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Studies have shown that susceptibility to scams, such as fake IRS agents who demand payment of back taxes or a fake lottery that requires money up front before distributing winnings, has been associated with progression from mild cognitive impairment (MCI) to Alzheimer disease. But a recent study involving 935 individuals, average age 81.2 years, found a link between scam susceptibility and dementia risk even among people who are cognitively normal.
The study, part of the ongoing Rush Memory and Aging Project, used a 5-item questionnaire to assess participants’ awareness of and susceptibility to scammers’ tactics. After 6 years of follow-up on average, those with a low scam awareness score were 60% more likely to have developed dementia. In addition, brain autopsies of the 264 participants who died during follow-up found that those with low scam awareness were more likely to have the pathological changes associated with Alzheimer disease.
Lead author Patricia Boyle, PhD, a neuropsychologist with the Rush Alzheimer’s Disease Center in Chicago, spoke with JAMA about her research into the relationship between complex behaviors, such as financial decision-making, and dementia risk. The following is an edited version of that conversation.
JAMA:What makes exploitation of elders a public health problem?
Dr Boyle:Elder fraud is a massive public health problem for a variety of reasons. Older people have accumulated the vast majority of the wealth that they will acquire. When they make financial mistakes or get involved in scams and lose money, they often don't have any options for recouping those losses. They're not like a 30-something-year-old who can go out and get a new job and spend the next 20 years regaining the wealth they lost. On top of those economic losses, evidence shows that there are significant psychological and health-related consequences of victimization as well. We know that older persons who are victimized tend to be more likely to develop depression and become socially isolated. They may be embarrassed or ashamed that they fell prey to a fraud, or they might be confused about how that happened and not want to talk about it. They can end up having difficulty taking care of themselves. Some evidence suggests that financial exploitation is in fact associated with early mortality.
JAMA:What are other complex behaviors that might serve as a harbinger of dementia?
Dr Boyle:People around the country are starting to look at complex behaviors such as financial decision-making and health care related decisions as people age. We have shown in other work from this cohort that changes in complex aspects of decision-making seem to be early harbingers of adverse health and cognitive outcomes. Scam susceptibility is a component of a broader construct of decision-making that appears to be an early complex ability affected by age-related changes in the brain.
JAMA:Are people with mild cognitive impairment more susceptible to scams?
Dr Boyle:We previously applied the same instrument we used in this study to people with mild cognitive impairment, and we compared them to those with no cognitive impairment. We found that those with some impairment tended to perform worse on this measure, indicating that they're more susceptible to falling prey to scams and engaging in the behaviors that we know are associated with victimization, which is what we measure with the scale.
JAMA:In an earlier study, you looked at the relationship between scam awareness scores and MRI [magnetic resonance imaging] brain scans in nondemented adults. What did you find?
Dr Boyle:We're interested in unraveling what brain networks are involved in regulating complex social behaviors and decision-making and related behaviors such as scam susceptibility. In that study, we found that temporal lobe structures that tend to support more complex cognitive abilities as well as memory tend to be involved in scam susceptibility. And in people in whom those regions are smaller [measured by lower gray matter volume], we tend to see more susceptibility or vulnerability.
JAMA:Could you describe the instrument that you used in this new study and in previous studies to measure people's scam awareness?
Dr Boyle:We use a measure designed to address knowledge of tactics commonly used to deceive older people and willingness to engage in behaviors that may increase the risk of falling prey to financial scams or other forms of exploitation. We chose a select set of behaviors to focus on based on the financial industry regulatory authority body, the FINRA Foundation, which has developed a measure of how likely someone is to participate in risky investments. Their research into the behaviors associated with victimization pointed us in the direction of 3 key areas. One, we look at openness to sales pitches, such as answering the phone when it's someone you don't know calling. The second area is interest in potentially risky investments, things that sound really good but should sound too good to be true. The third area is awareness of heightened vulnerability simply due to older age. We know that con artists frequently target older adults in their fraudulent activities and that older adults lose somewhere upwards of $35 billion annually to financial and other forms of scam and fraud. So we have a series of 5 items that assess those 3 domains of behavior.
JAMA:What were your main findings, and were you surprised by any of them?
Dr Boyle:Our main findings were that susceptibility to scams appears to be a very early sign that something is going wrong in the brain and an older person is at risk of developing Alzheimer disease, dementia, or mild cognitive impairment over an average span of about 6 years. I am a little bit surprised at the robustness of the findings. We adjusted in our analysis for how someone was doing cognitively using a very detailed, comprehensive measure of cognitive function. No matter where you start cognitively, having low scam awareness is a bad sign in terms of the likelihood of developing future cognitive problems.Another novel finding of this study was that, in a subset of people who died and underwent a brain autopsy, low scam awareness was associated with a greater accumulation of Alzheimer-associated changes in the brain. Not that many factors have been shown to relate to those changes during life. So here we show that scam susceptibility is related to amyloid, which is considered the earliest pathological manifestation of Alzheimer disease in the brain, as well as tau tangles.
JAMA:Could the findings be tied to other types of dementia besides Alzheimer disease?
Dr Boyle:It's actually very rare that dementia is driven only by Alzheimer disease. Older people have a whole host of other changes in the brain that also can cause symptoms that look like Alzheimer dementia. Our study did relate the scam awareness measure to the pathologic changes of Alzheimer disease specifically. However, it is possible, and likely probable, that many of the older people who died had other changes in their brain, and those changes, strokes and the like, might also impact scam susceptibility and these complex behaviors. We don't know the role other diseases might play. That is something we are very interested in investigating further.
JAMA:Have you thought about doing the same study with younger people?
Dr Boyle:I would love to do that. Despite many advances in our understanding of Alzheimer disease and dementia, it still remains very difficult at an individual level to determine who is really at high risk. It's very hard to know what behaviors to target and when to study those behaviors and how soon before the disease really shows itself clinically that we'll be able to see changes in behavior. What are the earliest signs of these diseases? Looking at this in a younger population would be of great interest. It will be important to extend these findings [in older adults] to a younger cohort. It's more difficult to do that because younger people don't tend to develop Alzheimer disease at the same rate as older people. You need a longer observation period and more data to be able to see these kinds of associations.
JAMA:Are you planning on following up to see if a low score on the scam awareness test is associated with a higher risk of victimization?
Dr Boyle:As you can imagine, it is very difficult to ascertain victimization because many times older people who are victimized don't know it or are embarrassed or ashamed to admit that they have been victims of exploitation. It's really difficult to get at those things, and there's no standard reporting agency that we can go to and leverage. So most actual victimizations are not reported. We are in the process of developing questions to try to get at evidence of victimization in a more detailed way. We're at the beginning of that process, but that is something that we will be looking into in more detail.
JAMA:At this point, do you think screening older people for scam awareness could help identify those with a higher risk of Alzheimer disease?
Dr Boyle:The measure that we used is not suitable for detection at an individual level. In a doctor's office, if one person filled out this questionnaire, it would be very difficult to know how much their responses predict what their likely cognitive outcomes will be. However, I do think that these findings, together with the other work we've been reporting on in recent years, suggest that development of measures that assess complex social abilities probably will hold some promise in terms of identifying in the clinic who is likely to develop Alzheimer disease.
Rubin R. Low Awareness of Scammers’ Tactics Linked to Dementia Risk in Cognitively Normal People. JAMA. Published online June 12, 2019. doi:10.1001/jama.2019.5765
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