1

Inventory of Neurocognitive Reserve (INNER): Translation, Adaptation, and Validation in the

French Population

Caputo Diégo

Instituto Superior de Ciências da Saûde- Norte

research Applied

DR. Vera Almeida

June 5th, 2023

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Abstract

In the literature, there is a lack of consensus about the measurement of cognitive

reserve (Harrison et al. 2015). Indeed, many articles show a large number of proxies to

measure cognitive reserve, yet there is no appropriate battery taking into account its different

factors to measure cognitive reserve. Proxies are defined as a variable that is not significant in

itself, which can be used as a substitute for a useful but unobservable variable. Cognitive

reserve can be described according to Grande et al. (2017) as the brain's capacity to withstand

neuropathologies, to reduce clinical symptoms and to allow cognitive tasks to be completed

by compensating with pre-existing cognitive processes or by developing new ones. There are

different types of reserve: emotional reserve, cognitive reserve and sensory reserve, all of

which influence each other. The emotional reserve is made up of brain patterns specific to

each individual, which have a disparate influence on emotional functioning and information

processing. The sensory reserve describes the differences in the way sensory information is

processed, which interferes with the cognitive and emotional reserves. All these reserves

influence cognitive reserve and must therefore be taken into account when measuring it.

Cognitive reserve is a factor that enables us to predict our patients' potential rehabilitation

capacity, which is why it is important to study it. The lack of a test to measure CR taking into

account the various contributions of the existing literature is therefore to be deplored. The aim

of this study is to fill this gap for different populations, particularly the French population.

Keywords : Neurocognitive reserve, Emotional reserve, Sensory reserve, Assessment

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Introduction

Cognitive reserve can be described according to Grande et al. (2017) as the brain's capacity

to withstand neuropathology, reduce clinical symptoms and allow cognitive tasks to be

completed through an active process whereby the deficit is compensated for by pre-existing

cognitive processes or by developing new ones. There are different types of reserve:

emotional reserve, cognitive reserve, cerebral reserve and sensory reserve, all of which

influence each other. There is an interdependent link between cognition, emotion and

sensation and this link is managed by the cerebral capacity. According to ((Mesulam, 1998b),

cognitive processes stem from the transformation of sensory stimuli that enable us to map the

world around us.

Objectives:

The researchers showed that hearing problems create retention deficits in patients because of

the cognitive effort required to understand information that is complex to perceive.

Methodology :

In order to create this literature review we relied on Joana Pinto's umbrella review on the

subject of cognitive reserve and its measurement. This is a literature review because its try to

be a published materials that provide examination of recent or current literature. Can cover

wide range of subjects at various levels of completeness and comprehensiveness. And its

include research findings. The study by Pinto et al (2021) lists all the data on the subject up to

2022. To complete this study, we also looked at the various studies published in 2022 and

2023. To do this, we used Pubmed to select all studies since 2022 on the subject of cognitive

reserve in humans that were clinical trials, empirical studies or randomised controlled trials

published in English or French. Our exclusion criteria were: Wrong publication type, Studies

that did not assess CR, Wrong population. (see the diagram).
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Results:

The emotional reserve is made up of brain patterns specific to each individual, which have a

disparate influence on affective functioning, but also on the processing of emotional

information, which is important for the brain's adaptation to pathology. We are influenced

throughout our lives by stressful events, and this will influence our behaviour and cognition

depending on the duration of the stress and its impact on our genetic factors. Emotional

reserve is supported by two well-studied processes, psychological resilience and emotional

self-regulation. Indeed, a good capacity for psychological resilience is linked to a better

connectivity between the different regions of the brain according to Son et al. (2019).

Emotional regulation enables individuals to manage negative emotions and stress. If this

regulation is not functional, it can lead to emotional distress, anxiety and depression. And as

the study by van der Horn, H. J., et al (2020) shows, individuals who have a poor ability to

manage emotions are more likely to have persistent symptoms after a mild traumatic injury

due to poor stress management, which leads to the release of pro-inflammatory cytokines.

Social interaction is also a big factor of neural plasticity, we can see that by the fact that

sociability is a factor to avoid developing dementia according to Fratiglioni et al. (2004b).

