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CONTEXT: Cognitively impaired older adults frequently need surrogate decision-making near the end-of-life. It is unknown whether differences in the surrogate’s relationship to the decedent are associated with different end-of-life treatment choices. OBJECTIVES: To describe differences in end-of-life care for community dwelling, cognitively impaired older adults when children and spouses are involved in decision-making. METHODS: Retrospective observational study. RESULTS: Among 742 community-dwelling adults with cognitive impairment (mild cognitive impairment or dementia) prior to death, children participated in end-of-life decisions for 615 patients (83%) and spouses participated in decisions for 258 patients (35%), with both children and spouses participating for 131 patients (18%). When controlling for demographic characteristics, decedents with only a spouse decision-maker were less likely to undergo a life-sustaining treatment than decedents with only children decision-makers (p < 0.05). There was no difference in the probability of in-hospital death or burdensome transfers across facilities across decedent-decision-maker relationships. Differences in rates of life-sustaining treatment were greater when we restricted to decedents with dementia. CONCLUSION: Decedents with cognitive impairment or dementia were less likely to receive life-sustaining treatments when spouses versus children were involved with end-of-life treatment decisions but were no less likely to experience other measures of potentially burdensome end-of-life care.

Introduction We examined the temporal sequence of the core features in probable dementia with Lewy bodies (DLB). Methods In 488 patients with probable DLB, the onset of each core feature and time to diagnosis was determined for men and women, and a pathologic subgroup (n = 209). Results REM sleep behavior disorder (RBD) developed before the other core features in men and women. Men were more likely to have RBD and were diagnosed with probable DLB earlier than women. Visual hallucinations developed after the other core features in men, but in women, they appeared earlier and concurrently with fluctuations and parkinsonism. Women were older and more cognitively impaired at first visit, were less likely to have RBD, more likely to be diagnosed with probable DLB later than men, and more likely to have neocortical tangles. Discussion An earlier latency to probable DLB was associated with men, RBD, and Lewy body disease without neocortical tangles.

We assessed sex differences in amyloid- and tau-PET retention in 119 amyloid positive patients with mild cognitive impairment or Alzheimer’s disease (AD) dementia. Patients underwent 3T-MRI, (11)C-PIB amyloid-PET and (18)F-Flortaucipir tau-PET. Linear ordinary least squares regression models tested sex differences in Flortaucipir-PET SUVR in a summary temporal region of interest as well as global PIB-PET. No sex differences were observed in demographics, Clinical Dementia Rating Sum of Boxes (CDR-SoB), Mini-Mental State Exam (MMSE), raw episodic memory scores, or cortical thickness. Females had higher global PIB SUVR (η(p)(2)=.043, p=.025) and temporal Flortaucipir SUVR (η(p)(2)=.070, p=.004), adjusting for age and CDR-SoB. Sex differences in temporal Flortaucipir-PET remained significant when controlling additionally for PIB SUVR and APOE4 status (η(p)(2)=.055, p=.013), or when using partial volume-corrected data. No sex differences were present in areas of known Flortaucipir off-target binding. Overall, females demonstrated greater AD regional tau-PET burden than males despite clinical comparability. Further characterization of sex differences will provide insight into AD pathogenesis and support development of personalized therapeutic strategies.

Current literature details an array of contradictory results regarding the effect of radiofrequency electromagnetic radiation (RF-EMR) on health, both in humans and in animal models. The present study was designed to ascertain the conflicting data published regarding the possible impact of cellular exposure (radiation) on male and female mice as far as spatial memory, anxiety, and general well-being is concerned. To increase the likelihood of identifying possible “subtle” effects, we chose to test it in already cognitively impaired (following mild traumatic brain injury; mTBI) mice. Exposure to cellular radiation by itself had no significant impact on anxiety levels or spatial/visual memory in mice. When examining the dual impact of mTBI and cellular radiation on anxiety, no differences were found in the anxiety-like behavior as seen at the elevated plus maze (EPM). When exposed to both mTBI and cellular radiation, our results show improvement of visual memory impairment in both female and male mice, but worsening of the spatial memory of female mice. These results do not allow for a decisive conclusion regarding the possible hazards of cellular radiation on brain function in mice, and the mTBI did not facilitate identification of subtle effects by augmenting them.

Because the US population is living to an older age, the number of individuals with cognitive impairment and periodontitis is increasing, as both conditions/diseases increase with age. Dental informed consent best practices for dental/periodontal treatment of individuals with cognitive impairment have not been explored, yet warrant consideration, because complex dental treatments to address periodontal needs/edentulism raise challenges for informed consent in the elderly with cognitive impairment. The purpose of this review is to help practitioners better understand this topic and develop best practices in dentistry for informed consent of patients with cognitive impairment that need extensive dental treatment, including surgical and implant therapy.

