Examining the Relationship between Care-receivers' Emotion Recognition and

Caregivers' Burden among Main Caregivers of Persons with Mild Cognitive Impairment

and Early Alzheimer's Disease: Expanding Pearlin's Stress Process Model

Naama Spitzer

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A THESIS SUBMITTED FOR THE DEGREE

"DOCTOR OF PHILOSOPHY"
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University of Haifa

Faculty of Social Welfare & Health Sciences

Department of Gerontology
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October 2018
 Examining the Relationship between Care-receivers' Emotion Recognition and

Caregivers' Burden among Main Caregivers of Persons with Mild Cognitive Impairment

and Early Alzheimer's Disease: Expanding Pearlin's Stress Process Model

By: Naama Spitzer

Supervised by: Prof. Perla Werner, Dr. Tal Shafir

A THESIS SUBMITTED FOR THE DEGREE "DOCTOR OF PHILOSOPHY"

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University of Haifa
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Faculty of Social Welfare and Health Sciences, Department of Gerontology
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October 2018

Recommended by Prof. Perla Werner (Supervisor) Date: 27-9-2018

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Signed:

Recommended by Dr Tal Shafir (Supervisor) Date: 27-9-2018

Signed:

Approved by Dr Tova Band Winterstein (Chairman of Ph.D. Committee) Date:___________

signed:________
 Table of Content
Table of Content I
Abstract IV
List of Tables XII
List of figures XIII
1. Introduction 1
2. Literature review 4
2.1 Dementia, Alzheimer’s Disease (AD) and Mild Cognitive Impairment (MCI) 4
2.1.1 MCI and AD diagnosis 5
2.1.2 Pathology in AD and MCI 6
2.2 Emotion Recognition 8

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2.2.1 Measuring emotion recognition 8
2.2.2 Emotion recognition from facial and bodily expressions 9
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2.2.3 Static and dynamic modes of emotion recognition
2.2.4 Emotion recognition in MCI and AD
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2.2.5 Emotion recognition from facial vs. bodily expressions in AD and MCI 13
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2.2.6 Static versus dynamic stimuli in AD and MCI 16
2.3 Caregiver's Burden 17
2.3.1 Pearlin's Stress Process Model 17
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2.3.2 Caregiver's burden in AD and MCI 19

2.3.3 Correlates of caregiver burden 20
2.3.4 The relationship between caregiver burden and emotion recognition 21
2.4 Literature Background Summary and the Study's Aims 23
2.5 The Study's Hypotheses 24
3. Methods 30
3.1 Participants and design 30
3.2 Procedure 33
3.3 Instruments and Variables 34
3.3.1 Measures for the first aim – emotion recognition assessments 34
3.3.2 Measures for the second aim – stress process variables 37
3.4 Statistical Analysis 41

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 4. Results 43
4.1 Descriptive results 43
4.1.1 Main variables in the first aim – comparing facial and bodily emotion
recognition across a continuum of cognitive functioning. 43
4.1.2 Main variables in the second aim - assessing the contribution of emotion
recognition as a correlate of caregiver burden using Pearlin's Stress Process Model 44
4.2.1 Hypothesis 1. Persons with early AD will be less accurate in recognizing
facial and whole body emotional expressions, compared to healthy elderly, and
persons with MCI will be in between both these groups in regard to the amount of
errors in their emotion recognition 46
4.2.2 Hypothesis 2. Persons with early AD and MCI will recognize body
expressions better than facial expressions 47

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4.2.3 Hypothesis 3. Relationship between caregivers' social and demographic
characteristics and caregivers' emotional burden 48
4.2.4 Hypothesis 4. The relationship between primary stressors and caregivers'
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burden 49
4.2.5 Hypothesis 5. Relationship between caregivers' burden and role captivity 50
4.2.6 Hypothesis 6. Relationship between family conflicts and caregivers
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burden 50
4.2.7 Hypothesis 7. Relationship between socio-demographic characteristics
and role captivity 50
4.2.8 Hypothesis 8. Relationship between the primary stressors and caregivers'
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role captivity 51
4.2.9 Hypothesis 9. Relationship between family conflicts and role captivity 51
4.2.10 Hypothesis 10. Relationship between socio-demographic characteristics
and social support 52
4.2.11 Hypothesis 11. Relationship between primary stressors, role captivity,
family conflicts, emotional burden and caregivers' social support 53
4.2.12 Hypothesis 12. The relationship between primary stressors and
caregivers' family conflicts 54
4.2.13 Hypothesis 13. Relationship between socio demographic characteristics
and family conflicts 55
4.2.14 Hypothesis 14. Relationship between socio-demographic characteristics
and care-receivers' cognitive status 55

