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Reduced heart rate variability can be an early sign of autonomic dysfunction in neurodegenerative diseases and may be related to brain dysfunction in the central autonomic network. As yet, such autonomic dysfunction has not been examined during sleep—which is an ideal physiological state to study brain–heart interaction as both the central and peripheral nervous systems behave differently compared to during wakefulness. Therefore, the primary aim of the current study was to examine whether heart rate variability during nocturnal sleep, specifically slow wave (deep) sleep, is associated with central autonomic network functional connectivity in older adults ‘at-risk’ of dementia. Older adults (n = 78; age range = 50–88 years; 64% female) attending a memory clinic for cognitive concerns underwent resting-state functional magnetic resonance imaging and an overnight polysomnography. From these, central autonomic network functional connectivity strength and heart rate variability data during sleep were derived, respectively. High-frequency heart rate variability was extracted to index parasympathetic activity during distinct periods of sleep, including slow wave sleep as well as secondary outcomes of non-rapid eye movement sleep, wake after sleep onset, and rapid eye movement sleep. General linear models were used to examine associations between central autonomic network functional connectivity and high-frequency heart rate variability. Analyses revealed that increased high-frequency heart rate variability during slow wave sleep was associated with stronger functional connectivity (F = 3.98, P = 0.022) in two core brain regions within the central autonomic network, the right anterior insular and posterior midcingulate cortex, as well as stronger functional connectivity (F = 6.21, P = 0.005) between broader central autonomic network brain regions—the right amygdala with three sub-nuclei of the thalamus. There were no significant associations between high-frequency heart rate variability and central autonomic network connectivity during wake after sleep onset or rapid eye movement sleep. These findings show that in older adults ‘at-risk’ of dementia, parasympathetic regulation during slow wave sleep is uniquely linked to differential functional connectivity within both core and broader central autonomic network brain regions. It is possible that dysfunctional brain–heart interactions manifest primarily during this specific period of sleep known for its role in memory and metabolic clearance. Further studies elucidating the pathophysiology and directionality of this relationship should be conducted to determine if heart rate variability drives neurodegeneration, or if brain degeneration within the central autonomic network promotes aberrant heart rate variability.

IntroductionThe susceptibility to suicidal behaviour has been linked to cognitive functioning deficits. Gamified assessments have emerged as a practical and engaging approach to assess these deficits, though their acceptability amongst young adults with suicidal thoughts is currently understudied.MethodsThirteen young Australian adults aged 18 to 25 years who experienced suicidal thoughts in the past year were recruited to evaluate the smartphone based CogGame app. Inductive thematic analysis was utilised to identify the themes obtained from the interviews. The relationships between cognitive functioning deficits and the severity of suicidal thoughts were explored by correlational analyses.ResultsAll participants found the GogGame app easy to learn to use and navigate. Positive experiences and high user satisfaction were reported with the use of CogGame app. Major areas for improvement include having clearer instructions and app information, adjusting the difficulty of the exercises, and addressing a few technical issues such as decreasing loading time. Higher levels of suicidal thoughts were found to be significantly associated with poorer visual learning performance on the CogGame app (p= .01).ConclusionPositive participant experiences with CogGame revealed the promising potential of gamified assessments to measure cognitive functioning in young adults with suicidal thoughts.

Late-life participation in cognitively stimulating activities is thought to contribute to an individual's cognitive reserve and thus protect against cognitive decline, yet its association with clinical markers of neurodegeneration is not well established. To investigate, we developed a 13-item self-report "cognitively stimulating activities" questionnaire (CSA-Q), which was completed by a community sample of 269 older adults (>50 years) at risk of dementia. Participants met criteria for Mild Cognitive Impairment (MCI) and were classified as amnestic (aMCI; n = 93) or non-amnestic (naMCI; n = 176). Weighted CSA-Q dimensions were calculated for activity intensity, mental engagement and social engagement via a panel of 23 inter-raters. The CSA-Q mean and its dimensions were examined in relation to: (a) demographics (age, sex), (b) cognitive reserve proxies (years of education, premorbid IQ), (c) neuropsychological markers across cognitive domains of executive function, processing speed, learning, and memory storage, and (d) neuroimaging markers (left and right hippocampal volume). Analyses were conducted for all MCI, as well as for aMCI and naMCI sub-types. The CSA-Q was found to have concurrent validity with cognitive reserve proxies. Among all MCI, the CSA-Q dimensions of intensity and mental engagement had moderate associations with left hippocampal volume, but not with neuropsychological performance. For naMCI, the CSA-Q had moderate associations with left hippocampal volume, and small associations with aspects of executive functioning and processing speed. No equivalent associations emerged for the aMCI subtype. Our findings show that the CSA-Q may be particularly useful for older adults with non-amnestic cognitive deficits.