Background: Assessing health-related quality of life in dementia poses challenges due to patients’ cognitive impairment. It is unknown if the newly introduced EQ-5D five-level version (EQ-5D-5L) is superior to the 3-level version (EQ-5D-3L) in this cognitively impaired population group. Objective: To assess the psychometric properties of the EQ-5D-5L in comparison to the EQ-5D-3L in patients living with dementia (PwD). Methods: The EQ-5D-3L and EQ-5D-5L were assessed via interviews with n = 78 PwD at baseline and three and six months after, resulting in 131 assessments. The EQ-5D-3L and EQ-5D-5L were evaluated in terms of acceptability, agreement, ceiling effects, redistribution properties and inconsistency, informativity as well as convergent and discriminative validity. Results: Mean index scores were higher for the EQ-5D-5L than the EQ-5D-3L (0.70 versus 0.64). Missing values occurred more frequently in the EQ-5D-5L than the EQ-5D-3L (8%versus 3%). Agreement between both measures was acceptable but poor in PwD with moderate to severe cognitive impairment. The index value’s relative ceiling effect decreased from EQ-5D-3L to EQ-5D-5L by 17%. Inconsistency was moderate to high (13%). Absolute and relative informativity increased in the EQ-5D-5L compared to the 3L. The EQ-5D-5L demonstrated a lower discriminative ability and convergent validity, especially in PwD with moderate to severe cognitive deficits. Conclusion: The EQ-5D-5L was not superior as a self-rating instrument due to a lower acceptability and discriminative ability and a high inconsistency, especially in moderate to severe dementia. The EQ-5D-3L had slightly better psychometric properties and should preferably be used as a self-rating instrument in economic evaluations in dementia.

Schizophrenia is characterised by cognitive impairments that are already present during early stages, including in the clinical high-risk for psychosis (CHR-P) state and first-episode psychosis (FEP). Moreover, data suggest the presence of distinct cognitive subtypes during early-stage psychosis, with evidence for spared vs. impaired cognitive profiles that may be differentially associated with symptomatic and functional outcomes. Using cluster analysis, we sought to determine whether cognitive subgroups were associated with clinical and functional outcomes in CHR-P individuals. Data were available for 146 CHR-P participants of whom 122 completed a 6- and/or 12-month follow-up; 15 FEP participants; 47 participants not fulfilling CHR-P criteria (CHR-Ns); and 53 healthy controls (HCs). We performed hierarchical cluster analysis on principal components derived from neurocognitive and social cognitive measures. Within the CHR-P group, clusters were compared on clinical and functional variables and examined for associations with global functioning, persistent attenuated psychotic symptoms and transition to psychosis. Two discrete cognitive subgroups emerged across all participants: 45.9% of CHR-P individuals were cognitively impaired compared to 93.3% of FEP, 29.8% of CHR-N and 30.2% of HC participants. Cognitively impaired CHR-P participants also had significantly poorer functioning at baseline and follow-up than their cognitively spared counterparts. Specifically, cluster membership predicted functional but not clinical outcome. Our findings support the existence of distinct cognitive subgroups in CHR-P individuals that are associated with functional outcomes, with implications for early intervention and the understanding of underlying developmental processes.

BACKGROUND: The Rotterdam Elderly Pain Observation Scale (REPOS) has not yet been validated for institutionalised cognitively impaired adults. To fill this gap of knowledge, we tested psychometric properties of the REPOS when used for pain assessment in this population.METHODS: In this multicentre observational study, residents were filmed during a possibly painful moment and at rest. Healthcare professionals were asked to rate residents' pain by means of a Numeric Rating Scale (NRS)-proxy. Two researchers assessed pain with the REPOS and the Chronic Pain Scale for Non Verbal Adults with Intellectual Disabilities (CPS-NAID) from video-recordings.RESULTS: In total, 168 observations from 84 residents were assessed. Inter-observer reliability between the two researchers was good, with Cohen's kappa 0.72 [95% confidence interval (CI) 0.64 to 0.79]. Correlation between the REPOS and CPS-NAID for a possibly painful moment was 0.73 (95% CI 0.65 to 0.79). Sensitivity (85%) and specificity (61%) for the detection of pain were calculated with REPOS ≥ 3 and NRS ≥ 4 as a reference value. Item response theory analysis shows that the item grimace displayed perfect discrimination between residents with and without pain.CONCLUSION: The REPOS is a reliable and valid instrument to assess pain in cognitively impaired individuals.

Background. The main aim of this study was to estimate the effect of physical activities (PA) on cognitive functions (CF) in cognitively impaired older adults divided according to the impairment severity. Methods. We searched Web of Science, Scopus, and PubMed for randomized controlled trials (RCT). We focused on the effect of exercise on CF in intervention groups and control groups separately in people with cognitive impairment across three levels - borderline intact, mild, and moderate cognitive impairment separately. Results. Data from 40 studies involving 1,780 participants from intervention groups and 1,508 participants from control groups were analyzed. 37.0% of intervention groups presented a statistically significant beneficial effect of PA on CF, while 5% presented a statistically significant harmful effect of PA on CF. 40.0% of the control groups showed a significant decrease in CF. 54.3% interventions had a statistically significant beneficial effect (Hedges’ g > 0). However, there was a great variability between the studies in terms of exercise program description and cognitive impairment of the subjects. Conclusions. Physical exercise was associated with cognitive function improvement in older people with cognitive impairment. The positive effect is stronger in people with a mild level of cognitive impairment.