Shamay-Tsoory et al. (2021) shows us the importance of social interaction on plasticity and

learning. Interaction-based learning occurs in all types of social information exchange, from

teacher-learner interaction to interactions that exchange information with each other. The

more interactions there are, the more effective the learning will be. There are therefore two

learning processes in one during a direct interaction learning phase, the task learning phase

and the alignment learning phase with the partner. This type of interaction allows the patient

to be enriched plastically by the double effort required. The emotional reserve is therefore

unique to each individual and conditions our emotional functioning, our ways of processing

information and therefore of managing positive or negative emotions. Experiencing stress is

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an immutable event in the life of any individual, but its length, the way it is managed and its

consequences are specific to each person. Psychosocial stress is a factor in biological ageing

according to Kelley et Schmeichel (2014) "Chronic stress has a direct impact on disease-

related cellular processes, through prolonged or repeated activation of the sympathoadrenal

system and release of neuroendocrine mediators, which would have a cumulative impact on

key biological pathways of ageing". Psychosocial stress can be defined as repeated exposure

to unfavourable social conditions. This can be described by adversity at the start of life or by

sick relatives accompanying the individual over a long period, leading to a feeling of anxiety

with a sense of lack of resources (social or psychological) and activating the stress control

system.. Early life stress may be due to low socio-economic status, abuse (physical, sexual,

psychological), or adversity at the start of life. Sensory reserve describes differences in the

processing of sensory information that interfere with cognitive and emotional reserve. As

shown by Pinto et al. (2021), age leads to a change in sensory functioning in individuals, and

these changes have an impact on their daily activitis. In fact, this study shows that as we get

older, the way we process information changes, moving from a sensory processing of

information to a sensory processing of information. According to (Misselhorn et al., 2020)

there is a link between ageing, multisensory integration and sensory processing. To this end,

she studied sensory evaluations and cognitive performance in adults and older people.

According to Misselhorn et al. (2020), ageing is associated with changes in sensory and

cognitive abilities due to the decline of the peripheral and central nervous system. He states

that after studying more than 34 articles on the subject, the evidence is accumulating that

there is a link between the decline in sensory functions and cognitive decline with ageing.

Some studies, such as that by Ong et al. (2012b), showed that an individual with poor visual

acuity had a higher percentage chance of having a cognitive impairment despite the non-

visual aspect of the tests used. Dupuis et al. (2015) showed in a sample of more than 300
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elderly people that poor hearing acuity was directly linked to a reduction in performance on

the Montreal cognitive assessment, despite adaptation to their sensory deficits. This test is still

used today to measure cognitive reserve in studies of cognitive reserve (Nicholson et al.,

2022). According to Piquado et al. (2010) carried out a study to assess the impact of hearing

loss on information retention. The researchers showed that hearing problems create retention

deficits in patients because of the cognitive effort required to understand information that is

complex to perceive. Moradi et al. (2014) also analysed data from 138,00 individuals and also

found that hearing loss was associated with difficulty fior visuospatial memory (short-term

memory and long-term episodic memory). Another longitudinal study by Sternäng et al.

(2010) reported a link between loss of visual and auditory acuity and memory. Humes et

Young (2016) have shown that the link between age, cognition and sensory processing is

observable for the oldest adults but also for all types of adults. The link between sensory

processing and cognition does not therefore depend on age. Humes et Young (2016) carried

out a study aimed at cataloguing measures of auditory and visual sensory processing. This

study therefore explains that certain sensory abilities are better indicators of cognitive

function than age and level of education. These studies have therefore shown that in order to

measure the impact of the sensory deficit, it is necessary to measure more than one sensory

domain and not just the threshold sensitivity. According to Michel, et al. (2009), cerebral

reserve is structural and comes from various factors such as the size of the brain, the quantity

of dendrites and connections between them and various genetic factors. The cerebral reserve

is structural, it depends on a quantitative notion of different factors, such as the size of the

brain, the quantity of neurons and connections available. But these factors are themselves

influenced by other behaviours such as diet, brain stimulation during childhood, the number

of brothers and sisters, etc. Cerebral reserve is opposed to CR because of the structural nature

of the former and the functional nature of the latter. Therefore, individuals, even with
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equivalent brain reserve, may express variable clinical sequelae depending on their cognitive

reserve (Medaglia et al., 2017). Cognitive reserve, according to Stern et al. (2020) describes

the difference between the results of neuropsychological tests and daily difficulties, and

doctors' observations of neuropathology (lesions, progress of the pathology, etc.). Cognitive

reserve is dynamic and depends on the quality of connections, and is influenced by different

factor. It improves with all the intellectual demands made on the patient. It is fed throughout

life by intellectually stimulating activities, as shown by Vance, et al. (2016). According to this

study, work appears to be a good source of nourishment for cognitive reserve. It appears to be

a good protective factor against cognitive ageing, given that the study shows that lack of

employment is a poor factor in cognitive ageing. According to Stern (2018), cognitive reserve

refers to cognitive and socio-behavioural factors that have an impact on cognitive adaptation

in the face of age, brain pathology or injury. It is supported by two types of mechanism:

neuronal reserve, which uses the most efficient brain networks. This mechanism is used in

both healthy and unhealthy individuals. The second mechanism is neuronal compensation,

which enables compensatory cerebral networks to be used because the patient can no longer

use the basic networks damaged by the pathology. The cognitive reserve is malleable and

depends on each person's experiences and past, so its resistance is specific to each individual.

