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Functional cognitive disorder describes patients with persistent, troublesome subjective cognitive complaints that are inconsistent with a recognized disease process, and where significant discrepancies are found between subjective and objectively observed cognitive functioning. The etiology is heterogeneous and potentially related to underlying psychological factors. Making a diagnosis of functional cognitive disorder can be challenging and there is the potential for misdiagnosis of early-stage neurodegeneration. We compared neuropsychological findings in three groups: functional cognitive disorder (FCD), mild cognitive impairment (MCI), and healthy controls. Participants were recruited from the ReMemBr Group Clinic, North Bristol NHS Trust, and via Join Dementia Research. Both the FCD and MCI groups showed elevated prospective and retrospective memory symptom scores. Performance on the Montreal cognitive assessment was equivalent in the FCD and MCI groups, both being impaired compared with the controls. The FCD group was younger than those with MCI. We discuss challenges and controversies in the diagnosis of functional cognitive disorder, alongside illustrative cases and proposals for areas of research priority.

Functional Cognitive Disorder (FCD) is a common diagnosis at the memory clinic. FCD is characterised by significant self-reported cognitive symptoms in the absence of external evidence of cognitive dysfunction. A potential explanation for this is a deficit in metacognition, the process by which we internally judge our own abilities. Here we investigated differences in accuracy, confidence, and metacognition between people with FCD (N = 20), neurodegenerative mild cognitive impairment (nMCI; N = 14), and healthy controls (N = 23). The groups were assessed on forced choice memory and perceptual tasks, with trial by trial confidence ratings. FCD and nMCI participants showed lower accuracy on the memory task (means FCD 63.65%, nMCI 63.96%, HC 71.22%), with a significant difference between the FCD and HC groups after controlling for age and sex. There were no between-group differences in memory task confidence (means FCD 3.19, nMCI 3.59, HC 3.71). The FCD group showed greater confidence when longer time was allowed on the memory task. No between group differences in perceptual task accuracy (means FCD 63.97%, nMCI 64.50%, FCD 65.86%) or confidence (means FCD 3.71, nMCI 3.43, HC 3.88) were found. No differences in metacognitive efficacy emerged between the groups, either on the memory or perceptual task (Memory Meta-d’/d’:FCD 0.63, nMCI 0.94 HC 0.85; Perceptual Meta-d’,d’: FCD 0.50, nMCI 0.51, HC 0.72). Participants showed greater metacognitive efficacy on the memory task compared to the perceptual task. The difficulties experienced by people with FCD do not appear to be due to metacognitive deficits. Their performance was similar to people with nMCI over aspects of the memory tasks, which suggests that the primary issue may lie with memory encoding or retrieval, rather than with their judgement of performance accuracy.

Functional cognitive disorder (FCD) is a relatively common cause of cognitive symptoms, characterised by inconsistency between symptoms and observed or self-reported cognitive functioning. We aimed to improve the clinical characterisation of FCD, in particular its differentiation from early neurodegeneration. Two patient cohorts were recruited from a UK-based tertiary cognitive clinic, diagnosed following clinical assessment, investigation and expert multidisciplinary team review: FCD, (n = 21), and neurodegenerative Mild Cognitive Impairment (nMCI, n = 17). We separately recruited a healthy control group (n = 25). All participants completed an assessment battery including: Hopkins Verbal Learning Test-Revised (HVLT-R), Trail Making Test Part B (TMT-B); Depression Anxiety and Stress Scale (DASS) and Minnesota Multiphasic Personality Inventory (MMPI-2RF). In comparison to healthy controls, the FCD and nMCI groups were equally impaired on trail making, immediate recall, and recognition tasks; had equally elevated mood symptoms; showed similar aberration on a range of personality measures; and had similar difficulties on inbuilt performance validity tests. However, participants with FCD performed significantly better than nMCI on HVLT-R delayed free recall and retention (regression coefficient −10.34, p = 0.01). Mood, personality and certain cognitive abilities were similarly altered across nMCI and FCD groups. However, those with FCD displayed spared delayed recall and retention, in comparison to impaired immediate recall and recognition. This pattern, which is distinct from that seen in prodromal neurodegeneration, is a marker of internal inconsistency. Differentiating FCD from nMCI is challenging, and the identification of positive neuropsychometric features of FCD is an important contribution to this emerging area of cognitive neurology.

