This prospective cohort study (n=965 ALS patients) examined whether premorbid behavioral regulation traits and socio-educational factors (education, occupation, Social Interaction Index) are associated with behavioral impairment in ALS, using a behavioral reserve framework. Behavioral outcomes were measured with the FrSBe (family-rated) and, in a subset (n=633), the ECAS-CI.
Premorbid behavioral regulation was the strongest predictor of behavioral impairment across all FrSBe models. Higher combined educational attainment and social exposure were associated with lower odds of behavioral impairment, with a significant interaction across multiple behavioral domains. Reserve proxies were not significantly associated with ECAS-CI total impairment, though domain-specific effects were seen.
Causal inference is limited by the observational design. Premorbid behavioral estimates may be subject to retrospective bias, despite sensitivity analyses. The ECAS-CI subset (n=633) may not fully represent the broader cohort.
In ALS, patients with lower premorbid behavioral regulation or limited education and social engagement may be at higher risk for behavioral impairment — consider early behavioral risk stratification in these individuals. Clinicians should assess socio-educational history as part of non-motor profiling in ALS.