People with high cognitive reserve therefore allow individuals to cope with more

neuropathology than others. It is important to define the behavioural factors that influence

cognitive reserve, and to do this we have studied various studies in the literature, listing the

most important factors. According to Yao et al. (2020) people who are active smokers are

more likely to have a difference between expected and observed cognition by measuring CR

as the difference between observed and expected cognition . Anatürk et al. (2021) arrived at

the same. According to the study by (Anatürk et al., 2021), people who drank alcohol

appeared to have higher than expected cognition. Alcohol and drugs do however affect the
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physiology necessary for negative neurohypercity. However, not all alcohols have a negative

effect on plasticity; in fact, Panza et al. (2004) showed that red wine protects cognitive

functions from age-related decline. Physical activity seems only to attenuate the relationship

between certain pathological markers such as frontal temporal volume and arthrosclerosis

(Casaletto et al., 2020b). However, its effect was not found for elderly people without

cognitive deficit (Buchman et al., 2019). Various researchers have looked at the impact of

different leisure activities and their impact on cognitive reserve capacity. This includes

intellectual, cultural and social activities. Some studies, such as that by Xu et al. (2020), show

that cognitive leisure activities are a factor in developing a reduced risk of mild cognitive

impairment. In addition, there is a reduced risk of developing dementia and specifically

Alzheimer's disease. Cognitive reserve increase by a mechanism referred to as positive

neuroplasticity and decrease trough negative neuroplasticity. Negative neuroplasticity refers

to the lack of environmental and level stimuli and physiological problem that result in

depleting cognitive reserve, which jeopardizes cognitive function. According to Colcombe et

al. (2006), physical exercise improves cardiovascular capacity and physiological function,

which has a positive effect on neuroplasticity. According to Boyke et al. (2008), it would

appear that failure to maintain the use of acquired knowledge results in the loss of connections

previously established when learning that knowledge. The study also suggests that nutrition

plays an important role in the factors influencing plasticity, given the inflammatory aspect of

foods low in antioxidants and high in sugar. Rangel et al (2021) propose an online

programme, Maintain Your Brain, aimed at giving dietary advice to help prevent cognitive

decline and dementia. Concerning the modele to asses the CR, there are different ways to

measuring CR in the litterature, so it is important to take into account that some results differ

between them because of differences in measurement methods (Song et al., 2021). The

Residual model examines the links between lifestyle factors and CR residuals. These residuals
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represent the cognitive variation that cannot be explained by demographic factors and brain

markers of cognition. The Moderation model aims to assess whether lifestyle factors play a

moderating role in the relationship between brain state and cognition. This is done by

studying the interaction between lifestyle factors and brain markers on cognitive outcomes.

The Control model involves performing multivariable regressions to examine the relationship

between lifestyle factors and cognition, taking into account the brain markers as covariates. It

may also be a question of regressing lifestyle factors with brain markers while controlling

cognition. There are different ways of studying and measuring the concept of Cognitive

reserve (Kartschimt et al., 2019). Some studies use socio-behavioural indicators such as level

of education, IQ, socio-economic status, occupation, pre-morbid cognitive level (hypothetical

or measured), leisure time (Stern et al,. 2018). The most common seems to be according to

Manly et al. (2004) education, it is measured with the level of study. However, it seems that

this is not the most ecological indicator, according to Berezuk et al. (2021) participation in

activities seems to be a better indicator of functional cognitive reserve than level of study. CR

can also be studied using standardised questionnaires, which have many advantages. They

allow a single score to be measured, are easy to administer, can be used to reach a large

audience for a study and can include different proxies depending on (Kartschmit et al., (2019).

Proxies can be defined as a variable that is not significant in itself, which can serve as a proxy

for a useful but unobservable or unmeasurable variable. Some researchers, such as Reed et al.

