ArticlePDF Available

Abstract and Figures

Cognitive functioning influences activities of daily living (ADL). However, studies reporting the association between ADL and neuropsychological performance show inconsistent results regarding what specific cognitive domains are related to each specific functional domains. Additionally, whether depressive symptoms are associated with a worse functional performance in older adults is still under explored. We investigated if specific cognitive domains and depressive symptoms would affect different aspects of ADL. Participants were 274 older adults (96 normal aging participants, 85 patients with mild cognitive impairment, and 93 patients probable with mild Alzheimer's disease dementia) with low formal education (∼4 years). Measures of ADL included three complexity levels: Self-care, Instrumental-Domestic, and Instrumental-Complex. The specific cognitive functions were evaluated through a factorial strategy resulting in four cognitive domains: Executive Functions, Language/Semantic Memory, Episodic Memory, and Visuospatial Abilities. The Geriatric Depression Scale measured depressive symptoms. Multiple linear regression analysis showed executive functions and episodic memory as significant predictors of Instrumental-Domestic ADL, and executive functions, episodic memory and language/semantic memory as predictors of Instrumental-Complex ADL (22 and 28% of explained variance, respectively). Ordinal regression analysis showed the influence of specific cognitive functions and depressive symptoms on each one of the instrumental ADL. We observed a heterogeneous pattern of association with explained variance ranging from 22 to 38%. Different instrumental ADL had specific cognitive predictors and depressive symptoms were predictive of ADL involving social contact. Our results suggest a specific pattern of influence depending on the specific instrumental daily living activity.
Content may be subject to copyright.
ORIGINAL RESEARCH
published: 20 July 2015
doi: 10.3389/fnagi.2015.00139
Edited by:
Manuel Menéndez-González,
Hospital Álvarez Buylla, Spain
Reviewed by:
Paul Gerson Unschuld,
University of Zürich, Switzerland
Rena Li,
Roskamp Institute, USA
*Correspondence:
Jonas J. de Paula,
Faculdade de Medicina, Instituto
Nacional de Ciências e Tecnologia
e em Medicina Molecular,
Universidade Federal de Minas
Gerais, Avenue Alfredo Balena 190,
Belo Horizonte, Minas Gerais
30130-100, Brazil
jonasjardim@gmail.com
Received: 08 February 2015
Accepted: 06 July 2015
Published: 20 July 2015
Citation:
de Paula JJ, Diniz BS, Bicalho MA,
Albuquerque MR, Nicolato R,
de Moraes EN, Romano-Silva MA
and Malloy-Diniz LF (2015) Specific
cognitive functions and depressive
symptoms as predictors of activities
of daily living in older adults with
heterogeneous cognitive
backgrounds.
Front. Aging Neurosci. 7:139.
doi: 10.3389/fnagi.2015.00139
Specific cognitive functions and
depressive symptoms as predictors
of activities of daily living in older
adults with heterogeneous cognitive
backgrounds
Jonas J. de Paula1,2*, Breno S. Diniz 1,3 , Maria A. Bicalho1,4 ,
Maicon Rodrigues Albuquerque1,5, Rodrigo Nicolato1,3 , Edgar N. de Moraes1,4 ,
Marco A. Romano-Silva1,3 and Leandro F. Malloy-Diniz1,3
1Faculdade de Medicina, Instituto Nacional de Ciências e Tecnologia e em Medicina Molecular, Universidade Federal de
Minas Gerais, Belo Horizonte, Brazil, 2Department of Psychology, Faculdade de Ciências Médicas de Minas Gerais,
Belo Horizonte, Brazil, 3Department of Mental Health, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo
Horizonte, Brazil, 4Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais,
Belo Horizonte, Brazil, 5Department of Physical Education, Universidade Federal de Viçosa, Viçosa, Brazil
Cognitive functioning influences activities of daily living (ADL). However, studies reporting
the association between ADL and neuropsychological performance show inconsistent
results regarding what specific cognitive domains are related to each specific functional
domains. Additionally, whether depressive symptoms are associated with a worse
functional performance in older adults is still under explored. We investigated if specific
cognitive domains and depressive symptoms would affect different aspects of ADL.
Participants were 274 older adults (96 normal aging participants, 85 patients with mild
cognitive impairment, and 93 patients probable with mild Alzheimer’s disease dementia)
with low formal education (4 years). Measures of ADL included three complexity levels:
Self-care, Instrumental-Domestic, and Instrumental-Complex. The specific cognitive
functions were evaluated through a factorial strategy resulting in four cognitive domains:
Executive Functions, Language/Semantic Memory, Episodic Memory, and Visuospatial
Abilities. The Geriatric Depression Scale measured depressive symptoms. Multiple linear
regression analysis showed executive functions and episodic memory as significant
predictors of Instrumental-Domestic ADL, and executive functions, episodic memory
and language/semantic memory as predictors of Instrumental-Complex ADL (22 and
28% of explained variance, respectively). Ordinal regression analysis showed the
influence of specific cognitive functions and depressive symptoms on each one of
the instrumental ADL. We observed a heterogeneous pattern of association with
explained variance ranging from 22 to 38%. Different instrumental ADL had specific
cognitive predictors and depressive symptoms were predictive of ADL involving social
contact. Our results suggest a specific pattern of influence depending on the specific
instrumental daily living activity.
Keywords: activities of daily living, functional performance, neuropsychological assessment, depression,
dementia, mild cognitive impairment, executive functions
Frontiers in Aging Neuroscience | www.frontiersin.org 1July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
Introduction
Cognitive and functional impairments are hallmarks of cognitive
disorders and defining features of mild cognitive impairment
(MCI) and dementia. In MCI, the cognitive deficits do not impair
the capacity to live independently, in contrast to individuals with
dementia that present pronounced functional deficits, such as the
ones observed in Alzheimer’s disease (AD; (Pereira et al., 2010;
Brown et al., 2011;Seelye et al., 2013). The most usual form to
assess functional performance in older adults is the investigation
of activities of daily living (ADL), common activities performed
by the majority of older adults in a specific cultural setting
(Lawton and Brody, 1969).
Prior studies have investigated the relationship between
cognitive and functional performance in older adults with
MCI or AD. Longitudinal changes in cognition are related
to longitudinal changes in ADL (Farias et al., 2009). In a
comprehensive review, Royall et al. (2007) showed a weak to
moderate association between global cognitive measures and
functional impairment. However, their results are heterogeneous
with cognitive features responding for 0 to 80% of the variance in
functional performance (mean of 21% with a SD of 20%; Gold,
2012). Methodological differences and sample characteristics
might explain part of this excessive variability.
Gold (2012) discuss some of the methodological issues. The
definition and the type of ADL investigated varies between
studies. Some studies focuses on a unitary construct of ADL,
in contrast with several evidences from the literature of a
multidimensional construct involving activities of different levels
of complexity (Thomas et al., 1998;Niti et al., 2007;Gold, 2012;
de Paula et al., 2014). Beyond the usual distinction between Basic
(BADL) and Instrumental (IADL) activities, some studies found
different latent structures in ADL questionnaires and scales.
Thomas et al. (1998) reported a multidimensional structure for
BADL and IADL combined, proposing its interpretation based
on levels of complexity (basic, intermediate, and complex). Niti
et al. (2007) found a bifactorial structure for IADL (“physical”
and “cognitive”) in a sample of Asian older adults with a
significant influence of specific cultural aspects on participants’
responses. In a sample of low educated older adults from Brazil,
de Paula et al. (2014) observed a different factorial solution
with a “Domestic” IADL component and a “Complex” IADL
component, in addition to a third component classified as BADL.
Therefore, ADL may be a multidimensional construct with
different components varying according to sample characteristics
(Bootsma-van der Wiel et al., 2001;Cabrero-García and López-
Pina, 2008;Fieo et al., 2011). Such differences might account for
some of the high heterogeneity between studies reported in Royall
et al. (2007). This emphasizes the importance of investigating
specificities in ADL structure (Gold, 2012).
Methodological difficulties include instrument bias. Sikkes
et al. (2009) reviewed the literature concerning the different
measures of IADL focusing on its psychometric properties. Their
results suggest that most of the scales adopted in clinical and
research settings still lack of psychometric studies, reducing its
validity and reliability for the functional assessment, although
great effort is being dispend on this matter (Fieo et al., 2011).
The source of information (e.g., patient vs. caregiver) is also
not consensual in studies including cases of dementia, which
is of extreme importance to the use and interpretation of
scales measurement (Farias et al., 2005). Bootsma-van der Wiel
et al. (2001) also highlight the conceptual difference between
a “can do” or an “actually do” score in specific activities.
Additionally, there is no consensus in the literature indicating
scales and questionnaires as adequate methods to functional
level measurement. There are more ecological measures of
ADL, which involve the observation of the patient’s behavior
on real life or simulated settings (a more precise estimation
of functional performance; Chaytor and Schmitter-Edgecombe,
2003). However, these procedures also have limitations such
as the higher costs of execution and the inherent complexity
of the assessment, and might not be well suited for most
of the clinical and research settings. The suitability of these
ecological measures for studies involving cognitive performance
is controversial. There are studies showing a stronger association
of cognitive measures with ecological measures of ADL (Burton
et al., 2006;Tam et al., 2008). However, the opposite pattern
was also demonstrated with the relation between cognitive
performance with ADL being stronger for ADL measured by
scales/questionnaires (Cahn-Weiner et al., 2002; Mariani et al.,
2008;de Paula et al., 2014). The cognitive processes assessed
by the neuropsychological tests used in these studies might be
associated with ADL in different and more specific ways (Gold,
2012).
Taking specific cognitive domains as predictors of functional
performance most of the studies report associations with
executive functions (Royall et al., 2007;Pereira et al., 2008;
de Paula and Malloy-Diniz, 2013). This complex cognitive
construct usually shows the strongest correlations with functional
performance. Executive functions involve planning, initiation,
monitoring, inhibition, and flexibility of goal-oriented behavior
(Diamond, 2013). These specific aspects of executive functions
may contribute differently to the ADL (Jefferson et al.,
2006). However, other cognitive functions may contribute
to specific aspects of ADL. Cognitive measures of spatial
processing predicted participants’ performance in an ecological
measure of visuospatial abilities in which the subject had to
estimate distances, positions, and directions in a “real-life”
setting developed by Farley et al. (2011). Activities demanding
communicative skills were related to semantic process and
language (Razani et al., 2011). Schmitter-Edgecombe et al.
(2009) investigated different aspects of episodic memory and its
association with ADL reporting significant associations of specific
memory components with specific functional components. In
this sense, although most of the studies have focused on executive
functions or global cognitive measures, different kinds of ADL
may depend on different cognitive abilities.