Objectives/AimsFunctional Cognitive Disorder (FCD) describes distressing or disabling cognitive symptoms that can be positively identified as internally inconsistent with recognised brain or systemic disease processes. FCD is common amongst attendees to cognitive or memory clinics. We aimed to improve the clinical characterisation of such patients, and identify means to differentiate them from patients with early neurodegeneration.MethodsWe identified two samples of patients recruited from a specialist cognitive clinic, classified on the basis of consensus expert clinical opinion following relevant investigations: FCD, (n=21), and neurodegenerative Mild Cognitive Impairment ‘MCI’, (n=17). We also recruited healthy control participants (n=25). All participants completed a cognitive battery: Montreal Cognitive Assessment (MoCA), Hopkins Verbal Learning Test-Revised (HVLT-R), Trail Making Test part B (TMT-B); and the Minnesota Multiphasic Personality Inventory (MMPI-2RF). Analyses included regression models controlling for age and gender. Analysis of the personality data focused on specific hypotheses generated from previous work on functional disorders.ResultsAs expected, the FCD participants were younger than the MCI participants (mean age 58 vs 72), and were more likely to be occupationally active (35% vs 6%).As described previously in this sample*, subjective cognitive symptoms were equally elevated in FCD and MCI compared to controls. Both the FCD and MCI groups were impaired in comparison to controls on MoCA, TMT-B and the initial recall component of HVLT-R. However, FCD participants demonstrated a dip in scores from free recall to recognition on HVLT-R, which was not seen in MCI (p<0.05). FCD and MCI groups scored equally high relative to controls on anxiety and depression, and on four personality indices: emotional or internalising dysfunction, somatic complaints (cognitive and non-cognitive analysed separately), and negative emotional experiences. There were no group differences in ‘introversion/low positive emotionality’.ConclusionsCognitive symptoms, basic bedside cognitive testing, personality analysis, and mood symptoms are all similar across both early neurodegenerative and FCD groups, making them hard to disentangle clinically. We hope that by highlighting certain testing modalities that can illustrate internal inconsistency (such as delayed recall spared relative to recognition, as opposed to consistently poor delayed recall and recognition that is more typical of Alzheimer’s neurodegeneration), we can improve diagnosis and thereby management strategies. It is unclear why both mood and non-cognitive somatic symptoms are elevated in both FCD and MCI; this could reflect an epiphenomenon of distress surrounding the cognitive symptoms, despite diverse origins of the cognitive symptoms.ReferencePennington C, Ball HA, Swirski M. Functional cognitive disorder: diagnostic challenges and future directions. Diagnostics 2019; 9: 131.

Biochemical and neuropsychological changes due to poor sleep may contribute to the development of neurodegenerative disorders, such as dementia. Physical activity is widely thought to improve sleep; however, the optimal intensity/duration of physical activity required is unknown. This 14-week, single-blind study (n=23) investigated the feasibility of a self-directed physical activity intervention in healthy adults using actigraphy and cognitive function measures as primary outcomes. Participants were randomised to a control group (no change in routine) or the intervention group (increased physical activity) and were provided with an actigraphy device to monitor activity. Participants completed daily sleep/activity diaries and three cognitive assessment sessions. Vigorous physical activity increased between baseline and week 3 for the intervention group only, with no identifiable impact on sleep. This change was not sustained at week 12. Performance on an executive function task and delayed visuospatial recall improved from baseline to week 12 for the intervention group only. Contrary to our expectations, increasing light-moderate physical activity was associated with more impaired sleep across all participants. It is clear that the relationships between physical activity, sleep and cognition are complex and require further investigation. We discuss optimal methodologies for clinical trials investigating physical activity and/or sleep interventions targeting cognition.