Objective: The Halstead Category Test (HCT) has been demonstrated to be sensitive to executive dysfunction in adults and children. Children with a history of significant prenatal alcohol exposure (...

Background Despite experimental evidence suggesting that pain sensitivity is not impaired by cognitive impairment, observational studies in nursing home residents have observed an inverse association between cognitive impairment and resident-reported or staff-assessed pain. Under the hypothesis that the inverse association may be partially attributable to differential misclassification due to recall and communication limitations, this study implemented a missing data approach to quantify the absolute magnitude of misclassification of pain, pain frequency, and pain intensity by level of cognitive impairment. Methods Using the 2016 Minimum Data Set 3.0, we conducted a cross-sectional study among newly admitted US nursing home residents. Pain presence, severity, and frequency is assessed via resident-reported measures. For residents unable to communicate their pain, nursing home staff document pain based on direct resident observation and record review. We estimate a counterfactual expected level of pain in the absence of cognitive impairment by multiply imputing modified pain indicators for which the values were retained for residents with no/mild cognitive impairment and set to missing for residents with moderate/severe cognitive impairment. Absolute differences (∆) in the presence and magnitude of pain were calculated as the difference between documented pain and the expected level of pain. Results The difference between observed and expected resident reported pain was greater in residents with severe cognitive impairment (∆ = -10.2%, 95% Confidence Interval (CI): -10.9% to -9.4%) than those with moderate cognitive impairment (∆ = -4.5%, 95% CI: -5.4% to -3.6%). For staff-assessed pain, the magnitude of apparent underreporting was similar between residents with moderate impairment (∆ = -7.2%, 95% CI: -8.3% to -6.0%) and residents with severe impairment (∆ = -7.2%, 95% CI: -8.0% to -6.3%). Pain characterized as “mild” had the highest magnitude of apparent underreporting. Conclusions In residents with moderate to severe cognitive impairment, documentation of any pain was lower than expected in the absence of cognitive impairment. This finding supports the hypothesis that an inverse association between pain and cognitive impairment may be explained by differential misclassification. This study highlights the need to develop analytic and/or procedural solutions to correct for recall/reporter bias resulting from cognitive impairment.

Background Non-pharmacological interventions are recommended to manage challenging behaviours among cognitively impaired older adults, however few studies have enrolled patients in acute care. This study aimed to determine the feasibility of implementing non-pharmacological interventions to manage behaviours in hospitalized older adults. Method A self-identity approach was used to identify potentially engaging activities for 13 older medically ill adults admitted to acute hospital; these activities were trialed for a two-week period. Data were collected on frequency of intervention administration and assistance required, as well as frequency of behaviours and neuroleptic use in the seven days prior to and following the trial of activities. Results Per participant, 5–11 interventions were prescribed. Most frequently interventions were tried two or more times (46%); 9% were not tried at all. Staff or family assistance was not required for 27% of activities. The mean number of documented behaviours across participants was 4.8 ± 2.3 in the pre-intervention period and 2.1 ± 1.9 in the post-intervention period. Overall the interventions were feasible and did not result in increasing neuroleptic use Conclusion Non-pharmacologic interventions may be feasible to implement in acute care. More research in this area is justified.

Vascular contributions to early cognitive decline are increasingly recognized, prompting further investigation into the nature of related changes in perivascular spaces (PVS). Using magnetic resonance imaging, we show that, compared to a cognitively normal sample, individuals with early cognitive dysfunction have altered PVS presence and distribution, irrespective of Amyloid-β. Surprisingly, we noted lower PVS presence in the anterosuperior medial temporal lobe (1.29 times lower PVS volume fraction in cognitively impaired individuals compared with those unimpaired, p < 0.0001), which was associated with neurofibrillary tau tangle deposition in the right entorhinal cortex (beta (SE) = −0.98 (0.4); p = 0.014), one of the hallmarks of early Alzheimer’s disease pathology. We also observed higher PVS volume fraction in centrum semi-ovale of the white matter, but only in female participants (1.47 times higher PVS volume fraction in cognitively impaired individuals compared with those unimpaired, p = 0.0011). Furthermore, we observed PVS changes in participants with history of hypertension (higher PVS volume fraction in the white matter and lower PVS volume fraction in the anterosuperior medial temporal lobe). Our results suggest that anatomically specific alteration of the PVS is an early neuroimaging feature of cognitive impairment in aging adults, which is differentially manifested in female.

