Midlife cardiovascular risk factors and risk of dementia in late life

Insulin in combination with other diabetes medication is associated with less Alzheimer neuropathology

OBJECTIVE

To examine the association between treatment for diabetes and Alzheimer disease (AD) neuropathology.

METHODS

This postmortem study matched 124 subjects with diabetes to 124 without diabetes from the Mount Sinai School of Medicine Brain Bank, on age (mean = 81.2 + 9.3), sex (57.3% F), and severity of dementia (Clinical Dementia Rating [CDR] 2.4 + 1.7). Densities of neuritic plaques (NPs) and of neurofibrillary tangles (NFTs) were assessed in several neocortical regions and in the hippocampus, entorhinal cortex, and amygdala. Diabetic subjects were classified according to their recorded lifetime antidiabetic medications: none (n = 29), insulin only (n = 49), diabetes medications other than insulin only (n = 28), or concomitant use of both insulin and any oral antidiabetic medications (n = 18). For each dependent variable, analysis of covariance controlling for age at death, sex, and CDR distinguished among the nondiabetic patients and four diabetic subgroups.

RESULTS

There were differences among the five groups for NP ratings in the entorhinal cortex (p = 0.003), amygdala (p = 0.009), and overall NP (p = 0.014) as well as counts of NPs in all regions examined (p values ranging from 0.009 to 0.04). NP ratings in the hippocampus (p = 0.057) and the combined neocortical measure (p = 0.052) approached significance. In each analysis, the concomitant medication group had significantly fewer NPs (approximately 20%) than any of the other groups, which were relatively similar. No significant NFT differences were found.

CONCLUSION

The results of this study suggest that the combination of insulin with other diabetes medication is associated with substantially lower neuritic plaque density consistent with the effects of both on the neurobiology of insulin.

Vascular health risks and fMRI activation during a memory task in older adults

Vascular problems increase Alzheimer's disease (AD) risk, but the nature of this relationship remains unclear. Older adults having genetic risk for AD show regionally increased functional magnetic resonance imaging (fMRI) activity during memory, possibly representing compensation for a genetically induced neural deficit. We investigated whether vascular health risks, which similarly could lead to neuropsychological deficits, also showed increased fMRI activity during a memory task performed by 30 cognitively intact, primarily normotensive older adults (mean age=61). Vascular risk measures included systolic blood pressure (sBP), body mass index (BMI), and total cholesterol. Higher sBP and BMI (but not total cholesterol) were significantly correlated with increased activation in posterior cingulate cortex and frontal, temporal, and parietal regions. In posterior cingulate and parietal cortices, these relationships were evident even within sBP and BMI ranges considered normal, and were independent of hippocampal volume. Our results are similar to those in prior AD risk research, and suggest that fMRI reveals an abnormal response to cognitive processes in cognitively intact older adults with increased vascular risk.

Type 2 diabetes mellitus, hypertension, dyslipidemia and obesity: A systematic comparison of their impact on cognition

Vascular risk factors, such as type 2 diabetes mellitus, hypertension, dyslipidemia and obesity, have been associated with an increased risk of cognitive dysfunction, particularly in the elderly. The aim of this systematic review was to compare these risk factors with regard to the nature and magnitude of the associated cognitive decrements. Cross-sectional and longitudinal studies that assessed cognitive functioning in non-demented persons in relation to diabetes/impaired glucose metabolism (k = 36), hypertension (k = 24), dyslipidemia (k = 7) and obesity (k = 6) and that adjusted or matched for age, gender and education were included. When possible, effect sizes (Cohen's d) were computed per cognitive domain. Diabetes and hypertension were clearly associated with cognitive decrements; the results for obesity and dyslipidemia were less consistent. Effect sizes were moderate (median approximately -0.3) for all risk factors. Decline was found in all cognitive domains, although the effects on cognitive speed, mental flexibility and memory were most consistent. Methodological aspects of included studies and implications of these findings are discussed.

Baseline serum cholesterol is selectively associated with motor speed and not rates of cognitive decline: the Women's Health and Aging Study II

BACKGROUND

Although several studies have investigated the association between cholesterol and dementia, few have examined cholesterol and decline across cognitive domains. We examined serum total and high-density lipoprotein (HDL) cholesterol, total-to-HDL ratio, and trajectories across cognitive domains.

METHODS

Participants were 436 community-residing women (70-79 years old) in the Women's Health and Aging Study II; they were screened to be physically high-functioning and cognitively intact at baseline. Cognition and other health-related variables were assessed at five intervals spanning 9 years. Cognitive assessments included Trail Making Test Parts A (TMT-A) and B (TMT-B), Hopkins Verbal Learning Test-Revised, Purdue Pegboard, and Mini-Mental State Examination (MMSE). The association between baseline levels of serum lipids and cognitive trajectories were evaluated using Generalized Estimating Equations (GEE). Covariates included age, education, race, vascular disease, serum creatinine, depression, and lipid-lowering medications.

RESULTS

In multivariate analyses, baseline higher total (p =.02) and HDL (p =.03) cholesterol were associated with better performance on the Purdue Pegboard. Using clinical cholesterol cutoffs, baseline serum total cholesterol levels >240 mg/dL were associated with the best performance (p =.02). Baseline lipids were not associated with any other cognitive tests; there were no Lipid x Time interactions.

CONCLUSION

Higher baseline serum lipid levels predicted better performance over time on a measure of motor speed, but not memory or psychomotor or executive functioning in this population of elderly women. This association suggests that peripheral cholesterol levels, measured in late-life, may not be a good predictor of subsequent cognitive decline. Future research examining peripheral cholesterol over the life span and its relationship with cognition is needed.

The Atorvastatin/Donepezil in Alzheimer's Disease Study (LEADe): design and baseline characteristics

BACKGROUND

Growing evidence suggests that elevated cholesterol levels in mid-life are associated with increased risk of developing Alzheimer's disease (AD), and that statins might have a protective effect against AD and dementia. The Lipitor's Effect in Alzheimer's Dementia (LEADe) study tests the hypothesis that a statin (atorvastatin 80 mg daily) will provide a benefit on the course of mild to moderate AD in patients receiving background therapy of a cholinesterase inhibitor (donepezil 10 mg daily).

METHODS

This is an international, multicenter, double-blind, randomized, parallel-group study with a double-blind randomized withdrawal phase of patients with mild to moderate AD (Mini-Mental State Examination [MMSE] score, 13 to 25). Inclusion criteria included age 50 to 90 years, receiving donepezil 10 mg for at least 3 months before randomization, and low-density lipoprotein cholesterol levels (LDL-C) 2.5 to 3.5 mmol/L (95 to 195 mg/dL). Co-primary end points are changes in AD Assessment Scale-cognitive subscale (ADAS-cog) and AD Cooperative Study-Clinical Global Impression of Change (ADCS-CGIC) scale scores. A confirmatory end point is rate of change in whole brain and hippocampal volumes in patients who enrolled in the magnetic resonance imaging substudy.