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 4.2.15 Hypothesis 15. Relationship between socio-demographic characteristics
and care-receivers' problematic behaviour 56
4.2.16 Hypothesis 16. Relationship between socio-demographic characteristics
and care-receivers' emotion recognition 56
4.3 Multi-variate analyses - Examining the theoretical model 57
5. Discussion 61
5.1 The first aim – examining emotion recognition across cognitive functioning 61
5.1.1 Examining healthy older adults, persons with MCI and early AD's ability
to recognize dynamic bodily and facial emotion expressions 61
5.1.2 Differences between facial and bodily emotion recognition abilities
among people with MCI and early AD 63
5.2 The second aim – examining the contribution of emotion recognition as a correlate

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of caregiver burden using Pearlin's Stress Process Model as its theoretical framework 65
5.2.1 Caregivers' burden 65
5.2.2 The formation process of caregiving burden
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5.2.3 The unique contribution of emotion recognition to the understanding of
caregiver burden 70
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6. The study's limitations 73
7. The study's implications 74
7.1 Theoretical implications 74
7.1.1 Theoretical implications to the area of emotion recognition 74
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7.1.2 Theoretical implications to the area of caregiver burden 75

7.2.1 Practical implications to the area of emotion recognition 76
7.2.2 Practical implications to the area of caregiver burden 77
8. Bibliography 78
9. Appendices 97
9.1 Appendix A - Hebrew Questioners 97

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 Examining the Relationship between Care-receivers' Emotion Recognition and

Caregivers' Burden among Main Caregivers of Persons with Mild Cognitive Impairment

and Early Alzheimer's Disease: Expanding Pearlin's Stress Process Model

Naama Spitzer

Abstract

Background

The number of people with dementia is on the rise, as is the number of family

members who care for them and serve as their main caregivers. Since, it has been

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demonstrated that caregivers for older people with dementia often experience major life

changes and personal sacrifices, which lead to increased burden, it is important to understand
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what are the factors associated with this burden in order to try to reduce it. Indeed, caregiver's
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burden has been a subject discussed in myriad studies, mostly using Pearlin's (1990)

conceptual model of caregivers' stress. However, the theoretical and applied search for factors

that can predict this burden still continues.

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The ability of people with dementia to correctly recognize emotions might be such a

factor because of two main interrelated reasons: First, it has been shown that the ability to

correctly recognize nonverbal cues of emotion expressions is impaired in both persons with

Mild Cognitive Impairment (MCI) and with early Alzheimer's Disease (AD). Second, deficits

in the care-receivers' ability to recognize other persons' expression of emotions can make the

interaction between the caregiver and the care-receiver very difficult which might increase the

stress and burden associated with the caregiving role. It is interesting, therefore, that over the

years, there have been only a few studies that studied this subject.

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 The purpose of this research

The main aims of the present study were: 1. To assess emotion recognition across

groups that differ in their cognitive functioning level by comparing recognition from two

modes of emotional expressions – through the face and through the body – among healthy

elderly persons, persons with MCI and persons with early AD. 2. To examine for the first time

how the ability to recognize others' facial and bodily emotional expressions among persons

with MCI and early AD uniquely contributes to the explanation of caregiver's burden within

the framework of Pearlin's Stress Process Model

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Participants

A sample of 150 dyads of care-receivers and caregivers was used (75 persons with
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MCI and 75 persons with early AD). Additionally, for the first aim of the study a control
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group of 40 healthy persons was recruited. The majority of the care-receivers were female and

married. Their mean age was 77 years (SD = 7.60; range 65-95). The majority of caregivers

were female, married and lived together with the care-receiver. Their mean age was 63.45
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years (SD = 13.67; range 27-87). The majority of the control participants were woman,

married, with mean age of 79.38 (SD = 9.98 years, range = 65 – 99).