Obstructive sleep apnea (OSA) increases the risk of developing dementia. Home sleep apnea testing (HSAT) is a convenient and validated method to screen for OSA among cognitively well individuals; however, it is unknown if it is a clinically feasible and practical approach in clinic patients with cognitive impairment. We evaluated if HSAT was a feasible and practical approach to screen for OSA in clinic patients with cognitive impairment.Patients with cognitive impairment due to neurodegenerative and/or vascular etiologies completed OSA screening using HSAT. HSAT was considered a feasible technique if ≥ 80% of those who attempted HSAT obtained analyzable data (ie, ≥ 4 hours of flow, effort, and oxygen evaluation), and a practical technique if ≥ 50% of all patients approached for study inclusion obtained analyzable data.Of the 119 patients who were approached for participation, 83 were enrolled and offered HSAT; 5 did not complete HSAT screening, and the remaining 78 patients attempted HSAT; mean age (± standard deviation) of 72.86 (± 9.89) years and 46% were male. In those that attempted HSAT, 85.9% (67/78) obtained analyzable data and 56.3% (67/119) of eligible patients approached for study inclusion obtained analyzable data.HSAT is a feasible and practical technique in a clinic population with cognitive impairment. As OSA is a modifiable risk factor for patients with dementia, HSAT has the potential to lead to expedited treatment for OSA, which may potentially improve health-related outcomes such as cognition.

A prospective longitudinal mixed-method study was undertaken to evaluate an intergenerational community program involving older adults and school aged-children. Data were collected from nine childr...

ObjectiveLack of palliative care knowledge among caregivers may pose an access barrier for cognitively impaired older adults, who may benefit from the specialized care. Therefore, this study aims to examine the effectiveness of an educational intervention in improving palliative care knowledge among informal caregivers of cognitively impaired older adults.MethodUsing a one-group, pre- and post-test intervention design, this study implemented an individual, face-to-face educational intervention with an informational brochure for 43 informal caregivers of chronically or seriously ill older adults (50+) with cognitive impairment, recruited from communities in West Alabama. Their level of knowledge about palliative care was assessed by the Palliative Care Knowledge Scale (PaCKS). The pre- and post-test scores were compared by the Wilcoxon signed-ranks test, and the racial subgroup (Whites vs. Blacks) comparison was made by the Mann–Whitney U test.ResultsThere was a statistically significant difference between the pre- and post-test scores (z = 5.38, p < 0.001), indicating a statistically significant effect of the educational intervention in improving palliative care knowledge among participants. There was a significant difference (U = 143, p < 0.05) between Whites and Blacks in the pre-test, which, however, disappeared in the post-test (U = 173.50, p > 0.05), suggesting that the amount of increased PaCKS scores were significantly greater for Blacks (Mdn = 9.50) than for Whites (Mdn = 4.00, U = 130.50, p < 0.05).Significance of resultsThis study demonstrated that a one-time educational intervention can improve the level of palliative care knowledge among informal caregivers of chronically or seriously ill older adults with cognitive impairment, particularly among Black caregivers. Therefore, further educational efforts can be made to promote palliative care knowledge and reduce racial disparities in palliative care knowledge and its use.

Objective:Incidental learning and memory, as well as processing speed, were examined in human immunodeficiency virus (HIV)-positive adults and a seronegative control group.Methods:Participants completed a computerized Symbol-Digit Modalities Test (cSDMT) with two blocked conditions: a set of trials with the standard symbol–digit pairings and the second set with a rearranged symbol–digit pairings.Results:HIV-positive adults showed slower overall reaction time compared to the HIV-negative group. More importantly, the most cognitively impaired HIV-positive group showed no interference in the rearranged set of symbol–digit pairings from the standard pairings on the cSDMT.Conclusion:The relative slowing, or interference, in the HIV-negative group and two HIV-positive groups (unimpaired and impaired) was quite large (between 122 and 131 ms). We argue that the lack of such relative slowing in the most cognitively impaired HIV-positive group indicates a deficit in incidental learning and memory.

The speed of information processing is one of the most reliable indices of cognitive efficiency. The most common way to evaluate this ability is to assess reaction times (RTs). The technical limitations of previous tasks, aimed at measuring RT, have motivated us to develop a new battery for their evaluation. The aim of this study is to build an open-source, open-access reaction time test (OORTT), which has the following characteristics: rapid and easy administration, robust Italian normative data based on a wide age range, a simple scoring system, compatibility with all operating systems, no license or activation costs, and based on an open-source software platform. The battery is composed of three tasks: simple reaction times (SRT), Go/No-Go (GNG) condition, and four-position reaction times (4PRT). The battery was administered to 300 healthy participants aged between 14 and 89, and 3 groups of patients: 24 right brain-damaged; 21 left brain-damaged, and 19 degenerative cognitively impaired. We have developed specific norms for each task of the test battery: SRT, GNG, and 4PRT. Compared with healthy individuals, all groups obtained lower scores. More specifically, cognitively impaired patients obtained significantly longer RTs than healthy participants as well as unilateral brain-damaged patients. In the 4PRT task, right brain-damaged patients obtained a significantly left > right difference in RTs. In conclusion, the OORTT test battery proved to be a valuable tool which can be used in the clinical environment for cases of different attentional deficits after focal or degenerative brain damage.

