Treatment of depression and anxiety in Parkinson’s Disease

This thesis examined the treatment of depression and anxiety in Parkinson’s disease (PD) and comprised four studies. Study 1 was a meta-analysis of treatments for depression and anxiety in PD. Study 2 examined the validity of the DASS-21 as an assessment tool in PD. Study 3 was a randomised controlled trial of group CBT for depression and anxiety in PD. Study 4 was a cross-sectional cohort study examining mental health service utilisation and barriers to treatment

Clarifying perceptions of cognitive functioning in normal aging and after mild traumatic brain injury : a thesis presented in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at Massey University, Albany, New Zealand

The cognitive symptoms reported more than 3 months after a mild traumatic brain injury (mTBI) are often found to have no association with objective cognitive functioning as evaluated by formal assessment measures. They are believed to relate more to physical symptoms such as pain or fatigue, psychological factors such as affective distress, and misattributions regarding the causes of ongoing subjective difficulties. This is similar to normal aging where for similar reasons, subjective complaints of worsening of cognitive function are also often not supported by objective assessment. The present research aimed to explore factors which have been suggested in the literature as potentially contributing to the development of subjective cognitive complaints (SCCs) in both populations. These factors included level of awareness of age-related change in cognition, affective distress, processing speed (PS), cognitive reserve (CR), and use of compensatory strategies. The present research consisted of two parts. In Part A, secondary analyses of two databases were conducted to inform development of a survey and model in Part B. The results supported inclusion of CR, PS, and compensatory strategies in the survey, and indicated the need for inclusion of a measure of psychological stress. Part B consisted of two studies which examined the hypothesized model of factors that influence reporting of SCCs. Data from a total of 659 individuals recruited from the New Zealand population was split into two groups - normal aging (n=436) and mTBI (n=223). Structural equation modelling (SEM) was employed to assess the relationships between the identified factors and SCCs in each of these groups. The results provided support for the hypothesized model in that this model explained 47.6% of variance in reporting of SCCs in normal aging, and 62.5% of variance in reporting of SCCs in mTBI. Psychoeducation-based interventions, compensatory strategy training, and in some instances individual psychological assessment and therapy are recommended as potentially helpful in reducing the reporting of SCCs.

Understanding activities of daily living in people with dementia: Why is there a gap between performance and ability?

People with dementia’s (PwD) performance of activities of daily living (ADLs) relates to what the PwD does in their daily routine, while their ability to complete tasks refers to what they could potentially do. The World Health Organization (WHO) launched the International Classification of Functioning, Disability and Health (ICF) (WHO, 2001) which highlighted the importance of identifying the gap between performance and ability to complete tasks and to consider how different factors contribute to disability, to make adjustments and promote participation. Although several studies have examined how intrinsic factors affect the performance and potential ability to carry out ADLs, very few of them have investigated the role of extrinsic factors, including both the physical and the human environment (represented by the primary carer), in PwD’s ADL functioning. Using the ICF model, this thesis aimed to investigate the role of both intrinsic and extrinsic factors on PwD’s ADL functioning, and how they may explain the gap that exists between the performance of ADLs and the actual ability to perform them. A mixed-methods approach was used to address the research questions. The first study used an experimental design to investigate the role of the environment in PwD’s ability to perform ADLs. Results showed that PwD performed better at home, even though the level of clutter was higher in their home environment than in the research-lab. Cognition was the only factor that predicted better functioning. The second study investigated how the combination of both intrinsic (cognition and apathy) and extrinsic factors (carer’s style) affected ADLs in PwD. Apathy levels and carer’s use of criticism style negatively affected ADL performance, while cognition and carer’s use of encouragement style improved performance of daily tasks. The next study investigated how the human environment affected the discrepancy between the reported and the observed ADL performance. Results showed a high disagreement between performance and ability to perform ADLs in PwD, and the carer’s use of encouragement and active management style were the factors that predicted this discrepancy. The final study used a qualitative approach to identify the types of assistance provided by carers, when the PwD performs a task. Five different themes were identified, and the findings suggested that the types of assistance used by carers could either enhance or hinder ADL performance of PwD. This thesis has shown that ADL functioning in PwD is affected by both the human and the physical environment and has revealed how the combination of extrinsic and intrinsic factors contributes to the changes in task performance of PwD. This work has confirmed the important role extrinsic factors play in shaping disability and that disability does not depend exclusively on disease-related factors. The findings provide evidence to support the development of multi-component non-pharmacological interventions that aim to reduce the gap between performance and ability to perform ADLs in PwD

