges to following the requirements of the Mental Capacity Act 2005. Both capacity assessments and best interests decisions may prove more difficult in the current situation. This may create a more paternalistic situation in decisions about the care of the cognitively impaired which is at risk of taking on a utilitarian focus. We look to these issues and consider whether there is a risk of patients who lack capacity to make their own care decisions being short-changed. (shrink)

BackgroundIndividuals with early phase cognitive impairment are frequently affected by existential distress, social avoidance and associated health issues. The demand for efficient psychological support is crucial from both an individual and a societal perspective. We have developed a novel psychological intervention manual for providing a non-medical path to enhanced psychological health in the cognitively impaired population. The current article provides specific information on the randomized controlled trial -design and methods. The main hypothesis is that participants receiving PIPCI will (...) increase their psychological flexibility compared to participants in the active control group and the waiting list control group. The secondary hypotheses are that participants receiving PIPCI will improve psychological health compared to participants in the active control group and the waiting list control group.Materials and MethodsThis three-arm RCT will recruit participants from the cognitive centers at Karolinska University Hospital in Stockholm and randomize approximately 120 individuals in the early phase of cognitive impairment to either an experimental group, an active control group or a waiting list control group. Intervention outcome will be evaluated with self-report questionnaires on physical and psychological aspects of health, cognitive assessment, biological markers and health care costs. Assessments will be performed at pre- and post-intervention, as well as at a 6-month follow-up.DiscussionThe development of a potentially feasible and effective psychological intervention tailored for early phase cognitive impairment has the potential to advance the non-pharmacological intervention field. This is especially important given the extensive burden for many affected individuals and their families and the current lack of effective treatments. If the psychological intervention discussed here shows feasibility and efficacy, there is potential for far-reaching healthcare implications for patients with early cognitive impairment at risk of developing dementia.Clinical Trial RegistrationClinicalTrials.gov: NCT04356924. Date of registration: April 22, 2020. URL: https://clinicaltrials.gov/ct2/show/NCT04356924. (shrink)

_Introduction:_ Clinically relevant information can go uncaptured in the conventional scoring of a verbal fluency test. We hypothesize that characterizing the temporal aspects of the response through a set of time related measures will be useful in distinguishing those with MCI from cognitively intact controls. _Methods:_ Audio recordings of an animal fluency test administered to 70 demographically matched older adults (mean age 90.4 years), 28 with mild cognitive impairment (MCI) and 42 cognitively intact (CI) were professionally transcribed and (...) fed into an automatic speech recognition (ASR) system to estimate the start time of each recalled word in the response. Next, we semantically cluster participant generated animal names and through a novel set of time-based measures, we characterize the semantic search strategy of subjects in retrieving words from animal name clusters. This set of time-based features along with standard count-based features (e.g., number of correctly retrieved animal names) were then used in a machine learning algorithm trained for distinguishing those with MCI from CI controls. _Results:_ The combination of both count-based and time-based features, automatically derived from the test response, achieved 77% on AUC-ROC of the support vector machine (SVM) classifier, outperforming the model trained only on the raw test score (AUC, 65%), and well above the chance model (AUC, 50%). _Conclusion:_ This approach supports the value of introducing time-based measures to the assessment of verbal fluency in the context of this generative task differentiating subjects with MCI from those with intact cognition. (shrink)

In Older Adults (OAs), Electroencephalogram (EEG) slowing in frontal lobes and a diminished muscle atonia during Rapid Eye Movement sleep (REM) have each been effective tracers of Mild Cognitive Impairment (MCI), but this relationship remains to be explored by non-linear analysis. Likewise, data provided by EEG, EMG (Electromyogram) and EOG (Electrooculogram)—the three required sleep indicators—during the transition from REM to Non-REM (NREM) sleep have not been related jointly to MCI. Therefore, the main aim of the study was to (...) explore, with results for Detrended Fluctuation Analysis (DFA) and multichannel DFA (mDFA), the Color of Noise (CN) at the NREM to REM transition in OAs with MCI vs. subjects with good performances. The comparisons for the transition from NREM to REM were made for each group at each cerebral area, taking bilateral derivations to evaluate interhemispheric coupling and anteroposterior and posterior networks. In addition, stationarity analysis was carried out to explore if the three markers distinguished between the groups. Neuropsi and the Mini-Mental State Examination (MMSE) were administered, as well as other geriatric tests. One night polysomnography was applied to 6 OAs with MCI (68.1 ± 3) and to 7 subjects without it (CTRL) (64.5 ± 9), and pre-REM and REM epochs were analyzed for each subject. Lower scores for attention, memory and executive funcions and a greater index of arousals during sleep were found for the MCI group. Results confirmed that EOGs constituted significant markers of MCI, increasing the CN for the MCI group in REM sleep. The CN of the EEG from the pre-REM to REM was higher for the MCI group vs. the opposite for the CTRL group at frontotemporal areas. Frontopolar interhemispheric scaling values also followed this trend as well as right anteroposterior networks. EMG Hurst values for both groups were lower than those for EEG and EOG. Stationarity analyses showed differences between stages in frontal areas and right and left EOGs for both groups. These results may demonstrate the breakdown of fractality of areas especially involved in executive functioning and the way weak stationarity analyses may help to distinguish between sleep stages in OAs. (shrink)

It is a familiar idea that showing respect for someone requires an effort to take account of how she sees the world. There is more than one way we might do this. Williams suggests that each person is owed an effort at identification, whereas Rawls remarks that “mutual respect is shown … in our willingness to see the situation of others from their point of view.” The author explores these ideas as they apply to people with profound and multiple learning (...) difficulties and disabilities (PMLD), whose condition raises special difficulties in the way of complying with the conduct described here. The author examines the ideas of having a point of view and identifying with the person whose point of view it is, and shows how much—and also how little—these views can contribute to a principle of respect that includes people with PMLD. (shrink)

Music-based interventions (MBI) have become increasingly widely adopted for dementia and related disorders. Previous research shows that music engages reward-related regions through functional connectivity with the auditory system, but evidence for the effectiveness of MBI is mixed in older adults with mild cognitive impairment (MCI) and Alzheimer’s disease (AD). This underscores the need for a unified mechanistic understanding to motivate MBIs. The main objective of the present study is to characterize the intrinsic connectivity of the auditory and reward (...) systems in healthy aging individuals with MCI, and those with AD. Using resting-state fMRI data from the Alzheimer’s Database Neuroimaging Initiative, we tested resting-state functional connectivity within and between auditory and reward systems in older adults with MCI, AD, and age-matched healthy controls (N = 105). Seed-based correlations were assessed from regions of interest (ROIs) in the auditory network (i.e., anterior superior temporal gyrus, posterior superior temporal gyrus, Heschl’s Gyrus), and the reward network (i.e., nucleus accumbens, caudate, putamen, and orbitofrontal cortex). AD individuals were lower in both within-network and between-network functional connectivity in the auditory network and reward networks compared to MCI and controls. Furthermore, graph theory analyses showed that the MCI group had higher clustering and local efficiency than both AD and control groups, whereas AD individuals had lo... (shrink)

BackgroundThe cognitive outcomes induced by subthalamic nucleus deep brain stimulation (STN-DBS) remain unclear, especially in PD patients with mild cognitive impairment (MCI). This study explored the cognitive effects of STN-DBS in PD patients with MCI.MethodsThis was a retrospective cohort study that included 126 PD patients who underwent STN-DBS; all patients completed cognitive and motor assessments before and at least 6 months after surgery. Cognitive changes were mainly evaluated by the Montreal cognitive assessment (MoCA) (...) scale and the seven specific MoCA domains, including visuospatial/executive function, naming, attention, language, abstract, delayed recall, and orientation. Motor improvement was evaluated by the UPDRS-III. Cognitive changes and motor improvements were compared between PD-MCI and normal cognitive (NC) patients. Logistic regression analyses were performed to explore predictors of post-operative cognitive change.ResultsAt the time of surgery, 61.90% of the included PD patients had MCI. Compared with the PD-MCI group, the PD-NC group had a significantly higher proportion of cases with post-operative cognitive decline during follow-up of up to 36 months (mean 17.34 ± 10.61 months), mainly including in global cognitive function, visuospatial/executive function and attention. Covariate-adjusted binary logistic regression analyses showed that pre-operative global cognitive status was an independent variable for post-operative cognitive decline. We also found that pre-operative cognitive specific function could predict its own decline after STN-DBS, except for the naming and orientation domains.ConclusionPD-MCI patients are at a lower risk of cognitive decline after STN-DBS compared with PD-NC patients. (shrink)

ObjectiveThis study aimed to develop a diagnostic model of multi-kinematic parameters for patients with amnestic mild cognitive impairment (aMCI).MethodIn this cross-sectional study, 94 older adults were included (33 cognitively normal, CN; and 61 aMCI). We conducted neuropsychological battery tests, such as global cognition and cognitive domains, and collected gait parameters by an inertial-sensor gait analysis system. Multivariable regression models were used to identify the potential diagnostic variables for aMCI. Receiver operating characteristic (ROC) curves were applied to assess (...) the diagnostic accuracy of kinematic parameters in discriminating aMCI from healthy subjects.ResultsMultivariable regression showed that multi-kinematic parameters were the potential diagnostic variables for aMCI. The multi-kinematic parameter model, developed using Timed Up and Go (TUG) time, stride length, toe-off/heel stride angles, one-leg standing (OLS) time, and braking force, showed areas under ROC (AUC), 0.96 [95% confidence interval (CI), 0.905–0.857]; sensitivity, 0.90; and specificity, 0.91. In contrast, a single kinematic parameter’s sensitivity was 0.26–0.95 and specificity was 0.21–0.90. Notably, the separating capacity of multi-kinematic parameters was highly similar to Montreal Cognitive Assessment (MoCA; AUC: 0.96 vs. 0.95). Compared to cognitive domain tests, the separating ability was comparable to Auditory Verbal Learning Test (AVLT) and Boston Naming Test (BNT; AUC: 0.96 vs. 0.97; AUC: 0.96 vs. 0.94).ConclusionWe developed one diagnostic model of multi-kinematic parameters for patients with aMCI in Foshan. (shrink)

BackgroundAlthough gait patterns disturbances are known to be related to cognitive decline, there is no consensus on the possibility of predicting one from the other. It is necessary to find the optimal gait features, experimental protocols, and computational algorithms to achieve this purpose.PurposesTo assess the efficacy of the Stable Sparse Classifiers procedure for discriminating young and healthy older adults, as well as healthy and cognitively impaired elderly groups from their gait patterns. To identify the walking tasks or combinations of (...) tasks and specific spatio-temporal gait features that allow the best prediction with SSC.MethodsA sample of 125 participants was studied. They underwent assessment with five neuropsychological tests that explore different cognitive domains. A summarized cognitive index, based on the Mahalanobis distance from normative data, was calculated. The sample was divided into three groups using k-means clustering of MDCog in addition to Age. The participants executed four walking tasks and their gait patterns, measured with a body-fixed Inertial Measurement Unit, were used to calculate 16 STGF and dual-task costs. SSC was then employed to predict which group the participants belonged to. The classification's performance was assessed using the area under the receiver operating curves and the stable biomarkers were identified.ResultsThe discrimination HE vs. MCI-E revealed that the combination of the easy dual-task and the fast walking task had the best prediction performance. The features related to gait variability and to the amplitude of vertical acceleration had the largest predictive power. SSC prediction accuracy was better than the accuracies obtained with linear discriminant analysis and support vector machine classifiers.ConclusionsThe study corroborated that the changes in gait patterns can be used to discriminate between young and healthy older adults and more importantly between healthy and cognitively impaired adults. A subset of gait tasks and STGF optimal for achieving this goal with SSC were identified, with the latter method superior to other classification techniques. (shrink)

ObjectivesThis study examined the association between childhood adversity and cognitive impairment in later life and explored the potential moderation effect of gender and race.MethodsThe study sample included 15,133 participants of the Health and Retirement Study who had complete data on key study measures and were more than 50. The outcome variable is a dichotomous indicator of cognitive impairment as assessed by the Telephone Interview for Cognitive Status for self-respondents and the 16-item Informant Questionnaire on (...) class='Hi'>Cognitive Decline in the Elderly for proxies. A total of six childhood adversity indicators included grade retention, parental substance abuse, physical abuse, trouble with the police, moving due to financial hardship, and receipt of help due to financial hardship in early life. The estimation of the association between childhood adversity and cognitive impairment involved Cox proportional hazards regression. Results: Grade retention had the largest effect on incident cognitive impairment, followed by physical abuse by a parent. The impact of grade retention was more detrimental to women than men. Parental substance abuse was associated with a lower risk of incident cognitive impairment for most racial groups, but this association was reversed in “non-Hispanic other” race, consisting mainly of Asians.DiscussionSome aspects of childhood adversity continue to harm cognitive functioning in later life, while some events may have the opposite effect, with evidence of heterogeneity across gender and race. (shrink)

This commentary draws connections between technological culture emergence and recent trends in using assistive technology to reduce the burden of Alzheimer's disease. By the technical-reasoning hypothesis, cognitively-impaired individuals will lack the cognitive ability to employ technologies. By the technological reserve hypothesis, social-motivational and cultural transmissibility factors can provide foundations for using technology as cognitive prosthetics even during neurodegenerative illnesses.