RESULTS

Enrollment of 641 subjects is complete. The baseline mean data are age 74 +/- 8 years, 53% women, MMSE 22 +/- 3, ADAS-cog 23 +/- 10, AD Functional Assessment and Change Scale (ADFACS) 13 +/- 9, Neuropsychiatric Inventory (NPI) 10 +/- 11, and Clinical Dementia Rating-Sum of Boxes (CDR-SB) 6 +/- 3. Mean prior donepezil treatment was 409 +/- 407 days. Mean baseline lipid levels are total cholesterol 5.8 +/- 0.8 mmol/L (224 +/- 33 mg/dL), LDL-C 3.7 +/- 0.7 mmol/L (143 +/- 26 mg/dL), triglycerides 1.5 +/- 0.7 mmol/L (132 +/- 64 mg/dL), and high-density lipoprotein cholesterol 1.6 +/- 0.5 mmol/L (64 +/- 18 mg/dL).

CONCLUSIONS

LEADe will report in 2008 and is expected to provide a more definitive evaluation of the potential for statins in the treatment of people with AD.

Alpha7 nicotinic acetylcholine receptor expression by vascular smooth muscle cells facilitates the deposition of Abeta peptides and promotes cerebrovascular amyloid angiopathy

Deposition of beta-amyloid (Abeta) peptides in the walls of brain blood vessels, cerebral amyloid angiopathy (CAA), is common in patients with Alzheimer's disease (AD). Previous studies have demonstrated Abeta peptide deposition among vascular smooth muscle cells (VSMCs), but the source of the Abeta and basis for its selective deposition in VSMCs are unknown. In the present study, we examined the deposition patterns of Abeta peptides, Abeta40 and Abeta42, within the cerebrovasculature of AD and control patients using single- and double-label immunohistochemistry. Abeta40 and Abeta42 were abundant in VSMCs, especially in leptomeningeal arteries and their initial cortical branches; in later-stage AD brains this pattern extended into the microvasculature. Abeta peptide deposition was linked to loss of VSMC viability. Perivascular leak clouds of Abeta-positive material were associated primarily with arterioles. By contrast, control brains possessed far fewer Abeta42- and Abeta40-immunopositive blood vessels, with perivascular leak clouds of Abeta-immunopositive material rarely observed. We also demonstrate that VSMCs in brain blood vessels express the alpha7 nicotinic acetylcholine receptor (alpha7nAChR), which has high binding affinity for Abeta peptides, especially Abeta42. These results suggest that the blood and blood-brain barrier permeability provide a major source of the Abeta peptides that gradually deposit in brain VSMCs, and the presence and abundance of the alpha7nAChR on VSMCs may facilitate the selective accumulation of Abeta peptides in these cells.

Metabolic syndrome and Alzheimer's disease: a link to a vascular hypothesis?

Current evidence from epidemiological, neuroimaging, pathological, pharmacotherapeutic, and clinical studies indicate an association of Alzheimer's disease with risk factors of vascular atherosclerotic disease either in isolation or in aggregate. "Metabolic syndrome" (MetS) is the name for a clustering of risk factors for cardiovascular disease and type 2 diabetes that are of metabolic origin. These include central obesity, elevated plasma glucose, high blood pressure, atherogenic dyslipidemia, a prothrombotic state, and a proinflammatory state. In this article, we provide an overview of the relevant literature with regard to the relationship of Alzheimer's disease with MetS. Accumulating evidence suggests a "vascular hypothesis" to be related to the pathology of Alzheimer's disease. In the light of this evidence, clinician may consider lifestyle interventions toward an early and effective cardiovascular risk-factor management to reduce the cardiometabolic and the cognitive decline risk, while further research of other preventive strategies may be warranted.

Kidney function and cognitive impairment in US adults: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

The association between kidney function and cognitive impairment has not been assessed in a national sample with a wide spectrum of kidney disease severity.

STUDY DESIGN

Cross-sectional.

SETTING & PARTICIPANTS

23,405 participants (mean age, 64.9 +/- 9.6 years) with baseline measurements of creatinine and cognitive function participating in the REasons for Geographic And Racial Differences in Stroke (REGARDS) Study, a study of stroke risk factors in a large national sample.

PREDICTOR

Estimated glomerular filtration rate (eGFR).

OUTCOME

Cognitive impairment.

MEASUREMENTS

Chronic kidney disease (CKD) was defined as eGFR less than 60 mL/min/1.73 m(2). Kidney function was analyzed in 10-mL/min/1.73 m(2) increments in those with CKD, and in exploratory analyses, across the range of kidney function. Cognitive function was assessed using the 6-Item Screener, and participants with a score of 4 or less were considered to have cognitive impairment.

RESULTS

CKD was associated with an increased prevalence of cognitive impairment independent of confounding factors (odds ratio, 1.23; 95% confidence interval, 1.06 to 1.43). In patients with CKD, each 10-mL/min/1.73 m(2) decrease in eGFR less than 60 mL/min/1.73 m(2) was associated with an 11% increased prevalence of impairment (odds ratio, 1.11; 95% confidence interval, 1.04 to 1.19). Exploratory analyses showed a nonlinear association between eGFR and prevalence of cognitive impairment, with a significant increased prevalence of impairment in those with eGFR less than 50 and 100 mL/min/1.73 m(2) or greater.

LIMITATIONS

Longitudinal measures of cognitive function were not available.

CONCLUSIONS

In US adults, lower levels of kidney function are associated with an increased prevalence of cognitive impairment. The prevalence of impairment appears to increase early in the course of kidney disease; therefore, screening for impairment should be considered in all adults with CKD.

Classifying late-onset dementia with MRI: is arteriosclerotic brain degeneration the most common cause of Alzheimer's syndrome?

Our aim was to use early magnetic resonance imaging (MRI) to investigate the causes of cognitive decline in elderly people with mild cognitive impairment (MCI). Baseline structural and flow quantification MR sequences, and clinical and neuropsychological follow-up for at least two years, were performed on 62 elderly subjects with MCI. Of these subjects, 17 progressed to dementia, and 15 of these progressed to dementia of the Alzheimer type (DAT). Conversion to clinically diagnosed DAT was related to six distinct MR profiles, including one profile suggesting severe AD (20% of these converters) and five profiles suggesting severe cerebrovascular dysfunction. Two profiles suggested arteriosclerotic brain degeneration, one profile suggested severe venous windkessel dysfunction, and two suggested marked cerebral hypoperfusion associated with very low craniospinal compliance or marked brain atrophy. As compared with vascular MR type converters, AD MR type converters showed high executive and mobility predementia performances. Severe whole anteromesial temporal atrophy and predominantly left brain atrophy on visual MR analysis was only observed in AD MR type converters. In conclusion, these observations enhance the pathogenic complexity of the Alzheimer syndrome, and suggest that the role of arteriosclerotic brain degeneration in late life dementia is underestimated.