(2010), even work to predict this same score using a model based on the measurement of

episodic memory, to which end they take into account certain demographic and physiological

variables and a residual. According to the umbrella review the variable asses are participation

in cognitive or leisure activities, work, intellectual abilities, social ties (support and network),

ability to speak several languages, vocabulary and reading, socio-economic status of parents,

musical abilities, premorbid adjustment abilities and functioning, Big Five personality
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characteristics (low level of neuroscience and high level of consciousness), episodic memory

and ethnicity and sexual characteristics (sex and gender). Intelligence was most often

measured by general intelligence (weschler intelligence scale), verbal intelligence (weschler

test of adult reading) and premorbid intelligence (Shipley Vocabulary). The subjects' musical

abilities can be measure by the number of years of practice and related experience. To study

the education proxy the variable most used was the number of years of study, for the

education proxy it was the professional activity, for leisure and cognitive activities it was the

current or past activities. For verbal and intellectual abilities, the Weschler Intelligence Scale

and its sub-tests are used: the vocabulary sub-test of the Weschler Adult Intelligence Scale

(proxy for premorbid IQ and verbal IQ in the case of the vocabulary sub-test); the Weschler

Adult Intelligence Scale (proxy for intellectual functioning); the National Adult Reading Test

(proxy for vocabulary knowledge). Studies using questionnaires appear to be the Cognitive

Reserve Index Questionnaire, the Cognitive Reserve Questionnaire and the Cognitive Reserve

Scale. The Cognitive Reserve Index Questionnaire (CRIq), but according to Nucci et al.

(2018) this test only measures education, working activity and leisure time. The CRS

measures activities of daily living, training information, hobbies and social life according to

Landenberger et al. (2019b). The CRQ measures: level of education, parents' level of

education, training courses, work, musical training, language, reading and intellectual games.

Despite the fact that education remains the most widely used factor for measuring CR, it

would appear from Maccora et al. (2020) that the link between education and CR is not

uniform. The MoCA is build to allows the assessment of the DCL (mild cognitive

impairment). In this sense, in 2020 some authors (Kaur et al., 2020) mentioned that the

inconsistent nature of CR measurement was a handicap in research or clinical practice.

Harrison et al. (2015) focused on creating an umbrella review to examine techniques for

operationalising cognitive reserve. With regard to the French population and the measurement
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of CR, some studies attempt to observe the impact of a variable on the population, such as the

study by Dartigues et al (2013), which measures the frequency of playing board games in

relation to the onset of dementia in individuals. Other studies, such as that by Kesse-Guyot,

E., (2013), compared the diet of French individuals and their cognitive abilities, but using

traditional cognitive tests (digit span task, trail making test, etc.) and selecting certain other

factors from the literature: education level, occupation, tobacco use, physical activity,

supplementation group, baseline self-reported memory difficulties. His studies used common

cognitive tests such as the Weschler intelligence scale, making it possible to use validated and

translated versions of these tests. Other studies, such as this one, use the number of years of

education or vocabulary skills (National Adult Reading Test), variables that can be measured

by specific tests that have already been translated and validated. There is, however, a French

version of the Cognitive Reserve Index Questionnaire (CRIq) and the MoCA, according to

Nucci et al. (2018) and Nasreddine et al. (2005) . The CRS and The CRQ has not been

translated into French population. Despite the great advantages of these different scales, they

do not allow us to measure all the necessary variables that are measurable for neurocognitive

reserve.

Discussion of results :

It appears that one of the future goals required for the advancement of literature and clinical

practice, as stated by Kaur et al. (2020), is the development of a formula to calculate the

cognitive reserve (CR) score. This formula should consider the relative importance of each

indicator and differentiate indicators associated with CR acquired early in life from those

related to CR throughout one's lifespan. Additionally, according to Chapko et al. (2018), a

challenge in the field is to investigate the interaction among different CR indicators to gain a

better understanding of their combined impact. Other objectives in the research on this topic

include assessing the ecological validity of tests used to measure CR. This involves
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determining to what extent these tests reflect actual cognitive abilities in everyday life.

Furthermore, it is important to identify which interventions hold the greatest potential to

enhance cognitive reserve and determine the optimal timing for their implementation.

Conclusion :
The authors concluded that there is a lack of consensus on proxies for measuring CR.

According to the literature, future studies on the measurement of CR should therefore take

into account education, work occupation; occupational complexity; socioeconomic status;

bilingualism capacity, leisure as: cognitive stimulating, physical activity, artistic activities,

cultural and social activites; personality traits; sensorial acuity, sensorial perception. In

addition it seems that the use of measures of people's social networks are neglected measures.

In fact, as Bertola et al. (2019) show, its measurement is a good resilience factor and may

therefore be worth considering.

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Annexes: