Article

Financial Management Skills in Aging, MCI and Dementia: Cross Sectional Relationship to 18F-Florbetapir PET Cortical β-amyloid Deposition

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Abstract

Background: There is a need to more fully characterize financial capacity losses in the preclinical and prodromal stages of Alzheimer's disease (AD) and their pathological substrates. Objectives: To test the association between financial skills and cortical β-amyloid deposition in aging and subjects at risk for AD. Design: Cross-sectional analyses of data from the Alzheimer's Disease Neuroimaging Initiative (ADNI-3) study conducted across 50 plus sites in the US and Canada. Setting: Multicenter biomarker study. Participants: 243 subjects (144 cognitively normal, 79 mild cognitive impairment [MCI], 20 mild AD). Measurements: 18F-Florbetapir brain PET scans to measure global cortical β-amyloid deposition (SUVr) and the Financial Capacity Instrument Short Form (FCI-SF) to evaluate an individual's financial skills in monetary calculation, financial concepts, checkbook/register usage, and bank statement usage. There are five sub scores and a total score (range of 0-74) with higher scores indicating better financial skill. Results: FCI-SF total score was significantly worse in MCI [Cohen's d= 0.9 (95%CI: 0.6-1.2)] and AD subjects [Cohen's d=3.1(CI: 2.5-3.7)] compared to normals. Domain scores and completion times also showed significant difference. Across all subjects, higher cortical β-amyloid SUVr was significantly associated with worse FCI-SF total score after co-varying for age, education, and cognitive score [Cohen's f2=0.751(CI: 0.5-1.1)]. In cognitively normal subjects, after covarying for age, gender, and education, higher β -amyloid PET SUVr was associated with longer task completion time [Cohen's f2=0.198(CI: 0.06-0.37)]. Conclusion: Using a multicenter study sample, we document that financial capacity is impaired in the prodromal and mild stages of AD and that such impairments are, in part, associated with the extent of cortical β-amyloid deposition. In normal aging, β-amyloid deposition is associated with slowing of financial tasks. These data confirm and extend prior research highlighting the utility of financial capacity assessments in at risk samples.

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... The FCI is used in twenty-two studies included in this review (i.e., Clark et al., 2014;Earnst et al., 2001;Gerstenecker et al., 2019Gerstenecker et al., , 2018Gerstenecker et al., , 2017bGerstenecker et al., , 2017aGerstenecker et al., , 2016Griffith et al., 2010Griffith et al., , 2007Griffith et al., , 2003Lassen-Greene et al., 2017;Marson et al., 2000;Martin et al., 2008Martin et al., , 2019Martin et al., , 2013Niccolai et al., 2017;Okonkwo et al., 2009Okonkwo et al., , 2006Sherod et al., 2009;Stoeckel et al., 2013;Tracy et al., 2017;Triebel et al., 2009). 6 The Financial Capacity Instrument-Short Form (FCI-SF; Tolbert et al., 2019) assesses complex financial abilities and is a modified shorter version of the FCI. Five domains, i.e., (1) 'mental calculation', (2) 'financial conceptual knowledge', (3) 'single checkbook/register task', (4) 'complex checkbook/register task', and (5) 'using bank statement' are included. ...
... Scores can be determined for all five domains separately and a total score based on the sum of these five domains can be calculated, with higher scores indicating a better financial capacity. The FCI-SF is used in one study included in this review (i.e., Tolbert et al., 2019). 7 The Financial Competency Questions (FCQ; Bassett, 1999) evaluates a participants' understanding of financial issues related to the use and maintenance of a checking account by asking five questions. ...
... Some studies found evidence that a higher age was associated with lower performances on FDM tests in people living with MCI (Duke Han et al., 2015;Lassen-Greene et al., 2017;Lui et al., 2013;Tolbert et al., 2019). Age can, however, not fully explain the differences that were found between people living with MCI and healthy controls regarding FDM since some studies controlled for age in their group analyses and still found significant differences between groups on tests of FDM (Arcara et al., 2019;Benavides-Varela et al., 2015;Duke Han et al., 2015;Griffith et al., 2010;Martin et al., 2019;Triebel et al., 2009). ...