Procedure

The data collection of the family dyads occurred in two ways: Most dyads (n = 107)

were recruited through a memory clinic in a hospital in the centre of Israel, and the rest (n =

43) were recruited through several other sources: private geriatric clinic, day centres, support

groups for caregivers of people with AD, and through snowballing. The control group was

recruited mainly from the community (n = 27) and from an assisted living facility (n = 13).

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 Data collection was conducted at the participants' place of preference, usually at their

home, where care-receivers completed the emotion recognition test, and caregivers completed

a structured questionnaire. The protocol of the study was approved by the Helsinki Ethics

Committee of the hospital as well as by the Ethics Committee of the Faculty of Social Welfare

and Health Sciences at the University of Haifa.

Instruments

Care-receivers and healthy controls' measures included two tests to assess emotion

recognition abilities: For recognition of body emotional expressions we used 3 second video

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clips of whole body emotional expressions taken from Atkinson and colleagues validated set

(Atkinson et al., 2004, 2007) and for recognition of facial emotional expressions we used 3
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second morphed facial clips based on Ekman and Frisen's validated FACS (Facial Action
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Coding System) set (Ekman & Friesen, 1976). Caregivers' measures included 6

questionnaires, 4 of which assessed their own experience: The Short Form of the Zarit Burden

Interview (ZBI-SF) (Bédard et el., 2001) for assessing caregiver burden, Role Captivity
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Questionnaire (Pearlin 1990 appendix H) for assessing an experience of being captivated in

the caregiving role, Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et

al., 1988) for measuring the caregivers' perceived level of social support, and The Family

Conflict Scale (Semple, 1992) for examining caregivers' role strains in regards to conflicts in

the family dimension . The other two caregivers questionnaire assessed care-receivers'

cognitive state and problematic behaviour: Pearlin's Cognitive Status Scale (1990) for

measuring caregivers' evaluation on the care-receivers'' cognitive level, and Pearlin's

Problematic Behaviour Scale (1990) for assessing caregivers' evaluation on the care-receivers'

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behavioural problems. Additionally, the measures included a socio-demographic questionnaire

for assessing the context characteristics of all participants.

Statistical analysis

The data were analysed using the SPSS and AMOS program with maximum likelihood

estimation statistics. Descriptive statistics (percentages, mean, and standard deviation) were

used to describe participants' socio-demographic characteristics as well as the study's main

variables. To test the study's hypotheses, a two-way mixed-model repeated measures ANOVA

was used to find group differences and differences between facial and body emotion

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recognition accuracy within each group. Pearson correlations, t tests and one-way ANOVAs

were used to examine bi-variate relationship between caregivers' burden, role captivity, family
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cohesion, social support, problematic behaviour, cognitive difficulties, face and body emotion
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recognition and contextual variables. Finally, path analysis was used to examine the model.

Findings

Regarding the study's first aim, results of the study showed that persons with early AD
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were less accurate in recognizing whole body and facial emotional expressions, compared to

healthy elderly, and that persons with MCI were in between both these groups in the number

of errors in their emotion recognition. Moreover, we found that persons with early AD and

MCI were less accurate in recognizing bodily emotional expressions, compared to facial

emotional expressions.

Regarding its second aim the current study showed that: a. As care-receivers'

problematic behaviour increased, caregiver's burden increased. b. An indirect relationship was

found between care-receivers' problematic behaviour and caregiver's burden, through

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caregiver's role captivity as a mediator of the relationship. c. Care-receivers' increased ability

to recognized emotions was associated with caregivers reporting better cognitive functioning

in their relatives. d. The better the care-receiver's behavioural functioning as reported by

caregivers, the higher the level of social support and family coherence they reported receiving.

Theoretical implications

The present study has several important theoretical implications both for the area of

emotion recognition and for the area of caregivers' stress.