Background: Treatment decisions based on guidelines rather than patients’ preferences determine adherence to and compliance with treatment, which, in turn, could improve health-related outcomes. Objectives: To summarize the stated treatment and care preferences of people with dementia (PwD). Methods: A systematic review was conducted to assess the stated preferences of PwD. The inclusion criterion was the use of quantitative methods to elicit stated preferences, enabling a ranking of preferences. Results: Eleven studies revealed preferences for diagnostics, treatment decisions, patient-related outcomes, care services, end-of-life care, leisure activities, and digital life story work. PwDs prefer accurate, pain-free, and comfortable diagnostic procedures without radioactive markers as well as being accompanied by a caregiver. PwD’s quality of life (QoL), self-efficacy, and depression were equally most important for PwD and caregivers. However, PwD memory was only important for caregivers but not for PwD, and caregiver QoL was moderately important for PwD but least important for caregivers. Additionally, comfort and family involvement were most important for patients’ end-of-life care, whereas caregivers most preferred good communication and pain management. Also, preferences depend on the living situation: Patients living not alone prefer a regular care provider most, whereas those living alone only want to live nearby the caregiver. Preferences for leisure activities did not differ between past and present ratings, indicating that PwD prefer activities that have always been carried out. Conclusion: Only a few studies have applied quantitative methods to elicit the preferences of PwD. More research is needed to capture the stated preferences for the treatment, care, and support of PwD to improve health-related outcomes and the allocation of healthcare resources.

In this case, a 93-year-old woman declines rapidly following glossectomy surgery and experiences rapid weight loss. She becomes withdrawn and uncommunicative and is diagnosed as failure to thrive and potentially cognitively impaired. The eventual explanation for her decline is unexpected, surprising—and counterintuitive. This case illustrates the importance of investigating every aspect of medication use related to outcomes including medication administration, therapeutics, and health system dynamics.

Background Task-based functional MRI (tb-fMRI) is a well-established technique used to identify eloquent cortex, but has limitations, particularly in cognitively impaired patients who cannot perform language paradigms. Resting-state functional MRI (rs-fMRI) is a potential alternative modality for presurgical mapping of language networks that does not require task performance. The purpose of our study is to determine the utility of rs-fMRI for clinical preoperative language mapping when tb-fMRI is limited. Methods We retrospectively reviewed 134 brain tumor patients who underwent preoperative fMRI language mapping. rs-fMRI was post-processed with seed-based correlation (SBC) analysis, when language tb-fMRI was limited. Two neuroradiologists reviewed both the tb-fMRI and rs-fMRI results. Six neurosurgeons retrospectively rated the usefulness of rs-fMRI for language mapping in their patients. Results Of the 134 patients, 49 cases had limited tb-fMRI and rs-fMRI was post-processed. Two neuroradiologists found rs-fMRI beneficial for functional language mapping in 41(84%) and 43 (88%) cases respectively; Cohen’s kappa is 0.83, with a 95% confidence interval (0.61, 1.00). The neurosurgeons found rs-fMRI “definitely” useful in 26 cases (60%) and “somewhat” useful in 13 cases (30%) in locating potential eloquent language centers of clinical interest. Six unsuccessful rs-fMRI cases were due to: head motion (2 cases), nonspecific functionality connectivity outside the posterior language network (1 case), and an unknown system instability (3 cases). Conclusions This study is a proof of concept that shows SBC rs-fMRI may be a viable alternative for clinical language mapping when tb-fMRI is limited.

Aim Tongue bites frequently occur during seizures in epilepsy patients. We report two cases of cognitively impaired Lennox-Gastaut syndrome patients with reactive lesions on the tongues. Case presentations Case 1 was a 30-year-old man whose chief complaint was mouth pain. Local finding was a small bean-sized pedunculated mass on the tongue, histopathologically diagnosed as inflammatory fibrous hyperplasia. Case 2 was a 45-year-old man whose chief complaint was bleeding from the mouth. His clinical finding was blood loss anemia. Local finding was a 20-mm-diameter pedunculated mass on the tongue, histopathologically diagnosed as pyogenic granuloma. Conclusion These mass lesions were believed to be reactive, caused by repetitive minor damage involving reparative fibrous tissue response. Therefore, the two cases may have involved reparative responses to mucosal injury incurred by accidental bites during epileptic seizures. Intellectual disability made medical treatment difficult and had allowed the massive lesions to form. It is necessary for cognitively impaired epilepsy patients to undergo regular dental examinations in order to get used to dental checks and to increase the number of intraoral observations in the context of close cooperation between dentists and epilepsy therapists.