An ongoing need exists for innovation in service delivery to ensure that mental health services deliver high-quality treatment and prevention in the population. This Special Article proposes the adoption of “staged care” as a population health–oriented service delivery model for packages of specialized services delivered largely in ambulatory care settings for individuals with common affective disorders. Staged care integrates measures of clinical need alongside clinical stage and personal choice to select hierarchically arranged service packages for individuals. Packages then vary according to the intensity, duration, and mix of treatment options. This Special Article describes five levels of care in staged care: self- or family-directed monitoring and management, low-intensity services, moderate-intensity services, high-intensity services, and acute and specialist community mental health services. The care environment, treatment team, and length of treatment are also described, and provisional criteria are specified for assigning individuals to different care levels on the basis of current clinical need and clinical stage. Staged care is presented as a model that guides treatment selection and health service delivery to ensure that the high-quality care aims of “right care first time” and prevention are achieved and optimal use of available resources is considered.

Background and Objectives As part of the WHO Rehabilitation 2030 call for action, the WHO Rehabilitation Programme is developing its Package of Interventions for Rehabilitation (PIR) to support ministries of health around the globe in integrating rehabilitation services into health systems. As a vital step for this PIR development, we conducted a systematic review of clinical practice guidelines (CPGs) for dementia to identify interventions for rehabilitation and related evidence. Research Design and Methods Following WHO Rehabilitation Programme and Cochrane Rehabilitation’s methodology, quality CPGs published in English between January 2010 and March 2020 were identified using PubMed, Embase, CINAHL, PEDro, Google Scholar, guideline databases, and professional society websites. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (II). Results Of the 22 CPGs that met the selection criteria, 6 satisfied the quality evaluation. Three hundred and thirty rehabilitation-related recommendations were identified, mostly concentrated in the areas of cognition, emotion, and carer support. There were many strong interventions, with moderate- to high-quality evidence that could be easily introduced in routine practice. However, major limitations were found both in the quality of evidence and scope, especially in areas such as education and vocation, community and social life, and lifestyle modifications. Discussion and Implications Further rigorous research is needed to build quality evidence in dementia rehabilitation in general, and especially in neglected areas for rehabilitation. Future work should also focus on the development of CPGs for dementia rehabilitation. A multipronged approach is needed to achieve Universal Health Coverage for dementia rehabilitation.

It is not yet known which specific qualities of cognitively stimulating activities are most likely to enhance cognitive reserve in older adults. Taking an inductive approach to this problem, we asked 504 older adults with subjective and/or cognitive impairment to complete the Cognitively Stimulating Activities Questionnaire (CSA-Q). Exploratory factor analysis identified a 4-factor structure within a split-half sample, after which confirmatory factor analysis cross-validated the model. Retaining 12 CSA-Q items, the 4 factors were dubbed

Major Depressive Disorder (MDD) is common and disabling, and is linked to functional impairment and increased mortality. While current treatments for MDD are moderately effective, ultimately, up to one third of patients do not achieve full remission. Interestingly, while affective symptoms of major depression typically resolve with the depressive episode, cognitive impairment frequently persists, and has been identified as one of the most prominent predictors of illness recurrence. Additionally, MDD is well-recognised as a key risk factor for further cognitive decline and dementia. Yet, available treatments for MDD do not typically address cognitive impairment. Cognitive training, represents a promising and novel therapeutic intervention in this regard. This review systematically identified and evaluated the evidence for cognitive training in adults with MDD. Following PRISMA guidelines, eligible studies were selected according to pre-defined criteria delineating our target population (adults with clinically defined MDD), parameters for cognitive training interventions (computer-or strategy-based, clinician-facilitated), and study design (controlled trials including pre-post cognitive and psychological or functional outcome data). Of 448 studies identified, nine studies met inclusion criteria. These studies were evaluated for methodological quality and risk of bias. Despite heterogeneity, qualitative and meta-analytic synthesis of study findings revealed significant improvements in cognitive and affective outcomes following cognitive training, with moderate pooled effect sizes. Unfortunately, very few studies investigated 'far transfer' to broader domains of everyday functioning. Overall, given the strong evidence for the efficacy and value of cognitive training in this context, cognitive training should be considered as a primary therapeutic intervention in the treatment of MDD.

Disturbed sleep and irregular sleep-wake patterns have been associated with poor outcomes in older adults. Sleep regularity however has not been studied in a sample with current or remitted major depression.138 participants (63.8±8.6 years; n=27 current major depression, n=64 remitted, and n=47 healthy controls) were monitored using wrist-worn actigraphy. The Sleep Regularity Index (SRI), sleep-wake fragmentation and stability, sleep onset and offset timing, number of awakenings and measures from cosinor analysis were computed.Compared with controls, older adults with current depression had lower SRI (p0.01), lower relative amplitude (p0.05), and higher activity during sleeping and post-midnight hours (p0.05). Older adults with remitted depression displayed lower activity during the day (p0.05), showed reduced average activity and lower amplitude than controls. Total sleep time, sleep timing, and number of awakenings did not differ between groups. All groups differed significantly in self-reported sleep quality and depression severity.Longitudinal studies which examine how sleep-wake patterns change based on depressive episode recency, severity and how medications may influence these patterns are needed.Older adults with current or remitted major depression do not differ from controls on traditional sleep metrics but do report poor quality sleep and show differences in sleep regularity and rest-activity patterns. Reducing the risk of poor outcomes in both groups may be aided by interventions that help promote sleep regularity and increased activity.

