Simon Forstmeier, Moyra Mortby, Andreas Maercker

1. Differential impact of midlife motivational abilities on cognitive impairment and depression/apathyin people with Alzheimer’s Simon Forstmeier, Moyra Mortby, Andreas Maercker University of Zurich, Dept. of Psychology, Zurich, Switzerland

2. Motivational abilities(Heckhausen, Kuhl) Preintentional phase: Choice between alternative goals Decision regulation Postintentional phase: Implementation of chosen goal Activation regulation Self efficacy Motivation regulation

3. Brain ReserveValenzuela & Sachdev (2006) Brain Reserve Physical activities & abilities Cognitive activities & abilities  Cognitive Reserve Motivational activities & abilities  Motivational Reserve Social activities & abilities

4. German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe) • Longitudinal study on risk factors of MCI and dementia • PI: Prof. W. Maier and Prof. H. van den Bussche • Recruitment via general practitioners, in 6 centers in Germany • Baseline (2003-2004): 75+ years of age, no dementia • Exclusion criteria: consultations only through home visits, residence in a nursing home, insufficient knowledge of German, deafness or blindness, not being a regular patient of the participating practice. • Follow-up I und II after 1.5 and 3 years • Of 10.850 eligible patients 6.619 randomly selected. • At baseline 3.327, at follow-up II 2.368 • State of the art diagnosis of Alzheimer’s dementia • and Mild Cognitive Impairment

5. The O*NET includes A classification system of occupations Hundreds of empirically collected variables for each occupation, including cognitive, motivational, physical, social etc. abilities needed for a job  If we know the main job an individual held during his life, we can estimate his premorbid motivational and cognitive abilities. Estimation of midlifemotivational abilities • Based on main occupation • Coded according to O*NET

6. Validation study:Correlations between O*NET variables and… Forstmeier & Maercker, 2008, Psychology & Aging

7. Covariates: other potential risk factors • Age • Gender • Education (CASMIN: low, moderate, high) • O*NET-based midlife cognitive abilities • Baseline cognitive abilities (MMSE) • Baseline functional abilities (ADL) • Cognitive activities (frequency of 7 activities) • Physical activities (frequency of 7 activities) • Social network (family status, siblings, children) • Vascular risk factors (hypertension, hypercholesterolemia, diabetes mellitus) • Vascular diseases (myocardial infarction, coronary heart disease, cardiac arrhythmia, stroke) • Baseline depressive symptoms (GDS) • Lifetime depression (CIDI) • ApoE ɛ4 allele

8. Midlife motivational abilities and incidence of MCI Forstmeier et al., 2011, Psychology & Aging

9. Midlife motivational abilities and incidence of AD Forstmeier et al., 2011, Psychology & Aging

10. Midlife motivational abilities and incidence of AD *fully adjusted model • Motivational abilities only predictor of AD in ApoE-carriers Forstmeier et al., 2011, Psychology & Aging

11. Aging, Demographics and Memory Study (ADAMS) Longitudinal (N=252) 115 excluded due to clinical diagnoses 3 cohorts (N=137) MCI (N=70) Unimpaired cognition (N=48) AD (N= 19) • Sub-study of the US-representative Health and Retirement Study (HRS) • Increased risk of developing dementia • Above 70 years • Stratified according to cognition, age and gender • Longitudinal study: - baseline 2001 to 2003 (N=856) • - follow-up after 18 m 2002-2005 (N=252)

12. ADAMS: Results: Apathy NPI Apathy T1 T2 T1 T2 T1 T2 Unimpaired MCI AD (Mortby, Maercker & Forstmeier , 2011)

13. Conclusions • Model of assimilative and accommodative processes (Brandtstädter): • (assimilative) persisting goal pursuit • (accommodative) flexible goal adjustment • Occupation-basedmeasuremightcaptureonlypersistinggoalpursuit. • whichis adaptive in peoplewith mild to moderate dementia • but not adaptive anymore in severedementia • Being confronted with severe cognitive loss might be a situation where holding on to unattainable goals with strong motivational efforts leads to • - unproductive persistence • - depressive reaction • - more apathetic behavior

14. Outlook into the future • Motivational (assimilative and accomodative) processes are trainable! • (Forstmeier & Rüddel, 2008) • Future prevention programmes should include a training of motivational abilities – besides other aspects!

