Cognitive Control Performance Research Articles

Examining the interaction between cognitive control and reward sensitivity in substance use dependence

BackgroundDrug dependence is characterized by altered reward processing and poor cognitive control, expressed as a preference for immediate rewards and impaired inhibitory control, respectively. To examine the interaction between reward processing (via the presence or absence of reward) and mechanisms of inhibitory control in drug dependence, the current study used the Monetary Incentive Control Task (MICT) to examine whether a group of opiate dependent persons demonstrated greater difficulty exerting control over immediate rewards compared to neutral stimuli. MethodsThe MICT is a Go/Stop paradigm that examines inhibitory control over immediate rewards. Performance of 32 opiate dependent individuals was compared to 29 healthy controls. ResultsOpiate users demonstrated poorer inhibitory performance than controls, irrespective of cues signaling immediate reward. Whereas control participants’ responses were modulated by probability cues, the opiate group did not show a capacity to up-regulate their cognitive control performance. ConclusionsThe present results suggest a general decrease in cognitive control in opiate dependence, accompanied by a reduced ability to optimally modulate behavior in accordance with external cues. Opiate users and controls did not differ in the interaction between cognitive control and reward. The study highlights important issues for future research to consider when further examining this interaction in drug dependence.

Changes in cortico-subcortical and subcortico-subcortical connectivity impact cognitive control to emotional cues across development

The capacity to suppress inappropriate thoughts, emotions and actions in favor of appropriate ones shows marked changes throughout childhood and adolescence. Most research has focused on pre-frontal circuit development to explain these changes. Yet, subcortical circuitry involving the amygdala and ventral striatum (VS) has been shown to modulate cue-triggered motivated behaviors in rodents. The nature of the interaction between these two subcortical regions in humans is less well understood, especially during development when there appears to be heightened sensitivity to emotional cues. In the current study, we tested how task-based cortico-subcortical and subcortico-subcortical functional connectivity in 155 participants ages from 5 to 32 impacted cognitive control performance on an emotional go/nogo task. Functional connectivity between the amygdala and VS was inversely correlated with age and predicted cognitive control to emotional cues, when controlling for performance to neutral cues. In contrast, increased medial pre-frontal-amygdala connectivity was associated with better cognitive control to emotional cues and this cortical-subcortical connectivity mediated the association between amygdala-VS connectivity and emotional cognitive control. These findings suggest a dissociation in how subcortical-subcortical and cortical-subcortical connectivity impact cognitive control across development.

Effects of Tai Chi training on postural control and cognitive performance while dual tasking - a randomized clinical trial.

This single-blinded, randomized controlled study investigated the effects of practicing Tai Chi on the postural control and cognitive performance of older women while dual tasking. Community-dwelling older women (n=31) were recruited from community centers. They were randomized to Tai Chi group (n=15, 12-form Yang style Tai Chi training) or a control group (n=16, general interest classes) for 16 weeks. Balance was tested in single leg stance after stepping down from a step, with and without a concurrent auditory response task (auditory Stroop test). Balance was measured by total sway path and sway area of subject's center of pressure (COP). The reaction time and the correctness of the auditory Stroop test were also measured. Tai Chi subjects made fewer errors in auditory Stroop test under dual-task condition after Tai Chi training (p=0.01). They also showed significant decreases in the COP path (p<0.05) and the COP area (p<0.05) in their postural control after training in both single- and dual-task conditions. The subjects in the control group did not show any significant improvement in dual-task condition after the intervention. Tai Chi training improves the cognitive and postural control performance of older women when dual tasking.

The Impact of Emotional States on Cognitive Control Circuitry and Function.

Typically in the laboratory, cognitive and emotional processes are studied separately or as a stream of fleeting emotional stimuli embedded within a cognitive task. Yet in life, thoughts and actions often occur in more lasting emotional states of arousal. The current study examines the impact of emotions on actions using a novel behavioral paradigm and functional neuroimaging to assess cognitive control under sustained states of threat (anticipation of an aversive noise) and excitement (anticipation of winning money). Thirty-eight healthy adult participants were scanned while performing an emotional go/no-go task with positive (happy faces), negative (fearful faces), and neutral (calm faces) emotional cues, under threat or excitement. Cognitive control performance was enhanced during the excited state relative to a nonarousing control condition. This enhanced performance was paralleled by heightened activity of frontoparietal and frontostriatal circuitry. In contrast, under persistent threat, cognitive control was diminished when the valence of the emotional cue conflicted with the emotional state. Successful task performance in this conflicting emotional condition was associated with increased activity in the posterior cingulate cortex, a default mode network region implicated in complex processes such as processing emotions in the context of self and monitoring performance. This region showed positive coupling with frontoparietal circuitry implicated in cognitive control, providing support for a role of the posterior cingulate cortex in mobilizing cognitive resources to improve performance. These findings suggest that emotional states of arousal differentially modulate cognitive control and point to the potential utility of this paradigm for understanding effects of situational and pathological states of arousal on behavior.