In our ageing world, a rising number of people suffer from cognitive deficit, which most of the time leads to a reduced autonomy. Even with their impaired capacities, these persons often stay at home or they go live with a relative. They then have to perform important daily tasks (such as cooking) using devices and appliances designed for healthy people, which do not take into consideration their cognitive impairment. Using these devices is risky and may lead to a tragedy (e.g. fire). A potential answer to this challenge is to provide automated systems, which perform tasks on behalf of the impaired user. However, clinical studies have shown that encouraging users to maintain their autonomy greatly help to preserve health, dignity, and motivation. Therefore, we present in this paper a new smart range prototype allowing monitoring and guiding a cognitively impaired user in the activity of preparing a meal. This new original prototype is capable of giving adapted prompting to the user in the completion of several recipes by exploiting load cells, heat sensors and electromagnetic contacts embedded in the range. Our system is also able to detect risky situations and is able of taking preventive actions accordingly. It includes a state-transition recognition algorithm incorporating a model of the main cognitive errors. Finally, we present several experiments with the prototype and a study conducted with the targeted users, with companies, public organisms and professionals.

Aging physicians are at a higher risk of cognitive impairment, undermining patient safety and unraveling physicians' careers. Neurologists, occupational health physicians, and psychiatrists will participate in both health system policy decisions and individual patient evaluations. We address cognitive impairment in aging physicians and attendant risks and benefits. If significant cognitive impairment is found after an appropriate evaluation, precautions to confidentially support physicians' practicing safely for as long as possible should be instituted. Understanding that there is heterogeneity and variability in the course of cognitive disorders is crucial to supporting cognitively impaired, practicing physicians. Physicians who are no longer able to practice clinically have other meaningful options.

A robot is a programmed actuated mechanism with a degree of autonomy. Medical robots came a long way since first prototypes based on industrial robots in the 1960s-70 s to become modern complex systems that assist surgeons, patients, and nurses. Over time, robots proved their usefulness and evolved for the ability to operate in confined spaces inside human bodies, help people recover the functions of injured limbs, or provide support to physically and cognitively impaired persons. This chapter provides an overview along with the challenges of current robotics in healthcare.

Purpose: This paper examines the changes in functional connectivity (FC) and effective connectivity (EC) of the visual (VIS)-network and attention network (AN) in patients with cognitive impairment caused by temporal lobe epilepsy (CI-TLE) through independent component analysis (ICA) and Granger causality analysis (GCA).Material and methods: Resting-state functional magnetic resonance imaging（rs-fMRI）data and Montreal cognitive assessment（CoMA） were collected from 32 patients with CI-TLE and 29 age-matched healthy controls.Results: In the VIS network of CI-TLE patients, FC decreased in the right inferior occipital gyrus (IOG) and the left lingual gyrus (LG) and in the right temporal-parietal junction (TPJ) in the Doral attention network (DAN). FC increased in the right middle frontal gyrus (MFG) and right precuneus gyrus (PG). In the DAN, FC decreased in the left superior parietal gyrus (SPG) and right inferior parietal gyrus (LG). GCA revealed the decreased EC from the left LG to the right IOG within the VIS network and from the right inferior parietal gyrus (IPG) of the DAN to the left LG of the VIS network. In contrast, CI-TLE patients demonstrated increased EC from the right SPG to the right IPG within DAN，and from the right IPG of the DAN to the right TPJ of the VAN, and from the right TPJ to the left PG within VAN. Compared with healthy controls , Voxel-wise GCA in CI-TLE patients showed positive EC from the left LG to the right SPG. In contrast, increased EC was exhibited from the right TPJ to the right caudate. Pearson analysis showed a negative correlation between the CoMA scores and GC values from the right IPG to the right TPJ.Conclusion: The results indicate intrinsic brain network connectivity dysfunction in CI-TLE patients and the causal connection abnormality in the resting-state VIS network and AN. Also, it was found that CI-TLE patients possibly have a compensatory mechanism in the above networks. These findings shed new insights on the neuroimaging marker of CI-TLE.

Ching-Ju Chiu,1 Min-Chia Yang,2 Chi-Chang Huang,3 Chia-Ming Chang1,3 1Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, 70101, Taiwan; 2Department of Medicine, College of Medicine, National Cheng Kung University, Tainan, 70101, Taiwan; 3Division of Geriatrics and Gerontology, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, TaiwanCorrespondence: Min-Chia YangDepartment of Medicine, College of Medicine, National Cheng Kung University, No.1, University Road, Tainan, 70101, TaiwanTel +886-6-2353535 ext. 5739Fax +886-6-3028175Email kh9531023@gmail.comBackground: In this study, factors associated with the duration of a disability before death in older adults who are moderately to severely disabled in Taiwan are investigated.Methods: A nationally representative sample of older adults (65+) in 1996 who died before 2016 (n = 1139) were analyzed to calculate their disability status and the length of time they were disabled before death.Results: The mean period during which the participants experienced moderate to severe disability before death for older adults in Taiwan was 5.53 years (SD = 3.15). Men who were overweight had an average of 1.17 more survival years (βoverweight = 1.17, p < 0.05) as compared to those who were normal weight, and in the case of those who were cognitively impaired (SPMSQ ≤ 7), years of survival were decreased by an average of 1.70 years as compared to those who were cognitively intact before death (βcognition = − 1.70, p < 0.01). The aforementioned effects were independent of age. In women, the number of diseases was the most dominant independent correlate for survival years (βdisease = − 0.34, p < 0.05).Conclusion: Disability distribution at various time points before death among the elderly in Taiwan was revealed in the study. At 10 years before death, 93% of the elderly were free from any ADL disabilities, and only 4% reported more than three ADL disabilities. At 6 years before death, an average of 10% of the participants had more than three ADL disabilities, and at one year before death, moderate to severe disability increased to 38%. Factors associated with the survival years among those who were moderately to severely disabled showed distinct gender differences.Keywords: disability, duration before death, elderly, risk factor