Theoretical implications to the area of emotion recognition

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Studies on the deficits that form the neurodegenerative disease symptoms mainly focus

on memory loss, however it is important to study also the “non-memory” deficits such as
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deficits in emotion recognition because they have a dramatic socio-psychological effect in
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terms of the care-receivers' experience. Impaired emotion recognition does not only explain

difficulties experienced subjectively by care-receivers, but in fact it also has consequences in

terms of their significant others' experience. The present study is one of a few studies that
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examined the impact of emotion recognition abilities among people with early cognitive

deterioration on their caregivers, rather than the impact on the care-receivers themselves. The

interest in the impact of emotion recognition deficits which extends beyond the care-receivers

emphasises the theoretical importance of assessing emotion recognition when predicting

burden among caregivers for people with MCI and early AD.

Theoretical implications to the area of caregiver burden

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 The burden that caregivers experience is an outcome of a complex stress process, in

which there are relationships among many conditions. It is important to better understand this

process and predict it, in order to help decrease or even prevent the experience of burden. For

dementia caregivers, the strongest predictors of caregiver burden are primary stressors, such

as the care-receiver's behaviour problems and cognitive deficits (Sörensen & Conwell, 2011).

One of the current study's theoretical implications is that persons with cognitive deterioration

ability to recognize emotions could be conceptualized as an additional primary stressor to be

introduced into Pearlin's (1990) stress process model. Adding emotion recognition items to the

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standard measures of caregivers' reports on care-receivers' cognitive and behavioural problems

may better estimate the needs and risk of both care-receivers and caregivers. Thus, future
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research which seeks to reduce the caregiver stress should consider incorporating the
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assessment of emotion recognition as a condition associated with behaviour and cognitive

problems of dementia.

Moreover, emotion recognition, as measured objectively, improved the explaining

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power of the model which consists of mainly subjective measures. Indeed, many other studies

(Bangerter, Liu, & Zarit, 2017; Tornal & Martínez, 2017) which explored Pearlin's model

(1990) incorporated objective measures in combination with the original subjective measures

of the model.

Practical implications

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 Several practical implications can be derived from the findings of the current study:

Practical implications to the area of emotion recognition

Given the current study's finding regarding care-receivers' difficulties in recognizing

bodily emotional expressions, work with persons with MCI and early AD should direct

rehabilitation interventions to improve not just facial emotion recognition deficits (García-

Casal et al., 2017) but to improve recognizing bodily emotional expression as well.

Moreover, psychosocial interventions aimed at supporting informal caregivers should

suggest caregivers practical ways in which to deal with care-receivers' bodily emotion

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recognition deficits, such as teaching caregivers how to emphasise their own non-verbal facial

and body emotional cues in order to make it easier for care-receivers to ‘read’ facial and
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bodily expressions correctly and decrease their own burden concomitantly. Such an
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intervention could be supported by Atkinson's et al.'s (2004) finding that exaggerating bodily

emotional expressions increases the recognisability of the expressed emotion and its rated

intensity.
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Practical implications to the area of caregiver burden

It is important that the emotional support which is provided to informal caregivers will

acknowledge the centrality of the care-receivers' deficits to recognize emotions in their

interaction with their family caregivers. Therapeutic work and support programs should make

sure the caregivers understand these deficits' origin and their influence. Caregivers' increased

awareness to this problem might better prepare them for the potential changes in their

relationship with the care-receivers and consequently improve their quality of care. This

implication is in line with the ageing-in-place care policy (Andrews & Phillips, 2004;

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Iecovich, 2014) which encourages caregivers to lean on their families as a main source of

support and allows people with dementia to age in a homecare setting.