The Impact of Social Pressure and Monetary Incentive on Cognitive Control.

We compare the effects of two prominent organizational control mechanisms—social pressure and monetary incentive—on cognitive control. Cognitive control underlies the human ability to regulate thoughts and actions in the pursuit of behavioral goals. Previous studies show that monetary incentives can contribute to goal-oriented behavior by activating proactive control. There is, however, much less evidence of how social pressure affects cognitive control and task performance. In a within-subject experimental design, we tested 47 subjects performing the AX-CPT task to compare the activation of cognitive control modes under social pressure and monetary incentive beyond mere instructions to perform better. Our results indicate that instructing participants to improve their performance on its own leads to a significant shift from a reactive to a proactive control mode and that both social pressure and monetary incentive further enhance performance.

White matter structural integrity differs between people with schizophrenia and healthy groups as a function of cognitive control

A behavioral hallmark of schizophrenia is poor cognitive control. Recent evidence suggests that problems with cognitive control in schizophrenia are related to disconnectivity along major white matter fibers. Although deficits of cognitive control are common in schizophrenia, a proportion of otherwise healthy subjects show poor cognitive control performance. The present study sought to address this potential confound by comparing white matter integrity between a group with schizophrenia and otherwise healthy individuals with either high or low levels of cognitive control (based on working memory span performance). Diffusion tensor imaging was used to evaluate white matter integrity in 24 participants with schizophrenia, 24 healthy participants with high cognitive control (HCC), and 25 healthy participants with low cognitive control (LCC). To test for differences in fractional anisotropy (FA) across major white matter fiber tracts, a voxelwise region of interest analysis was conducted in standardized brain space. In a separate analysis, regions of interest were manually drawn in native brain space to isolate superior longitudinal fasciculus (SLF), a tract implicated in cognitive control performance. The voxelwise analysis demonstrated widespread lower FA in the schizophrenia group compared to the HCC group. With a high degree of concordance, the manual ROI analysis revealed lower FA in the schizophrenia group compared to the HCC group. Taken together, these results provide evidence to suggest that structural differences identified between healthy groups and schizophrenia may not be entirely specific to the disease process and can vary as a function of cognitive control capacity in the comparison group.

Interrelation of resting state functional connectivity, striatal GABA levels, and cognitive control processes.

Important issues for cognitive control are response selection processes, known to depend on fronto-striatal networks with recent evidence suggesting that striatal gamma-amino butyric acid (GABA) levels play an important role. Regional GABA concentrations have also been shown to modulate intrinsic connectivity, e.g. of the default mode network. However, the interrelation between striatal GABA levels, basal ganglia network (BGN) connectivity, and performance in cognitive control is elusive. In the current study, we measure striatal GABA levels using magnetic resonance spectroscopy (MRS) and resting state parameters using functional magnetic resonance imaging (fMRI). Resting state parameters include activity within the BGN, as determined by the low frequency power (LFP) within the network, and the functional connectivity between the BGN and somatomotor network (SMN). Specifically, we examine the interrelation between GABA, resting state parameters, and performance (i.e., accuracy) in conflict monitoring using a Simon task. Response control was affected by striatal GABA+ levels and activity within the BGN, especially when response selection was complicated by altered stimulus-response mappings. The data suggest that there are two mechanisms supporting response selection accuracy. One is related to resting state activity within the BGN and modulated by striatal GABA+ levels. The other is related to decreased cortico-striatal network connectivity, unrelated to the GABAergic system. The inclusion of all three factors (i.e., striatal GABA+ levels, activity within the BGN, and BGN-SMN network connectivity) explained a considerable amount of variance in task accuracy. Striatal neurobiochemical (GABA+) and parameters of the resting state BGN represent important modulators of response control.

Genetics of cognitive control: Implications for Nimh's research domain criteria initiative.

Cognitive control refers to a set of mental processes that modulate other cognitive and emotional systems in service of goal-directed adaptive behavior. There is growing support for the notion that cognitive control abnormalities are a central component of many of the neuropsychological deficits observed in individuals with mental illnesses, particularly those with psychotic disorders. NIMH's research domain criteria (RDoC) initiative, which is designed to develop biologically informed constructs to better understand psychopathology, designated cognitive control a construct within the cognitive systems domain. Identification of genes that influence cognitive control or its supportive brain systems will improve our understating of the RDoC construct and provide candidate genes for psychotic disorders. We examine evidence for cognitive control deficits in psychosis, determine if these measures could be useful endophenotypes, and explore work linking genetic variation to cognitive control performance. While there is a wealth of evidence to support the notion the cognitive control is a valid endophenotype for psychosis, its genetic underpinning remains ill characterized. However, existing work provides a promising foundation on which future endeavors might build. Confirming existing individual gene associations will go some way to expanding our understanding of the genetics of cognitive control, and by extension, psychotic disorders. Yet, to truly understand the molecular underpinnings of such complex traits, it may be necessary to evaluate genes in tandem, focusing not on single genes but rather on empirically derived gene sets or on functionally defined networks of genes.

COMT genotype and response to cognitive remediation in schizophrenia

BackgroundA functional polymorphism of the catechol-O-methyltransferase (COMT) gene (Val158Met) partially appears to influence cognitive performance in schizophrenia subjects and healthy controls by modulating prefrontal dopaminergic activity. This study evaluated the association of the COMT Val108/158 Met genotype with response to computerized neurocognitive remediation (CRT). Method145 subjects with DSM-IV-TR schizophrenia or schizoaffective disorder were genotyped via saliva sampling. Subjects were evaluated on neurocognitive assessments (MATRICS) and clinical symptoms (PANSS) at baseline and endpoint after 12weeks of CRT. “Improvement” was defined as ≥67% of cognitive domains (≥4) showing performance increases. If ≤67% (≤2) of domains improved, the change was defined as “minimal improvement.” A general linear model was conducted for change of each cognitive domain. ResultsOf 145 subjects, data from 138 subjects were usable. Distribution of COMT genotype: Met/Met: 28 (20.29%), Val/Met: 61 (44.20%), and Val/Val: 49 (35.51%). No significant differences were seen among genotype groups at baseline or across genotype group for “Improvement” vs. “Minimal Improvement.” GLM analysis showed significant differences in Verbal Learning (p=0.003), Visual Learning (p=0.014) and Attention/Vigilance (p=0.011) favoring Met/Met and Val/Met groups. ConclusionsThe low activity Met allele (Met/Met; Val/Met) was associated with significantly greater improvements in the MATRICS domains of Verbal Learning, Visual Learning and Attention/Vigilance after CRT.

A trial-by-trial analysis reveals more intense physical activity is associated with better cognitive control performance in attention-deficit/hyperactivity disorder

Hyperactivity is a key symptom and the most observable manifestation of attention-deficit/hyperactivity disorder (ADHD). The over-activity associated with ADHD can cause specific challenges in academic settings, extracurricular activities and social relationships. Cognitive control challenges are also well established in ADHD. The current study included 44 children between the ages of 10 and 17 diagnosed with ADHD or who were typically developing (TD), all of whom had no psychiatric co-morbidity or significant learning disorders. Participants wore an actometer on their ankle while performing a flanker paradigm in order to objectively measure their rates of activity in association with cognitive control. Analyses assessed the relationship between frequency and intensity of activity to task accuracy on a trial-by-trial basis. A significant interaction effect between group and performance revealed that more intense movement was associated with better performance in the ADHD group but not in the TD group. The ADHD group demonstrated more intense activity than the TD group during correct (but not error) trials. Within-group, children with ADHD generated higher intensity movements in their correct trials compared to their error trials, whereas the TD group did not demonstrate any within-group differences. These findings suggest that excessive motoric activity associated with clinically significant ADHD symptoms may reflect compensatory efforts to modulate attention and alertness. Future research should systematically explore the relationship between motion in ADHD and how it might be used to improve cognitive performance.