Article
Self and proxy reported questionnaires indicate that people living with a neurodegenerative disease (NDD) have more difficulties with financial decision-making (FDM) than healthy controls. Self-reports, however, rely on adequate insight into everyday functioning and might, therefore, be less reliable. The present study provides a comprehensive overview and meta-analysis of studies evaluating FDM in people living with an NDD. For this, the reliability of performance-based tests to consistently identify FDM difficulties in people living with an NDD compared to healthy controls is evaluated. Furthermore, the associations between FDM and disease severity, performances on standard measures of cognition and demographics are evaluated. All 47 included articles, consistently reported lower performances on performance-based FDM tests of people living with an NDD (including Alzheimer’s disease, mild cognitive impairment, frontotemporal dementia, Parkinson’s disease, multiple sclerosis or Huntington’s disease) compared to healthy controls. The majority of studies, however, focused on Alzheimer’s disease and mild cognitive impairment (k = 38). FDM performance appears to be related to cognitive decline, specifically in working memory, processing speed and numeracy.
... [4][5][6][7][8][9][10][11][12][13][14] However, it remains unclear whether IADL impairment can be detected cross-sectionally in even earlier stages of Alzheimer's disease (AD), in particular in the biomarker-defined stage of preclinical AD. 15 To date, few publications have examined systematic IADL assessment in CN individuals with high cortical amyloid burden consistent with preclinical AD and CN individuals with low amyloid. 16,17 In the current study, we analyzed the Anti-Amyloid Treatment in Asymptomatic Alzheimer's Disease (A4) Study 18 screening data of CN participants who underwent florbetapir positron emission tomography (PET) to determine the cross-sectional associations among IADL, as measured by the participant and study partnerreported ADCS ADL-PI, cortical amyloid deposition as measured by florbetapir PET, and cognition. We hypothesized that subtle difficulties in IADL will be associated with greater cortical amyloid burden and worse cognition. ...
... 5 Items address IADL, such as managing finances, traveling, and organizing activities (see Tables 2 and 3). For the A4 Study, three technology-related items were added (items [16][17][18], aimed at capturing aspects of use of cellphones, smartphones, computers, tablets, and e-readers. They were pretested among CN volunteers for clarity of wording and feasibility. ...
... Prior studies in CN participants have shown associations between amyloid burden and objective and subjective cognitive function [23][24][25][26] but only limited evidence for a relationship with IADL difficulties. 16,17 The current analyses demonstrated an association among IADL, amyloid burden, objective cognition, and subjective cognitive concerns. ...
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Introduction: We examined the associations among instrumental activities of daily living (IADL), cortical amyloid, and cognition in cognitively normal (CN) older adults. Methods: CN participants screening for the A4 Study (n = 4486) underwent florbetapir (amyloid) positron emission tomography. IADL were assessed using the Alzheimer's Disease Cooperative Study Activities of Daily Living Prevention Instrument. Separate logistic regression models were run with cortical amyloid or cognition as independent variable and IADL as dependent variable, adjusting for age and sex. Results: IADL difficulties were endorsed infrequently (≤16%). Overall IADL and four select IADL item difficulties ("remembering appointments," "finding belongings," "following TV programs," and "remembering current events") reported by both participant and study partner were significantly associated with greater amyloid burden and worse cognition. Discussion: Although IADL deficits were infrequent in this CN cohort, greater participant and study partner report of overall IADL deficits and subtle difficulties in specific IADL items were associated with mildly higher amyloid burden and worse cognition.
... As described above, previous studies have displayed an association between IADL and certain brain regions, but few studies have assessed the relationship between financial capacity and AD pathology. One such recent study found that higher cortical amyloid burden was significantly associated with higher impairment in financial capacity in participants with early-stage AD [20]. However, to our knowledge, no previous study has investigated the relationship between tau pathology and financial capacity. ...
... While association were modest in strength, this suggests that the FCI-SF, used in the current study, may be more sensitive to detecting the earliest IADL changes in the preclinical stage of AD, while the FAQ, used in the previous study, may be more geared toward detecting IADL changes at the stage of MCI and mild AD dementia. A few prior studies have shown an association between IADL changes and cortical amyloid within CN older adults [20,38]. However, to our knowledge, this is the first study to show an association between regional tau burden and IADL within CN older adults. ...