Communicating personal Alzheimer’s disease risk profiles based on validated risk algorithms may improve public knowledge about risk reduction, and initiate action. This proof of concept pilot trial aimed to test whether this is feasible and potentially effective and/or harmful. Older at-risk adults (N=24) were provided with their personal Alzheimer’s disease risk profile online, which contained information on their personal risk level, scores and tailored recommendations to manage modifiable risk factors. After receiving the risk profile, participants were significantly more accurate in identifying risk and protective factors, and revised their perceived risk to be lower than their initial estimate. There was no apparent harm seen in psychological distress or dementia-related worry. This shows preliminary support for the feasibility of delivering personal dementia risk profiles to low risk, help-seeking older adults in an online format. A definitive trial examining behavioural outcomes and testing in groups with higher risk profiles is now warranted.

Background and objectivesIn the absence of a cure for dementia, investigation of novel strategies aimed at delaying or preventing the onset of dementia are gaining momentum. In this regard, using the RE-AIM framework, we outline steps taken to adapt and implement an evidence-based cognitive training program for older adults ‘at risk’ of developing dementia within a clinical setting of a major metropolitan hospital. The primary aim was to explore feasibility (or ‘reach’), tolerability (or ‘implementation’), and acceptability (or ‘adoption’). The secondary aim was to explore the most sensitive clinical outcomes and measurement tools (i.e. ‘efficacy’) to inform a subsequent formal feasibility randomised controlled trial. MethodThis was an exploratory feasibility pilot study, using a pre-post single-arm study design. We conducted this study within the Older People’s Mental Health Service at St Vincent’s Hospital, Sydney, Australia. Seventy-nine participants, with a mean age of 78 years (SD=5.8, range=67-94) were enrolled. All enrolled participants engaged in ‘Club Connect’ an adaptation of a 10-week, group-based multifaceted program, comprised of psychoeducation and computer-based cognitive training. At baseline and follow-up, all participants completed a battery of neuropsychological tests and several questionnaires related to mood and psychosocial functioning. ResultsImplementing cognitive training within a clinical setting was feasible, well tolerated and accepted by participants. Further, cognitive training was associated with large to very large effect size improvements in verbal learning, memory for verbal and visual information, and semantic fluency, as well as quality of life, and reductions in anxiety and stress. We also found small to medium effect size improvements for other cognitive and psychosocial outcomes. ConclusionsOur preliminary findings support the feasibility of translating a group-based cognitive training program into the clinical setting, and provide key data to facilitate the next phase of implementation.

The thalamus is a key diencephalic structure involved in major depressive disorder (MDD). Studies have consistently revealed abnormalities in thalamic volumes in older adults with late-onset depression (LOD), however abnormalities in older adults with early-onset depression (EOD) have not yet been well-studied.Fifty-nine euthymic participants with a history of EOD and fifty-nine matched comparison participants without a lifetime history of depression underwent neuroimaging, medical and neuropsychological assessments. Thalamic volumes were compared between groups. To investigate the previously-proposed right hemispheric (RH) dominance theory of MDD, we explored the bilateral, right and left hemispheric (LH) thalamic volumes. Multiple regression analyses were used to evaluate between-group and within-group effects. Correlational analyses examined associations between group and cognitive performance.Relative to the comparison group, those with EOD had significantly larger bilateral, LH and RH thalamic volumes. Those with EOD, those who were younger, and those who had fewer years of education demonstrated larger bilateral and LH thalamic volumes. For RH thalamic volumes, those with EOD and those who were younger demonstrated larger RH thalamic volumes. EOD within-group models were also run to assess associations between relevant depression variables. The results showed that only age was significant for bilateral and RH thalamic volumes. For the LH thalamic volumes, the model was not significant. No significant correlations were found between cognitive performance and EOD groups.Older adults with a history of EOD showed significantly larger bilateral, RH and LH thalamic volumes. Further research is needed to delineate potential underlying mechanisms of this change.

Objectives:Older adults presenting with mild cognitive impairment (MCI) have a higher risk of developing dementia and also demonstrate impairments in social cognition. This study sought to establish whether in people with MCI, poorer theory of mind (ToM) was associated with volumetric changes in the amygdala and hippocampus, as well as early changes in behaviour.Methods:One hundred and fourteen people with MCI and fifty-two older adult controls completed the Reading the Mind in the Eyes Test (RMET), while close informants (e.g., spouse/family member/friend/carer) described any current behavioural changes using the Revised Cambridge Behavioural Inventory (CBI-R). A subsample of participants completed structural magnetic resonance imaging (MRI).Results:The MCI group showed poorer performance on all neuropsychological tests administered, and moderate reductions on the RMET compared to the control group (d = .44), with greater reduction observed in those with amnestic compared to non-amnestic MCI (p = .03). While a robust correlation was identified between poorer RMET performance and smaller hippocampal volume in the control group (ρ = .53, p = .01), this relationship was not apparent in the MCI group (ρ = .21, p = .11). In the MCI group, poorer RMET performance was associated with poorer everyday skills (ρ = −.26, p = .01) assessed by the CBI-R.Conclusions:Our findings cross-validate previous reports that social cognitive deficits in ToM are a feature of MCI and also suggest that disruptions to broader neural networks are likely to be implicated. Furthermore, ToM deficits in MCI are associated with a decline in everyday skills such as writing or paying bills.