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 List of Tables

Table 1 Participants' socio-demographic characteristics .............................................. 32

Table 2 Mean (SD) and percent of care-receivers recognizing emotions adequately by

mode of assessment (facial/body)............................................................................................. 44

Table 3 Mean (SD) of the stress model's main variables ............................................. 45

Table 4 ANOVA findings regarding facial and bodily emotion recognition among

participants with early AD (n = 75), MCI (n = 75), and healthy controls (n = 40) .................. 47

Table 5 ANOVA findings regarding facial and bodily emotion recognition among

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participants with early AD (n = 75) and MCI (n = 75) ............................................................ 48

Table 6 Pearson correlations coefficients between care receivers' primary stressors and
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caregivers' burden (n care-receivers = 150, n caregivers = 150) .............................................. 49
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Table 7 Pearson correlations coefficients between primary stressors and caregivers'

role captivity (n care-receivers = 150, n caregivers = 150) ...................................................... 51

Table 8 Bi-variate associations between caregivers' socio-demographic characteristics

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and caregivers' social support (n = 150) ................................................................................... 53

Table 9 Pearson correlations coefficients between caregivers' role captivity, family

conflicts, burden, care-receivers' primary stressors and caregivers' social support (n care-

receivers = 150, n caregivers = 150) ........................................................................................ 54

Table 10 Pearson correlations coefficients between care receivers' primary stressors

and caregivers' family conflicts (n care-receiver = 150, n caregivers = 150)........................... 55

Table 11 Bivariate associations between caregivers' socio-demographic characteristics

and care- receivers' emotion recognition (n care-receiver = 150, n caregivers = 150) ............ 57

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 List of figures

Figure 1 - Theoretical model for aim 2 ........................................................................ 25

Figure 2 – Examining the theoretical model ................................................................ 59

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 1. Introduction

In light of recent demographic changes, the population of older people is on the rise, as is

the number of people with dementia (Prince, Comas-Herrera, Knapp, Guerchet, &

Karagiannidou, 2016). These changes go hand in hand with an increase in the number of people

who care for people with dementia. Family members, and mostly spouses and adult children

serve as the main caregivers of persons with dementia (Wolff et al., 2017). Those who become

main caregivers for ill older people, often experience major life changes and personal sacrifices,

which lead to increased burden and distress (Colvin & Bullock, 2016; Garlo, O’Leary, Ness, &

Fried, 2010), and to worsening physical and psychological health (Richardson, Lee, Berg-Weger,

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& Grossberg, 2013). Therefore, it is important to understand what are the factors associated with

this burden in order to try to reduce it.

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Indeed, caregiver's burden has been a subject discussed in myriad studies, mostly using
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Pearlin's conceptual model of caregivers' stress (Leonard I Pearlin, Mullan, Semple, & Skaff,

1990). Pearlin's stress process attends to the relationships among the many conditions leading to

personal stress amidst caregivers of people with Alzheimer's disease (AD). Four domains make
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up this process: the background and context of stress; the stressors; the mediators and moderators

of stress; and the outcomes of stress.Various objective and subjective sources of stress were

shown to predict the outcome of increased caregiver burden, such as care-receivers' problematic

behaviour (Mohamed, Rosenheck, Lyketsos, & Schneider, 2010) and caregivers' sense of being

captured in their care giving role (P. Campbell et al., 2008). While the literature examining the

factors associated with caregiver burden is abundant (Gilhooly et al., 2016), further examination

of the concept and the need to identify additional correlates that will help increase its

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understanding and impact, has been noted (Sörensen & Conwell, 2011). The ability of people

with dementia to correctly recognize emotions might be such a correlate.

The rationale for examining care-receivers' emotion recognition as a correlate of

caregiver's burden stemmed from two main interrelated reasons: First, it has been shown that the

ability to correctly recognize nonverbal cues of emotion expressions is impaired in both persons

with Mild Cognitive Impairment (MCI) and with early AD (Klein-Koerkamp, Beaudoin, Baciu,

& Hot, 2012; Spoletini et al., 2008; Weiss et al., 2008). Second, deficits in the care-receivers'

ability to recognize other persons' expression of emotions can make the interaction between the

caregiver and the care-receiver very difficult (Nelis et al., 2011; Shimokawa et al., 2001), which

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might increase the stress and burden associated with the caregiving role.