Risk factors for dementia in a rural area of Northeastern Brazil

OBJECTIVE: To identify risk factors for dementia among the elderly in a rural area of Northeastern Brazil. METHOD: The subjects assessed were all 60 years old or older, and lived in a rural region of Bahia, a Northeastern State of Brazil. CAMDEX, a structured clinical evaluation protocol, was used for diagnosis, and applied at the home of the subjects. RESULTS: The risk factors identified were divided in accordance with socio-demographic characteristics, the presence of co-morbid conditions, and the use of medications. The variables with strong association with dementia were age, history of stroke, arterial hypertension, and sight impairment. CONCLUSION: Advanced age, arterial hypertension, and vascular brain injury were the main risk factors associated with dementia, which suggests that public health measures adopted to prevent and control modifiable risk factors can mitigate the prevalence of high rates of dementia.

Adiposity, hyperinsulinemia, diabetes and Alzheimer's disease: an epidemiological perspective

The objective of this manuscript is to provide a comprehensive review of the epidemiologic evidence linking the continuum of adiposity, hyperinsulinemia, and diabetes with Alzheimer's disease. The mechanisms for these associations remain to be elucidated, but may include direct actions from insulin, advanced products of glycosilation, cerebrovascular disease, and products of adipose tissue metabolism. Elevated adiposity in middle age is related to a higher risk of Alzheimer's disease. The evidence relating adiposity in old age to Alzheimer's disease is conflicting. Several studies have shown that hyperinsulinemia, a consequence of higher adiposity and insulin resistance, is also related to a higher risk of Alzheimer's disease. Hyperinsulinemia is a risk factor for diabetes, and numerous studies have shown a relation of diabetes with higher Alzheimer's disease risk. Most studies fail the take into account the continuum linking these risk factors which may result in underestimation of their importance in Alzheimer's disease. The implication of these associations is that a large proportion of the world population may be at increased risk of Alzheimer's disease given the trends for increasing prevalence of overweight, obesity, hyperinsulinemia, and diabetes. However, if proven causal, these associations also present a unique opportunity for prevention and treatment of Alzheimer's disease.

Diabetes and other vascular risk factors for dementia: which factor matters most? A systematic review

Vascular risk factors, such as type 2 diabetes, hypertension, obesity and dyslipidaemia often co-occur. Each of these factors has been associated with an increased risk of dementia, but it is uncertain which factor imposes the greatest risk. Moreover, the effect of age at time of exposure may differ across factors. This paper systematically reviews the evidence for the association of each of these risk factors with dementia. Longitudinal population-based studies that assessed the incidence of dementia in relation to diabetes (n=14), hypertension (n=13), dyslipidaemia (n=8) or obesity (n=9) were included. All four risk factors were indeed associated with an increased risk of dementia, but the results of studies on diabetes and obesity were most consistent. The magnitude of the effects was comparable across the risk factors, with odds ratios for 'any dementia' around 1.5. For hypertension, obesity and dyslipidaemia age appeared to modulate the association: the risk of dementia was generally largest in studies that measured the risk factor in midlife (compared to late life) and had a long follow-up time. At midlife, the population attributable risk of dementia was highest for hypertension, up to 30% of cases of late life dementia. Later in life diabetes appears to convey the highest risk of dementia. This review shows that vascular risk factors should be regarded as a major target for preventive measures, but that timing of such measures appears to be critical.

High-Normal Blood Pressure Is Associated With Poor Cognitive Performance

While the relation between systolic blood pressure (SBP) and vascular events is linear down to the high-normal range, the relation between SBP and cognition is less clear. We cross-sectionally assessed the relation between SBP and cognition in a cohort extending from mid- to late-life. From a total of 2200 community-dwelling individuals we recruited 377 aged 44 to 82 years (median: 64 years, 171 male) in the SEARCH-Health study (Systematic evaluation and alteration of risk factors for cognitive health). Participants were studied with a comprehensive neuropsychological test battery that provided, based on principal component analysis, 5 composite scores for cognition (learning and memory, attention and executive function, spatial skills, working memory, and verbal skills). Global cognition was calculated from the sum of the composite scores. SBP (corrected R 2 =0.007), education (corrected R 2 =0.203), age (corrected R 2 =0.102), and gender (corrected R 2 =0.011) explained one third of variance in global cognitive performance ( P <0.001) on multivariate analyses. Moreover, the relation between SBP (based on 10 mm Hg-categories from <120 mm Hg to >170 mm Hg) and global cognitive performance was linear in this range of SBP-values, ie, even in the normotensive range (β=−0.110, P <0.05). Subgroup analysis showed that the association of SBP and cognition was driven by results in midlife (<60 years) individuals (β=−0.291, P <0.005). Thus, even in the normotensive range increasing systolic blood pressure is inversely related to cognition.

Angiotensin converting enzyme inhibitors and cognitive and functional decline in patients with Alzheimer's disease: an observational study

We previously reported that angiotensin converting enzyme inhibitors (ACEIs) decrease the rate of cognitive decline in elderly patients with hypertension, but their impact on patients with Alzheimer's disease (AD) is not known. A total of 62 elderly patients with AD were enrolled, and 52 completed the study for 6 months. Mini-Mental Status Examination (MMSE), Clock Draw Test (CDT), working memory (Digit Ordering), Instrumental Activities of Daily Living (IADL) scale, and the Screen for Caregiver Burden (SCB) were collected at baseline, 3 months, and 6 months. AD patients receiving ACEI (N = 15) demonstrated a slower rate of decline in digit forward (P = .003) and IADL scale (P = .003) and an improved measure of caregiver burden (P = .04) but not MMSE (P =.15) or CDT (P =.9) compared with those not receiving ACEI after adjusting for other risk factors. This study suggests that use of ACEI in AD patients is associated with slower rate of AD progression. A randomized clinical trial is needed to confirm our finding.

Increased glucose levels are associated with episodic memory in nondiabetic women

OBJECTIVE

Patients with type 2 diabetes have an increased risk of a reduction in cognitive function. We investigated the hypothesis that plasma glucose is associated with a reduction in episodic and/or semantic memory already in nondiabetic subjects.

RESEARCH DESIGN AND METHODS

We linked two large population-based datasets in Sweden: the Betula study, in which a random sample from the population aged 35-85 years was investigated for cognitive function, including episodic and semantic memory; and the Västerbotten Intervention Program, a health survey with subjects aged 40, 50, and 60 years, that includes measuring of fasting and 2-h plasma glucose, along with other risk factors for diabetes and cardiovascular disease. We identified 411 (179 men and 232 women, mean age 50.6 +/- 8.0 years) nondiabetic subjects, free from dementia, who had participated in the two surveys within 6 months.