Background: Older adults living with amnestic mild cognitive impairment (aMCI) not only demonstrate impairments in Theory of Mind (ToM), relative to adults with non-amnestic MCI (naMCI), but are also at a higher risk of developing dementia. Objective: Our primary objective was to ascertain whether default mode network (DMN) functional connectivity was differentially associated with ToM abilities between MCI subgroups. Methods: Using functional magnetic resonance imaging, we investigated alterations in resting-state functional connectivity within the brain’s DMN in a sample of 43 older adults with aMCI (n = 19) and naMCI (n = 24), previously reported to demonstrate poorer ToM abilities. Results: Compared to naMCI, the aMCI subgroup revealed a significant association between poorer ToM performance and reduced functional connectivity between the bilateral temporal pole (TempP) and the left lateral temporal cortex (LTC) (LTC_L-TempP_L: b = –0.06, t(33) = –3.53, p = 0.02; LTC_L-TempP_R: b = –0.07,t(33) = –3.20, p = 0.03); between the right TempP and the dorsal medial prefrontal cortex (dMPFC) (b = –0.04, t(33) = –3.02, p = 0.03) and between the left and right TempP (b = –0.05, t(33) = –3.26, p = 0.03). In the naMCI subgroup, the opposite relationship was present between the bilateral TempP and the left LTC (Combined correlation: r = –0.47, p = 0.02), however, not between the right TempP and the dMPFC (r = –0.14, p = 0.51) or the left and right TempP (r = –0.31, p = 0.14). Conclusion: Our findings suggest that alterations in functional connectivity within the DMN involving temporal and frontal lobe regions are associated with ToM deficits in aMCI.

IntroductionMelatonin has multiple proposed therapeutic benefits including antioxidant properties, synchronisation of the circadian system and lowering of blood pressure. In this protocol, we outline a randomised controlled trial to assess the feasibility, acceptability and tolerability of higher dose (25 mg) melatonin to target brain oxidative stress and sleep disturbance in older adults with mild cognitive impairment (MCI).Methods and analysisThe study design is a randomised double-blind, placebo-controlled, parallel group trial. Forty individuals with MCI will be recruited from the Healthy Brain Ageing Clinic, University of Sydney and from the community, and randomised to receive either 25 mg oral melatonin or placebo nightly for 12 weeks. The primary outcomes are feasibility of recruitment, acceptability of intervention and adherence to trial medication at 12 weeks. Secondary outcomes will include the effect of melatonin on brain oxidative stress as measured by magnetic resonance spectroscopy, blood pressure, blood biomarkers, mood, cognition and sleep. Outcomes will be collected at 6 and 12 weeks. The results of this feasibility trial will inform a future conclusive randomised controlled trial to specifically test the efficacy of melatonin on modifiable risk factors of dementia, as well as cognition and brain function. This will be the first trial to investigate the effect of melatonin in the population with MCI in this way, with the future aim of using this approach to reduce progression to dementia.Ethics and disseminationThis protocol has been approved by the Sydney Local Health District Ethics Committee (X18-0077). This randomised controlled trial will be conducted in compliance with the protocol published in the registry, the International Conference for Harmonisation on Good Clinical Practice and all other applicable regulatory requirements. The findings of the trial will be disseminated via conferences, publications and media, as applicable. Participants will be informed of results of the study at the conclusion of the trial. Eligible authors will include investigators who are involved in the conception and design of the study, the conduct of the trial, the analysis of the results, and reporting and presentation of study findings.Trial registration numberAustralian and New Zealand Clinical Trials Registry (ANZCTRN 12619000876190).Protocol versionV.8 15 October 2020.

No intervention exists that can stop or reverse the progression of symptoms in people with dementia; however, several nonpharmacological treatments, including cognitively oriented treatments (COTs) and physical activity (PA) treatments, have shown promise in relation to cognitive outcomes. This chapter summarizes the cognitive and associated functional limitations of people with dementia, discusses the nature of the main approaches to COTs, and provides an overview of the evidence in relation to cognitive training, cognitive rehabilitation and cognitive stimulation therapy, as well as physical activity treatments. Clinician knowledge, competence, and confidence, the appropriateness of the intervention for that person, person with dementia engagement, and care partner involvement should be considered when implementing interventions. Ethnoracial and cultural factors, pragmatic trials, combination treatments, and new technologies are areas of future development and treatment.