AIMS: To examine concurrent and construct validity of inertial sensor 360°turn measures in relation with motion capture and mobility assessments in cognitively impaired older adults. METHODS: Data was collected in 31 participants, mean age 85.2 (SD 5.2), during clockwise (CW) and counter clockwise (CCW) 360° turns using (1) APDM body-worn inertial sensors and (2) Qualisys 8-camera laboratory-based motion capture. RESULTS: Absolute agreement between inertial sensor and motion capture measures was excellent for turn duration and turn peak velocity (ICC = 0.96–0.98). Strong to moderate correlations were present between inertial sensor turn measures and performance on the Timed Up and Go, Short Physical Performance Battery and 90-s Balance Test. ROC curve analysis of CCW 360° turn duration and turn peak velocity distinguished higher risk versus lower risk for mobility disability. CONCLUSIONS: Inertial sensor 360° turn measures demonstrated concurrent and construct validity in relation to motion capture and mobility assessments.

This chapter is written to introduce two concepts—ambiguous loss and chronic sorrow—that help illuminate the latter circumstance, whether it is connected with the ultimate death of a loved one or any of the other uncountable ways in which loss arises in life. It explores these constructs under one heading might provide a springboard for the discussion of bereavement from a broader perspective. Ambiguous loss is a particularly stressful kind of loss because it is not typically officially acknowledged, and there is no possibility of closure. At times, as when someone is literally missing or is cognitively impaired, the loss remains unclear, as people don’t know whether a loved one is dead or alive, absent or present. The concept of chronic sorrow was originally based on observations of parents of children with developmental impairments. Descriptions of ambiguous loss and chronic sorrow readily apply to many of the same experiences.

We present the 10-item Simplified System Usability Scale (SUS) for Cognitively Impaired and Older Adults, which we have used in several studies since 2016. The Simplified SUS is a revised version of the SUS, a brief, psychometrically valid, and widely used global measure of usability. To improve the ease of administration, the Simplified SUS rewords 9 of 10 SUS items and replaces the original SUS question about inconsistency with a question about confusion. The Simplified SUS retains the SUS's 10-item design, five-item agreement-based Likert scale, and alternating valence of positively worded odd items and negatively worded even items. Because of this, the Simplified SUS can be interpreted the same way as the traditional SUS. The Simplified SUS is an example of an off-the-shelf human factors method adapted for work with vulnerable populations and usable by practitioners or researchers without human factors training.

Purpose The purpose of this study was to determine the feasibility of using a tablet-based portable audiometer to identify hearing loss in a cognitively impaired population. Method In this study, we used a retrospective chart review of an outpatient memory clinic. During a quality initiative, older adult ( M age = 74.6) patients ( n = 91) completed pure-tone hearing testing (0.5–4 kHz) via automated self-administration and technician-administered threshold testing (gold standard) on a tablet-based audiometer. Results Technician-administered auditory threshold testing was successfully conducted in all patients. A total of 54 of the 91 patients (59%) also had hearing thresholds reliably obtained with automated self-administration. In bivariate analyses, older age, lower Mini-Mental State Examination (MMSE) scores, lower education, male sex, and higher degree of hearing impairment were associated with higher odds of having an unreliable self-administered test defined as multiple recorded false positives at 2 or more test frequencies. In multivariable analysis, lower MMSE scores and poorer hearing were significantly associated with higher odds of having an unreliable self-administered test. Conclusion Technician-administered hearing threshold testing using a portable, tablet-based audiometer can be successfully administered to patients with cognitive impairment. Reliability of automated self-administration is limited in patients with lower MMSE scores.