RESULTS

Women had better episodic (score 7.37 +/- 1.42) and semantic memory (score 16.05 +/- 2.76) than men (score 6.59 +/- 1.29 and 15.15 +/- 2.92, respectively, P < 0.001 for both). In an adjusted multivariate model, fasting plasma glucose (fPG) and 2-h plasma glucose (2hPG) were significantly negatively associated with episodic memory (fPG: B -0.198, SE 0.068, beta -0.209, P = 0.004; and 2hPG: B -0.061, SE 0.031, beta -0.148, P = 0.048, respectively) in women but not in men. The association was not found in relation to semantic memory.

CONCLUSIONS

We conclude that an increase in plasma glucose is associated with impairment in episodic memory in women. This could be explained by a negative effect on the hippocampus caused by raised plasma glucose levels.

Predictors of cognitive impairment and dementia in older people with diabetes

AIMS/HYPOTHESIS

Diabetes is associated with an increased risk of dementia but the reasons for this association are unclear because there are many potential mechanisms. We explored the relative contribution of diabetes-related variables as predictors of dementia in older individuals with diabetes.

METHODS

Survivors, aged > or =70 or more, were recruited from an existing observational cohort study 7.6 +/- 1.0 years after baseline, when they underwent a comprehensive assessment of diabetes, complications and cardiovascular risk factors. Dementia, probable Alzheimer's disease and cognitive impairment without dementia were diagnosed clinically. Logistic regression modelling determined independent predictors of cognitive diagnoses.

RESULTS

Of 302 participants, aged 75.7 +/- 4.6 years, 28 (9.3%) had dementia (16 with probable Alzheimer's disease) and 60 (19.9%) had cognitive impairment without dementia. The major independent longitudinal predictors of dementia were older age (per decade; odds ratio 4.0, 95% CI 1.59-10.10), diabetes duration (for each 5 years; odds ratio 1.69, 95% CI 1.24-2.32), peripheral arterial disease (odds ratio 5.35, 95% CI 2.08-13.72) and exercise (which was protective; odds ratio 0.26, 95% CI 0.09-0.73). For Alzheimer's disease, diabetes duration was an independent predictor in addition to age and diastolic blood pressure. The results of the cross-sectional analyses were similar with respect to diabetes duration and peripheral arterial disease.

CONCLUSIONS/INTERPRETATION

Peripheral arterial disease is a strong independent risk factor for dementia in diabetes. After adjustment for a wide range of potential risk factors, diabetes duration remains independently associated with dementia and probable Alzheimer's disease, indicating that factors not measured in this study may be important in the pathogenesis of dementia in diabetes.

Cholesterol-related genetic risk scores are associated with hypometabolism in Alzheimer's-affected brain regions

We recently implicated a cluster of nine single nucleotide polymorphisms from seven cholesterol-related genes in the risk of Alzheimer's disease (AD) in a European cohort, and we proposed calculating an aggregate cholesterol-related genetic score (CREGS) to characterize a person's risk. In a separate study, we found that apolipoprotein E (APOE) epsilon4 gene dose, an established AD risk factor, was correlated with fluorodeoxyglucose (FDG) positron emission tomography (PET) measurements of hypometabolism in AD-affected brain regions in a cognitively normal American cohort, and we proposed using PET as a presymptomatic endophenotype to help assess putative modifiers of AD risk. Thus, the objective in the present study is to determine whether CREGS is related to PET measurements of hypometabolism in AD-affected brain regions. DNA and PET data from 141 cognitively normal late middle-aged APOE epsilon4 homozygotes, heterozygotes and noncarriers were analyzed to evaluate the relationship between CREGS and regional PET measurements. Cholesterol-related genetic risk scores were associated with hypometabolism in AD-affected brain regions, even when controlling for the effects of APOE epsilon4 gene dose. The results support the role of cholesterol-related genes in the predisposition to AD and support the value of neuroimaging in the presymptomatic assessment of putative modifiers of AD risk.

Alzheimer's disease - the ways of prevention

Several vascular and lifestyle related factors have been suggested to influence the development of dementia and Alzheimer's disease (AD), creating new prevention opportunities. This paper discusses current epidemiological evidence and new findings from the Finnish population based CAIDE study linking some of these factors to dementia/AD. Such findings provide an optimistic outlook especially for persons with genetic susceptibility; it may be possible to reduce the risk or postpone the onset of dementia by adopting healthy lifestyle options. The interplay of genes and environment in the aetiology of AD needs to be further investigated as well as the role of lifestyle and pharmacological interventions for the prevention of dementia.

Vascular risk factors, cognitive decline, and dementia

Dementia is one of the most important neurological disorders in the elderly. Aging is associated with a large increase in the prevalence and incidence of degenerative (Alzheimer's disease) and vascular dementia, leading to a devastating loss of autonomy. In view of the increasing longevity of populations worldwide, prevention of dementia has turned into a major public health challenge. In the past decade, several vascular risk factors have been found to be associated with vascular dementia but also Alzheimer's disease. Some longitudinal studies, have found significant associations between hypertension, diabetus mellitus, and metabolic syndrome, assessed at middle age, and dementia. Studies assessing the link between hypercholesterolemia, atrial fibrillation, smoking, and dementia have given more conflicting results. Furthermore, some studies have highlighted the possible protective effect of antihypertensive therapy on cognition and some trials are evaluating the effects of statins and treatments for insulin resistance. Vascular risk factors and their treatments are a promising avenue of research for prevention of dementia, and further long-term, placebo-controlled, randomized studies, need to be performed.

Natalizumab: targeting alpha4-integrins in multiple sclerosis

In 1992, it was shown that monoclonal antibodies blocking alpha(4)-integrins prevent the development of experimental autoimmune encephalomyelitis, an animal model for multiple sclerosis (MS). As alpha(4)beta(1)-integrin was demonstrated to mediate the attachment of immune-competent cells to inflamed brain endothelium in experimental autoimmune encephalomyelitis, the therapeutic effect was attributed to the inhibition of immune cell extravasation and inflammation in the central nervous system. This novel therapeutic approach was rapidly and successfully translated into the clinic. The humanized anti-alpha(4)-integrin antibody natalizumab demonstrated an unequivocal therapeutic effect in preventing relapses and slowing down the pace of neurological deterioration in patients with relapsing-remitting MS in phase II and phase III clinical trials. The occurrence of 3 cases of progressive multifocal leukoencephalopathy in patients treated with natalizumab led to the voluntary withdrawal of the drug from the market. After a thorough safety evaluation of all patients receiving this drug in past and ongoing studies for MS and Crohn's disease, natalizumab again obtained approval in the US and the European Community. A treatment targeting leukocyte trafficking in MS has now re-entered the clinic. Further thorough evaluation is necessary for a better understanding of the risk-benefit balance of this new treatment option for relapsing MS. In this review, we discuss the basic mechanism of action, key clinical results of clinical trials and the emerging indication of natalizumab in MS.

The spectrum of dementia: frequency, causes and clinical profile. A national referral hospital-based study in Oman

BACKGROUND AND OBJECTIVE

There is a paucity of epidemiological data on dementia in the Arabian Peninsular region, particularly Oman. To determine the spectrum, clinical profile, and the behavioral manifestations of dementia in Omani patients evaluated at a tertiary referral hospital.

METHODS

We retrospectively reviewed the demographic and clinical spectrum of 116 patients with probable dementia diagnosed in this center. The diagnosis of dementia was made according to DSM-IV criteria, and staged according to the Clinical Dementia Rating scale. Exclusion criteria included psychiatric disorders, cranial trauma, cerebral tumors, and mild cognitive impairment. The vascular risk patterns and behavioral data were analyzed.

RESULTS

Alzheimer's disease was observed to be the commonest dementia subtype seen in 61 patients (52.6%), while 24.1% had vascular dementia and 9.5% constituted frontotemporal lobar degeneration. Early onset dementia was seen in 45% and potentially reversible dementia constituted 8.6%. Behavioral and psychopathological disturbances in dementia appear to be universal with certain differentiating features between the three major subtypes of dementia.

CONCLUSIONS

This is the first published report of dementia from Oman. Dementia is an important health problem not only of the elderly but also of the young population in Oman.

Type 2 diabetes and risk of cognitive impairment and dementia

Diabetes is a major public health burden. Even a modest effect of diabetes on cognitive function has significant public health implications. Several lines of mechanistic evidence implicate a role of insulin and glucose metabolism on risk of developing dementia, including Alzheimer's disease. Population-based studies have shown that those with type 2 diabetes mellitus have an increased risk of cognitive impairment, dementia, and neurodegeneration. There are many mechanisms through which diabetes could increase risk of dementia, including glycemia, insulin resistance, oxidative stress, advanced glycation endproducts, inflammatory cytokines, and microvascular and macrovascular disease. This paper presents a review of the evidence on diabetes and increased risk of dementia and cognitive impairment, a discussion of different possible mechanisms, and remaining gaps in our knowledge.

Growing old with epilepsy: the neglected issue of cognitive and brain health in aging and elder persons with chronic epilepsy

The purpose of this review is to examine what is known about cognitive and brain aging in elders with chronic epilepsy. We contend that much remains to be learned about the ultimate course of cognition and brain structure in persons with chronic epilepsy and concern appears warranted. Individuals with chronic epilepsy are exposed to many risk factors demonstrated to be associated with abnormal cognitive and brain aging in the general population, with many of these risk factors present in persons with chronic epilepsy as early as midlife. We suggest that a research agenda be developed to systematically identify and treat known modifiable risk factors in order to protect and promote cognitive and brain health in aging and elder persons with chronic epilepsy.

Metabolic and vascular determinants of impaired cognitive performance and abnormalities on brain magnetic resonance imaging in patients with type 2 diabetes

AIMS/HYPOTHESIS

The determinants of cerebral complications of type 2 diabetes are unclear. The present study aimed to identify metabolic and vascular factors that are associated with impaired cognitive performance and abnormalities on brain MRI in patients with type 2 diabetes.

METHODS

The study included 122 patients and 56 controls. Neuropsychological test scores were divided into five cognitive domains and expressed as standardised z values. Brain MRI scans were rated for white matter lesions (WML), cortical and subcortical atrophy, and infarcts. Data on glucose metabolism, vascular risk factors and micro- and macrovascular disease were collected.

RESULTS

Patients with type 2 diabetes had more cortical (p < 0.001) and subcortical (p < 0.01) atrophy and deep WML (p = 0.02) than the control group and their cognitive performance was worse. In multivariate regression analyses within the type 2 diabetes group, hypertension (p < 0.05) and a history of vascular events (p < 0.01) were associated with worse cognitive performance, while statin use was associated (p < 0.05) with better performance. Retinopathy and brain infarcts on MRI were associated with more severe cortical atrophy (both p < 0.01) and statin use with less atrophy (p < 0.05). Insulin level and brain infarcts were associated with more severe WML and statin use with less severe WML (all p < 0.05).

CONCLUSIONS/INTERPRETATION

Type 2 diabetes is associated with modest impairments in cognition, as well as atrophy and vascular lesions on MRI. This 'diabetic encephalopathy' is a multifactorial condition, for which atherosclerotic (macroangiopathic) vascular disease is an important determinant. Chronic hyperglycaemia, hyperinsulinaemia and hypertension may play additional roles.

Pharmacotherapy of Alzheimer disease

OBJECTIVE

To systematically review published clinical trials of the pharmacotherapy of Alzheimer disease (AD).

METHOD

We searched MEDLINE for published English-language medical literature, using Alzheimer disease and treatment as key words. No other search engine was used. Our review focused on randomized clinical trials (RCTs) and corresponding metaanalyses.

RESULTS

Although there are many RCTs for the treatment of mild cognitive impairment (MCI), none have been successful in their primary analysis. The cholinesterase inhibitors donepezil, rivastigmine, and galantamine have demonstrated efficacy in 3- to 12-month placebo-controlled RCTs assessing cognitive, functional, behavioural, and global outcomes in patients with mildly to moderately severe AD. Recent data from patients with severe stages of AD demonstrate the efficacy of donepezil on cognitive and functional measures but not on behaviour. The N-methyl-D-aspartate receptor antagonist memantine has been demonstrated to be effective in 6-month, placebo-controlled RCTs of 6 months duration assessing cognitive, functional, and global outcomes of inpatients with moderate-to-severe AD (defined as a Mini Mental State Examination score below 20). Post hoc analyses have demonstrated a benefit in regard to agitation and (or) aggression, but this needs to be confirmed in a prospective RCT across Canada. Disease-modifying treatments are being tested in mild stages of AD in 18-month RCTs with cognitive and global outcomes as primary efficacy outcomes, primarily with drugs reducing amyloid synthesis or aggregation. Successful treatment in mild stages of AD could lead to RCTs in MCI and, possibly, in genetically high-risk asymptomatic individuals.

CONCLUSION

The significant advances in the symptomatic pharmacotherapy of AD may be followed by disease-modification treatments.