Study Objectives Cardiovascular autonomic dysfunction, as measured by short-term diurnal heart rate variability (HRV), has been reported in older adults with mild cognitive impairment (MCI). However, it is unclear whether this impairment also exists during sleep in this group. We, therefore, compared overnight HRV during sleep in older adults with MCI and those with subjective cognitive impairment (SCI). Methods Older adults (n = 210) underwent overnight polysomnography. Eligible participants were characterized as multi-domain MCI or SCI. The multi-domain MCI group was comprised of amnestic and non-amnestic subtypes. Power spectral analysis of HRV was conducted on the overnight electrocardiogram during non-rapid eye movement (NREM), rapid eye movement (REM), N1, N2, N3 sleep stages, and wake periods. High-frequency HRV (HF-HRV) was employed as the primary measure to estimate parasympathetic function. Results The MCI group showed reduced HF-HRV during NREM sleep (p = 0.018), but not during wake or REM sleep (p > 0.05) compared to the SCI group. Participants with aMCI compared to SCI had the most pronounced reduction in HF-HRV across all NREM sleep stages—N1, N2, and N3, but not during wake or REM sleep. The naMCI sub-group did not show any significant differences in HF-HRV during any sleep stage compared to SCI. Conclusions Our study showed that amnestic MCI participants had greater reductions in HF-HRV during NREM sleep, relative to those with SCI, suggesting potential vulnerability to sleep-related parasympathetic dysfunction. HF-HRV, especially during NREM sleep, may be an early biomarker for dementia detection.

OBJECTIVE This study aimed to investigate the relationship between obesity and oxidative stress in older adults at risk for dementia. It also aimed to explore the influence of physical activity on the relationship between obesity and oxidative stress in this at risk cohort. METHODS Older adults at risk for dementia underwent comprehensive medical, neuropsychological, and psychiatric assessment. At risk was defined as participants with subjective or mild cognitive impairment. Glutathione was assessed by magnetic resonance spectroscopy in the left hippocampus and the anterior and posterior cingulate cortex. Body mass index (BMI) was calculated and classified as healthy (BMI

Objectives:With the rapid growth of the older population worldwide, understanding how older adults with mild cognitive impairment (MCI) use memory strategies to mitigate cognitive decline is important. This study investigates differences between amnestic and nonamnestic MCI subtypes in memory strategy use in daily life, and how factors associated with cognition, general health, and psychological well-being might relate to strategy use.Methods:One hundred forty-eight participants with MCI (mean age = 67.9 years, SD = 8.9) completed comprehensive neuropsychological, medical, and psychological assessments, and the self-report ‘Memory Compensation Questionnaire’. Correlational and linear regression analyses were used to explore relationships between memory strategy use and cognition, general health, and psychological well-being.Results:Memory strategy use does not differ between MCI subtypes (p > .007) despite higher subjective everyday memory complaints in those with amnestic MCI (p = .03). The most marked finding showed that increased reliance-type strategy use was significantly correlated with more subjective memory complaints and poorer verbal learning and memory (p < .01) in individuals with MCI. Moreover, fewer subjective memory complaints and better working memory significantly predicted (p < .05) less reliance strategy use, respectively, accounting for 10.6% and 5.3% of the variance in the model.Conclusions:In general, the type of strategy use in older adults with MCI is related to cognitive functioning. By examining an individual’s profile of cognitive dysfunction, a clinician can provide more personalized clinical recommendations regarding strategy use to individuals with MCI, with the aim of maintaining their day-to-day functioning and self-efficacy in daily life.

Background Dementia prevalence is expected to increase substantially over the next few decades. Since there is currently no cure for dementia available, there is an urgent need for the early identification of individuals at high risk for dementia, so that primary and secondary prevention strategies can be implemented. Recently, the LIfestyle for BRAin health (LIBRA) index was developed as a new dementia risk algorithm. It specifically focuses on modifiable risk and protective factors that can be targeted in midlife. Objective The objective of this study was to evaluate the LIBRA index in relation to markers of cognitive functioning in a clinical, health-seeking sample of community-based older adults. Methods 484 participants (mean age 62.7 years) were recruited from the Healthy Brain Ageing Clinic at the Brain and Mind Centre, Sydney. Participants underwent comprehensive clinical and neuropsychological assessment and completed a self-report survey pack. Participants were rated via consensus as having either subjective cognitive complaints (SCC) or meeting criteria for mild cognitive impairment (MCI). The LIBRA score was calculated based on 11 available risk and protective factors. Results 65.4% of the sample met criteria for MCI. People with MCI showed a significantly higher LIBRA score compared to people with SCC. Furthermore, multiple cognitive domains, in particular executive functioning, were associated with a higher LIBRA score, with stronger correlations in people with MCI. Conclusion The LIBRA index might be a useful tool to determine lifestyle-attributable risk of cognitive decline in an older health-seeking population, including people with MCI.

Introduction Depression in older people is associated with changes in sleep, however associations between sleep architecture and cognition have not yet been delineated. We examined sleep architecture in older people with and without depressive symptoms, and relationships with neuropsychological performance. Methods Adults over 50 years underwent overnight polysomnography and memory and executive function tests. Depression and controls groups were defined by a Geriatric Depression Scale-15 cut off score of 6. Sleep architectural outcomes included amount of slow wave sleep (SWS), rapid eye movement (REM) sleep, REM onset latency (ROL), NREM slow wave activity (SWA, 0.5–4 Hz), N2 sleep spindle density and REM density. Results The sample comprised of 71 participants with depressive symptoms and 101 controls (mean age both groups = 64, mean GDS-15 dep= 9.3, con= 1.8). There were no significant group differences in time spent in SWS, REM, REM density or SWA. Those with depressive symptoms had later ROL (p=.008) and less N2 sleep spindles (p=.03) compared to controls. A differential association was observed with less SWS being associated with poor memory recall in the depression group only (z=.342, p=0.008). No associations between sleep and executive function performance were observed. Discussion The link between less time in SWS and poorer memory in those with depressive symptoms could suggest that SWS is particularly pertinent for cognition in depression or that both sleep and cognition mechanisms are influenced by depressive state. Further studies are needed to determine if changes in sleep are linked with underlying neurobiological changes.