An investigation into cognitive assessment tools for use in primary care

Background: More sensitive indicators of cognitive decline are needed in Primary Care. Self-report measures offer some potential but, to date, are not yet reliable indicators of objective performance or progression to dementia. Relationships between self-reported and objective performance remains unclear. Recent research suggests that prospective memory (PM) failures might reflect current and future cognitive decline more accurately than retrospective memory (RM) failures, yet PM is rarely assessed in clinical practice. Methods: In order to determine the nature, extent and possible underlying causes of self-reported cognitive difficulties in older Irish adults, Study 1 obtained PRMQ data as well as sociodemographic, mood state and health-related information from 518 community-dwelling adults >50+ years using an anonymous survey. Study 2 obtained PRMQ data and data on objective tests recommended for Primary Care from a separate sample (n = 97) of community dwelling adults without history of dementia. Participants were then classified as high reporters/low reporters of memory difficulty and the effectiveness of objective tests for determining group membership was assessed. Study 3 employed advanced statistical methods in an attempt to identify an improved self-assessment tool (short-form PRMQ) that might prove useful in primary care whilst Study 4 generated normative data specific to older Irish adults (both for the long-form and the proposed short-form PRMQ) and examined the potential utility of the proposed short-form PRMQ for case-ascertainment. Results: Study 1 data revealed that self-reported PM and RM failures are common in the older Irish population and are related, at least to some extent, to sociodemographic, mood state and health-status. Results from analysis of relationships between objective and subjective memory performance (Study 2) revealed complex relationships dependent upon factors such as mood state and multimorbidity. Study 3 resulted in a short-form PRMQ that does not compromise the psychometric properties of the long-form, whilst Study 4 resulted in normative data conversion tables and a proposed algorithm to aid GPs in their decision-making. Conclusions: The relationships between self-reported memory failures and objective memory performance are complex but can be better understood when account is taken of co-morbidities such as mood state, sleep disturbance and multimorbidity. Based on these findings, care should be taken to understand the complexity and clinical relevance of self-reported difficulties in older adults but recognising atypical reports of everyday memory failures in older adults is worthy of greater consideration in primary care practice

The Distinct Contributions of Affective Distress and Personality to Memory Complaints Made in Older Adulthood

Whilst a substantial amount of research has investigated the role of affective distress and features of personality in memory complaints made by older adults, little effort has been directed towards understanding their distinct contributions to complaints. Given considerable overlap between affective distress and features of personality, such evidence is necessary to inform theoretical frameworks pertaining to memory complaints and clarify results from other empirical studies examining these concepts. Consequently, the current study examined symptoms of depression and anxiety as predictors of memory complaints within the context of features of personality and other relevant contextual variables (i.e., age, gender, education, premorbid intellectual functioning and memory performance) utilizing a correlational design. Study participants included 177 (115 females, 62 males) community-dwelling older adults between 65 and 90 years of age. The results of the study unanimously suggested that affective distress (i.e., depressive and anxiety symptomatology) was not associated with memory complaints beyond pertinent features of personality and other relevant contextual variables. This finding was consistent regardless of how memory complaints were assessed (i.e., General Frequency of Forgetting scores or via a global, dichotomous measure) or how affective distress was conceptualized (i.e., overall or specific features of depression and anxiety). The results suggest changes to several theoretical frameworks in the memory complaint literature are necessary, if the results can be replicated with different variable measures. From a clinical perspective, the results of the current study suggest older adults complaining of memory difficulties may exhibit an ongoing risk of symptoms of depression and anxiety. In addition, the results also help to clarify why cognitively-healthy older adults who complain of memory problems exhibit an increased risk of subsequent dementia

Aberrant brain activation and coupling in Depression – Links between Psychopathology and Neurophysiology

