1. Mild Cognitive Impairment, Activity Participation, Functional Difficulty, and Adaptations in Functionally Vulnerable Elderly People: A Closer Look Laraine Winter & Laura N. Gitlin Center for Applied Research on Aging and Health, Thomas Jefferson University ABSTRACT OBJECTIVES In recognition of the prevalence and practical implications of mild cognitive impairment (MCI), we explored functional difficulties, functional adaptations, and activity participation as predictors of MCI. DESIGN Twelve-month prospective cohort. SETTING Participants were interviewed in their homes by trained interviewers. PARTICIPANTS 127 community-dwelling urban elders who had enrolled in a larger study of physical functioning and had scored > 23 on the Mini Mental Status Examination (MMSE) at baseline. MEASUREMENT Baseline measures included difficulty with instrumental and activities of daily living (IADLs, ADLs), and mobility; 4 types of functional adaptations (use of assistive devices, help from others, changes in frequency or ways of performing tasks); activity participation (sum of 19 types of activities); MMSE; demographic characteristics; depression; and treatment assignment. The 12-month interview also included an MCI battery. RESULTS Nearly 40% scored in the MCI range or worse at 12 months. Mean MMSE dropped slightly from baseline to 12 months, with 10.1 percent scoring below 24. Greater cognitive impairment at 12 months was associated with lower activity participation, greater difficulty with using the telephone, and receiving help from others at Baseline. CONCLUSIONS Activity participation and telephone use may represent a higher order level of daily functioning Change in level of activity engagement, reliance on help from others, and difficulty in selected IADLS may signal preclinical cognitive changes. Implications are discussed for screening of older adults and early intervention. INTRODUCTION Recognition of the prevalence and practical implications of mild cognitive impairment (MCI) has grown rapidly in recent years, despite a lack of consensus as to what MCI represents. In general, MCI patients are understood to be cognitively impaired persons who do not meet criteria for dementia but who manifest related clinical features including loss of memory and executive function. There is an emerging consensus that MCI represents an intermediate stage between normal age-associated changes and pathological features of Alzheimer’s disease (AD). Whereas recent research has focused on the neuropathological features of MCI, the clinical and functional predictors of MCI have not been adequately explored. Although the absence of impairment in physical function has been specified as an important diagnostic criterion for MCI, recent research has documented difficulties performing everyday activities in some MCI patients compared to the general population. Identifying preclinical manifestations and specific behavioral and functional domains associated with MCI are important in order to advance early diagnosis and treatment. Understanding functional or behavioral associates of MCI may have considerable utility in identifying who is at risk. Some research indicates that families of elders with MCI experience significant caregiver burden even at this early stage of impairment.10 Thus, helping families recognize early signs of potential decline may enable them to seek prompt diagnosis and support. The purpose of this exploratory study was to identify predictors of MCI, focusing on specific types of functional difficulties, adaptations to difficulties, and participation in activities. In contrast to previous studies of MCI, most of which have been based on patient data, the present study enrolled a sample of community-dwelling adults 70 years or older who were experiencing difficulty with one or more activities of daily living because of health conditions but who were not receiving homecare or other services for these difficulties. These urban White and African American elderly people had scored in the normal range on the Mini Mental Status Examination (MMSE; i.e., 24/30 or higher) at the time of their enrollment in a larger randomized trial. METHODSubjects Participants were 127 of 319 men and women 70 years of age or older who were enrolled in a larger randomized controlled trial to test the efficacy of a home-based intervention to reduce functional difficulties. Recruited through social service agencies or media announcements, participants were 70 years of age or older, cognitively intact (MMSE score > 23 on a scale ranging from 0 to 30), English speaking, not receiving homecare, and reporting need for help or difficulties with one or more basic activities of daily living (ADL) or two or more instrumental activities (IADL). As part of an exploratory effort, at the 12- month follow-up interview, the MCI battery was administered to 127 of the original 319 enrolled in the larger study. Sample characteristics are presented in Table 3. MCIInstructionsScoring Clock Draw Draw the face of a clock, putting in the numbers and setting the hands to eight-twenty or twenty after eight. 3= severely impaired 2= moderately impaired 1= mildly impaired 0 = normal Animal naming (verbal fluency) Name all the animals you can think of in 60 seconds. 3= fewer than 5 2 = 5-8 1 = 9-12 0 = 12 or more Serial subtractions by (a test of mental control) After being given the first example (100-3=97), participants subtract three from each successive number, starting with 97. One point is given for each incorrect number, to a maximum of 4 errors. Delayed intentional recall repeat and remember three words (ball, flag, tree). The number of words not recalled is scored, with a maximum of 3. 19 Spatial and temporal orientation street and number, town or city, zip code, and phone number with area code. What is the day of the week, the month, date, and year? Up to 8 errors are recorded. Total MCI score number of errors for each test was recorded, yielding a possible range of 0 to 22. 5 or higher = MCI or worse CES-D ( Depression) 0 (never or rarely) to 4 (always). The possible range of scores is 0- 60. A score of 16 or higher is considered indicative of clinical depression. Activity Participation examined (Table 1). Participation (yes/no) in 19 common discretionary activities Total score reflects number of activities,possible scores ranging 0-19. ADLs 6 items Scored individually 1-5 IADLs 6 items Scored individually 1-5 Mobility 6 items Scored individually 1-5 Types of adaptations 4 items Count across ADL, IADL, & mobility items Demographics characteristics 5 items (see Table 1)