Fractional Gaussian noise (fGn) provides a parsimonious model for stationary increments of a self-similar process parameterised by the Hurst exponent, H, and variance, sigma2. Fractional Gaussian noise with H < 0.5 demonstrates negatively autocorrelated or antipersistent behaviour; fGn with H > 0.5 demonstrates 1/f, long memory or persistent behaviour; and the special case of fGn with H = 0.5 corresponds to classical Gaussian white noise. We comparatively evaluate four possible estimators of fGn parameters, one method implemented in the time domain and three in the wavelet domain. We show that a wavelet-based maximum likelihood (ML) estimator yields the most efficient estimates of H and sigma2 in simulated fGn with 0 < H < 1. Applying this estimator to fMRI data acquired in the "resting" state from healthy young and older volunteers, we show empirically that fGn provides an accommodating model for diverse species of fMRI noise, assuming adequate preprocessing to correct effects of head movement, and that voxels with H > 0.5 tend to be concentrated in cortex whereas voxels with H < 0.5 are more frequently located in ventricles and sulcal CSF. The wavelet-ML estimator can be generalised to estimate the parameter vector beta for general linear modelling (GLM) of a physiological response to experimental stimulation and we demonstrate nominal type I error control in multiple testing of beta, divided by its standard error, in simulated and biological data under the null hypothesis beta = 0. We illustrate these methods principally by showing that there are significant differences between patients with early Alzheimer's disease (AD) and age-matched comparison subjects in the persistence of fGn in the medial and lateral temporal lobes, insula, dorsal cingulate/medial premotor cortex, and left pre- and postcentral gyrus: patients with AD had greater persistence of resting fMRI noise (larger H) in these regions. Comparable abnormalities in the AD patients were also identified by a permutation test of local differences in the first-order autoregression AR(1) coefficient, which was significantly more positive in patients. However, we found that the Hurst exponent provided a more sensitive metric than the AR(1) coefficient to detect these differences, perhaps because neurophysiological changes in early AD are naturally better described in terms of abnormal salience of long memory dynamics than a change in the strength of association between immediately consecutive time points. We conclude that parsimonious mapping of fMRI noise properties in terms of fGn parameters efficiently estimated in the wavelet domain is feasible and can enhance insight into the pathophysiology of Alzheimer's disease.

BackgroundFrailty is widely recognised as a distinct multifactorial clinical syndrome that implies vulnerability. The links between frailty and adverse outcomes such as death and institutionalisation have been widely evidenced. There is currently no gold standard frailty assessment tool; optimizing the assessment of frailty in older people therefore remains a research priority. The objective of this systematic review is to identify existing multi-component frailty assessment tools that were specifically developed to assess frailty in adults aged ≥60 years old and to systematically and critically evaluate the reliability and validity of these tools.MethodsA systematic literature review was conducted using the standardised COnsensus‐based Standards for the selection of health Measurement INstruments (COSMIN) checklist to assess the methodological quality of included studies.ResultsFive thousand sixty-three studies were identified in total: 73 of which were included for review. 38 multi-component frailty assessment tools were identified: Reliability and validity data were available for 21 % (8/38) of tools. Only 5 % (2/38) of the frailty assessment tools had evidence of reliability and validity that was within statistically significant parameters and of fair-excellent methodological quality (the Frailty Index-Comprehensive Geriatric Assessment [FI-CGA] and the Tilburg Frailty Indicator [TFI]).ConclusionsThe TFI has the most robust evidence of reliability and validity and has been the most extensively examined in terms of psychometric properties. However, there is insufficient evidence at present to determine the best tool for use in research and clinical practice. Further in-depth evaluation of the psychometric properties of these tools is required before they can fulfil the criteria for a gold standard assessment tool.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-016-0225-2) contains supplementary material, which is available to authorized users.

The review confirms the effectiveness of CBT for anxiety disorders in older people but is suggestive of lower efficacy in older than working-age people. The small effect sizes in favor of CBT over an active control condition illustrate the need to investigate other treatment approaches that may be used to substitute or augment CBT to increase the effectiveness of treatment of anxiety disorders in older people.

ObjectivesTo review the efficacy of cognitive interventions on improving general cognition in dementia.MethodOnline literature databases and trial registers, previous systematic reviews and leading journals were searched for relevant randomised controlled trials. A systematic review, random-effects meta-analyses and meta-regression were conducted. Cognitive interventions were categorised as: cognitive stimulation (CS), involving a range of social and cognitive activities to stimulate multiple cognitive domains; cognitive training (CT), involving repeated practice of standardised tasks targeting a specific cognitive function; cognitive rehabilitation (CR), which takes a person-centred approach to target impaired function; or mixed  CT and stimulation (MCTS). Separate analyses were conducted for general cognitive outcome measures and for studies using ‘active’ (designed to control for non-specific therapeutic effects) and non-active (minimal or no intervention) control groups.Results33 studies were included. Significant positive effect sizes (Hedges’ g) were found for CS with the mini-mental state examination (MMSE) (g=0.51, 95% CI 0.29 to 0.69; p<0.001) compared to non-active controls and (g=0.35, 95% CI 0.06 to 0.65; p=0.019) compared to active controls. Significant benefit was also seen with the Alzheimer's disease Assessment Scale-Cognition (ADAS-Cog) (g=−0.26, 95% CI −0.445 to −0.08; p=0.005). There was no evidence that CT or MCTS produced significant improvements on general cognition outcomes and not enough CR studies for meta-analysis. The lowest accepted minimum clinically important difference was reached in 11/17 CS studies for the MMSE, but only 2/9 studies for the ADAS-Cog. Additionally, 95% prediction intervals suggested that although statistically significant, CS may not lead to benefits on the ADAS-Cog in all clinical settings.ConclusionsCS improves scores on MMSE and ADAS-Cog in dementia, but benefits on the ADAS-Cog are generally not clinically significant and difficulties with blinding of patients and use of adequate placebo controls make comparison with the results of dementia drug treatments problematic.

CBT for depression in older people is more effective than waiting list or TAU, but greater efficacy than active controls or other treatment has not been demonstrated. More high-quality RCTs comparing CBT with active controls need to be conducted before firm conclusions can be drawn about the efficacy of CBT for depression in older people. Other treatment approaches that could be contrasted with or augment CBT (e.g., pharmacotherapy) also need to be explored further.

ObjectiveInflammation has been implicated in the aetiology of mental illness. We conducted the first systematic review and meta-analysis of the association between peripheral markers of inflammation and generalised anxiety disorder (GAD).DesignSystematic review and meta-analysis of studies measuring peripheral cytokine levels in people with GAD compared with controls.Data sourcesMEDLINE (1950–), EMBASE (1947–), PsycINFO (1872–) and Web of Science (1945–) databases up until January 2018.Eligibility criteriaPrimary, quantitative research studies of people with a diagnosis of GAD assessed using a standardised clinical interview that measured peripheral inflammatory markers.Data extraction and synthesisTwo independent reviewers extracted data and assessed study quality. Meta-analysis using a random-effects model was conducted for individual cytokines where data from three or more studies were available.Results14 of 1718 identified studies met the inclusion criteria, comprising 1188 patients with GAD and 10 623 controls. In total 16 cytokines were evaluated. Significantly raised levels of C reactive protein (CRP), interferon-γ and tumour necrosis factor-α were reported in patients with GAD compared with controls in two or more studies. Ten further proinflammatory cytokines were reported to be significantly raised in GAD in at least one study. However, 5 of 14 studies found no difference in the levels of at least one cytokine. Only CRP studies reported sufficient data for meta-analysis. CRP was significantly higher in people with GAD compared with controls, with a small effect size (Cohen’s d=0.38, 0.06–0.69), comparable with that reported in schizophrenia. However, heterogeneity was high (I2=75%), in keeping with meta-analyses of inflammation in other psychiatric conditions and reflecting differences in participant medication use, comorbid depression and cytokine sampling methodology.ConclusionThere is preliminary evidence to suggest an inflammatory response in GAD, but it remains unclear whether inflammatory cytokines play a role in the aetiology. GAD remains a poorly studied area of neuroinflammation compared with other mental disorders, and further longitudinal studies are required.

Supervised benzodiazepine withdrawal augmented with psychotherapy should be considered in older people, although pragmatic reasons may necessitate consideration of other strategies such as medication review.

No abstract