Depressive symptoms can also impair functional performance
in older adults, usually in more complex activities (Bombin et al.,
2012;Tomita and Burns, 2013;Zahodne et al., 2013;Park et al.,
2014). Our group reported a weak association between depressive
symptoms and functional performance in older adults with low
formal education diagnosed with MCI or AD (de Paula and
Malloy-Diniz, 2013). A stronger association was recently reported
Frontiers in Aging Neuroscience | www.frontiersin.org 2July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
in a similar sample (Assis et al., 2014). Cahn-Weiner et al.
(2002) found an association of depressive symptoms with ADL
independent from cognitive functioning. Remission of depressive
symptoms is associated with improvement of ADL (Nyunt
et al., 2012). Nonetheless, there is evidence for the contrary,
suggesting that depressive symptoms are not associated with
IADL after controlling for cognitive symptoms (Reppermund
et al., 2011;Wadsworth et al., 2012). Then, whether depressive
symptoms affect functional performance by behavioral symptoms
(depressed mood, lack of pleasure, apathy, and vegetative
symptoms) or through cognitive impairment associated with
depression remains unclear.
Functional deficit is one of the hallmarks of MCI and AD in
older adults. Improving cognitive functions and mood symptoms
may result in gains in functional performance. Therefore, a better
understanding of how specific cognitive abilities and depressive
symptoms contribute to the performance of specific ADL could
be important to the development of tailored rehabilitation
programs to improve daily functioning in individuals with
cognitive disorders in a personalized way. The objective of
the present study is to assess how specific cognitive abilities
and symptoms of depression are associated to different aspects
of ADL.
Materials and Methods
Participants
We evaluated 274 older adults from a public outpatient clinic
specialized in cognitive disorders and frailty. The center usually
receives elderly patients referred from primary-care physicians
when they suspect of cognitive impairment, mental disorders,
or multiple chronic diseases. Patients usually have a very low
socioeconomic status and less than 4 years of formal education.
Participants’ sociodemographic characteristics are shown in
Tab l e 1 . A more detailed description of the typical profile of
patients assessed in this center was published elsewhere (Bicalho
et al., 2013;de Paula et al., 2013a).
The participants underwent a detailed clinical, cognitive,
and behavioral assessment for diagnostic purposes as described
below. During the geriatrician examination and the clinical
neuropsychological assessment, the patients underwent
cognitive, functional and behavioral assessment to determine
their cognitive status. Ninety-three participants were diagnosed
with mild Alzheimer’s disease dementia (AD), 85 patients were
diagnosed with amnestic MCI (MCI) and 96 older adults were
normal aging participants without clinical history, cognitive,
or functional status suggestive of dementia or AD. AD was
diagnosed by the NINCDS-ADRDA criteria for probable
dementia (McKhann et al., 1984). Only patients with mild
dementia, according to Clinical Dementia Rating (CDR; Morris,
1993), were invited for participation in this study. MCI diagnosis
was based on a modified version of the Mayo Clinic diagnostic
criteria (Petersen et al., 2001). Criteria for MCI was as follow:
(1) Subjective cognitive complaint, preferably corroborated by
an informant/caregiver.
TABLE 1 | Participants’ demographic profile.
Cognitive status Normal aging 35%
Mild cognitive impairment 31%
Alzheimer’s disease dementia 34%
Gender Male 39%
Female 61%
Depression1Present 30%
Absent 70%
Age 60–69 years 34%
70–79 years 43%
80+years 23%
Formal education Illiterate 12%
1–4 years 57%
5–8 years 13%
9+years 12%
12+years 6%
Occupations2Craft and related trades workers 13%
Elementary occupations 34%
Service and sale workers 22%
Others 31%
Retired? No 13%
Yes 87%
Marital status Married 53%
Divorced 12%
Single 9%
Widow 36%
1According to the Geriatric Depression Scale 15 cut-off (5/6).
2According to the International Labour Office (ILO, 2012).
(2) Objective impairment on specific cognitive measures of
the assessment battery for diagnosis according to Brazilian
norms and cut-off scores (Porto et al., 2003;Nitrini et al.,
2004). The cognitive battery includes the Verbal Learning
Test of the CERAD Neuropsychological Battery (Morris
et al., 1989), the memory test from the Brief Cognitive Battery
(Nitrini et al., 2007), and subscales of the Mattis Dementia
Rating Scale (Mattis, 1988).
(3) Normal global cognitive functioning (MMSE above the cut-
off for dementia and CDR <1).
(4) Preserved or minimal impairments in ADL assessed by a
clinical interview and the CDR.
(5) Not demented based on the DSM-IV-TR criteria (American
Psychiatric Association [APA], 2000).
All groups (i.e., AD, MCI, and control) were combined in a
unique heterogeneous sample. This strategy was adopted to
increase statistical power and to avoid detection loss of cognitive
processes that are likely to underlie functional performance
(Farias et al., 2009;Gold, 2012).
Cognitive, Functional, and Mood Assessment
We adopted an unstructured protocol of neuropsychological
tests designed for the assessment of older adults with low formal
Frontiers in Aging Neuroscience | www.frontiersin.org 3July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
TABLE 2 | Neuropsychological measures used to extract the four cognitive factors according to de Paula et al. (2013a).
Cognitive domain Test Test measures Reference
Executive functions Frontal assessment battery Total score Dubois et al. (2000)
Verbal fluency Animals Lezak et al. (2004)
Fruits
Letter “S”
Digit span forward Correct trials ×Span Kessels et al. (2008)
Digit span backward Correct Trials ×Span Kessels et al. (2008)
Language semantic memory TN-LIN (naming test) Nouns Malloy-Diniz et al. (2007a)
Actions
Professions
Episodic memory RAVLT Short term memory (A1) Malloy-Diniz et al. (2007b)
Immediate recall (A6)
Delayed recall (A7)
Sum of words
Recognition memory
Visuospatial abilities Stick design test Total score Baiyewu et al. (2004)
Clock drawing test Total score Shulman (2000)
Token test (short version) Visual attention De Renzi and Faglioni (1978)
Complex comprehension
TN-LIN, Naming test of the laboratory of neuropsychological investigations; RAVLT, Rey auditory-verbal learning test.
TABLE 3 | Participants’ description and group comparisons.
Measures NA (N=96) MCI (N=85) AD (N=93) F/χ2Comparisons2
M(SD) M(SD) M(SD)
Age 72.61 (7.76) 73.18 (8.46) 73.18 (8.46) 1.80
Education 5.22 (4.29) 4.71 (4.00) 4.82 (3.46) 0.48
GDS-15 4.33 (3.95) 2.94 (2.84) 3.82 (3.22) 3.81
Sex (% Female) 67% 60% 55% 2.591
MMSE 25.75 (3.85) 23.52 (3.62) 20.59 (3.98) 42.58∗∗ NA >MCI >AD
Language/Semantic memory 0.34 (1.20) 0.76 (0.96) 1.69 (1.16) 27.28∗∗ NA =MCI >AD
Episodic memory 0.28 (0.80) 1.22 (0.72) 1.76 (0.65) 93.47∗∗ NA >MCI >AD
Visuospatial abilities 0.31 (1.08) 0.84 (1.04) 1.47 (1.05) 30.38∗∗ NA >MCI >AD
Executive functions 0.58 (1.34) 1.21 (1.05) 2.25 (1.09) 46.91∗∗ NA >MCI >AD
GADL self-care 9.94 (0.32) 9.99 (0.11) 9.78 (0.87) 4.01NA =MCI >AD
GADL domestic 7.68 (0.86) 7.41 (1.20) 5.74 (2.19) 19.61∗∗ NA =MCI >AD
GADL complex 7.55 (1.27) 6.91 (1.47) 4.35 (2.57) 59.61∗∗ NA =MCI >AD
GADL global score 25.16 (2.06) 24.03 (2.34) 19.88 (3.92) 75.03∗∗ NA =MCI >AD
*0.05, **<0.001. NA, Normal aging; MCI, Mild cognitive impairment; AD, Alzheimer’s disease; M, Mean; SD, Standard-deviation; GDS-15, Geriatric Depression Scale 15
items; GADL, General Activities of Daily Living Scale; 1Chi-Square test; 2One-Way ANOVA and Sidak’s post hoc test (p <0.05).
education. The tests were not included in patients’ diagnosis.
Cognitive composite factors were obtained through factor
analysis from our sample (statistical procedures detailed below).
This approach allows the assessment of different aspects of
cognitive functioning (here, the core domains recommended for
the MCI and AD diagnosis) with greater specificity. The protocol
comprised tests of executive functions (Frontal Assessment
Battery, Verbal Fluency tests, and Digit Span); language
and semantic memory (Laboratory of Neuropsychological
Investigations Naming Test – Nouns, Verbs and Professions,
Token Test verbal comprehension component); episodic
memory (components of learning, recognition, immediate, and
delayed recall of the Rey Auditory-Verbal Learning Test); and
visuospatial abilities (Clock Drawing Test, Stick Design Test,
and Token Test visual attention components). These tests are
valid and reliable for the assessment of older adults with a
low educational background (de Paula et al., 2013a). The test
measures are shown in Tab l e 2 .
The assessment of ADL occurred during the clinical and
neuropsychological assessment by an interview with participants’
caregivers. For this study, we used the ‘General Activities of Daily
Living Scale’ (GADL) (de Paula et al., 2014), a multidimensional
functional measure of BADL/IADL based on the Lawton and
Brody (1969)andKatz et al. (1970) indexes of ADL. The
GADL shows a hierarchical structure with a general score and
three components of more specific activities: a measure of
Frontiers in Aging Neuroscience | www.frontiersin.org 4July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
FIGURE 1 | Association between Cognitive Factors and General
Activities of Daily Living Scale (GADL). The correlations of cognitive
factors with functional performance were all significant (p<0.001).
Executive functions showed the strongest correlation with GADL total
score (r=0.478), followed by episodic memory (r=0.449),
language/semantic memory (r=0.410), and visuospatial abilities
(r=0.302). The number of dots in the scatterplot differs from the
sample size due to superposed values.
BADL (Self-care: ability to change clothes, use the toilet, use
the shower, transference from bed or chair, and feed itself)
and two components of IADL. Instrumental Domestic ADL
include ability to perform domestic chores, use the telephone,
prepare meals, and do the laundry. Instrumental Complex ADL
include ability to manage financial matters, shopping, adequate
use of medication, and go out alone using transportation.
This structure was determined by factor analysis on the same
sample of the present study and showed evidence of reliability
and validity (de Paula et al., 2014). We scored each activity
using a 3-point Lickert scale (dependent, partially dependent,
or independent of assistance to perform the activity). The
GADL subscores of Self-care (0–10), Instrumental-Domestic
(0–8), Instrumental-Complex (0–8), and the Global score (0–
26) represented the general ADL measures in our study. To
investigate the association of different cognitive functions with
specific measures of functional performance, we also used each
item of the scale (13 different ADL) independently.
We assessed the depressive symptoms with the Brazilian
version of the Geriatric Depression Scale-15 (GDS-15; Sheikh and
Yeasavage, 1986). A validation study conducted in Brazil attested
its sensitivity and specificity for the detection of depression
(Almeida and Almeida, 1999). However, since our focus was not
to identify patients with major depressive disorder, but to use
a dimensional measure of its symptoms, we used the GDS-15
total score in this research. The GDS use for depression diagnosis
in dementia is controversial. To reduce biases we selected only
patients with mild dementia for the AD group (CDR 1). Due to
participants’ low formal education, the examiner read the GDS
questions aloud to ensure the comprehension and validity of
patients’ report.
Statistical Procedures
Our four cognitive domains were extracted by factor analysis
(principal axis factoring with an oblique rotation of the
neuropsychological tests described in Cognitive Assessment)
Frontiers in Aging Neuroscience | www.frontiersin.org 5July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
FIGURE 2 | Association between depression and GADL scores. A weak
correlation was observed between depressive status and GADL total score
(r=−0.151, p=0.013). In the scatterplot, blue dots represent the participants
under the cut-off for depression according to the Geriatric Depression Scale and
green dots the participants above the cut-off for depression. The number of
dots in the scatterplot differs from the sample size due to superposed values.
from our sample. The procedures were described in detail
elsewhere (de Paula et al., 2013a). Briefly, the cognitive factors
were saved by a regression method and standardized (Z-Score)
based on the performance of our cognitively normal non-
depressed participants. The four factors were executive functions,
episodic memory, language/semantic memory, and visuospatial
Abilities. These factors showed high internal consistency and
reliability (Cronbach’s alpha >0.800 for all factors).
We carried out univariate analysis of variance (continuous
variables) or chi-square tests (categorical variables) to evaluate
baseline differences in sociodemographic, clinical, cognitive,
and ADL measures between the AD, MCI, and control groups.
Part of this data was previously published (de Paula et al.,
2013a). For a preliminary assessment of the relationship
between cognitive functioning, depressive level and ADL,
we correlated each measure with the GADL global score.
The influence of age, education, and gender in ADL was
investigated by linear regression models (forced entry)
containing each ADL measure as dependent variables. We
also explored the pattern of association between cognitive
performance and depressive symptoms through Pearson
correlations to evaluate if the contribution of cognitive
abilities and symptoms of depression to ADL performance is
independent.
We used multiple linear regressions with a forced entry model
to test whether the performance on specific cognitive domains
and the intensity of depressive symptoms could predict the
scores of the GADL components. Z-scores of executive functions,
episodic memory, language/semantic memory, and visuospatial
abilities, along with depressive symptoms (GDS-15 total score),
were entered as independent variables in the models. In addition,
we carried out ordinal regression analysis to assess whether the
cognitive factors and depressive level predict the performance on
each specific item of the GADL. Effect sizes were estimated by the
adjusted R2(linear regression) or Nagelkerke Pseudo-R2(ordinal
regression).
Results
Tab l e 3 shows the sociodemographic, clinical data, ADL,
and Z-scores for individual cognitive domains, according
to diagnosis. Group comparisons indicate no differences
in sociodemographic measures (p>0.05), but significant
Frontiers in Aging Neuroscience | www.frontiersin.org 6July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
TABLE 4 | Linear regression models of cognitive function and depressive symptoms as predictors of different ADL.
Fdf pR
2Predictors Standard βp
GADL: Global score
22.90 (5,268) <0.001 29% Executive functions 0.30 <0.001
Episodic memory 0.25 <0.001
Language/Semantic memory 0.18 0.011
Visuospatial abilities 0.13 0.084
Depressive Symptoms 0.08 0.140
GADL: Self-care score
1.37 (5,268) 0.234 <1% Executive functions 0.20 0.039
Episodic memory 0.02 0.780
Language/Semantic memory 0.01 0.931
Visuospatial abilities 0.14 0.116
Depressive symptoms 0.05 0.299
GADL: Instrumental-domestic score
14.39 (5,268) <0.001 19% Executive functions 0.33 <0.001
Episodic memory 0.18 0.009
Language/Semantic memory 0.09 0.211
Visuospatial abilities 0.10 0.237
Depressive symptoms 0.05 0.402
GADL: Instrumental-complex score
24.66 (5,268) <0.001 30% Executive functions 0.22 0.007
Episodic memory 0.28 <0.001
Language/Semantic memory 0.23 0.001
Visuospatial abilities 0.12 0.120
Depressive symptoms 0.08 0.108
ADL, Activities of daily living; GADL, General Activities of Daily Living Scale; df, Degrees of freedom.
differences in cognitive (p<0.01), and ADL (p<0.05) measures.
The normal aging group outperformed both MCI and AD groups
in cognitive measures, except for language/semantic memory
compared with MCI patients. MCI patients showed higher scores
than AD patients in all cognitive measures. Differences in ADL
occurred only between AD and the other groups.
Correlations between each cognitive factor, depressive
symptoms and the global score of the GADL are show in
Figures 1 and 2. All correlations between cognitive measures and
ADL were significant (p<0.001) and moderate, but we found
only a weak correlation between depressive symptoms and the
functional measure (r=−0.151, p=0.013). The correlations
between depressive symptoms and cognitive performance were
significant for executive functions (r=−0.192, p=0.001), but
we found no association with episodic memory (r=−0.019,
p=0.753), language/semantic memory (r=−0.085, p=0.162)
and visuospatial abilities (r=−0.039, p=0.525). The influence
of sociodemographic factors (age, education and gender) on ADL
performance was not significant: GADL Complex (F=1.31,
p=0.272), GADL Domestic (F=1.13, p=0.336), GADL
Self-care (F=1.56, p=0.200), and the global score (F=2.40,
p=0.068).
Tab l e 4 shows the predictors of GADL subscales scores.
For the global score of the GADL the model was significant
(F=22.90, p<0.001, R2=0.29) and contained as predictors
executive functions (p<0.001), episodic memory (p<0.001),
and language/semantic memory (p=0.011). The Self-Care
model was not significant (F=1.37, p=0.234, R2<0.01).
The model for Instrumental-Complex ADL was significant
(F=24.66, p<0.001, R2=0.30) and contained as predictors
executive functions (p=0.007), episodic memory (p<0.001),
and language/semantic memory (p=0.001). The model
for Instrumental-Domestic was also significant (F=14.39,
p<0.001, R2=0.19) and involved executive functions
(p<0.001) and episodic memory (p-0.009) as significant
predictors.
Tab l e s 5 and 6show the role of specific cognitive factors
and depressive symptoms as predictors of specific IADL. Since
the cognitive factors and depressive symptoms were unrelated
to GADL Self-Care scores, the analyses were carried out
for Instrumental-Domestic and Instrumental-Complex activities
only.
All Instrumental-Domestic activities were associated with
executive functions (p<0.05) and, except for the independence
in doing personal laundry, with episodic memory (p<0.05).
Language/semantic memory was related only to the correct
use of the telephone (p=0.014). Visuospatial abilities were
not significantly related to any Domestic ADL (all p>0.05).
Depressive symptoms were predictors of doing personal laundry
(p=0.025) and difficulties using the telephone (p=0.003). The
effect sizes for the comparisons were moderate-large, ranging
from 22 to 28% of explained variance.
Episodic memory was a significant predictor of all
Instrumental-Complex ADL (p<0.05). Executive Functions
Frontiers in Aging Neuroscience | www.frontiersin.org 7July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
TABLE 5 | Ordinal regression analysis of cognitive functions and depressive symptoms as predictors of Instrumental-Domestic activities of daily living.
χ2df pR
2Predictors Est. SE p
Do simple domestic chores
48.70 5 <0.001 26% Executive functions 0.74 0.22 0.001
Episodic memory 0.74 0.28 0.008
Language/Semantic memory 0.24 0.19 0.207
Visuospatial abilities 0.49 0.25 0.065
Depressive symptoms 0.06 0.05 0.224
Do personal laundry
45.91 5 <0.001 24% Executive functions 0.72 0.20 <0.001
Episodic memory 0.61 0.25 0.015
Language/Semantic memory 0.08 0.18 0.649
Visuospatial abilities 0.29 0.23 0.209
Depressive symptoms 0.11 0.05 0.025
Use the telephone
52.97 5 <0.001 28% Executive functions 0.57 0.20 0.005
Episodic memory 0.37 0.26 0.147
Language/Semantic memory 0.45 0.18 0.014
Visuospatial abilities 0.14 0.24 0.558
Depressive symptoms 0.15 0.05 0.003
Prepare meals
42.53 5 <0.001 22% Executive functions 0.64 0.19 0.001
Episodic memory 0.47 0.24 0.046
Language/Semantic memory 0.01 0.17 0.978
Visuospatial abilities 0.01 0.22 0.950
Depressive symptoms 0.02 0.05 0.668
χ2, Chi-Square test; df, Degrees of freedom; R2, Nagelkerke pseudo R-Square; Est., Ordinal logistic regression model estimate; SE, Standard error.
followed a similar pattern (p<0.05), but was not predictive
of the individual’s ability to manage finances (p=0.089).
Language/Semantic Memory was a significant predictor of
independence in performing simple shopping (p<0.001) and
managing finances (p=0.008). The Visuospatial abilities were
a significant predictor of the ability to go out alone and use
transportation (p=0.012). Depressive symptoms predicted the
ability to shop (p=0.030), handle financial matters (p=0.016),
and go out alone using transportation (p<0.001), but not the
medication management (p=0.162). The effect sizes of these
models were large, ranging from 30 to 38% of explained variance.
Discussion
In the present study, we showed distinct cognitive domains
having a significant impact on ADL in older adults with a
wide range of cognitive deficits. Executive functioning and
Episodic Memory showed the strongest significant association
with functional performance. Language/Semantic Memory
contributed to complex aspects of ADL and visuospatial abilities
contributed only to a specific instrumental activity. Depressive
symptoms had a significant influence on more complex ADL
such as handling finances. Self-care ADL were not related to
cognitive performance. Executive functions showed only a
weak correlation with depressive symptoms. The results are
in agreement with previous studies and highlight the close
relationship between deficits in specific cognitive domains and
functional loss.
Episodic memory and executive functions were the most
important predictors of domestic ADL performance. The
execution of these activities requires skills related to the
identification and ordering of different steps necessary to achieve
the final goal (e.g., different steps to prepare a meal) or recalling
information after a period of time or in face of distractors (e.g.,
remembering what of house cleaning was already done and what
was not). These behaviors are intrinsically related to different
aspects of executive functioning and episodic memory.
Similar to our findings, previous studies showed executive
functions and episodic memory tests as significant predictors
of the ability to cook and to do household chores (Farias
et al., 2003;Matsuda and Saito, 2005;Mariani et al., 2008).
Jefferson et al. (2006) found association between verbal fluency
and food preparing, cognitive flexibility, and selective attention
with doing laundry, but no correlations between executive
functions and house cleaning. An interesting research using
extrapyramidal signs and structural brain imaging found that,
controlling these previous factors and sociodemographic aspects,
the performance in tests of memory and executive functions
was still associated with cooking, and specific measures of
executive functions with the ability to perform simple domestic
chores (Bennett et al., 2006). We found an association between
depressive symptoms with doing laundry. We hypothesize that
this might be a sample bias. Most of the older adults assessed
Frontiers in Aging Neuroscience | www.frontiersin.org 8July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
in our study had a very low socioeconomic level and usually
do not have laundry machines. Since they do the laundry
manually, the association with depressive symptoms may be due
to lack of energy or apathy since this activity is very physically
demanding.
We found significant associations between executive
functions, language/semantic memory, depressive symptoms,
and telephone use. The engagement of these specific cognitive
functions may reflect the necessity of communication to
perform this activity. The neuropsychological battery used
in this study included instruments related to expressive
language, comprehension, and access to semantic and
phonological lexicons. Therefore, we expected that ADL
related to communicative skills would be influenced by the
performance on these cognitive domains (Taler and Phillips,
2008;Razani et al., 2011). Farias et al. (2003), however, found
motor praxis as the only predictor of telephone use. Depressive
symptoms also influenced telephone use in our study. Social
isolation, a common characteristic of elderly persons with
depression (Corcoran et al., 2013), may reduce the individual
willingness to actively pursue contact with other people, leading
to impairments in this specific activity.
Two of the Complex-ADL activities involve management
of finances. Episodic memory and language/semantic memory
predicted financial management, while executive functions,
episodic memory, and language/semantic memory predicted
shopping ability. These are complex activities and involve
several cognitive processes (Marson et al., 2009). Sherod et al.
(2009) decomposed financial managing it in basic financial
skills, financial conceptual knowledge, financial transactions,
checkbook control, banking control, and financial judgment. The
authors identified the cognitive predictors of financial capacity
in the spectrum of normal aging, MCI, and AD using a specific
questionnaire for financial management and a comprehensive
battery of neuropsychological tests. Their findings suggest that
arithmetic skills (which relies on working memory) are the main
predictor of financial capacity. Jefferson et al. (2006)foundan
association between selective attention and the ability to shop
and to control finances. Tasks related to episodic memory, basic
math skills, and a test related to language/semantic memory
predicted financial control in Matsuda and Saito (2005)study.
Razani et al. (2011) evaluated skills related to the management
of money and found similar predictors to the present study:
how to write out checks was associated with language, control
the checkbook was related to executive functions, and shopping
ability was associated with memory and executive functions.
Motor praxis also might be related to financial management
(Farias et al., 2003). Additionally, we observed depressive
symptoms predicting worse performance in the management of
finances. This finding is in contrast to Farias et al. (2003)who
found no significant association between depressive symptoms
and management of finances.
TABLE 6 | Ordinal regression analysis of cognitive functions and depressive symptoms as predictors of Instrumental-Complex activities of daily living.
χ2df pR
2Predictors Est. SE p
Manage finances
67.43 5 <0.001 30% Executive functions 0.30 0.18 0.089
Episodic memory 0.81 0.23 <0.001
Language/Semantic memory 0.43 0.16 0.008
Visuospatial abilities 0.05 0.20 0.801
Depressive symptoms 0.11 0.05 0.016
Shopping
91.15 5 <0.001 38% Executive functions 0.42 0.18 0.018
Episodic memory 0.95 0.24 <0.001
Language/Semantic memory 0.60 0.16 <0.001
Visuospatial abilities 0.31 0.21 0.139
Depressive symptoms 0.10 0.05 0.030
Use of medication
96.07 5 <0.001 38% Executive functions 0.71 0.18 <0.001
Episodic memory 0.99 0.22 <0.001
Language/Semantic memory 0.27 0.15 0.077
Visuospatial abilities 0.36 0.20 0.065
Depressive symptoms 0.06 0.04 0.162
Go out alone and use transports
75.93 5 <0.001 33% Executive functions 0.51 0.18 0.004
Episodic memory 0.72 0.22 0.001
Language/Semantic memory 0.23 0.20 0.252
Visuospatial abilities 0.40 0.16 0.012
Depressive symptoms 0.14 0.04 0.001
χ2, Chi-Square test; df, Degrees of freedom; R2, Nagelkerke pseudo R-Square; Est., Ordinal logistic regression model estimate; SE, Standard error.
Frontiers in Aging Neuroscience | www.frontiersin.org 9July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
The correct use of medications was associated with executive
functions and episodic memory in the present research in
accordance with previous studies (Maddigan et al., 2003;Sino
et al., 2014). A very common complaint by patients with
memory impairment is to forget when to take medications
or difficult to remember if he/she has already take it or not.
This emphasizes the importance of different aspects of the
episodic memory for the correct maintenance of medical care
routine (Matsuda and Saito, 2005). Complex medication routines
may demand more executive control (Maddigan et al., 2003).
A study reported that performance in executive functions tests
(including working memory) was a significant predictor of
medication use in older adults (Insel et al., 2006). However,
Jefferson et al. (2006) did not find any significant associations
in this direction. Compensatory strategies might explain these
discrepancies. Carlson et al. (2005) tested two objective measures
of medication use capacity (schedule and pillbox) and found
a significant association between memory performance and
the schedule strategy and between executive functions and the
pillbox.
We found executive functions, episodic memory, visuospatial
skills, and depressive symptoms as predictors of ADL related to
going out of home alone to distant locations using transportation.
Different aspects of executive functions such as planning,
cognitive flexibility, and selective attention were associated with
transportation in the study of Jeferson et al. (2006). Deficits in
these functions were associated with impairment in “visually”
dependent activities such as driving, orientation, and transport
use (Silva et al., 2009;Farley et al., 2011). However, despite the
expected relationship between visuospatial abilities and the ability
to travel long distances, few studies have found a significant
direct association between the neuropsychological performance
and its functional counterpart. Our findings provide a model in
which visuospatial and navigation abilities depend on executive
functions, episodic memory, and visuospatial skills. Matsuda and
Saito (2005) found similar results in the Japanese population.
Depressive symptoms also predicted performance in the ability
to travel. As in telephone use, social isolation might mediate
the association between depressive symptoms and functional
performance on this task.
In our view, the strengths of the current study are the
relatively large sample size, the heterogeneity of the participants
and the use of fine-grained cognitive and functional measures.
The use of cognitive factors validated for this population
instead of tests’ raw scores allow the construction of more
precise conceptual models and is easier to be generalized for
other settings, since the data is analyzed in the cognitive
construct level and can be represented by different cognitive
tests. However, the present results should be viewed in light
of its limitations. Although the neuropsychological measures
used comprise four specific cognitive domains, the protocol had
no specific measure of processing speed, a cognitive domain
related to functional performance and a potential mediator of
depression influence on daily functioning (Brown et al., 2013).
The executive functions factor adopted in this study may be
related to processing speed in our population since processing
speed and executive functions influence verbal fluency in an
independent way in older adults with low formal education (de
Paula et al., 2013b). Therefore, the relationship between the
executive function domain and functional performance could be
secondary to its processing speed component. Additional studies
including specific measures of processing speed should evaluate
its impact on ADL. Additionally, the present study has a cross-
sectional design, which limits the interpretation of our findings.
Future studies with a longitudinal design are necessary to assess
the impact of changes in specific cognitive functions on the
performance of specific ADL. Another aspect is the lack of an
ecological functional measure since our work relies on scales of
caregiver report, which may result in different results.
Conclusion
We found executive function and episodic memory as the
cognitive domains most frequently related to impairment in
general constructs of ADL. Nonetheless, language, semantic
memory, and visuospatial abilities may influence specific
functional aspects of ADL. The development of better predictive
models can aid to the development of tailored and personalized
rehabilitation programs to improve functional performance of
subjects with neurocognitive disorders.
Funding
This work was supported by the following grants: APQ-01972/12-
10, APQ-02755-10, APQ-04706-10, CBB-APQ-00075-09 from
FAPEMIG, and 573646/2008-2 from CNPq. The funders had no
role in study design, data collection, analysis, decision to publish,
or preparation of the manuscript.
References
Almeida, O. P., and Almeida, S. A. (1999). Short versions of the geriatric depression
scale: a study of their validity for the diagnosis of a major depressive episode
according to ICD-10 and DSM-IV. Int. J. Ger iatr. Psychiatry 14, 858–865. doi:
10.1002/(SICI)1099-1166(199910)14:10<858::AID-GPS35>3.0.CO;2-8
American Psychiatric Association [APA]. (2000). Diagnostic and Statistical Manual
of Mental Disorders, 4th Edn. Washington, DC: Author.
Assis, L. O., de Paula, J. J., Assis, M. G., Moraes, E. N., and Malloy-Diniz,
L. F. (2014). Psychometric properties of the Brazilian version of Pfeffer’s
Functional Activities Questionnaire. Front. Aging Neurosci. 6:255. doi: 10.3389/
fnagi.2014.00255
Baiyewu, O., Unverzagt, F. W., Lane, K. A., Gureje, O., Ogunniyi, A., Musick, B.,
et al. (2004). The stick design test: a new measure of visuoconstructional ability.
J. Int. Neuropsychol. Soc. 11, 598–605.
Bennett, H. P., Piguet, O., Grayson, D. A., Creasey, H., Waite, L. M., Lye, T., et al.
(2006). Cognitive, extrapyramidal, and magnetic resonance imaging predictors
of functional impairment in nondemented older community dwellers: the
sydney older person study. J. Am. Geriatrc. Soc. 54, 3–10. doi: 10.1111/j.1532-
5415.2005.00532.x
Bicalho, M. A. C., Pimenta, F. A., Bastos-Rodrigues, L., Hansen, E. O., Neves,
S. N., Melo, M., et al. (2013). Sociodemographic characteristics, clinical factors,
and genetic polymorphisms associated with Alzheimer’s disease. Int. J. Geriatr.
Psychiatry 28, 640–646. doi: 10.1002/gps.3875
Frontiers in Aging Neuroscience | www.frontiersin.org 10 July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
Bombin, I., Santiago-Ramajo, S., Garolera, M., Vega-González, E. M., Cerulla, N.,
Caracuel, A., et al. (2012). Functional impairment as a defining feature
of: amnestic MCI cognitive, emotional, and demographic correlates. Int.
Psychogeriatr. 24, 1494–1504. doi: 10.1017/S1041610212000622
Bootsma-van der Wiel, A., Gussekloo, J., de Craen, A. J., van Exel, E., Knook,
D. L., Lagaay, A. M., et al. (2001). Disability in the oldest old: “can do”
or “do do”? Am. Geriatr. Soc. 49, 909–914. doi: 10.1046/j.1532-5415.2001.
49181.x
Brown, P. J., Devanand, D. P., Liu, X., Caccappolo, E., and Alzheimer’s disease
Neuroimaging Initiative. (2011). Functional impairment in elderly patients with
mild cognitive impairment and mild Alzheimer disease. Arch.Gen.Psychiatry
68, 617–626. doi: 10.1001/archgenpsychiatry.2011.57
Brown, P. J., Liu, X., Sneed, J. R., Pimontel, M. A., Devanand, D. P., and Roose,
S. P. (2013). Speed of processing and depression affect function in older adults
with mild cognitive impairment. Am. J. Geriatr. Psychiatry 21, 675–684. doi:
10.1016/j.jagp.2013.01.005
Burton, C. L., Strauss, E., Hultsch, D. F., and Hunter, M. A. (2006). Cognitive
functioning and everyday problem solving in older adults. Clin. Neuropsychol.
20, 432–452. doi: 10.1080/13854040590967063
Cabrero-García, J., and López-Pina, J. A. (2008). Aggregated measures of functional
disability in a nationally representative sample of disabled people: analysis of
dimensionality acco rding to gender and se verity of disability. Qual. Life Res. 17,
425–436. doi: 10.1007/s11136-008-9313-x
Cahn-Weiner, D. A., Boyle, P. A., and Malloy, P. F. (2002). Tests of
executive function predict instrumental activities of daily living in
community-dwelling older individuals. Appl. Neuropsychol. 9, 187–191.
doi: 10.1207/S15324826AN0903_8
Carlson, M. C., Fried, L. P., Xue, Q. L., Tekwe, C., and Brandt, J. (2005).
Validation of the Hopkins Medication Schedule to identify difficulties in
taking medications. J.Gerontol.ABiol.Sci.Med.Sci. 60, 201–223. doi:
10.1093/gerona/60.2.217
Chaytor, N., and Schmitter-Edgecombe, M. (2003). The ecological validity of
neuropsychological tests: a review of the literature on everyday cognitive
skills. Neuropsychol. Rev. 13, 181–197. doi: 10.1023/B:NERV.0000009483.91
468.fb
Corcoran, J., Brown, E., Davis, M., Pineda, M., Kadolph, J., and Bell, H. (2013).
Depression in older adults: a Meta-Synthesis. J. Gerontol. Soc. Work 56, 509–
534. doi: 10.1080/01634372.2013.811144
de Paula, J. J., Bertola, L., Ávila, R. T., Moreira, L., Coutinho, G., de Moraes,
E. N., et al. (2013a). Clinical applicability and cutoff values for an unstructured
neuropsychological assessment protocol for older adults with low formal
education. PLoS ONE 8:e73167. doi: 10.1371/journal.pone.0073167
de Paula, J. J., Costa, D. S., Bertola, L., Moraes, E. N., and Malloy-Diniz, L. F.
(2013b). Verbal fluency in older adults with low educational level: what is
the role of executive functions and processing speed? Rev. Bras. Psiquiatr. 35,
440–442. doi: 10.1590/1516-4446-2013-1118
de Paula, J. J., Bertola, L., Ávila, R. T., Assis Lde, O., Albuquerque, M., and Bicalho,
M. A. et al. (2014). Development validity and reliability of the General Activities
of Daily Living Scale: a multidimensional measure of activities of daily living for
older people. Rev. Bras. Psiquiatr. 36, 143–152. doi: 10.1590/1516-4446-2012-
1003
de Paula, J. J., and Malloy-Diniz, L. F. (2013). Executive functions as predictors
of functional performance in mild Alzheimer’s dementia and mild cognitive
impairment elderly. Estud. Psicol. (Natal) 18, 117–124. doi: 10.1590/S1413-
294X2013000100019
De Renzi, E., and Faglioni, P. (1978). Normative Data and screening power of
a shortened version of the token test. Cortex 14, 41–49. doi: 10.1016/S0010-
9452(78)80006-9
Diamond, A. (2013). Executive Functions. Annu. Rev. Psychol. 64, 35–68. doi:
10.1146/annurev-psych-113011-143750
Dubois, B., Slachevsky, A., Litvan, I., and Pilon, B. (2000). The FAB:
a frontal assessment battery at bedside. Neurology 55, 1621–1626. doi:
10.1212/WNL.55.11.1621
Farias, S., Cahn-Weiner, D. A., Harvey, D. J., Reed, B. R., Mungas, D., Kramer, J. H.,
et al. (2009). Longitudinal changes in memory and executive functioning are
associated with longitudinal change in instrumental activities of daily living in
older adults. Clin. Neuropsychol. 23, 446–461. doi: 10.1080/13854040802360558
Farias, S. T., Harrell, E., Neumann, C., and Houtz, A. (2003). The relationship
between neuropsychological performance and daily functioning in individuals
with Alzheimer’s disease: ecological validity of neuropsychological tests. Arch.
Clin. Neuropsychol. 18, 655–672. doi: 10.1016/S0887-6177(02)00159-2
Farias, S., Mungas, D., and Jagust, W. (2005). Degree of discrepancy between self
and other-reported everyday functioning by cognitive status: dementia, mild
cognitive impairment, and healthy e lders. Int. J. Geriatr . Psychiatry 20, 827–834.
doi: 10.1002/gps.1367
Farley, K. L., Higginson, C. I., Sherman, M. F., and MacDougall, E.
(2011). The ecological validity of clinical tests of visuospatial function in
community-dwelling older adults. Arch. Clin. Neuropsychol. 26, 728–738. doi:
10.1093/arclin/acr069
Fieo, R. A., Austin, E. J., Starr, J. M., and Deary, I. J. (2011). Calibrating ADL-
IADL scales to improve measurement accuracy and to extend the disability
construct into the preclinical range: a systematic review. BMC Geriatr. 11:42.
doi: 10.1186/1471-2318-11-42
Gold, D. A. (2012). An examination of instrumental activities of daily living
assessment in older adults and mild cognitive impairment. J. Clin. Exp.
Neuropsychol. 34, 11–34. doi: 10.1080/13803395.2011.614598
Insel, K., Morrow, D., Brewer, B., and Figueredo, A. (2006). Executive function,
working memory, and medication adherence among older adults. J. Gerontol. B
Psychol. Sci. Soc. Sci. 61, 102–107. doi: 10.1093/geronb/61.2.P102
International Labour Office (ILO). (2012). International Standard Classification of
Occupations. Geneva: ILO Publications.
Jefferson, A. L., Paul, R. H., Ozonoff, A., and Cohen, R. A. (2006). Evaluating
elements of executive functioning as predictors of instrumental activities
of daily living (IADLs). Arch. Clin. Neuropsychol. 21, 311–320. doi:
10.1016/j.acn.2006.03.007
Katz, S., Downs, T. D., Cash, H. R., and Grotz, R. C. (1970). Progress
in the development of the index of ADL. Gerontologist 10, 20–30. doi:
10.1093/geront/10.1_Part_1.20
Kessels, R. P., van den Berg, E., Ruis, C., and Brands, A. (2008). The backward span
of the Corsi Block-Tapping Task and its association with the WAIS-III Digit
Span. Assessment 15, 426–434. doi: 10.1177/1073191108315611
Lawton, M. P., and Brody, E. M. (1969). Assessment of older people: self-
maintaining and instrumental activiti es of daily living. Gerontologist 9, 179–186.
doi: 10.1093/geront/9.3_Part_1.179
Lezak, M. D., Howieson, D. B., and Loring, D. W. (2004). Neuropsychological
Assessment, 3rd Edn. New York, NY: Oxford University Press.
Maddigan, S. L., Farris, K. B., Keating, N., Wiens, C. A., and Johnson, J. A.
(2003). Predictors of older adults’ capacity for medication management in a self-
medication program: a retrospective chart review. J. Aging Health 15, 332–352.
doi: 10.1177/0898264303251893
Malloy-Diniz, L. F., Bentes, R. C., Figueiredo, P. M., Brandão-Bretas, D., Costa-
Abrantes, S., Parizzi, A. M., et al. (2007a). Normalización de una batería de
tests para evaluar las habilidades de comprensión del lenguaje, fluidez verbal
y denominación en niños brasileños de 7 a 10 años: resultados preliminares.
Rev. Neurol. 44, 275–280.
Malloy-Diniz, L. F., Lasmar, V. A. P., Gazinelli, L. S. R., Fuentes, D., and
Salgado, J. V. (2007b). The Rey Auditory-Verbal Learning Test: applicability
for the Brazilian elderly population. Rev. Bras. Psiquiatr. 29, 324–329. doi:
10.1590/S1516-44462006005000053
Mariani, E., Monastero, R., Ercolani, S., Rinaldi, P., Mangialasche, F., Costanzi, E.,
et al. (2008). Influence of comorbidity and cognitive status on instrumental
activities of daily living in amnestic mild cognitive impairment: results from
the ReGA1 project. Int. J. Geriatr. Psychiatry 23, 523–530. doi: 10.1002/
gps.1932
Marson,D.C.,Martin,R.C.,Wadley,V.,Grith,H.R.,Snyder,S.,
Goode, P. S., et al. (2009). Clinical Interview assessment of financial
capacity in older adults with mild cognitive impairment and Alzheimer’s
disease. Am. Geriatr. Soc. 57, 806–814. doi: 10.1111/j.1532-5415.2009.
02202.x
Matsuda, O., and Saito, M. (2005). Functional competence and Cognitive ability in
mild Alzheimer’s disease: relationship between ADL assessed by a relative/carer-
rated scale and neuropsychological performance. Int. Psychogeriatr. 17, 275–
288. doi: 10.1017/S1041610205001304
Mattis, S. (1988). Dementia Rating Scale. Professional Manual. Florida:
Psychological Assessment Resources.
McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D., and Stadlan,
E. M. (1984). Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-
ADRDA Work Group under the auspices of Department of Health and
Frontiers in Aging Neuroscience | www.frontiersin.org 11 July 2015 | Volume 7 | Article 139
de Paula et al. Cognitive functions, depression, and ADL
Human Service s Task Force on Alzheimer’s disease. Neurology 34, 939–944. doi:
10.1212/WNL.34.7.939
Morris, J. C. (1993). The Clinical Dementia Rating (CDR): current version
and scoring rules. Neurology 43, 2412–2414. doi: 10.1212/WNL.43.11.
2412-a
Morris, J. C., Heyman, A., Mohs, R. C., Hughes, J. P., van Belle, G., Fillenbaum, G.,
et al. (1989). The Consortium to Establish a Registry for Alzheimer’s disease
(CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer’s
disease. Neurology 39, 1159–1165. doi: 10.1212/WNL.39.9.1159
Niti, M., Ng, T. P., Chiam, P. C., and Kua, E. H. (2007). Item bias was present
in instrumental activities of daily living scale in Asian older adults. J. Clin.
Epidemiol. 60, 366–374. doi: 10.1016/j.jclinepi.2006.07.012
Nitrini, R., Caramelli, P., Herrera, E. Jr., Porto, C. S., Charchat-Fichman, H.,
Carthery, M. T., et al. (2004). Performance of illiterate and literate
nondemented elderly subjects in two tests of long-term memory.
J. Int. Neuropsychol. Soc. 10, 634–638. doi: 10.1017/S13556177041
04062
Nitrini, R., Caramelli, P., Porto, C. S., Charchat-Fichman, H., Formigoni, A. P.,
Carthery-Goulart, M. T., et al. (2007). Brief cognitive battery in the diagnosis of
mild Alzheimer’s disease in subjects with medium and high levels of education.
Dement. Neuropsychol. 1, 32–36.
Nyunt, M. S., Lim, M. L., Yap, K. B., and Ng, T. P. (2012). Changes
in depressive symptoms and functional disability among community-
dwelling depressive older adults. Int. Psychogeriatr. 24, 1633–1641. doi:
10.1017/S1041610212000890
Park, B., Jun, J. K., and Park, J. (2014). Cognitive impairment and depression in the
early 60s: which is more problematic in terms of instrumental activities of daily
living? Geriatr. Gerontol. Int. 14, 62–70. doi: 10.1111/ggi.12055
Pereira,F.S.,Yassuda,M.S.,Oliveira,A.M.,Diniz,B.S.,Radanovic,M.,Talib,
L. L., et al. (2010). Profiles of functional deficits in mild cognitive impairment
and dementia: benefits from objective measurement. J. Int. Neuropsychol. Soc.
16, 297–305. doi: 10.1017/S1355617709991330
Pereira, F. S., Yassuda, M. S., Oliveira, A. M., and Forlenza, O. V. (2008). Executive
dysfunction correlates with impaired functional status in older adults with
varying degrees of cognitive impairment. Int. Psychogeriatr. 20, 1104–1115. doi:
10.1017/S1041610208007631
Petersen, R. C., Doody, R., Kurz, A., Mohs, R. C., Morris, J. C., Rabins, P. V.,
et al. (2001). Current concepts in mild cognitive impairment. Arch. Neurol. 58,
1985–1992. doi: 10.1001/archneur.58.12.1985
Porto, C. S., Fichman, H. C., Caramelli, P., Bahia, V. S., and Nitrini, R.
(2003). Brazilian version of the Mattis Dementia Rating Scale: Diagnosis of
mild dementia in Alzheimer’s disease. Arq. Neuropsiquiatr. 61, 339–345. doi:
10.1590/S0004-282X2003000300004
Razani, J., Bayan, S., Funes, C., Mahmoud, N., Torrence, N., Wong, J., et al.
(2011). Pattern of deficits in daily functioning and cognitive performance of
patients with Alzheimer’s disease. J. Geriatr. Psychiatry Neurol. 24, 23–32. doi:
10.1177/0891988710390812
Reppermund, S., Brodaty, H., Crawford, J. D., Kochan, N. A., Slavin,
M. J., Trollor, J. N., et al. (2011). The relationship of current depressive
symptoms and past depression with cognitive impairment and instrumental
activities of daily living in an elderly population: the Sydney Memory and
Ageing Study. J. Psychiatr. Res. 45, 1600–1607. doi: 10.1016/j.jpsychires.2011.
08.001
Royall, D. R., Lauterbach, E. C., Kaufer, D., Malloy, P., Coburn, K. L., Black,
K. J., et al. (2007). The cognitive correlates of functional status: a review
from the Committee on Research of the American Neuropsychiatric
Association. J. Neuropsychiatry Clin. Neurosci. 19, 249–265. doi:
10.1176/appi.neuropsych.19.3.249
Schmitter-Edgecombe, M., Woo, E., and Greeley, D. R. (2009). Characterizing
multiple memory deficits and their relation to everyday functioning in
individuals with mild cognitive impairment. Neuropsychology 23, 168–177. doi:
10.1037/a0014186
Seelye, A. M., Schmitter-Edgecombe, M., Cook, D. J., and Crandall, A. (2013).
Naturalistic assessment of everyday activities and prompting technologies
in mild cognitive impairment. J. Int. Neuropsychol. Soc. 19, 442–452. doi:
10.1017/S135561771200149X
Sheikh, J. I., and Yeasavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent
Evidence and Dev elopment of a shorter version. Clin. Gerontol. 5, 165–172. doi:
10.1300/J018v05n01_09
Sherod, M. G., Griffith, H. R., Copeland, J., Belue, K., Krzywanski, S., Zamrini,
E. Y., et al. (2009). Neurocognitive predictors of financial capacity across the
dementia spectrum: normal aging, mild cognitive impairment, and Alzheimer’s
disease. J. Int. Neuropsychol. Soc. 15, 528–267. doi: 10.1017/S1355617709090365
Shulman, K. (2000). Clock-drawing: is it the ideal cognitive screening
test? Int. J. Geriatr. Psychiatry 15, 548–561. doi: 10.1002/1099-
1166(200006)15:6<548::AID-GPS242>3.0.CO;2-U
Sikkes, S. A., de Lange-de Klerk, E. S., Pijnenburg, Y. A., Scheltens, P., and
Uitdehaag, B. M. (2009). A systematic review of Instrumental Activities of
Daily Living scales in dementia: room for improvement. J. Neurol. Neurosurg.
Psychiatry 80, 7–12. doi: 10.1136/jnnp.2008.155838
Silva, M. T., Laks, J., and Engeldardt, E. (2009). Neuropsychological tests and
driving in dementia: a review of the recent literature. Rev. Assoc. Med. Bras.
55, 484–488. doi: 10.1590/S0104-42302009000400027
Sino, C. G., Sietzema, M., Egberts, T. C., and Schuurmans, M. J. (2014). Medi cation
management capacity in relation to cognition and self-management skills
in older people on polypharmacy. J. Nutr. Health Aging 18, 44–49. doi:
10.1007/s12603-013-0359-2
Taler, V., and Phillips, N. A. (2008). Language performance in Alzheimer’s
disease and mild cognitive impairment: a comparative review. J. Clin. Exp.
Neuropsychol. 30, 501–556. doi: 10.1080/13803390701550128
Tam,C.W.,Lam,L.C.,Lui,V.W.,Chan,W.C.,Chan,S.S.,Chiu,H.F.,etal.
(2008). Clinical correlates of functional performance in community-swelling
Chinese older persons with mild cognitive impairment. Int. Psychogeriatr. 20,
1059–1070. doi: 10.1017/S1041610208007345
Thomas, V. S., Rockwood, K., and McDowell, I. (1998). Multidimensionality in
instrumental and basic activities of daily living. J. Clin. Epidemiol. 51, 315–321.
doi: 10.1016/S0895-4356(97)00292-8
Tomita, A., and Burns, J. K. (2013). Depression, disability and functional status
among community-dwelling older adults in South Africa: evidence from the
first South African National Income Dynamics Study. Int. J. Geriatr. Psychiatry
28, 1270–1279. doi: 10.1002/gps.3954
Wadsworth,L.P.,Lorius,N.,Donovan,N.J.,Locascio,J.J.,Rentz,D.M.,
Johnson, K. A., et al. (2012). Neuropsychiatric symptoms and global functional
impairment along the Alzheimer’s continuum. Dement. Geriatr. Cogn. Disord.
34, 96–111. doi: 10.1159/000342119
Zahodne, L. B., Devanand, D. P., and Stern, Y. (2013). Coupled cognitive and
functional change in Alzheimer’s disease and the influence of depressive
symptoms. J. Alzheimers Dis. 34, 851–860. doi: 10.3233/JAD-121921
Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Copyright © 2015 de Paula, Diniz, Bicalho, Albuquerque, Nicolato, de Moraes,
Romano-Silva and Malloy-Diniz. This is an open-access article distributed under the
terms of the Creative Commons Attribution License (CC BY). The use, distribution or
reproduction in other forums is permitted, provided the original author(s) or licensor
are credited and that the original publication in this journal is cited, in accordance
with accepted academic practice. No use, distribution or reproduction is permitted
which does not comply with these terms.
Frontiers in Aging Neuroscience | www.frontiersin.org 12 July 2015 | Volume 7 | Article 139
... Te relationship between IADL and depressive symptoms in older adults is complex and bidirectional [10]. Studies have shown that older adults with poor IADL report signifcantly more depressive symptoms [11,12]. ...
Article
Full-text available
Background: The potential association and underlying mechanisms between instrumental activities of daily living (IADL) and depressive symptoms in middle- and older-aged adults remain unclear. This study explores the bidirectional relationship between IADL disability and depressive symptoms among Chinese middle-aged and older adults and examines the mediating or moderating effects of self-rated health (SRH) and age on this relationship. Methods: We used data from five waves (2011, 2013, 2015, 2018, and 2020) of the China Health and Retirement Longitudinal Study (CHARLS), a nationally representative survey. A total of 4830 participants aged 45 and older were included in the analysis. Longitudinal associations between IADL disability, SRH, and depressive symptoms were tested using cross-lagged models to simultaneously evaluate the bidirectional association and the strength of the temporal association. Results: Among middle-aged and older adults, there was a significant bidirectional longitudinal relationship between IADL disabilities and depressive symptoms. Higher levels of IADL disability predicted an increased risk of depressive symptoms and vice versa. SRH mediated the bidirectional relationship between IADL disabilities and depressive symptoms. Higher levels of IADL disability led to lower SRH, which further increased the risk of depressive symptoms and vice versa. Age moderated the cross-lagged models, indicating that the effect of SRH on the bidirectional relationship between IADL disability and depressive symptoms was stronger in the middle-aged group than that in the older group. Conclusion: The study results clarified the bidirectional relationship between IADL disability and depressive symptoms in middle-aged and older adults. Healthcare providers can use the findings to design targeted interventions to address the decline in IADL function and potentially benefit mental health. Helping middle-aged and older adults improve their SRH may interrupt the vicious cycle linking IADL disability and depressive symptoms, particularly in middle-aged adults transitioning to old age.