Plasma cytokines profile in older subjects with late onset Alzheimer's disease or vascular dementia

Some cytokines have been involved in the pathogenesis of late onset Alzheimer's disease (LOAD). A possible increase in plasma cytokines levels has been reported in LOAD and vascular dementia (VD), but the results of previous studies are conflicting. We evaluated the plasma levels of IL-6, TNF-alpha, IL-1beta, and IL-10 in four groups of older individuals: 60 patients with LOAD, 80 patients with VD, 40 subjects with cerebrovascular disease but without dementia (CDND), and 42 controls (C). By analysis of covariance (adjustment for age, gender, coronary heart disease, diabetes, hypertension, smoking, and alcohol consumption) we found that: *IL-1beta was higher in VD, LOAD, and CDND compared with controls (p<0.005). *TNF-alpha was higher in VD and LOAD compared to C (p<0.05), and in VD compared to LOAD (p<0.03). *IL-6 was higher in VD compared with LOAD (p<0.03). No differences in IL-10 values were found (Kruskal-Wallis, Asymp. Sig. 0.14). By logistic regression analysis, we demonstrated that high levels (defined as above the median) of IL-1beta and TNF-alpha, but not of IL-6, were associated with increased likelihood of having VD and LOAD compared to C, while high IL-6 levels were associated with a increased probability of having VD, compared with LOAD. Our study support the notion of a low-grade systemic inflammation in older patients with LOAD or VD, characterized by an increase in plasma IL-1beta and TNF-alpha levels. The high IL-6 levels found in VD might be not a specific finding, as it might come from several conditions including atherosclerosis and related vascular risk factors, comorbidity, and frailty.

High dietary cholesterol facilitates classical conditioning of the rabbit's nictitating membrane response

Studies have shown that modifying dietary cholesterol may improve learning and that serum cholesterol levels can be positively correlated with cognitive performance. Rabbits fed a 0, 0.5, 1 or 2% cholesterol diet for eight weeks and 0.12 ppm copper added to their drinking water received trace and then delay classical conditioning pairing tone with corneal air puff during which movement of the nictitating membrane (NM) across the eye was monitored. We found that the level of classical conditioning and conditioning-specific reflex modification (CRM) as well as the number of beta amyloid-labeled neurons in the cortex and hippocampus were a function of the concentration of cholesterol in the diet. The data provide support for the idea that dietary cholesterol may facilitate learning and memory.

Midlife risk factors for subtypes of dementia: a nested case-control study in Taiwan

OBJECTIVE

To identify the midlife risk factors for subtypes of dementia newly developed later in life.

METHODS

A nested case-control study was conducted on 157 demented cases and 628 comparison cases selected from 40,636 men and women who were enrolled from 1982 to 1992. Four comparison cases were frequency-matched on age, time at enrollment (within 6 months), gender, and residential township. Midlife risk factors included vascular risk factors (body mass index [BMI], total cholesterol, total triglycerides, blood glucose, cerebrovascular accident [CVA] history, diabetes mellitus history, and hypertension history), cigarette smoking, and alcohol consumption. Dementia assessments were ascertained through the computerized data linkage from National Health Insurance Database from 2000 to 2002 and clinically confirmed by neurologists or psychiatrists. Conditional logistic regression analysis was used to estimate the matched odds ratio (OR) and its 95% confidence intervals (CI) for each risk factor.

RESULTS

A J-shaped relationship was observed between BMI (kg/m(2)) and dementia. The multivariate-adjusted ORs (95% CI) of developing dementia were 1.84 (1.02-3.33), 1.87 (1.08-3.23) and 2.44 (1.39-4.28), respectively, for BMIs of <20.5, 23.0-25.4, >or=25.5 compared with a BMI of 20.5-22.9 as the referent group (OR = 1.0). Similar findings were observed for Alzheimer disease (AD) and vascular dementia (VaD). The association between obesity (BMI >or=25.5) and both AD and VaD was statistically significant among cigarette smokers but not among nonsmokers. Additionally, history of CVA was a significant risk factor for VaD, but not for AD.

CONCLUSION

Being underweight, being overweight, and a cerebrovascular accident in midlife may increase the risk of dementia in late life.

Plasma growth hormones, P300 event-related potential and test of variables of attention (TOVA) are important neuroendocrinological predictors of early cognitive decline in a clinical setting: evidence supported by structural equation modeling (SEM) parameter estimates

A review of the literature in both animals and humans reveals that changes in sex hormone have often been associated with changes in behavioral and mental abilities. Previously published research from our laboratory, and others, provides strong evidence that P300 (latency) event-related potential (ERP), a marker of neuronal processing speed, is an accurate predictor of early memory impairment in both males and females across a wide age range. It is our hypothesis, given the vast literature on the subject, that coupling growth hormones (insulin-like growth factor-I, (IGF-I) and insulin-like growth factor binding protein 3 (IGF-BP3)), P300 event-related potential and test of variables of attention (TOVA) are important neuroendocrinological predictors of early cognitive decline in a clinical setting. To support this hypothesis, we utilized structural equation modeling (SEM) parameter estimates to determine the relationship between aging and memory, as mediated by growth hormone (GH) levels (indirectly measured through the insulin-like growth factor system), P300 latency and TOVA, putative neurocognitive predictors tested in this study. An SEM was developed hypothesizing a causal directive path, leading from age to memory, mediated by IGF-1 and IGF-BP3, P300 latency (speed), and TOVA decrements. An increase in age was accompanied by a decrease in IGF-1 and IGF-BP3, an increase in P300 latency, a prolongation in TOVA response time, and a decrease in memory functioning. Moreover, independent of age, decreases in IGF-1 and IGF-BP3, were accompanied by increases in P300 latency, and were accompanied by increases in TOVA response time. Finally, increases in P300 latency were accompanied by decreased memory function, both directly and indirectly through mediation of TOVA response time. In summary, this is the first report utilizing SEM to reveal the finding that aging affects memory function negatively through mediation of decreased IGF-1 and IGF-BP3, and increased P300 latency (delayed attention and processing speed).

Hypertension, hypercholesterolemia, diabetes, and risk of Parkinson disease

OBJECTIVE

To determine whether history of hypertension, hypercholesterolemia, or diabetes is associated with risk of Parkinson disease (PD).

METHODS

Prospective study among participants in two large cohorts: the Nurses' Health Study (121,046 women) and the Health Professionals Follow-up Study (50,833 men). Mean duration of follow-up was 22.9 years in women, aged 30 to 55 years at baseline, and 12.6 years in men, aged 40 to 75 years at baseline. Relative risks (RRs) of PD were estimated from a Cox proportional hazards model adjusting for potential confounders.

RESULTS

We identified a total of 530 incident cases of PD during the follow-up. Risk of PD was not associated with self-reported history of hypertension (RR = 0.96, 95% CI = 0.80 to 1.15), high cholesterol (RR = 0.98, 95% CI = 0.82 to 1.19), or diabetes (RR = 1.04, 95% CI = 0.74 to 1.46), after adjusting for age and smoking in pack-years. Risk of PD decreased modestly with increasing levels of self-reported total cholesterol (RR for a 50-mg/dL increase in total cholesterol = 0.86, 95% CI = 0.78 to 0.95, p for trend = 0.02), but use of cholesterol-lowering drugs was not associated with PD risk (RR comparing users with nonusers = 0.85, 95% CI = 0.59 to 1.23). Among individuals with PD, systolic blood pressure was similar to noncases up to the time of diagnosis but declined afterward.

CONCLUSIONS

Results of this large prospective study suggest that Parkinson disease risk is not significantly related to history of hypertension, hypercholesterolemia, or diabetes but may modestly decline with increasing blood cholesterol levels.

Relation of Blood Pressure to Cognitive Impairment and Dementia

Over the past decade several studies have assessed the relation of blood pressure with cognitive function and dementia. While some cross-sectional studies have shown an inverse association between blood pressure levels and cognitive performance or dementia, longitudinal studies yielded controversial results. Most studies relating blood pressure levels in mid-life with late-life risk of cognitive decline or dementia reported a harmful effect of higher blood pressure levels on cognitive function. Studies assessing the effect of late-life blood pressure levels reported that low diastolic and very high systolic levels may increase the risk. Observational studies and randomized cinical trials provide limited evidence for a protective effect of antihypertensive therapy. It seems that the older the person and the more advanced the disease process, the less harmful or even inverted the effect of blood pressure elevation on dementia risk. The reason for this may be that blood pressure declines with age-related pathology, such as vessel stiffening, weight loss, and changes in the autonomic regulation of blood flow.

Age-Varying Association Between Blood Pressure and Risk of Dementia in Those Aged 65 and Older: A Community-Based Prospective Cohort Study

OBJECTIVES

To assess variation in the association between blood pressure (BP) and risk for dementia across a spectrum of older ages and to examine BP changes before dementia onset.

DESIGN

Prospective cohort study.

SETTING

A large health maintenance organization in Seattle, Washington.

PARTICIPANTS

A cohort of 2,356 members of a large health maintenance organization aged 65 and older who were initially without dementia.

MEASUREMENTS

Dementia diagnosis was assessed biennially, and systolic (SBP) and diastolic BP (DBP) were measured at baseline and at four follow-up assessments. Cox proportional hazards models were used to estimate hazard ratios (HRs) for dementia and Alzheimer's disease (AD) associated with baseline BP in different age groups.

RESULTS

Within the youngest age group (65-74 at enrollment) a greater risk for dementia was found in participants with high SBP (> or = 160 mmHg) (hazard ratio (HR) = 1.60, 95% confidence interval (CI) = 1.01-2.55) or borderline-high DBP (80-89 mmHg) (HR = 1.59, 95% CI = 1.07-2.35) than for those with normal BP (SBP < 140 mmHg and DBP < 80 mmHg). The dementia risk associated with SBP declined with increasing age (SBP-by-age interaction, P=.01). SBP declined similarly with aging in subjects who developed dementia and those who did not. Thus, in this sample, the association between SBP and dementia risk was not dependent on when BP was measured in relation to onset of dementia.

CONCLUSION

High SBP was associated with greater risk of dementia in the young elderly (< 75) but not in older subjects. Adequate control of hypertension in early old age may reduce the risk for dementia.

The protocols for the 10/66 dementia research group population-based research programme

Background

Latin America, China and India are experiencing unprecedentedly rapid demographic ageing with an increasing number of people with dementia. The 10/66 Dementia Research Group's title refers to the 66% of people with dementia that live in developing countries and the less than one tenth of population-based research carried out in those settings. This paper describes the protocols for the 10/66 population-based and intervention studies that aim to redress this imbalance.

Methods/design

Cross-sectional comprehensive one phase surveys have been conducted of all residents aged 65 and over of geographically defined catchment areas in ten low and middle income countries (India, China, Nigeria, Cuba, Dominican Republic, Brazil, Venezuela, Mexico, Peru and Argentina), with a sample size of between 1000 and 3000 (generally 2000). Each of the studies uses the same core minimum data set with cross-culturally validated assessments (dementia diagnosis and subtypes, mental disorders, physical health, anthropometry, demographics, extensive non communicable disease risk factor questionnaires, disability/functioning, health service utilisation, care arrangements and caregiver strain). Nested within the population based studies is a randomised controlled trial of a caregiver intervention for people with dementia and their families (ISRCTN41039907; ISRCTN41062011; ISRCTN95135433; ISRCTN66355402; ISRCTN93378627; ISRCTN94921815). A follow up of 2.5 to 3.5 years will be conducted in 7 countries (China, Cuba, Dominican Republic, Venezuela, Mexico, Peru and Argentina) to assess risk factors for incident dementia, stroke and all cause and cause-specific mortality; verbal autopsy will be used to identify causes of death.

Discussion

The 10/66 DRG baseline population-based studies are nearly complete. The incidence phase will be completed in 2009. All investigators are committed to establish an anonymised file sharing archive with monitored public access. Our aim is to create an evidence base to empower advocacy, raise awareness about dementia, and ensure that the health and social care needs of older people are anticipated and met.

The epidemiology of the dementias: an update

PURPOSE OF REVIEW

The epidemiology of dementia is one of the priority fields in aging research. This review aims to highlight the most relevant findings over last years concerning occurrence, risk factors, and prevention of dementia and its major subtypes.

RECENT FINDINGS

It is estimated that currently around 24 million people have dementia in the world, with the number being projected to double every 20 years, and that 60% of dementia patients live in developing countries, with the proportion being raised to more than 70% by 2040. Current evidence suggests that vascular factors, such as midlife hypertension, diabetes, and cerebrovascular disease, contribute significantly to the development of dementia and Alzheimer's disease, and that active engagement in mental, physical, and social activities may postpone the onset of dementia by providing cognitive reserve.

SUMMARY

Dementia represents a major public health challenge as a consequence of rapid increase in the aging population worldwide, especially in developing countries. This challenge can be partly confronted by successful development of preventive strategies. Evidence has emerged that proper control of vascular disorders and maintenance of active lifestyles may prevent or delay the onset and progression of dementia and Alzheimer's disease. Intervention trials are warranted to determine, to what extent, such programs are effective against dementia.

Hypertension, cognitive decline, and dementia: an epidemiological perspective

Hypertension is a known risk factor for stroke, and thus for vascular dementia. However, recent large observational studies have suggested that high blood pressure may also play a role in Alzheimer's disease. The mechanisms linking hypertension to Alzheimer's disease remain to be elucidated, but white matter lesions seen on cerebral magnetic resonance imaging appear to be a good marker of this association. It is not yet clearly established whether lowering blood pressure reduces the risk of white matter lesions and dementia, so large trials dealing with this question are eagerly awaited. These future trials could confirm the hope that, by lowering blood pressure, we may have a preventive treatment for dementia. This issue is of major importance, as the number of cases of dementia is expected to rise sharply in the near future.