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Background: Financial capacity is often one of the first instrumental activities of daily living to be affected in cognitively normal (CN) older adults who later progress to amnestic mild cognitive impairment (MCI) and Alzheimer's disease (AD) dementia. Objective: The objective of this study was to investigate the association between financial capacity and regional cerebral tau. Methods: Cross-sectional financial capacity was assessed using the Financial Capacity Instrument -Short Form (FCI-SF) in 410 CN, 199 MCI, and 61 AD dementia participants who underwent flortaucipir tau positron emission tomography from the Alzheimer's Disease Neuroimaging Initiative (ADNI). Linear regression models with backward elimination were used with FCI-SF total score as the dependent variable and regional tau and tau-amyloid interaction as predictors of interest in separate analyses. Education, age sex, Rey Auditory Verbal Learning Test Total Learning, and Trail Making Test B were used as covariates. Results: Significant associations were found between FCI-SF and tau regions (entorhinal: p < 0.001; inferior temporal: p < 0.001; dorsolateral prefrontal: p = 0.01; posterior cingulate: p = 0.03; precuneus: p < 0.001; and supramarginal gyrus: p = 0.005) across all participants. For the tau-amyloid interaction, significant associations were found in four regions (amyloid and dorsolateral prefrontal tau interaction: p = 0.005; amyloid and posterior cingulate tau interaction: p = 0.005; amyloid and precuneus tau interaction: p < 0.001; and amyloid and supramarginal tau interaction: p = 0.002). Conclusion: Greater regional tau burden was modestly associated with financial capacity impairment in early-stage AD. Extending this work with longitudinal analyses will further illustrate the utility of such assessments in detecting clinically meaningful decline, which may aid clinical trials of early-stage AD.
... For patients who do progress to MCI due to AD (with/ without MBI), initial clinical symptoms typically include short-term memory impairment, followed by subsequent decline in additional cognitive domains (15) (Figure 1). On a day-to-day basis, an individual with MCI due to AD may struggle to find the right word (language), forget recent conversations (episodic memory), struggle with completing familiar tasks (executive function), or get lost in familiar surroundings (visuospatial function) (15,16). As individuals have varying coping mechanisms and levels of cognitive reserve, patients' experiences and symptomology vary widely; however, patients tend to remain relatively independent at this stage, despite potential marginal deficits in function. ...
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The capacity to manage one's financial affairs, known as financial capacity, comprises a broad range of conceptual, pragmatic, and judgment abilities, used across a range of everyday settings, that are critical to the independent functioning of adults in our society. Older adults are the most vulnerable to cognitive impairment, yet hold a disproportionate amount of wealth in the United States. Financial capacity is also understudied, so the authors present in this issue of Generations a comprehensive look at the four domains of financial capacity: economic, clinical, legal, and public policy.
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Financial capacity is an instrumental activity of daily living (IADL) that comprises multiple abilities and is critical to independence and autonomy in older adults. Because of its cognitive complexity, financial capacity is often the first IADL to show decline in prodromal and clinical Alzheimer's disease and related disorders. Despite its importance, few standardized assessment measures of financial capacity exist and there is little, if any, normative data available to evaluate financial skills in the elderly. The Financial Capacity Instrument-Short Form (FCI-SF) is a brief measure of financial skills designed to evaluate financial skills in older adults with cognitive impairment. In the current study, we present age- and education-adjusted normative data for FCI-SF variables in a sample of 1344 cognitively normal, community-dwelling older adults participating in the Mayo Clinic Study of Aging (MCSA) in Olmsted County, Minnesota. Individual FCI-SF raw scores were first converted to age-corrected scaled scores based on position within a cumulative frequency distribution and then grouped within 4 empirically supported and overlapping age ranges. These age-corrected scaled scores were then converted to age- and education-corrected scaled scores using the same methodology. This study has the potential to substantially enhance financial capacity evaluations of older adults through the introduction of age- and education-corrected normative data for the FCI-SF by allowing clinicians to: (a) compare an individual's performance to that of a sample of similar age and education peers, (b) interpret various aspects of financial capacity relative to a normative sample, and (c) make comparisons between these aspects. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
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The North American Alzheimer's Disease Neuroimaging Initiative (ADNI) was originally conceived as a study to develop markers of disease progression, but has also become a strong technological platform for the multi-centric collection of clinical data and imaging and biological markers. Because the ADNI platform was first imported in Europe, thanks to the pilot European ADNI, several ADNI-related initiatives have flourished, funded by the European Commission's 7th Framework Programme, national governments, and the Alzheimer's Association aimed at: (i) collecting fresh data ADNI style (FP7 AddNeuroMed, Innovative Medicine Initiative Pharma-Cog/European ADNI, Swedish ADNI, and Italian ADNI); (ii) developing standard operational procedures for the collection of markers (International Harmonization of CSF Abeta42 and tau, and European Alzheimer's Disease Consortium–ADNI Harmonization of Hippocampal Volumetry); and (iii) developing infrastructures for the treatment of ADNI data (FP7 neuGRID and outGRID, and the French Centre pour l'Acquisition et le Traitement de l'Image). Although this fragmented scenario is not surprising given the structure of scientific funding in Europe, opportunities are being developed for high order networking and harmonization at the continental level (Joint Programming for Neurodegenerative Diseases).