It is interesting, therefore, that over the years, there have been only a few studies (Daley,
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Sugarman, Shirk, & O'Connor, 2017; Greve, Cadieux, & Hale, 1995; McCade et al., 2013; Miller
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et al., 2013) which examined the correlation between emotion recognition among persons with

AD and MCI, and caregiver's burden. Most of these studies (Greve et al., 1995; McCade et al.,

2013; Miller et al., 2013) found that care-receivers' deficits in emotion recognition increase
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significantly caregivers' burden, while one study (Daley et al., 2017) had opposite results: they

found that spared emotion recognition increases caregivers' burden. Despite the importance of

these studies, their findings are limited because they were not based on a theoretical model, did

not examine recognition of emotion from dynamic facial expressions or from body expressions,

and each explored the question in only one population on the cognitive continuum - Daley et al.,

2017; Greve et al., 1995; and Miller et al., 2013 explored AD, McCade et al., 2013 explored MCI

- but did not compare the two populations.

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 The current study intended to expand the knowledge gained in this area by being the first

to examine how emotion recognition from body compared to facial expressions among persons

with cognitive deterioration was associated with their caregiver's burden using Pearlin's

theoretical framework of caregivers' stress. Furthermore, the current study was unique in

including both persons with MCI and early AD, and in using an ecologically valid measure of

dynamic facial and bodily expressions for testing emotion recognition. A better understanding of

how emotion recognition deficits impact caregivers could yield useful insights toward improving

informal care.

Therefore, the present study had two main aims: The first was to assess emotion

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recognition across different levels of cognitive functioning by comparing recognition from two

modes of emotional expressions – through the face and through the body – among healthy elderly
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persons, persons with MCI and persons with early AD. The second aim was to examine for the
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first time how the ability to recognize others' facial and bodily emotional expressions among

persons with MCI and early AD uniquely contributes to the explanation of caregiver's burden

within the framework of Pearlin's Stress Process Model (Leonard I Pearlin et al., 1990).
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The literature review will start with a presentation of the concepts of AD and MCI, will

continue with exploring care-receiver's emotion recognition abilities and family caregiver's

burden and finally will present the study's hypotheses.

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 2. Literature review

2.1 Dementia, Alzheimer’s Disease (AD) and Mild Cognitive Impairment (MCI)

Dementia is an inclusive term, which refers to a group of neurological disorders that are

characterized by decreased cognitive and functional abilities. Most types of dementias are

progressive and degenerative (Gaugler, James, Johnson, Scholz, & Weuve, 2013). To date, it is

estimated that there are at least 47 million persons with dementia worldwide (Prince et al., 2016).

While Alzheimer’s disease (AD) is the most common form of dementia in older persons and

contributes to 60-70% of all dementia cases, there are other types of dementia, including vascular

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dementia, frontal lobe dementia or Lewy Body dementia (Alzheimer's Association, 2017).

In the early stages of AD the main symptoms such as memory loss, are still mild (Aisen et
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al., 2017), but as the disease progresses persons with AD gradually lose memory and thinking

skills, manifest depressive symptoms and deficits in attention, language, spatial orientation and
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visuo-spatial function, and eventually lose the ability to carry out simple tasks of daily living.

Today, there is no cure for AD but appropriate social and medical care can slow down the
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progress of the disease and increase the quality of patients’ life (Prince et al., 2016).

The yearly cost of caring for people with AD and other dementias in the United States

was estimated to be $203 billion per year, and this amount is projected to increase to $1.2 trillion

per year by 2050 (Gaugler et al., 2013). Thus, extensive efforts are invested in increasing the

early detection of the disease. The benefit of early detection in AD is that medications can

improve some of the symptoms and slow down the progression of the disease, and from a global

burden perspective, even small delays in the onset and progression of AD can significantly

reduce the costs which are associated with this world epidemic (Brookmeyer, Johnson, Ziegler-

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Graham, & Arrighi, 2007). Thus, expanding the knowledge about the early recognition of

dementia in general, and about Mild Cognitive impairment (MCI) - in particular, is one of the

latest developments in the area of cognitive deterioration.

MCI is characterized by a newly acquired decrease in cognitive functioning that is greater

than expected in relation to the person's education and age, and the cognitive deficits do not

interfere with capacity for daily living functioning (American Psychiatric Association, 2013).