Cognition and dementia in Type 2 diabetes: brain imaging correlates and metabolic and vascular risk factors

This review addresses the impact of Type 2 diabetes mellitus on the brain. We show that there is convincing evidence that Type 2 diabetes mellitus is associated with accelerated cognitive decline and dementia. The structural basis for these cognitive deficits includes both vascular lesions and global cerebral atrophy. Cerebral changes may already develop in prediabetes mellitus stages. Several areas of uncertainty need to be resolved in order to develop effective preventive strategies. Information on the risk factors for accelerated cognitive decline in patients with Type 2 diabetes mellitus is still scarce. Identification of these factors might help to identify individuals who are at risk for clinically relevant impairments and to develop specific interventions. Further studies on the course of development of cognitive decline in Type 2 diabetes mellitus may help to decide at what stage these interventions should be initiated.

Screening of cognitive impairment in chronic obstructive pulmonary disease

Cognitive dysfunction is common and clinically important in severe chronic obstructive pulmonary disease (COPD). We investigated the diagnostic accuracy of the Mini Mental State Examination (MMSE) and Instrumental Activities of Daily Living (IADL) scale in screening severe cognitive dysfunction in 149 patients with COPD, mean age 69.3+/-8.5 years, forced expiratory volume in 1 s=36.6+/-17.8% of the predicted. Patients underwent the MMSE and an in-depth neuropsychological assessment based upon the Mental Deterioration Battery (MDB). The 5-item IADL scale was assessed. The sample was randomly divided into a training (n=73) and a testing (n=76) population. The diagnostic accuracy of MMSE, IADL scale or both versus cognitive dysfunction corresponding to abnormal performance in 3 or more MDB tests was assessed in the training population and the model obtained was tested in the testing population. The combination of MMSE<24 and dependence in at least 1 IADL had better diagnostic accuracy than either MMSE or IADL, with sensitivity=52.4, specificity=82.7, positive predictive value=55.0% and negative predictive value=81.1% in the testing population. MMSE and the 5-item IADL scale can be used to exclude, but not to detect cognitive dysfunction in COPD patients. A confirmatory cognitive test should be administered to patients with an MMSE score of <24 and who are dependent in at least 1 IADL.

A 26-week, prospective, open-label, uncontrolled, multicenter study to evaluate the effect of an escalating-dose regimen of trandolapril on change in blood pressure in treatment-naive and concurrently treated adult hypertensive subjects (TRAIL)

OBJECTIVE

This study evaluated the effectiveness of an escalating-dose regimen of trandolapril in subjects with stage 1 or stage 2 hypertension.

METHODS

This was a 26-week, prospective, open-label,multicenter study in Canadian primary care centers. Subjects with hypertension who were treatment naive or whose disease was uncontrolled on current first-line antihypertensive monotherapy were treated with trandolapril for 26 weeks alone or in addition to their current treatment. Uncontrolled hypertension was defined as systolic/diastolic blood pressure (SBP/DBP) >or=140/90 mm Hg in subjects with no other risk factors or >or=130/80 mm Hg in subjects with diabetes or kidney disease. Trandolapril therapy was initiated at 1 mg/d and was titrated as required to 2 or 4 mg at 4 and 9 weeks after initiation of treatment, respectively, in those not achieving BP targets. At 14 weeks after treatment initiation, subjects not achieving BP targets could receive a combination of trandolapril 4 mg plus a calcium channel blocker (verapamil 240 mg) with or without a diuretic. Primary outcome was the percentage of patients reaching target BP after 14 weeks.

RESULTS

A total of 1683 subjects from 192 general practice clinics across Canada completed the 14-week trandolapril dose-optimization phase, and 1650 completed the full 26-week follow-up. Mean (SD) age was 56.6 (12.6) years, and 49.2% of the subjects were men. At baseline, 82.4% (1359/1650) of subjects were antihypertensive-treatment naive. At the trial end, 73.4% (95% CI, 70.9-75.9) of subjects achieved a target level of SBP/DBP <140/90 mm Hg. The mean (SD) reductions in SBP and DBP were -21.5 (14.0) and -11.9 (9.1) mm Hg, respectively (P < 0.001), and -22.4 (14.0) and -12.7 (9.0) mm Hg, respectively (P < 0.001), at 26 weeks. A total of 343 predominantly mild, nonserious adverse events were attributed to the study drugs, reported by 252 (15.3%) of the 1650 subjects. The most frequently reported nonserious adverse events were cough (6.3%); gastrointestinal disorders (2.3%), predominantly nausea; and headache (2.1%). No serious adverse events were attributed to the study treatment. Trandolapril was generally well tolerated.

CONCLUSIONS

A titration-based, escalating-dose regimen of trandolapril was effective and well tolerated in the management of these subjects who were antihypertensive-treatment naive or whose disease was uncontrolled on a diuretic or a calcium channel blocker in this open-label, uncontrolled, multicenter study. Overall, 73.4% of subjects achieved their target blood pressure goal (<140/90 mm Hg).

Invited commentary: lipoproteins and dementia - is it the apolipoprotein A-I?

Because of the aging of the population, dementia has become a major public health problem. There has been growing evidence for a possible association between lipids and dementia. A large body of literature has demonstrated multiple hypothesized biologic links between lipids and neurodegenerative or other biologic pathways connected to dementing processes. However, the epidemiologic associations have been conflicting: dyslipidemia at middle age, but not in later life, seems to be associated with higher dementia risk in some but not all studies. Results from the Honolulu-Asia Aging Study reported by Saczynski et al. (Am J Epidemiol 2007;165:985-92) suggest that lipoprotein constituents, such as apolipoprotein A-I, a major component of the high density lipoprotein, may be more informative in enlightening the association between lipids and dementia. In this commentary, the epidemiology and biology of apolipoprotein A-I in relation to dementia is reviewed.

Risk of dementia in stroke-free patients diagnosed with atrial fibrillation: data from a community-based cohort

AIMS

To estimate the incidence of dementia after the first atrial fibrillation (AF), and its impact on survival in a community-based cohort.

METHODS AND RESULTS

Olmsted County, Minnesota adult residents diagnosed with first AF during 1986-2000 were identified, and followed until 2004. The primary outcome was new detection of dementia. Interim stroke was censored in the analyses. Of 2837 subjects (71 +/- 15 years old) diagnosed with first AF and without any evidence of cognitive dysfunction or stroke at the time of AF onset, 299 were diagnosed with dementia during a median follow-up of 4.6 years [interquartile (IQR) range 1.5-7.9 years], and 1638 died. The Kaplan-Meier cumulative rate of dementia was 2.7% at 1 year and 10.5% at 5 years. After adjustment for age and sex, dementia was strongly related to advancing age [hazard ratio (HR)/10 years, 2.8; 95% confidence interval (CI), 2.5-3.2], but did not vary with sex (P = 0.52). The occurrence of post-AF dementia was associated with significantly increased mortality risk (HR 2.9; 95% CI 2.5-3.3), even after adjustment for multiple comorbidities, and did not vary with age (P = 0.75) or sex (P = 0.33).

CONCLUSION

Dementia appeared common following the diagnosis of first AF, and was associated with premature death.