Mobility decline and worsening of the cognitive status are all too often the result of acute hospital treatment in older patients. This is particularly pronounced in patients with pre-existing cognitive impairment. This study strived to analyze the routines of geriatric acute care and identify reasons and triggers for sedentary behavior during acute hospitalization of cognitively impaired inpatients.A sample of 20 moderately cognitively impaired geriatric inpatients (average age 84 years) were recruited on an acute care ward. Information on persons attending the patient, daytime, location, context, patient's activity behavior and difficulty of action were collected by behavioral mapping over a period of 35 1‑min timeslots and extrapolated to a period of 525 min. Routines were further analyzed via semi-structured interviews with five healthcare professionals (HCP).Relevant relations between various categorical and ordinal variables, such as patients' activity behavior, persons attending the patient, daytime, location, difficulty of action and contextual factors were found. Extrapolated data showed that patients spent 396.9 min (75%) in their room, 342.0 min (65%) were spent alone and 236.2 min (45%) lying in bed. The time patients spent alone was grossly underestimated by HCP.Time spent without company, lacking meaningful activities and continuous bedridden periods due to missing demands to leave the room might have led to time spent inactive and alone. These seem to be strong predictors for sedentariness. Routines of acute care should be reorganized to increase physical activity and thereby reduce sedentary behavior of this patient group.HINTERGRUND UND ZIELSETZUNG: Mobilitätsstörungen und Verschlechterungen des kognitiven Status sind oft Folge einer akuten Krankenhausbehandlung älterer Patienten. Besonders ausgeprägt ist dies bei Patienten mit vorbestehender kognitiver Beeinträchtigung. Diese Studie hat zum Ziel, Routinen der geriatrischen Akutversorgung, Gründe und Auslöser für Bewegungsmangel bei akutem Krankenhausaufenthalt von kognitiv beeinträchtigten, stationären Patienten zu analysieren.Eine Stichprobe von 20 stationären Patienten (Durchschnittsalter 84 Jahre) mit mittelschwerer kognitiver Beeinträchtigung wurde auf einer Akutstation rekrutiert. Informationen zu Patientenbetreuern, Tageszeit, Aufenthaltsort, Kontext sowie Aktivitätsverhalten und Handlungsschwierigkeit wurden mithilfe von „behavioral mapping“ gesammelt, die dann zu einem 525 min dauernden Zeitraum von 9 bis 19 Uhr hochgerechnet wurden. Routinen wurden in halbstrukturierten Interviews mit 5 Angehörigen unterschiedlicher Gesundheitsberufe analysiert.Es wurden relevante Zusammenhänge zwischen verschiedenen kategorialen und ordinalen Variablen wie Patientenaktivität, Patientenbetreuern, Tageszeit, Aufenthaltsort, Handlungsschwierigkeiten und Kontextfaktoren festgestellt. Extrapolierte Daten zeigen, dass die Patienten 396,9 min (75 %) in ihrem Zimmer, 342,0 min (65 %) allein und 236,2 min (45 %) im Bett liegend verbrachten. Die Zeit, die Patienten allein verbrachten, wurde von Angestellten stark unterschätzt.Ohne Gesellschaft verbrachte Zeit, fehlende sinnvolle Aktivitäten und ununterbrochene Bettlägerigkeit aufgrund fehlender Anreize, führten möglicherweise dazu, dass die Zeit inaktiv und allein im Patientenzimmer verbracht wurde. Dies scheinen starke Prädiktoren für Bewegungsmangel zu sein. Routinen der Akutversorgung sollten neu organisiert werden, um körperliche Aktivität zu steigern und sedentäres Verhalten dieser Patientengruppe zu verringern.

Introduction This study investigates the relationship between retinal image features and β-amyloid (Aβ) burden in the brain with the aim of developing a noninvasive method to predict the deposition of Aβ in the brain of patients with Alzheimer's disease. Methods Retinal images from 20 cognitively impaired and 26 cognitively unimpaired cases were acquired (3 images per subject) using a hyperspectral retinal camera. The cerebral amyloid status was determined from binary reads by a panel of 3 expert raters on 18F-florbetaben positron-emission tomography (PET) studies. Image features from the hyperspectral retinal images were calculated, including vessels tortuosity and diameter and spatial-spectral texture measures in different retinal anatomical regions. Results Retinal venules of amyloid-positive subjects (Aβ+) showed a higher mean tortuosity compared with the amyloid-negative (Aβ−) subjects. Arteriolar diameter of Aβ+ subjects was found to be higher than the Aβ− subjects in a zone adjacent to the optical nerve head. Furthermore, a significant difference between texture measures built over retinal arterioles and their adjacent regions were observed in Aβ+ subjects when compared with the Aβ−. A classifier was trained to automatically discriminate subjects combining the extracted features. The classifier could discern Aβ+ subjects from Aβ− subjects with an accuracy of 85%. Discussion Significant differences in texture measures were observed in the spectral range 450 to 550 nm which is known as the spectral region known to be affected by scattering from amyloid aggregates in the retina. This study suggests that the inclusion of metrics related to the retinal vasculature and tissue-related textures extracted from vessels and surrounding regions could improve the discrimination performance of the cerebral amyloid status.

Background: The primary objective of this systematic review was to determine effective interventions to improve gait (speed, stride length, double limb support) in older adults with cogniti...