15. Thanks to: • AgeCoDe leading investigators: • Bonn: Prof. W. Maier • Hamburg: Prof. H. van den Bussche • Düsseldorf: Prof. H. H. Abholz • Leipzig: Prof. S. Riedel-Heller • München: Prof. H. Bickel • Mannheim: Prof. S. Weyerer • All General Practitioners • All participants • Funding: • German Federal Department of Education and Research • Dr. med. Kurt Fries Foundation, Zurich, Switzerland

17. Motivational abilities as preditors of … • … Health behavior (Schwarzer et al., 2007) • … Depression (Rholes et al., 1989) • … Anxiety disorders (Casey et al., 2004) • … Well-being (Luszczynska et al., 2005, Kruglanski et al., 2005) • … Pain control (Bandura et al., 1987) • … Health status in chronic diseases (Riazi et al., 2004) • … Recovering from somatic diseases (Schröder et al., 1998) • … Coping with stress (Beckmann et al., 2004) • … Immune system (Wiedenfeld et al., 1990)

18. Motivational abilities as predictor of cognition • Expl. 1: Self-efficacy predicts memory performance of old people • (longitudinal study; Valentijn et al., Psych & Aging, 2006, 21) • Expl. 2: Conscientiousness predicts risk of dementia • (longitudinal study; Wilson et al., Arch Gen Psychiatry, 2007, 64)

19. Methods • 1. Neuropsychological assessment: • - Structured Interview for the Diagnosis of Dementia, Alzheimer‘s, Multi-infarct, and other Dementias according to DSM-IV and ICD-10 (SIDAM) • - 4 subscales: Orientation, Memory, Intellectual performance, Higher cortical functions (verbal & constructive abilities, language, etc.) • - CERAD: Verbal fluency, verbal memory • 2. Alzheimer’s Dementia according to DSM-IV • 3. Mild Cognitive Impairment (MCI) according to Winblad et al. (2004)

20. Validation study:Participants • 147 non-demented participants, 10% mildly cognitively impaired • stratified for age category, sex, education • Age: mean 74 (SD 8), range 60-94 • Sex: 60% female • Education: mean duration 13.6 years • Living situation: 49% at home with others, 29% alone, 22% in old people‘s homes • Recruited via University for seniors, old people‘s homes, advertisement in magazine for seniors

21. Selection of O*NET variables • 1. On the basis of content validity • 2. On the basis of correlations with • established self-reported motivational abilities: • Motivation and decision regulation: Volitional Components Questionnaire (VCQ, Kuhl & Fuhrmann, 1998) • Activation regulation: Locomotion and Assessment Questionnaire (LAQ, Kruglanski et al., 2000) • General Self-Efficacy (GSE) Scale (Schwarzer, 2002) • premorbid intelligence: • Vocabulary test (“Wortschatztest”, Schmidt & Metzler, 1992)

22. Strengths and weaknesses of the study • Strengths • Large sample • Multi-site design • Controlling for most potential risk factors • Diagnosis of MCI and AD according to current definitions • Weaknesses • No residents of nursing homes and patients who were unable to attend their GP practice  rather conservative estimates of MCI and AD incidence rates • Only appr. 50% of randomly selected individuals participated  selection bias • Estimate of MR: additional studies applying other measures are necessary

23. Cardinal et al. (2002), Neural Networks, 19:Brain areas involved in motivational regulation, self-control, delay of gratification • OFC = orbitofrontal cortex: • assessment of affective reward value • regulation of reward value • decision regulation • Acb = nucleus accumbens: • anticipating rewards, • self-control, delay of gratification • BLA = basolateral amygdala: • self-control, delay of gratification • H = hippocampus: • Representation of context

24. O*NET Work Styles Questionnaire How important is PERSISTENCEto the performance of your current job? How important is SELF-CONTROLto the performance of your current job?

25. Sample Descriptive

26. Assessments Clinical diagnoses: - Cognitive test battery - Clinical examination incl. imagery where present • Neuropsychiatric symptoms: • Neuropsychiatric Inventory (NPI) (Cummings et al., 1994) • - Informant interview • - Presence, frequency and severity of 12 • neuropsychiatric domains incl. apathy and depression • - Domain score (0-12) Motivational abilities: Occupational Information Network (O*NET): - Retrospective estimate of motivational and cognitive abilities - Based on main occupation - Z-transformed scores for goal orientation and action planning (according to Forstmeier and Maercker, 2008)

27. ADAMS: Results: Depression (Mortby, Maercker und Forstmeier, 2011)

28. Summary Supports: apathy and depression as two separate syndromes Apathy and depression higher in AD patients  Supports research that apathy increases with increasing cognitive impairment  Depression levels remain relatively constant  Apathy increases but only in those with AD and high motivational abilities  Motivational abilities = moderator of relationship between cognitive impairment and apathy