Slow walking on a treadmill desk does not negatively affect executive abilities: an examination of cognitive control, conflict adaptation, response inhibition, and post-error slowing.

An increasing trend in the workplace is for employees to walk on treadmills while working to attain known health benefits; however, the effect of walking on a treadmill during cognitive control and executive function tasks is not well known. We compared the cognitive control processes of conflict adaptation (i.e., congruency sequence effects—improved performance following high-conflict relative to low-conflict trials), post-error slowing (i.e., Rabbitt effect), and response inhibition during treadmill walking (1.5 mph) relative to sitting. Understanding the influence of treadmill desks on these cognitive processes may have implications for worker health and productivity. Sixty-nine individuals were randomized to either a sitting (n = 35) or treadmill-walking condition (n = 34). Groups did not differ in age or body mass index. All participants completed a computerized Eriksen flanker task and a response-inhibition go/no-go task in random order while either walking on a treadmill or seated. Response times (RTs) and accuracy were analyzed separately for each task using mixed model analysis of variance. Separate ANOVAs for RTs and accuracy showed the expected conflict adaptation effects, post-error slowing, and response inhibition effects when collapsed across sitting and treadmill groups (all Fs > 78.77, Ps < 0.001). There were no main effects or interactions as a function of group for any analyses (Fs < 0.79, Ps > 0.38), suggesting no decrements or enhancements in conflict-related control and adjustment processes or response inhibition for those walking on a treadmill versus sitting. We conclude that cognitive control performance remains relatively unaffected during slow treadmill walking relative to sitting.

Reasoning training in veteran and civilian traumatic brain injury with persistent mild impairment

Traumatic brain injury (TBI) is a chronic health condition. The prevalence of TBI, combined with limited advances in protocols to mitigate persistent TBI-related impairments in higher order cognition, present a significant challenge. In this randomised study (n = 60), we compared the benefits of Strategic Memory Advanced Reasoning Training (SMART, n = 31), a strategy-based programme shown to improve cognitive control, versus an active learning programme called Brain Health Workshop (BHW, n = 29) in individuals with TBI with persistent mild functional deficits. Outcomes were measured on cognitive, psychological health, functional, and imaging measures. Repeated measures analyses of immediate post-training and 3-month post-training demonstrated gains on the cognitive control domain of gist reasoning (ability to abstract big ideas/goals from complex information/tasks) in the SMART group as compared to BHW. Gains following the SMART programme were also evident on improved executive function, memory, and daily function as well as reduced symptoms associated with depression and stress. The SMART group showed an increase in bilateral precuneus cerebral blood flow (CBF). Improvements in gist reasoning in the SMART group were also associated with an increase in CBF in the left inferior frontal region, the left insula and the bilateral anterior cingulate cortex. These results add to prior findings that the SMART programme provides an efficient set of strategies that have the potential to improve cognitive control performance and associated executive functions and daily function, to enhance psychological health, and facilitate positive neural plasticity in adults with persistent mild impairment after TBI.

CSF neuroinflammatory biomarkers in bipolar disorder are associated with cognitive impairment

Persistent cognitive impairment in the euthymic state of bipolar disorder is increasingly recognized. Mounting evidence also suggests an association between neuroinflammation and cognitive dysfunction. The purpose of this study was to test if cerebrospinal fluid (CSF) markers of neuroinflammation could account for cognitive impairment in bipolar disorder. Hierarchical linear regression models were applied to account for performance in five cognitive domains using CSF neuroinflammatory biomarkers as predictors in patients with bipolar disorder type I and II (N=78). The associations between these biomarkers and cognition were further tested in healthy age- and sex-matched controls (N=86). In patients with bipolar disorder, the CSF biomarkers accounted for a significant proportion of the variance in executive functions (42.8%, p=<.0005) independently of age, medication, disease status, and bipolar subtype. The microglial marker YKL-40 had a high impact (beta=−.99), and was the only biomarker that contributed individually. CSF biomarkers were not associated with cognitive performance in healthy controls. The CSF neuroinflammation biomarker YKL-40 is associated with executive performance in euthymic bipolar disorder, but not in healthy controls.

The effects of co-occurring ADHD symptoms on electrophysiological correlates of cognitive control in young people with Tourette syndrome.