Approximately 15 to 20 percent of older people (age 65 or over) have MCI (R. Roberts &

Knopman, 2013). Only a portion of those with MCI go on to meet dementia diagnostic criteria

over the medium term of their disease and the majority remain MCI (Alzheimer's Association,

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2017). However, systematic reviews found that people with MCI have an increased risk of

developing dementia as compared to cognitively normal individuals: approximately a third of

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individuals with MCI develop AD within 5 years (Cooper, Sommerlad, Lyketsos, & Livingston,
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2015) . Therefore, while there is currently no consensus suggesting that early detection and

treatment of MCI will reduce and prevent the onset of dementia, some studies have shown that

early clinical diagnosis of MCI can help individuals to plan for the future, and to get prescribed
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medications which inhibit the symptoms (Roberts, Karlawish, Uhlmann, Petersen, & Green,

2010).

2.1.1 MCI and AD diagnosis

MCI is a new addition to the latest edition of the Diagnostic and Statistical Manual of

Mental Disorders (2013) (DSM-5). In the guideline, MCI is diagnosed when there is evidence for

a modest cognitive decline from a previous level of performance in at least one cognitive domain

(such as learning and memory). The evidence is based on an objective demonstration of cognitive

deficits (cognitive test) and also relies on the individual and/or a family member's report as well

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as on the clinician's judgment. Moreover, the cognitive deficits do not interfere with the

individual's capacity for independence in everyday activities (such as paying bills), they do not

occur exclusively in the context of a delirium and they are not better explained by another mental

disorder (for example, by major depressive disorder).

According to DSM-5 (2013) AD is diagnosed when there is a gradual progression of

impairment in at least one cognitive domain for mild AD and at least two domains for major AD,

one of which should be learning and memory. For both mild and major AD there are two

categories: possible and probable. The presence of a causative AD genetic mutation or the

absence of evidence for another disease (mixed aetiology) increase the certainty of the diagnosis

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to ‘probable’ in the case of major AD. Otherwise, 'possible' major AD should be diagnosed. For

mild AD, a ‘probable’ diagnosis is only reached if there is evidence of a causative AD mutation,
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and a ‘possible’ diagnosis requires the typical features of decline in memory and learning, steady
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progression and no mixed aetiology. The current study focused on mild (early) AD.

2.1.2 Pathology in AD and MCI

AD is the result of tissue loss and nerve cell death throughout the brain. Over time, the
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brain shrinks acutely, affecting nearly all its functions. There is no clear answer for the causes of

cell death and tissue loss in the brain, but it is suspected that they are instigated by two processes:

abnormal clusters of protein fragments build up between nerve cells, termed plaques, and dying

of nerve cells which contain twisted strands of another protein: termed tangles. The enthorinal

cortex and the hippocampus which are associated with memory and emotion are the first main

parts that get damaged in AD (Alzheimer's Association, 2017; Bloom, 2014).

Studies showed that the Default Mode Network (DMN) is also damaged in AD. The

DMN is a network of brain regions responsible for cognitive processes in a rested wakeful state,

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such as visualizing the future, recalling autobiographical memories and understanding the

perspective of others (Buckner, Andrews-Hanna, & Schacter, 2008). The DMN includes the

posterior hippocampal, cingulo-temporal and parietal regions, and it supports various cognitive

processes, visuospatial abilities and episodic memory, all functions which are damaged in AD.

The damage to episodic memory, which is the ability to encode and retrieve our daily personal

experiences (Dickerson & Eichenbaum, 2010), contributes to the amnesic symptoms seen in AD.

Visuospatial deficits entail impaired ability to identify stimulus and its location, and they are

mainly due to pathology in the spatial orientation and vision-related brain areas such as the

parieto-occipital junction (Quental, Brucki, & Bueno, 2009).

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MCI is the result of a wide range of cellular dysregulations that happen prior to, and

during the disease process. There may be multiple pathological entities that urge the outbreak of
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MCI, such as traumatic brain injury, AD or other dementia types (American Psychiatric
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Association, 2013). Nevertheless, MCI is the result of the same plaques and tangles processes

that occur in AD, but it is also the result of a neuronal hyperactivity syndrome which damages

neurons and synapses (the junctions between two nerve cells) and includes a varied span of
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cellular, biochemical and molecular deficits (Haberman, Branch, & Gallagher, 2017; Stargardt,

Swaab, & Bossers, 2015).

