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The concept of cognitive reserve provides an explanation for differences between individuals in susceptibility to age-related brain changes or pathology related to Alzheimer's disease, whereby some people can tolerate more of these changes than others and maintain function. Epidemiological studies suggest that lifelong experiences, including educational and occupational attainment, and leisure activities in later life, can increase this reserve. For example, the risk of developing Alzheimer's disease is reduced in individuals with higher educational or occupational attainment. Reserve can conveniently be divided into two types: brain reserve, which refers to differences in the brain structure that may increase tolerance to pathology, and cognitive reserve, which refers to differences between individuals in how tasks are performed that might enable some people to be more resilient to brain changes than others. Greater understanding of the concept of cognitive reserve could lead to interventions to slow cognitive ageing or reduce the risk of dementia.

The goal of this paper is to review my current understanding of the concepts of cognitive reserve (CR), brain reserve and brain maintenance, and to describe our group’s approach to using imaging to study their neural basis. I present a working model for utilizing data regarding brain integrity, clinical status, cognitive activation and CR proxies to develop analyses that can explore the neural basis of cognitive reserve and brain maintenance. The basic model assumes that the effect of brain changes on cognition is mediated by task-related activation. We treat CR as a moderator to understand how task-related activation might vary as a function of CR, or how CR might operate independently of these differences in task-related activation. My hope is that this presentation will spark discussion across groups that study these concepts, allowing us to come to some common agreement on definitions, methodology and approaches.

The concept of reserve is used to explain the observation that some individuals function better than others in the presence of brain pathology. This article reviews the concept of reserve from its theoretical basis to the implication of reserve for clinical practice. A distinction between brain reserve, referring to individual differences in the anatomic substrate, and cognitive reserve, referring to differences in the flexibility or adaptivity of cognitive networks, is useful. Epidemiologic evidence indicates that a set of life exposures including higher educational and occupational attainment, and engaging in leisure activities is associated with a lower risk of incident dementia, suggesting that these life exposures may enhance cognitive reserve. This provides a basis for controlled clinical studies that can test specific exposures that may enhance reserve. The concept of cognitive reserve also has important implications for clinical practice in terms of diagnosis and prognosis.

In 2018, the US National Institute on Aging and the Alzheimer's Association proposed a purely biological definition of Alzheimer's disease that relies on biomarkers. Although the intended use of this framework was for research purposes, it has engendered debate and challenges regarding its use in everyday clinical practice. For instance, cognitively unimpaired individuals can have biomarker evidence of both amyloid β and tau pathology but will often not develop clinical manifestations in their lifetime. Furthermore, a positive Alzheimer's disease pattern of biomarkers can be observed in other brain diseases in which Alzheimer's disease pathology is present as a comorbidity. In this Personal View, the International Working Group presents what we consider to be the current limitations of biomarkers in the diagnosis of Alzheimer's disease and, on the basis of this evidence, we propose recommendations for how biomarkers should and should not be used for diagnosing Alzheimer's disease in a clinical setting. We recommend that Alzheimer's disease diagnosis be restricted to people who have positive biomarkers together with specific Alzheimer's disease phenotypes, whereas biomarker-positive cognitively unimpaired individuals should be considered only at-risk for progression to Alzheimer's disease.

•CAP analysis reveals dynamic brain states during reasoning tasks.•CAP2 (visual network) and CAP3 (DMN-sensorimotor) dominate during reasoning.•Longer engagement in specific CAPs correlates with better reasoning performance.•Aging reduces task-relevant CAP engagement, increasing transitions to baseline states.•CAP analysis provides novel insights into transient brain network reconfigurations. Brain activity exhibits substantial temporal variability during cognitive processes, yet traditional fMRI analyses often fail to capture these dynamic patterns. Co-activation pattern (CAP) analysis has emerged as a promising method to study brain dynamics. CAP analysis provides a powerful framework for capturing transient brain states, however, its application to cognitive tasks remains very limited, with no prior studies specifically investigating its role in reasoning performance. This study investigated CAPs during reasoning tasks, their relationship with cognitive performance, age and other individual differences. We applied CAP analysis to fMRI data from 303 participants performing three reasoning tasks—Matrix Reasoning, Letter Sets, and Paper Folding—along with resting-state data. Using K-means clustering, we identified four distinct CAPs, each exhibiting unique spatial and temporal characteristics. These CAPs were analyzed in relation to predefined resting-state networks, revealing their functional relevance to cognitive task engagement. Key temporal metrics, including fraction occupancy, dwelling time, and transition probabilities, were assessed across reasoning tasks and resting state. The results demonstrate that CAP2 and CAP3 are predominantly engaged during reasoning tasks, with CAP2 strongly overlapping with the visual network and CAP3 exhibiting concurrent default mode and sensorimotor network activations. CAP1, primarily dominant during rest, showed prolonged engagement in older individuals, while CAP4 appeared to function as a transitional state facilitating network reorganization. Regression analyses link longer dwelling times and higher fraction occupancy of CAP2 and CAP3 to superior reasoning performance, whereas excessive transitions to CAP4 negatively impacted cognitive task outcomes. Additionally, aging was associated with reduced engagement in task-relevant CAPs and an increased tendency to transition into baseline-like states. These findings underscore the critical role of dynamic brain state reconfigurations in supporting cognition specifically reasoning and highlight CAP analysis as a powerful tool for studying transient brain function and individual cognitive differences.

Early-life education (years of schooling) has been investigated in regards to cognition, health outcomes and mortality. It has been shown to confer cognitive reserve that might lessen the impact of brain pathology and its impact on cognitive and motor functioning in a variety of neurodegenerative diseases and, for instance, to influence electrical activity [Begum, T., Reza, F., Ahmed, I., & Abdullah, J. M. (2014). Influence of education level on design-induced N170 and P300 components of event related potentials in the human brain. J Integr Neurosci, 13(1), 71-88. doi:10.1142/S0219635214500058]. On the other hand, demonstrations of a direct association between education and brain-structural measures have been more equivocal and scant. The current study sought to identify univariate cortical-thickness patterns underlying education and general intelligence after adjusting for age, gender and possible in-scanner movement in 353 individuals aged 40 to 80. We followed up this idea with multivariate analyses as well. For univariate analyses, our analyses yielded no robust associations between education and general intelligence beyond confounding effects of gender, age and extraneous in-scanner movement. A subsequent multivariate analyses showed a relationship between education and regional cortical thickness with a robust pattern of negative as well as positive loadings in several right-sided brain areas, speaking to a subtle but robust distributed effect of education on cortical thickness. Cortical thickness variance that is the residual of this education-related pattern was shown to be positively associated with age and extraneous in-scanner movement. Our study thus presents a complex picture of the association of education with regional cortical thickness: education was associated with a distributed brain-wide pattern of positive as well as negative loadings with unaccounted residuals being larger for older participants. Focal regional associations beyond demographic and age covariates were not identified.

Recent studies have found a deleterious effect of age on a wide variety of measures of functional connectivity, and some hints at a relationship between connectivity at rest and cognitive functioning. However, few studies have combined multiple functional connectivity methods, or examined them over a wide range of adult ages, to try to uncover which metrics and networks seem to be particularly sensitive to age-related decline across the adult lifespan. The present study utilized multiple resting state functional connectivity methods in a sample of adults from 20-80 years old to gain a more complete understanding of the effect of aging on network function and integrity. Whole-brain results showed that aging results in weakening average within-network connectivity, lower system segregation and local efficiency, and higher participation coefficient. Network-level results suggested that nearly every primary sensory and cognitive network faces some degree of age-related decline, including reduced within-network connectivity, higher network-based participation coefficient, and reduced network-level local efficiency. Further, some of these connectivity metrics showed relationships with cognitive performance. Thus, these results suggest that a multi-method analysis of functional connectivity data may be critical to capture the full effect of aging on the health of brain networks.

The concept of cognitive reserve proposes that specific life experiences result in more flexible or resilient cognitive processing allowing some people to cope better with age- or disease-related brain changes than others. Imaging studies seeking to understand the neural implementation of cognitive reserve have most often used task-related fMRI studies. Using that approach, we recently described a task-invariant cognitive-reserve network whose expression correlated with IQ and that moderated between cortical thickness and cognitive performance. Here we sought to identify a pattern of resting BOLD connectivity related to cognitive reserve. We identified a connectome pattern whose connectivity correlated with IQ in both the derivation sample and a separate replication sample. The majority of the edges showing positive relationships with IQ implicate frontal regions. In the derivation sample, connectivity either moderated the relationship between mean cortical thickness and a set of cognitive outcomes or accounted for unique variance in cognitive performance after accounting for cortical thickness. In a replication sample we found that expression of this connectome correlated significantly with the primary endpoint of IQ, and also accounted for unique variance in cognitive performance beyond cortical thickness. Our findings represent an intermediate level of replication and are unlikely to have arisen purely by type-I error. This connectivity pattern therefore meets some of our theoretical criteria for a cognitive reserve-related network and provides insight into the neural implementation of cognitive reserve. Further, expression of this connectome could potentially be used as a direct measure of cognitive reserve, and as an outcome measure for intervention studies that seek to influence cognitive reserve. Future validation of and re-derivation of the pattern in expanded data sets by our and other groups will lead to further improved estimates of cognitive reserve in resting functional connectivity.

Studies assessing relationships between neural and cognitive changes in healthy aging have shown that a variety of aspects of brain structure and function explain a significant portion of the variability in cognitive outcomes throughout adulthood. Many studies assessing relationships between brain function and cognition have utilized time-averaged, or static functional connectivity methods to explore ways in which brain network organization may contribute to aspects of cognitive aging. However, recent studies in this field have suggested that time-varying, or dynamic measures of functional connectivity, which assess changes in functional connectivity over the course of a scan session, may play a stronger role in explaining cognitive outcomes in healthy young adults. Further, both static and dynamic functional connectivity studies suggest that there may be differences in patterns of brain-cognition relationships as a function of whether or not the participant is performing a task during the scan. Thus, the goals of the present study were threefold: (1) assess whether neural flexibility during both resting as well as task-based scans is related to participant age and cognitive performance in a lifespan aging sample, (2) determine whether neural flexibility moderates relationships between age and cognitive performance, and (3) explore differences in neural flexibility between rest and task. Participants in the study were 386 healthy adults between the ages of 20–80 who provided resting state and/or task-based (Matrix Reasoning) functional magnetic resonance imaging (fMRI) scan data as part of their participation in two ongoing studies of cognitive aging. Neural flexibility measures from both resting and task-based scans reflected the number of times each node changed network assignment, and were averaged both across the whole brain (global neural flexibility) as well as within ten somatosensory/cognitive networks. Results showed that neural flexibility was not related to participant age, and that task-based global neural flexibility, as well as task-based neural flexibility in several networks, tended to be negatively related to reaction times during the Matrix Reasoning task, however these effects did not survive strict multiple comparisons correction. Resting state neural flexibility was not significantly related to either participant age or cognitive performance. Additionally, no neural flexibility measures significantly moderated relationships between participant age and cognitive outcomes. Further, neural flexibility differed as a function of scan type, with resting state neural flexibility being significantly greater than task-based neural flexibility. Thus, neural flexibility measures computed during a cognitive task may be more meaningfully related to cognitive performance across the adult lifespan then resting state measures of neural flexibility.

Alzheimer's disease causes both cognitive and non-cognitive symptoms. There is increasing evidence that the presentation and course of Alzheimer's disease is highly heterogenous. This heterogeneity presents challenges to patients, their families, and clinicians due to the difficulty in prognosticating future symptoms and functional impairment. Behavioral and psychiatric symptoms are emerging as a significant contributor to this clinical heterogeneity. These symptoms have been linked to multiple areas of neurodegeneration, which may suggest that they are representative of network-wide dysfunction in the brain. However, current diagnostic criteria for Alzheimer's disease focus exclusively on the cognitive aspects of disease. Behavioral and psychiatric symptoms have been found in multiple studies to be related to disease severity and to contribute to disease progression over time. A better understanding of how behavioral and psychiatric symptoms relate to cognitive aspects of Alzheimer's disease would help to refine the models of disease and hopefully lead to improved ability to develop therapeutic options for this devastating disease.