Efficient cognitive control is implicated in tic control in young people with Tourette syndrome (TS). Attention-deficit/hyperactivity disorder (ADHD) frequently co-occurs with TS and is associated with impaired cognitive control. Young people with TS and ADHD (TS+ADHD) show poorer cognitive control performance than those with TS, but how co-occurring ADHD affects underlying neural activity is unknown. We investigated this issue by examining behavioural and event-related potential (ERP) correlates of cognitive control in young people with these conditions. Participants aged 9-17 with TS (n=17), TS+ADHD (n=17), ADHD (n=11), and unaffected controls (n=20) performed a visual Go/Nogo task during electroencephalography (EEG) recording. Behavioural performance measures (D-prime, RT, reaction time variability, post-error slowing) and ERP measures (N2, P3, error-related negativity (ERN), error positivity (Pe)) were analysed in a 2 (TS-yes, TS-no) × 2 (ADHD-yes, ADHD-no) factorial analysis to investigate the effects of TS, ADHD, and their interaction. The results of these analyses showed that ADHD was associated with poorer performance and reduced amplitude of all ERPs, reflecting widespread cognitive control impairments. Tourette syndrome was associated with slowed RTs, which might reflect a compensatory slowing of motor output to facilitate tic control. There was no interaction between the TS and ADHD factors for any behavioural or ERP measure, indicating the impairing effects of ADHD on behaviour and electrophysiological markers of cognitive control were present in TS+ADHD and that RT slowing associated with TS was unaffected by co-occurring ADHD symptoms.

The effect of parental loss on cognitive and affective interference in adolescent boys from a post-conflict region

Little is known about the impact of early-life stressors such as parental loss on cognitive-affective processing during adolescence, especially in regions chronically affected by war and armed conflict. Here, we tested 72 male adolescents living in Northern Uganda (ages 14–19), 52 of whom still had both of their parents and 20 participants who had experienced parental loss. Participants completed a classic color-naming Stroop task as well as an affective interference task, the opposite emotions test (OET). Adolescents with parental loss showed a decrease in performance over time, especially on the Stroop task. Critically, this decrement in performance was positively associated with reported symptoms of trauma, but only in the parental loss group. The current data suggest a difficulty in maintaining cognitive control performance in youths with experience of parental loss. The findings are discussed in relation to traumatic stress and mental health in post-conflict regions.

Shared dimensions of performance and activation dysfunction in cognitive control in females with mood disorders.

Major depressive disorder and bipolar disorder share symptoms that may reflect core mood disorder features. This has led to the pursuit of intermediate phenotypes and a dimensional approach to understand neurobiological disruptions in mood disorders. Executive dysfunction, including cognitive control, may represent a promising intermediate phenotype across major depressive disorder and bipolar disorder. This study examined dimensions of cognitive control in women with major depressive disorder or bipolar disorder in comparison to healthy control subjects using two separate, consecutive experiments. For Experiment 1, participants completed a behavioural cognitive control task (healthy controls = 150, major depressive disorder = 260, bipolar disorder = 202; age range 17-84 years). A sample of those participants (healthy controls = 17, major depressive disorder = 19, and bipolar disorder = 16) completed a similar cognitive control task in an event-related design functional magnetic resonance imaging protocol for Experiment 2. Results for Experiment 1 showed greater impairments on the cognitive control task in patients with mood disorders relative to healthy controls (P < 0.001), with more of those in the mood disorder group falling into the 'impaired' range when using clinical cut-offs (<5th percentile). Experiment 2 revealed only a few areas of shared activation differences in mood disorder greater than healthy controls. Activation analyses using performance as a regressor, irrespective of diagnosis, revealed within and extra-network areas that were more active in poor performers. In summary, performance and activation during cognitive control tasks may represent an intermediate phenotype for mood disorders. However, cognitive control dysfunction is not uniform across women with mood disorders, and activation is linked to performance more so than disease. These findings support subtype and dimensional approaches to understanding risk and expression of mood disorders and are a promising area of inquiry, in line with the Research Domain Criteria initiative of NIMH.