Disruptions in emotional, cognitive, and social behaviour are common in neuro-

degenerative disease and deficits in the ability to recognize the other's emotion expressions is one

of the debilitating characteristics of MCI and AD. Hence the next chapter will discuss issues

regarding to emotion recognition, first in a general manner and then specifically in relation to

MCI and early AD.

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2.2 Emotion Recognition

Accurately recognizing basic emotions in others is seen as a critical human ability and a

key for social interaction (Schlegel, Fontaine, & Scherer, 2017). Being able to correctly interpret

what others are feeling provides invaluable clues as to their intentions and what could be an

appropriate response, and allows us to predict disagreements and avoid conflicts (Siegel, 2015).

Deficits in emotion recognition abilities increase with older age (Halberstadt, Ruffman, Murray,

Taumoepeau, & Ryan, 2011; Kessels, Montagne, Hendriks, Perrett, & Haan, 2014; Ruffman,

Sullivan, & Dittrich, 2009) and have practical implications because they impair communication

with others and might therefore result in inadequate social interactions (McCade, Savage, &

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Naismith, 2012), reduced independence and impaired normal daily functioning (Szanto et al.,

2012). The decline in the ability to decipher emotional cues in healthy older adults often stems
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from age-related brain changes which affect information processing, however the exact
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mechanism underlying such decline is not well understood (Campbell, Ruffman, Murray, &

Glue, 2014; Ruffman, Henry, Livingstone, & Phillips, 2008). Thus, late adulthood is clearly

affected by emotion recognition deficits, and the deficits are shown to be evident across all
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emotion recognition task types (Ruffman et al., 2008), whether the affective processes that are

recruited are cognitive (Bernstein, Thornton, & Sommerville, 2011) or perceptual (Insch, Slessor,

Phillips, Atkinson, & Warrington, 2015; Pollux, Hermens, & Willmott, 2016).

2.2.1 Measuring emotion recognition

The tests that measure emotion recognition abilities differ between tasks that place a

cognitive load on, for example the working memory and comprehension, and between tasks that

might be more purely perceptual. In social cognition theory, emotion recognition is seen as one of

the compounds in our abilities to respond to emotional cues (Shamay-Tsoory, 2009), therefore a

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 social cognition task would involve testing the participant's understanding of the other person’s

point of view or perspective. For example, in False-belief tasks the participants are told stories

and then questioned to check if they understand that others may have different emotions or

mental states from themselves (Freedman, Binns, Black, Murphy, & Stuss, 2013). A perceptual

emotion recognition task for example would be facial affect matching task (participants need to

match a target expression to one of several alternative expressions) (Palermo, O’Connor, Davis,

Irons, & McKone, 2013) or facial affect discrimination task (looking at pairs of facial

photographs, one has to indicate whether the expressions shown are of the same or different

emotion) (Gunning-Dixon et al., 2003). The different tasks (social cognition tasks and perceptual

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emotion recognition tasks) reveal deficits in different processes: Low performance in perceptual

emotion recognition tasks will demonstrate damage in the ability to perceive an emotion when
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viewing actions of others, whereas low performance in social cognition will show damage in the
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ability to understand the context for the feeling (Why is the other person happy?) (De Waal,

2008; Shamay-Tsoory, Aharon-Peretz, & Perry, 2009). Because the present study investigated the

ability to recognize emotion among people with cognitive deterioration, a perceptual emotion
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recognition task (rather than social cognition) was selected as the suitable emotion recognition

task. This way we secured that inability to succeed in the task demonstrated damage in the ability

to perceive the other's emotions rather than the cognitive ability to understand the context of the

emotion.

2.2.2 Emotion recognition from facial and bodily expressions

While emotional information can be perceived through different modes of perception

(such as visual, auditory), the visual perception of emotions occurs mainly from facial and bodily

expressions. Indeed, most research on emotion recognition in non-clinical adults has been done

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