Article
To better understand how brain atrophy in amnestic mild cognitive impairment (MCI) as measured using magnetic resonance imaging (MRI) volumetrics could affect instrumental activities of daily living (IADLs) such as financial abilities. Controlled, matched-sample, cross-sectional analysis regressing MRI volumetrics with financial performance measures. University medical and research center. Thirty-eight people with MCI and 28 older adult controls. MRI volumetric measurement of the hippocampi, angular gyri, precunei, and medial frontal lobes. Participants also completed neuropsychological tests and the Financial Capacity Instrument (FCI). Correlations were performed between FCI scores and MRI volumes in the group with MCI. People with MCI performed significantly below controls on the FCI and had significantly smaller hippocampi. Among people with MCI, performance on the FCI was moderately correlated with angular gyri and precunei volumes. Regression models demonstrated that angular gyrus volumes were predictive of FCI scores. Tests of mediation showed that measures of arithmetic and possibly attention partially mediated the relationship between angular gyrus volume and FCI score. Impaired financial abilities in amnestic MCI correspond with volume of the angular gyri as mediated by arithmetic knowledge. The findings suggest that early neuropathology within the lateral parietal region in MCI leads to a breakdown of cognitive abilities that affect everyday financial skills. The findings have implications for diagnosis and clinical care of people with MCI and AD.
Article
To investigate financial capacity in patients with Alzheimer disease (AD) using a new theoretical model and prototype psychometric instrument. Cross-sectional comparisons of older control subjects (n=23) and patients with mild (n=30) and moderate AD (n=20). Financial capacity was measured using the Financial Capacity Instrument, a prototype psychometric instrument that tests financial capacity using 14 tasks of financial ability comprising 6 clinically relevant domains of financial activity: basic monetary skills, financial conceptual knowledge, cash transactions, checkbook management, bank statement management, and financial judgment. The Financial Capacity Instrument tasks and domains showed adequate to excellent internal, interrater, and test-retest reliabilities. At the task level, patients with mild AD performed equivalently with controls on simple tasks such as counting coins/currency and conducting a 1-item grocery purchase, but significantly below controls on more complex tasks such as using a checkbook/register and understanding and using a bank statement. At the domain level, patients with mild AD performed significantly below controls on all domains except basic monetary skills. Patients with moderate AD performed significantly below controls and patients with mild AD on all tasks and domains. Regarding capacity status outcomes (capable, marginally capable, incapable) on domains, patients with mild AD had high proportions of marginally capable or incapable outcomes (range, 47%-87%), particularly on difficult domains like bank statement management (domain 5) and financial judgment (domain 6), but variability in individual outcomes. Patients with moderate AD had almost exclusively incapable outcomes across the 6 domains (range, 90%-100%). Financial capacity is already significantly impaired in mild AD. Patients with mild AD demonstrate deficits in more complex financial abilities and impairment in most financial activities. Patients with moderate AD demonstrate severe impairment of all financial abilities and activities. The Financial Capacity Instrument has promise as an instrument for assessing domain-level financial activities and task-specific financial abilities in patients with dementia. Arch Neurol. 2000.
Article
To assess financial capacity in patients with mild cognitive impairment (MCI) using a standardized psychometric capacity measure. Participants were 21 cognitively normal older controls, 21 patients with amnestic MCI, and 22 patients with mild AD. The Financial Capacity Instrument (FCI), a psychometric capacity measure consisting of 18 financial ability tests (tasks), 9 domains (activities), and 2 total scores, was administered to participants along with a battery of neuropsychological tests sensitive to dementia. Group differences were examined on the neuropsychological and financial capacity variables. Relative to controls, the MCI group demonstrated impairments in episodic memory, and also semantic knowledge, executive function, written arithmetic, and spatial attention. MCI participants demonstrated impairments in FCI domains of conceptual knowledge, cash transactions, bank statement management, and bill payment, and in overall financial capacity. The control and MCI groups performed significantly better than patients with AD on most financial capacity and cognitive measures. On direct assessment, patients with amnestic MCI as a group demonstrate impairments across a range of financial abilities. These impairments are mild and may only apply to a subset of patients with MCI. However, existing diagnostic criteria for MCI should be applied flexibly to include mild impairments in higher order activities of daily life such as financial capacity.
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