Major Depressive Disorder (MDD) is the most common mental disorder and ranging under the top three of the most disabling diseases worldwide. Although various treatments exist for MDD, about 30 to 40 % of the patients don’t respond. A better understanding of the neurobiological correlates of MDD might lead to the development of new and the improvement of existing treatments. The dissertation at hand is dedicated to the aim of a better understanding of aberrant brain functioning and coupling in MDD. Further, we sought to investigate the behavioral and cognitive-affective underpinnings that lead to aberrant brain functioning and coupling in MDD, in terms of depressive rumination. In total this work comprises four studies. In our first study, we investigated the functional connectivity (FC) during resting state (rsFC) and task performance of the Trail Making Test (TMT) in subjects with late-life depression (LLD) and healthy controls (HC). FC was assessed via functional near-infrared spectroscopy (fNIRS) in areas of the cognitive control network (CCN). While we observed an expected pattern of change in FC in the healthy controls with relatively low FC during resting-state and an increase during task-performance, subjects with LLD showed an opposite pattern, with relatively high FC during resting-state and decreases during task-performance. Further, depressed and non-depressed subjects differed significantly during resting-state (LLD>HC) and the executive demanding condition of the TMT (HC>LLD). While these results were interesting from a standpoint of pathophysiological changes in FC, we couldn’t give a final explanation for the observed FC patterns in LLD. As a possible explanation, we assumed that some kind of depressive cognitive process could lead to hyper-connectivity within the CCN during resting-state that further disturbs cortical coupling during task performance. As depressive rumination is such a cognitive process that is common in depression, we developed a resting-state questionnaire to assess state rumination for subsequent studies. In study two, we investigated rsFC within subjects with MDD and HC with a parietal probeset covering parts of the default mode network (DMN), CCN and dorsal attention network (DAN). Further, we investigated in how far state- and trait rumination explained the differences between depressed and non-depressed subjects in rsFC. In contrast to our first study, we observed an opposite pattern of FC differences between the groups: within the parietal cortex, depressed subjects showed reduced FC in comparison to HC in a widespread bilateral network. While state rumination showed rather restricted effects, the measures of trait rumination showed wide-spread effects. Further, FC was negatively correlated with state- and trait rumination. Since our results so far were restricted to non-experimental between-subject associations, that don’t allow the investigation of causal relationships, we further designed a study in which we sought to induce rumination with the Trier Social Stress Test (TSST). In study three, we investigated the hemodynamic changes during the TSST in high and low trait ruminators in the CCN, further, we examined in how far state rumination would be induced through the TSST. Relationships between hemodynamic responses and state rumination were examined with a mediation analysis. As expected, we found increases in state rumination through the TSST. Further, these increases were higher in the high-trait ruminators. On a cortical level, low ruminators showed higher cortical activation in the stress condition than the high ruminators in the right inferior frontal gyrus (IFG). Further, group differences in post-stress state rumination were mediated by the cortical reactivity in this region. Subject with high IFG reactivity showed less state-rumination following the TSST. In study four, we further investigated in the same study cohort, if rsFC before and after stress would show an expected pattern with higher baseline FC in the high trait ruminators and a higher reactivity in rsFC in subjects with high increases in state rumination. As expected, baseline levels of rsFC were increased in the high-ruminators like in our first study for the LDD group. However, although state rumination increased in the high trait ruminators more strongly than in the low trait ruminators, rsFC only increased in the latter group. Since we didn’t observe a co-variation of change scores between rsFC and state rumination, we concluded that the effect of rumination on FC changes would be an indirect one. In the general discussion of this dissertation, I propose a model of indirect prolonged stress effects in high ruminating subjects that lead to higher stress levels and subsequently to permanent changes in FC. This model would explain the observed effects in our study and is in line with current research of FC alterations in chronic stress. I further outline, in how far the presented results and the research of biological underpinnings could improve the current theory development of mental diseases as well as treatment planning

Effects of Cognitive Functioning on Diabetes Self-Care in Adults with Type 2 Diabetes Mellitus

The present investigation comprised exploratory prospective and retrospective studies of the relationships between cognitive functioning, Diabetes Self-Management Behaviour (DSMB) completion, and diabetes-related and general Quality of Life (QoL). A prospective study explored the relationships among these variables in a sample of 26 adults over the age of 40 with Type 2 Diabetes Mellitus (T2DM). Measures used included validated neuropsychological tests assessing multiple cognitive domains and abilities, three self-report measures of DSMB, and the Audit of Diabetes Dependent Quality of Life (ADDQoL). Increased performance on a phonemic verbal fluency task was significantly related to better DSMB behaviour completion (r = .577, p = .002, r2 = .333). There were many significant relationships between a self-report measure of executive functioning and DSMB completion. Processing speed and objective and self-report measures of executive functioning correlated significantly with general QoL. An archival study investigated these relationships using data from the Health and Retirement Study (HRS). The Telephone Interview for Cognitive Status (TICS) assessed cognitive functioning, and measures of DSMB completion and impact of diabetes on life from the 2003 HRS diabetes survey were used to assess DSMB completion and QoL outcome variables in a sample of 776 community dwelling adults with T2DM. Cognitive functioning as measured by the TICS did not account for significantly more variance and did not significantly predict DSMB completion over and above demographic and health-related variables for any of the domains of DSMB completion. Cognitive functioning and a total score of difficulty with DSMB completion accounted for significantly more variance in diabetes impact over and above demographic and health-related variables when A1C was (F(2, 503) = 9.846, p \u3c .001) and was not (F(2, 700) = 13.282, p \u3c .001) included in the model. However, cognitive functioning was not a significant predictor of diabetes impact in either model. Difficulty with DSMB completion was a significant predictor in both models and thus accounted for most of the increase in variance explained above and beyond that explained by the demographic and health-related variables. The implications of the results for future studies of the relationships between cognitive functioning, DSMB completion, and QoL are discussed, as well as the strengths and limitations of the prospective and archival studies