Previous meta-analyses indicate that computerized cognitive training (CCT) is a safe and efficacious intervention for cognition in older adults. However, efficacy varies across populations and cognitive domains, and little is known about the efficacy of CCT in people with mild cognitive impairment or dementia.The authors searched Medline, Embase, PsychINFO, CINAHL, and CENTRAL through July 1, 2016, for randomized controlled trials of CCT in older adults with mild cognitive impairment or dementia. Overall cognition, individual cognitive domains, psychosocial function, and activities of daily living were pooled separately for mild cognitive impairment and dementia trials.The overall effect on cognition in mild cognitive impairment across 17 trials was moderate (Hedges' g=0.35, 95% CI=0.20-0.51). There was no evidence of publication bias or difference between active- and passive-controlled trials. Small to moderate effects were found for global cognition, attention, working memory, learning, and memory, with the exception of nonverbal memory, and for psychosocial functioning, including depressive symptoms. In dementia, statistically significant effects were found on overall cognition (k=11, g=0.26, 95% CI=0.01-0.52) and visuospatial skills, but these were driven by three trials of virtual reality or Nintendo Wii.CCT is efficacious on global cognition, select cognitive domains, and psychosocial functioning in people with mild cognitive impairment. This intervention therefore warrants longer-term and larger-scale trials to examine effects on conversion to dementia. Conversely, evidence for efficacy in people with dementia is weak and limited to trials of immersive technologies.

Cognitive impairment is now widely accepted as a fundamental aspect of Parkinson’s disease (PD). Given the prevalence of cognitive impairment and the associated impact on well-being, evidence-based interventions are needed. However, while research is continually accumulating in order to better understand the pathology and trajectory of cognitive changes, treatment options lag behind. Nonpharmacological approaches are of particular interest in this group, given the typical polypharmacy already present in PD patients. In this regard, cognitive training (CT) is a relatively new and prominent therapeutic option with accumulating scientific support and increasing public awareness. Research has now established benefits across many different populations, and trials investigating the use of CT specifically in PD are becoming more common. We offer a brief summary of CT and its efficacy in PD samples to date, as well as discuss areas requiring further exploration in this group. Crucially, we suggest that CT should be supported as a research priority in PD, given both proven and potential benefits as a noninvasive and well-tolerated behavioral intervention for cognitive impairment.

Major depressive disorders (MDD) are common and disabling, and are linked to functional impairment and increased mortality. While current treatments for MDD are moderately effective, ultimately up to one-third of patients do not achieve full remission. Interestingly, while affective symptoms of depression resolve with the resolution of a depressive episode, cognitive or neuropsychological impairment persists, and has been identified as one of the most prominent predictors of ongoing disability, reduced quality of life, and illness recurrence. Yet available treatments in MDD do not typically address neuropsychological dysfunction. Cognitive training, however, despite a small and heterogeneous evidence base, represents a promising and novel therapeutic intervention for neuropsychological impairment in MDD, which may yield neuropsychological, affective, and functional benefits.

Objectives: To test feasibility and potential effects of the interdisciplinary Home-bAsed Reablement Program (I-HARP) that integrates evidence-based strategies and cognitive rehabilitation techniqu...

Objectives:Disability in older adults is associated with a need for support in work, education, and community activities, reduced independence, and poorer quality of life. This study examines potential determinants of disability in a clinical sample of older adults across the continuum of cognitive decline, including sociodemographic, medical, psychiatric, and cognitive factors.Design:This is a cross-sectional study.Setting:Participants were recruited from a specialty clinic for adults “at risk” of or with early dementia (including subjective cognitive complaints, mild cognitive impairment, and early dementia).Participants:Four hundred forty-two older adults (mean age = 67.11, SD = 9.33) underwent comprehensive medical, neuropsychological, and mood assessments.Measurements:Disability was assessed via the self-report World Health Organization Disability Assessment Schedule 2.0. A stepwise (forward) linear regression model was computed to determine factors that contribute to disability within this group.Results:Depressive symptoms were the largest predictor, uniquely explaining 31.8% of the variance. Other contributing factors in the model included younger age, medical burden, and sleep quality, with all factors together accounting for a total of 50.4% of the variance in disability. Cognitive variables did not contribute to the model.Conclusions:Depressive symptoms account for a significant portion of the variance in disability, but other factors such as age, medical burden and sleep quality are also important contributors in older adults across the continuum of cognitive decline. The relative association of these variables with disability appears to differ for older (≥65 years) relative to younger (