... Research consistently demonstrates that individuals with depression often exhibit cognitive impairments, including deficits in attention, memory, executive function, and processing speed (36,37). These cognitive deficits and depression may significantly impact daily functioning and quality of life (38). On the other hand, engaging in leisure activities has been shown to have positive effects on mood and cognitive function in older adults, including those suffering from depression (39). ...
Article
Full-text available
Background This study delves into the complex interaction between leisure activities and cognitive function in older people with disabilities, with a particular emphasis on the moderating influence of depression. Despite the well-documented cognitive benefits of leisure activities among the older people, the intricate relationship between depression and the association between leisure activities and cognitive function in this specific demographic has been rarely reported. Methods Drawing on data from the 2017–2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS), this study meticulously examined a cohort of 713 participants aged 65–89 years. We constructed a moderation model to examine the impact of leisure activity on cognitive function in older people with disabilities, with depression levels as a moderating variable. Results We found a positive association between engagement in leisure activities and cognitive function, highlighting the potential cognitive advantages associated with leisure engagement among disabled older people. However, the present analysis also reveals a significant moderation effect of depression on this relationship, shedding light on the nuanced nature of this association. Specifically, elevated levels of depression emerge as a critical moderator, attenuating the otherwise favorable impact of leisure activities on cognitive function among older people contending with disabilities. Conclusion In conclusion, the findings provide a compelling rationale for tailored interventions that comprehensively target both leisure activity engagement and concurrent depression management, effectively fostering improvements in cognitive function among the cohort of disabled older people.
... become reintegrated in the community after brain injury (Keller et al., 2023), perform instrumental activities of daily living at home (IADLs; , and manage medications (e.g., Anderson & Birge, 2016;Hallowell et al., 2022) and finances (Hoskin et al., 2005). Additionally, scores on traditional EF tests have been shown to correlate with scores on laboratory-based IADL tasks (e.g., Mitchell & Miller, 2008b), and with scores on rating scales of IADL functioning (e.g., Alosco et al., 2014;Best et al., 2015;Boyle et al., 2002;Chiu et al., 2018;de Paula et al., 2015;Marshall et al., 2011; for reviews, see also Chaytor & Schmitter-Edgecombe, 2003;Overdorp et al., 2016). Despite this extensive literature, many articles that introduce or validate novel EF tests state as a matter of fact that traditional EF tests lack EV (e.g., Allain et al., 2014;Chevignard et al., 2008;Longaud-Valès et al., 2016;Renison et al., 2012;Rosetti et al., 2018;Shimoni et al., 2012;Torralva et al., 2012;Valls-Serrano et al., 2018;Verdejo-García & Pérez-García, 2007;Werner et al., 2009). ...
Article
Full-text available
The term “ecological validity” (EV) has traditionally referred to test scores’ ability to predict real-world functioning. However, a test’s similarity to real-world tasks is sometimes mistaken for evidence of its ability to predict daily life, sometimes bypassing rigorous validation research. The goal of this systematic review was to examine the type and quality of evidence used to support claims of EV of novel face-valid tests of executive functions (EF). MEDLINE and PsychINFO databases were searched using the following terms: ecologic* AND neuropsychol* AND (executive function* OR executive dysfunction OR executive abilit*). Thirty-two articles that explicitly stated that their results demonstrated EV of a novel face-valid test of EF were identified. Results showed that only 60% of studies based their claims about EV on test scores’ ability to predict functional outcomes, with the remaining 40% relying on other evidence (e.g., correlations with other measures, participant feedback, group differences). Among the studies that did base their conclusions on test scores’ ability to predict outcomes (n = 19), an overwhelming majority relied on behavioral rating scales, utilized small sample sizes and participant-to-variable ratios, and failed to control for covariates and multiple comparisons. Poor scientific rigor was particularly pronounced in studies of “naturalistic” tests. The present systematic review reveals significant conceptual, methodological, and statistical flaws among an overwhelming majority of studies that claim to have found support for the EV of a novel face-valid test of EF. We call upon authors, reviewers, and editors to safeguard the scientific rigor of research in this area.
... Indeed, some studies on older adults with and without cognitive decline showed that executive functions were particularly relevant to ADL capacity, given their role in the organization and regulation of mental processes and voluntary behavior (i.e., [10][11][12][13]; whereas other studies reported a key role of memory in supporting ADL [3,[14][15][16][17]. Moreover, the extent to which these results can be generalized is not clear, since the association of cognitive functions and ADL may be heavily influenced by moderator factors, such as educational level, emotional disorders, and assessment instruments [5,[18][19][20]. Thus, reliable identification of functional activities of daily living in patients with cognitive impairments seems necessary since patients with mild cognitive impairment (MCI) with IADL deficits have a higher risk of converting to dementia than patients with MCI without IADL deficits [4,21]. ...
Article
Literature suggests that dementia and, more generally, cognitive impairment affect the capacity to carry out activities of daily living (ADL) in aging. However, it is important to decipher the weight of specific cognitive domains and neurodegenerative profiles mainly related to ADL difficulties. A meta-analysis was conducted to investigate the nature and strength of the association between cognitive functioning and ADL in healthy older adults, mild cognitive impairment (MCI), and dementia. A comprehensive search of the PubMed, PsycINFO (PROQUEST), and Scopus databases for cross-sectional or longitudinal studies up until December 2022. Our meta-analytic results revealed that: overall, instrumental ADL (IADL) showed a significant association with executive functioning, in particular, abstraction ability/concept formation, set-shifting, and processing speed/complex attention/working memory, regardless of type of participants (i.e., healthy older adults, MCI, and dementia); whereas ADL (both basic ADL, BADL, and IADL) significantly correlated with global cognitive functioning and long-term verbal memory, with a moderator effect of clinical condition (e.g., increasing ES based on the level of cognitive impairment). Moreover, visuospatial and language abilities significantly correlated with ADL, mainly when performance-based tasks were used for ADL assessment. These findings emphasize the importance of neuropsychological assessment in aging to early identify people most at risk of functional decline and shed light on the need to consider specific cognitive abilities in rehabilitation programs.
... Visual-spatial processing is the ability to understand where objects are in space, which includes the perception of body parts and being able to tell how far objects are from you and from each other. de Paula et al. [29] describe visual-spatial processing impairment as a significant predictor of the ability to go out alone and use transportation, which clearly impacts the individual assessment of quality of life, and it has a negative impact not only on the patients' independence but also particularly on the performance of the activities of daily living [30]. Because the impairment of cognitive functions is part of the assessment of damage associated with SLE, patients with higher SLICC/ACR -DI scores can be expected manifest a higher frequency of executive function impairment, as found in this study. ...
Article
Full-text available
Background Cognitive dysfunction (CD) is a widespread manifestation in adult systemic lupus erythematosus (SLE) patients, but this subject is rarely examined in patients with childhood-onset SLE (cSLE). This study aimed to assess the frequency of CD, its associations with lupus clinical manifestations and its impact on the health-related quality of life (HRQL) in young adult cSLE patients. Methods We evaluated 39 cSLE patients older than 18 years. They underwent a rheumatologic evaluation and extensive neuropsychological assessment, encompassing all cognitive domains described by the American College of Rheumatology. HRQL was assessed with the WHOOQOL-BREEF, General Activities of Daily Living Scale (GADL) and Systemic Lupus Erythematosus-specific quality-of-life instrument (SLEQOL). The activity of SLE was evaluated with the modified sle disease activity index (sledai-2k). Results Impairment in at least one cognitive domain was found in 35 (87.2%) patients. The most compromised domains were attention (64.1%), memory (46.2%), and executive functions (38.5%). Patients with cognitive impairment were older, had more accumulated damage and had worse socioeconomic status. Regarding the association between cognitive dysfunction and HRQL, memory impairment was correlated with worse environmental perception and a worse relationship with the treatment. Conclusion In this study, the frequency of CD in cSLE patients was as high as that in the adult SLE population. CD can significantly impact the response of cSLE patients to treatment, justifying preventive measures in the care of this population.
... Among the elderly in China, ∼ 30% of men and 43% of women suffer from depression (13). The existing epidemiological literature shows that depression can reduce physical function, daily living ability, and cognitive ability (14); it is also the most critical factor leading to suicide in the elderly (15). In the context of healthy aging, it is necessary to explore the influencing mechanism of depression outcomes to help grandparents avoid health risks. ...
Article
Full-text available
Objectives Despite extensive studies about the direct effect of grandchild care on caregiver depression in China, understanding of its internal influencing mechanism has been limited. After controlling for socioeconomic factors, this study investigated whether the experience of caring for grandchildren had a long-term impact on the depression levels of grandparents, either directly or indirectly through generational support from adult children. Methods The subjects of this study were a total of 9,219 adults over 45 who participated in the China Health and Retirement Longitudinal Surveys in 2015 and 2018. We adopted a lag-behind variable to examine the impact of grandchild care on depressive symptoms of grandparents. The proposed mediation model was analyzed using bootstrap modeling, and the KHB method was conducted further to examine differences in the effects of generational support. Results The experience of caring for grandchildren had a significant negative correlation with the depression level of Chinese grandparents. Moreover, children's support significantly mediated the impact of parenting experience on grandparents' depression. Significantly, instrumental support mediated the effect to the greatest extent, while emotional support from children contributed the least. The intermediary effect has urban–rural heterogeneity. Conclusion These findings indicated that grandchild care significantly inhibited the depression level of Chinese grandparents through increased intergenerational support from adult children. The implications of the study's findings were discussed.
Article
Objective The influence of depression on the relationship between cognition and daily living in aging Mexican American adults requires further investigation, given projected trends in general growth as well as prevalence of depression and Alzheimer’s disease and related dementias (ADRD) in this population. Method In the present study, we examined the extent to which depression (assessed using the Geriatric Depression Scale – 15 item version) moderated the association between reported daily functioning (assessed using the Functional Activities Questionnaire [FAQ]) and objective neuropsychological performance in aging Mexican American adults in the National Alzheimer’s Coordinating Center cohort. Results Worse reported daily functioning (higher FAQ scores) was associated with worse memory and language performance among participants without elevated depression symptoms (ps < .05), but no associations were observed among those with elevated symptoms (ps > .05). Moreover, depression did not moderate associations of reported daily functioning with performance in attention and working memory or executive functioning and processing speed (ps > .05). Conclusions Aging Mexican American adults with elevated depression symptoms may have subjective informant reports of daily functioning that are discrepant from their objective performance on formal tests of memory and language. Within the context of neuropsychological evaluations for ADRD, failure to adequately assess mood to inform the nature of cognitive and/or functional changes could result in misdiagnosis and lead to delayed, premature, and/or improper intervention with this population.
Article
Aims This study aimed to evaluate the association between memory impairment and its risk and protective factors, focusing on demographic and health-related variables among older adults in Indonesia. Method The data analyzed were the Indonesian Family Life Survey-5 (IFLS-5) using cross-sectional variables of 4236 older adults aged 60 years and over included in the 2015 round. Memory impairment was assessed by immediate word list recall from the Telephone Interview for Cognitive Status (TICS). Sociodemographic factors and multiple health variables were included as predictors. Data were analyzed using frequency analyses bivariate and stepwise logistic regression tests. Result Among 4236 older adults, 49.7% were male and 50.3% were female. Stepwise backward analyses showed that memory impairment was independently associated with older age, being female, or not in a union (unmarried, separated, divorced, or widowed), having obtained low levels of education, living in a rural area, reporting low life satisfaction, low social capital, higher dependency, and having clinical depression. Only moderate (but not high or low) physical activity levels were associated with a lower risk. Being underweight increased the risk, but being overweight/obese (as assessed by BMI) protective factors for a lower immediate recall score. Conclusion Increasing education and continued engagement of older adults in psychosocial activities, including moderate physical activity, improving mental health, preventing weight loss, and maintaining functional ability to decrease dependency, are associated with increased episodic memory, especially in non-married and older women in rural areas of Indonesia.
Article
Full-text available
Pfeffer’s Functional Activities Questionnaire (FAQ) is one of the most commonly employed tools in studies on pathological cognitive ageing. Despite the different versions of the questionnaire translated for use in clinical practice, few studies have analyzed the psychometric properties of the Brazilian version of the FAQ (P-FAQ). Thus, the aim of the present study was to analyze the P-FAQ with regard to internal consistency, factorial structure and associations with demographic factors (age, sex and schooling), depressive symptoms, cognitive measures and other measures of functionality. One hundred sixty-one older adults were divided into four groups (91 with dementia, 46 with mild cognitive impairment, 11 with psychiatric disorders and 13 healthy controls). All participants were evaluated by cognitive, behavioral and functional tests and scales. Their caregivers answered the P-FAQ. The questionnaire showed high internal consistency (α = 0.91). Factor analysis revealed a two-factor structure, which, accounted for 66% of the total variance. The P-FAQ was not correlated with demographic factors, was weakly correlated with depressive symptoms (ϱ = 0.271, p < 0.01, R² = 7%) and strongly correlated with cognitive measures (Matttis Dementia Rating Scale total score: ϱ = -0.574, p < 0.01, R² = 33%) as well as complex instrumental activities of daily living (ϱ = -0.845, p < 0.01, R² = 71%). Cognitive performance and depression status were independent predictors of P-FAQ scores in regression models. The present findings indicate that the P-FAQ has satisfactory reliability, internal consistency, construct validity and ecological validity. Therefore, this questionnaire can be used in clinical practice and research involving the Brazilian population of older adults.
Article
Full-text available
Objective: To propose and evaluate the psychometric properties of a multidimensional measure of activities of daily living (ADLs) based on the Katz and Lawton indices for Alzheimer's disease (AD) and mild cognitive impairment (MCI). Methods: In this study, 85 patients with MCI and 93 with AD, stratified by age (≤ 74 years, > 74 years), completed the Mini Mental State Examination (MMSE) and the Geriatric Depression Scale, and their caregivers completed scales for ADLs. Construct validity (factor analysis), reliability (internal consistency), and criterion-related validity (receiver operating characteristic analysis and logistic regression) were assessed. Results: Three factors of ADL (self-care, domestic activities, and complex activities) were identified and used for item reorganization and for the creation of a new inventory, called the General Activities of Daily Living Scale (GADL). The components showed good internal consistency (> 0.800) and moderate (younger participants) or high (older participants) accuracy for the distinction between MCI and AD. An additive effect was found between the GADL complex ADLs and global ADLs with the MMSE for the correct classification of younger patients. Conclusion: The GADL showed evidence of validity and reliability for the Brazilian elderly population. It may also play an important role in the differential diagnosis of MCI and AD.
Article
Full-text available
Neuropsychological tests related to verbal fluency para-digms are among those most frequently used to assess executive functions in older adults. These tasks are quick and easy to administer and widely used for clinical assessment. However, despite their apparent simplicity, these tests involve different cognitive demands and are influenced by sociodemographic factors. 1 Two cognitive domains are particularly related to verbal fluency perfor-mance: executive functions and processing speed. Performance on these two cognitive domains declines with age and mediates the effect of other cognitive and demographic factors on verbal fluency scores. 2 The objective of the present report is to investigate the contribution of executive functions and processing speed on category fluency performance. We hypothesize that these two cognitive domains will be related to test performance, suggesting that verbal fluency may not be used as a unidimensional measure of executive functions.
Article
Full-text available
Objective To determine the medication management capacity of independently living older people (≥75 years) on polypharmacy (≥ 5 medications) in relation to their cognitive- and self-management skills. Design Cross-sectional study. Setting Two homecare organizations in the Netherlands. Participants Homecare clients aged 75 and older on polypharmacy (N=95). Measurements The primary outcome measure was medication management capacity, quantified as the number of ‘yes’ answers (range = 0–17) on the Medication Management Capacity (MMC) questionnaire. Other measures included self-management ability (assessed with the SMAS30) and cognitive skills (assessed with the clock drawing test). Results Overall, 48.4% (n= 46) of the participants were able to manage their medication by themselves at home. About 40% of the participants were unable to state the names of their medications, even with the aid of a medication list, and about 25% reported having problems with opening medication packages. Correlations were found between self-management ability (Rs = 0.473; p < 0.001), cognitive skills (Rs = 0.372; p < 0.001), and age (Rs = 0.216; p < 0.005) and Medication Management Capacity score. Self-management ability and medication management support were significantly associated with medication management capacity. Conclusion A considerable proportion of independently living older people who receive home care and regularly use five or more medications lack the knowledge and skills needed to independently manage their own medications. Cognition and self management ability were related to medication management capacity. Self-management ability and medication management support were predictors of medication management capacity.
Article
Full-text available
The neuropsychological exam plays a central role in the assessment of elderly patients with cognitive complaints. It is particularly relevant to differentiate patients with mild dementia from those subjects with mild cognitive impairment. Formal education is a critical factor in neuropsychological performance; however, there are few studies that evaluated the psychometric properties, especially criterion related validity, neuropsychological tests for patients with low formal education. The present study aims to investigate the validity of an unstructured neuropsychological assessment protocol for this population and develop cutoff values for clinical use. A protocol composed by the Rey-Auditory Verbal Learning Test, Frontal Assessment Battery, Category and Letter Fluency, Stick Design Test, Clock Drawing Test, Digit Span, Token Test and TN-LIN was administered to 274 older adults (96 normal aging, 85 mild cognitive impairment and 93 mild Alzheimer`s disease) with predominantly low formal education. Factor analysis showed a four factor structure related to Executive Functions, Language/Semantic Memory, Episodic Memory and Visuospatial Abilities, accounting for 65% of explained variance. Most of the tests showed a good sensitivity and specificity to differentiate the diagnostic groups. The neuropsychological protocol showed a significant ecological validity as 3 of the cognitive factors explained 31% of the variance on Instrumental Activities of Daily Living. The study presents evidence of the construct, criteria and ecological validity for this protocol. The neuropsychological tests and the proposed cutoff values might be used for the clinical assessment of older adults with low formal education.
Article
Objectives: To evaluate the effect of depression and cognition on function in older adults with amnestic and nonamnestic mild cognitive impairment (aMCI and nonaMCI). Design: The study uses baseline data from the National Alzheimer's Coordinating Center. Setting: Data were collected at multiple Alzheimer's Disease Centers in the United States. Participants: The sample included a total of 3,117 individuals with MCI, mean age = 74.37 years, SD: 9.37 (aMCI, n = 2,488; non-aMCI, n = 629). Measurements: The 10-item Pfeffer Functional Activities Questionnaire assessed function. Results: Depressive symptoms (Geriatric Depression Scale), memory impairment (Logical Memory II), and processing speed decrements (Digit Symbol Substitution Test) were significantly associated with functional impairment (p <0.001). Processing speed partially mediated the effect of depression on function and fully mediated the effect of executive dysfunction on function (p <0.001) in the total MCI and aMCI subsample, while in the non-aMCI subsample, processing speed mediated the effect of executive function but not the effect of depression (p = 0.20) on function. Conclusions: The findings show that processing speed is central to the effect that depression and executive dysfunction have on functional impairment in cognitively impaired older adults. Future studies are needed to better understand the physiologic underpinnings in age-related and disease-specific decrements in processing speed, and to address the problems in the assessment of processing speed in clinical samples.
Article
Cognitive functions (intelligence, attention and memory) of 67 depressive out-patients were assessed prior to a drug therapy. We investigated if severity of depression (as measured by Hamilton's Depression Rating Scale) affected the results of neuropsychological testing. Gender differences were taken into consideration. Results showed for the total group an effect of severity of depression on intelligence. Regarding attention and memory, results showed significant group differences between men and women. For women severity of depression affected the performance on neuropsychological tests, for men it didn't. Presently it is not clear if this is a matter of 'true' differences or if the relatively small number of men influenced the results. After eight weeks of drug therapy, sixteen patients were tested again. The improved performances on different tests could not be attributed to the recovery from depression.
Article
The current study examined the relationship between neuropsychological test performance and functional status in 42 individuals diagnosed with Alzheimer’s disease. A comprehensive battery of cognitive tests was employed in order to assess a wide range of neuropsychological abilities. Functional status was measured through the use of both a performance-based scale of activities of daily living (an expanded version of the Direct Assessment of Functional Status; DAFS, Loewenstein et al., 1989), and by a caregiver/informant-based rating scale (Instrumental Activities of Daily Living; IADL, Lawton & Brody, 1969). Findings suggest that neuropsychological functioning is moderately predictive of functional status. Using multiple regression analyses, neuropsychological variables accounted for 25% of the variance in the IADL and 50% of the variance in the DAFS. Individual domains of both functional measures were also significantly predicted by the neuropsychological variables. The findings provide evidence of a relationship between neuropsychological test performance and ADLs in an Alzheimer disease patient population.