Premorbid adjustment and clinical correlates of cognitive impairment in first-episode psychosis. The PEPsCog Study

BackgroundThe extent to which socio-demographic, clinical, and premorbid adjustment variables contribute to cognitive deficits in first-episode schizophrenia spectrum disorders remains to be ascertained. AimsTo examine the pattern and magnitude of cognitive impairment in first-episode psychosis patients, the profile of impairment across psychosis subtypes and the associations with premorbid adjustment. Methods226 first-episode psychosis patients and 225 healthy controls were assessed in the PEPsCog study, as part of the PEPs study. ResultsPatients showed slight to moderate cognitive impairment, verbal memory being the domain most impaired compared to controls. Broad affective spectrum patients had better premorbid IQ and outperformed the schizophrenia and other psychosis groups in executive function, and had better global cognitive function than the schizophrenia group. Adolescent premorbid adjustment together with age, gender, parental socio-economic status, and mean daily antipsychotic doses were the factors that best explained patients' cognitive performance. General and adolescent premorbid adjustment, age and parental socio-economic status were the best predictors of cognitive performance in controls. ConclusionsPoorer premorbid adjustment together with socio-demographic factors and higher daily antipsychotic doses were related to a generalized cognitive impairment and to a lower premorbid intellectual reserve, suggesting that neurodevelopmental impairment was present before illness onset.

Evidence cerebral blood-flow regulation mediates exercise-cognition links in healthy young adults.

Healthy young adults are presumed to be in their cognitive prime, yet emerging evidence indicates that regular engagement in physical activity can still benefit their cognitive functioning. The mechanisms supporting these exercise-related cognitive benefits remain unclear, but recent research points to cerebral blood-flow (CBF) regulation as potentially important. The current study investigated the possibility that efficacy of CBF regulation underpins exercise-cognition links in this high functioning population. In 55 healthy young adults, cognitive control performance (inhibition and switching) was examined in relation to habitual physical activity, aerobic fitness, and CBF regulation (evidenced by blood-flow responsiveness to increases and decreases in carbon dioxide: hypercapnic reactivity, n = 43, and hypocapnic reactivity, n = 42). Multiple regression analyses revealed that more frequent physical activity, and to some extent better aerobic fitness, predicted both better CBF regulation and better cognitive inhibitory control. CBF regulation also predicted better cognitive inhibitory control. Moreover, mediation analyses indicated that more frequent participation in physical activity may bring about improvements in cognitive inhibitory control through improved CBF regulation. These results provide novel insight into the cognitive and cerebrovascular benefits that may be gained with regular engagement in physical activity, even in a high-functioning population. Moreover, they point to better CBF regulation as a specific mechanism that may drive physical activity-related cognitive benefits, which converges with recent data in older women (Brown et al., 2010).

Dissociable effects of game elements on motivation and cognition in a task-switching training in middle childhood.

Although motivational reinforcers are often used to enhance the attractiveness of trainings of cognitive control in children, little is known about how such motivational manipulations of the setting contribute to separate gains in motivation and cognitive-control performance. Here we provide a framework for systematically investigating the impact of a motivational video-game setting on the training motivation, the task performance, and the transfer success in a task-switching training in middle-aged children (8–11 years of age). We manipulated both the type of training (low-demanding/single-task training vs. high-demanding/task-switching training) as well as the motivational setting (low-motivational/without video-game elements vs. high-motivational/with video-game elements) separately from another. The results indicated that the addition of game elements to a training setting enhanced the intrinsic interest in task practice, independently of the cognitive demands placed by the training type. In the task-switching group, the high-motivational training setting led to an additional enhancement of task and switching performance during the training phase right from the outset. These motivation-induced benefits projected onto the switching performance in a switching situation different from the trained one (near-transfer measurement). However, in structurally dissimilar cognitive tasks (far-transfer measurement), the motivational gains only transferred to the response dynamics (speed of processing). Hence, the motivational setting clearly had a positive impact on the training motivation and on the paradigm-specific task-switching abilities; it did not, however, consistently generalize on broad cognitive processes. These findings shed new light on the conflation of motivation and cognition in childhood and may help to refine guidelines for designing adequate training interventions.

Neurocognitive correlates of the course of bipolar disorder.

Significant cognitive dysfunction has been recognized as an important state and trait feature of bipolar disorder. In this article, longitudinal studies comparing cognitive performance in bipolar disorder patients and healthy controls are reviewed. In contrast to cross-sectional reports, current longitudinal research findings do not support a progressive cognitive decline over time. However, a higher within-person instability in cognitive performance was found relative to controls. The need for larger samples remains, as well as for longer and more frequent observations.