Major depressive disorders (MDD) are common and disabling, and are linked to functional impairment and increased mortality. While current treatments for MDD are moderately effective, ultimately, up to one third of patients do not achieve full remission. Interestingly, while affective symptoms of depression resolve with the resolution of a depressive episode, cognitive impairment frequently persists, and has been identified as one of the most prominent predictors of illness recurrence. Additionally, MDD is well-recognised as a key risk factor for further cognitive decline and dementia. Yet, available treatments in MDD do not typically address cognitive impairment. Cognitive training (CT), represents a promising and novel therapeutic intervention in this regard. Our review systematically identified and quantitatively evaluated the evidence for CT in adults with MDD. Following PRISMA guidelines, eligible studies were selected according to pre-defined criteria delineating our target population (adults with clinically defined MDD), parameters for CT interventions (computer-or strategy-based, clinician-facilitated), and study design (controlled trials including pre/post cognitive and psychological or functional outcome data). Of 111 identified, nine studies met inclusion criteria. These studies were evaluated for methodological quality and risk of bias. Despite heterogeneity, qualitative and meta-analytic synthesis of study findings revealed significant improvements in cognitive and affective outcomes following CT, with pooled effect sizes ranging from moderate to large. Unfortunately, very few studies investigated ‘far transfer’ to broader domains of everyday functioning. Overall, given the strong evidence supporting the efficacy and value of CT in this context, CT should be considered as a primary therapeutic intervention in the holistic treatment of MDD.

Background:Current treatments for Major Depression are only moderately effective. In fact, 20-30% do not achieve full recovery despite multiple interventions. Interestingly, while it is well recognised that cognitive impairment is associated with Major Depression, available treatments do not address cognitive impairment. In this regard, cognitive training (CT) represents a promising intervention, however CT is not typically offered in public health settings.Aim:To evaluate the feasibility of a blinded, randomised controlled trial of group-based CT in a hospital sample of older adults with clinically significant depressive symptoms or history of a major depressive episode within the last five years, and in doing so, to adapt and translate research findings to the clinical setting.Methods:40 older adults, aged at least 65 years, with depression or a history of depression, and without dementia were randomly allocated to Club Connect, a 10-week group-based healthy brain ageing CT program, or a waitlist, treatment-as-usual control group. Baseline assessment including review by a psychogeriatrician and a brief neuropsychological assessment was completed within a fortnight of the intervention starting, and follow-up assessment was completed within a fortnight of the intervention ceasing. Primary outcomes included feasibility of trial design, tolerability of the intervention, and acceptability of random allocation and data collection procedures (as perceived by both participants and clinicians). We also examined the most sensitive clinical outcomes and measurement tools to inform larger scale trials.Significance:The current health, social and economic costs of late-life depression, especially in those with concomitant cognitive impairment, renders the holistic treatment of depression in older adults a public health priority. CT represents an efficacious therapeutic intervention in this regard, however, there appears to be a paucity of CT programs being offered in public health settings. This trial represents the first step in addressing the ‘implementation gap’ that exists between care that is known to be effective and care that is delivered. We must recognise the need to evaluate not only health outcomes, but also to perform formative evaluations that assess the extent to which implementation is effective in order to optimise intervention benefits, to prolong sustainability, and to promote dissemination of findings.

Older adults with mild cognitive impairment (MCI) are at-risk of developing dementia, particularly Alzheimer's disease. While some research suggests that alterations in sleep architecture may mediate cognitive decline, the nature and magnitude of changes to sleep macro- (sleep stages) and micro-architecture (electroencephalography (EEG) oscillations) in MCI is not yet clear. This study aimed to systematically review and meta-analyse case-control studies objectively measuring sleep in MCI. A systematic search was conducted using PubMed, Scopus, Web of Science, Embase and Psycinfo databases and after review, a total of 10 studies met inclusion criteria. Of these, all reported sleep macro-architecture and four reported micro-architecture outcomes. A combined total of 430 participants (209 with and 221 without MCI) underwent objective sleep assessments in the included full text articles. Findings show that compared to healthy controls, those with MCI have pronounced changes in sleep macro-architecture with greater wake after sleep onset, reduced total sleep time, lower sleep efficiency, longer sleep onset latency, longer rapid eye movement sleep (REM) latency, reduced REM sleep, greater N1 sleep, and worse severity of hypoxemia. Pooling of sleep micro-architecture EEG measures was not possible due to limited studies, however reduced spindles in non-REM sleep and greater EEG slowing in REM sleep were reported.

The pathophysiological mechanism of freezing of gait (FoG) has been linked to executive dysfunction. Cognitive training (CT) is a non-pharmacological intervention which has been shown to improve executive functioning in Parkinson’s disease (PD). This study aimed to explore whether targeted CT can reduce the severity of FoG in PD. Patients with PD who self-reported FoG and were free from dementia were randomly allocated to receive either a CT intervention or an active control. Both groups were clinician-facilitated and conducted twice-weekly for seven weeks. The primary outcome was percentage of time spent frozen during a Timed Up and Go task, assessed both on and off dopaminergic medications. Secondary outcomes included multiple neuropsychological and psychosocial measures. A full analysis was first conducted on all participants randomized, followed by a sample of interest including only those who had objective FoG at baseline, and completed the intervention. Sixty-five patients were randomized into the study. The sample of interest included 20 in the CT group and 18 in the active control group. The primary outcome of percentage time spent frozen during a gait task was significantly improved in the CT group compared to active controls in the on-state. There were no differences in the off-state. Patients who received CT also demonstrated improved processing speed and reduced daytime sleepiness compared to those in the active control. The findings suggest that CT can reduce the severity of FoG in the on-state, however replication in a larger sample is required., Freezing of gait: a non-pharmacological approach Cognitive training can reduce the severity of gait freezing in Parkinson’s disease (PD) patients on dopaminergic medication. The inability to move forwards despite the intention to walk is one of the most debilitating symptoms in patients with PD and has been linked to cognitive dysfunction. Simon Lewis at the University of Sydney, Australia, and colleagues examined the effects of cognitive training in patients with self-reported freezing of gait and without dementia. Patients receiving cognitive therapy twice a week for seven weeks showed a significant reduction in gait freezing compared to the control group. Interestingly, the effect was observed when patients had maximum benefit from their PD medication (on-state) but not in the off-state. Cognitive training also improved patients’ processing speed and reduced their daytime sleepiness highlighting the usefulness of non-pharmacological interventions in the treatment of PD.

Research interest in sleep as a risk factor for dementia has grown, warranting an update in advances over the last 18 months, particularly in the mild cognitive impairment (MCI) stage in which interventions may be best targeted.The current systematic review includes empiric research articles published since 2016 that have investigated sleep (excluding obstructive sleep apnea) in MCI. Published articles include case-control studies, those examining clinical correlates of sleep problems, sleep microarchitecture, neuroimaging studies and novel cerebrospinal and blood-based markers.Evidence accumulated since 2016 continues to demonstrate that people with MCI manifest sleep disturbance on self-report measures. Neurophysiologically, sleep disturbance in MCI appears to be associated with diminished sleep spindles, key processes involved in overnight memory consolidation. Those with both MCI and sleep disturbance appear to have more pronounced functional connectivity alterations in temporoparietal brain regions and higher levels of the wake-promoting neurotransmitter orexin in cerebrospinal fluid than those with MCI alone. Novel findings also suggest that sleep may mediate homocysteine and oxidative stress mechanisms, warranting further exploration. Further studies focusing on novel interventions for sleep and circadian disturbance in MCI are warranted, particularly those targeting sleep spindles, orexin/hypocretin and the oxidative stress system.

Background: With the rise in the ageing population and absence of a cure for dementia, cost-effective prevention strategies for those 'at risk' of dementia including those with depression and/or mild cognitive impairment are urgently required. Objective: This study evaluated the efficacy of a multifaceted Healthy Brain Ageing Cognitive Training (HBA-CT) program for older adults 'at risk' of dementia. Methods: Using a single-blinded design, 64 participants (mean age = 66.5 years, SD = 8.6) were randomized to an immediate treatment (HBA-CT) or treatment-as-usual control arm. The HBA-CT intervention was conducted twice-weekly for seven weeks and comprised group-based psychoeducation about cognitive strategies and modifiable lifestyle factors pertaining to healthy brain ageing, and computerized cognitive training. Results: In comparison to the treatment-as-usual control arm, the HBA-CT program was associated with improvements in verbal memory (p = 0.03), self-reported memory (p = 0.03), mood (p = 0.01), and sleep (p = 0.01). While the improvements in memory (p = 0.03) and sleep (p = 0.02) remained after controlling for improvements in mood, only a trend in verbal memory improvement was apparent after controlling for sleep. Conclusion: The HBA-CT program improves cognitive, mood, and sleep functions in older adults 'at risk' of dementia, and therefore offers promise as a secondary prevention strategy. © 2015 IOS Press and the authors. All rights reserved.

Background: Using the Movement Disorder Society (MDS) Task Force Level 1 criteria, this study examined the classification of mild cognitive impairment in Parkinson's Disease (PD-MCI) derived from a range of cut-off scores that have previously been suggested by the MDS Task Force. Furthermore, differences in PD-MCI frequencies were examined when comparing performance on current neuropsychological testing to the normative sample, as opposed to decline from premorbid functioning, as evidence of cognitive impairment. Method: Two hundred and thirty-four non-demented PD patients underwent neurological and neuropsychological assessment at the Parkinson's Disease Research Clinic at the Brain and Mind Research Institute, University of Sydney. Results: When cognitive impairment was defined as 1SD and 1.5SD below premorbid intellect, 109 patients (47%) and 76 (32%) patients met criteria for PD-MCI respectively. This proportion dropped considerably to 50 patients (21%) with a 2SD cut-off score. However, when calculating impairment based on comparisons with normative data, only 68 patients (29%) and 41 patients (18%) met PD-MCI criteria when a cut-off score of 1 and 1.5SD was employed. This proportion dropped to just 22 patients (9%) with a 2SD cut-off score. Conclusion: Results from the present study suggest that the MDS PD-MCI criteria may be too broad, as substantial differences in frequencies of PD-MCI were observed with the application of differing criteria. We propose that a 1.5SD cut-off score below premorbid functioning may provide greater utility in characterizing PD-MCI than a 1.5SD cut-off below normative data, which has been widely applied in previous studies examining the MDS PD-MCI criteria.