Post-Traumatic Stress Disorder Following Stroke and Its Dispositional Risk Factors: A Cross-Cultural Study Between British and Chinese

Merged with duplicate record 10026.1/754 on 22.03.2017 by CS (TIS)Objectives: This thesis aimed to: 1) explore the subjective experiences of British and Chinese stroke patients, 2) investigate the trajectory of post-stroke PTSD and its relationship between alexithymia, health locus of control, and psychiatric co-morbidity, and 3) compare the differences between the British and Chinese samples in post-stroke PTSD, psychiatric co-morbidity and risk factors. Methods: Four focus group discussions in Britain and China were conducted for study 1. Study 2 was a prospective longitudinal design in which 90 British patients were recruited and assessed approximately 1.5 and 4 months after stroke using a battery of instruments. Study 3 was a cross-cultural study in which the data from the U.K. study above were compared with data from a group of 102 patients recruited from 3 hospitals in China, who were assessed using the same instruments described above. Results: Seven categories of participants' subjective experiences (e.g., feelings at the time of stroke; perceived causes of stroke) were identified in study 1. In study 2, 30% and 50% of stroke patients fulfilled Full and Partial PTSD at baseline which, overall, declined overtime; Stroke patients were significantly worse than the healthy control in psychiatric co-morbidity. After controlling for post-stroke physical disability, difficulty in identifying feelings predicted both PTSD and psychiatric co-morbidity symptoms. Also, alexithymia interacted with chance health locus of control in predicting post-stroke PTSD. In study 3, British patients were at greater risk for developing PTSD than the Chinese. However, Chinese patients developed more somatic problems, anxiety, and depression. For the Chinese samples, alexithymia did not predict PTSD symptoms. Rather, coping styles (i.e., chance health locus of control) were significantly associated with post-stroke PTSD and co-morbidity after controlling for post-stroke physical disability. Conclusion: Following stroke, people could experience PTSD symptoms which might change overtime and could also develop psychiatric co-morbidity. Although these psychological reactions existed in patients regardless of cultural differences, the way in which risk factors associated with outcomes changed depending on cultures

Does Hemoglobin A1c Influence the Relationship between Stressful Life Events and Cognition in Later Life? Findings from the VA Normative Aging Study

With Type 2 diabetes sharply growing in prevalence around the world, there has been an increased interest in adverse health outcomes resulting from excessively high blood sugar and the associated damage to blood vessels, increasing the risk of a variety of chronic illnesses and mortality. If untreated, high blood sugar can result in increased hemoglobin A1c (HbA1c), which can damage veins and arteries for the duration of these erythrocytes’ lifespan, resulting in accumulative damage and loss of efficiency of the circulatory system. Both HbA1c and stressful life events (SLEs) have demonstrated independent effects on cognition in late life, with higher levels of both stress and HbA1c impairing cognition. SLEs can influence a variety of physiological pathways, including HbA1c, thus it is possible that HbA1c can moderate the influence of SLEs on cognitive function. The present study investigated the mediating and moderating effects of HbA1c on the relationship between SLEs and cognitive outcomes in late life. Both global and fluid cognitive measures to investigate general and domain-specific declines associated with both SLEs and HbA1, and then age stratified these same analyses to examine whether the old-old (75+) are more vulnerable, will be used to investigate the potential relationships between these variables. The sample consisted of older adult males (N = 578) from the VA Normative Aging Study (M age = 74.3 years, SD = 6.5) . Structural equation models showed that both SLE and HbA1c exhibited direct effects that varied depending upon the cognitive outcome and type of analysis. However, SLE and HbA1c were unrelated in this sample, therefore no mediation effects were found. One moderation effect was found for the pattern recognition task in the general sample; however the interaction was in the opposite effect of the direct effects, and further investigation suggested a multicollinearity problems, potentially nullifying this result. The analyses stratified by age (< 75 and 75+) yielded some interesting results. Within age group, age was consistently an inversely associated with MMSE and word list total recall, but no significant relationship to verbal fluency and pattern recognition in the old-old group, suggesting either plateau effects, survivor effects, or potentially a specific vulnerability. Further, education appeared to be more protective against cognitive deficits in the old-old group when compared to the young-old group, and HbA1c was more consistently inversely related to cognition in the old-old group, while stress was more likely to have a significant relation in the young-old group. One moderation model for verbal fluency was significant for the old-old group, and results suggested that those high in HbA1c and SLE had lower scores for verbal fluency. Future research should be conducted with more diverse samples, and better aligning the timing of the stress and HbA1c assays. The implications of this work include, bolsters our understanding of how joint effects of physiology and stress may influence specific domains of cognitive function in aging, perhaps resulting in accelerated aging