Changes in cognition and mortality in relation to exercise in late life: a population based study

The impact of social vulnerability on the survival of the fittest older adults

BACKGROUND

even older adults who are fit experience adverse health outcomes; understanding their risks for adverse outcomes may offer insight into ambient population health. Here, we evaluated mortality risk in relation to social vulnerability among the fittest older adults in a representative community-dwelling sample of older Canadians.

METHODS

in this secondary analysis of the Canadian Study of Health and Aging, participants (n = 5,703) were aged 70+ years at baseline. A frailty index was used to grade relative levels of fitness/frailty, using 31 self-reported health deficits. The analysis was limited to the fittest people (those reporting 0-1 health deficit). Social vulnerability was trichotomised from a social vulnerability scale, which consisted of 40 self-reported social deficits.

RESULTS

five hundred and eighty-four individuals had 0-1 health deficit. Among them, absolute mortality risk rose with increasing social vulnerability. In those with the lowest level of social vulnerability, 5-year mortality was 10.8%, compared with 32.5% for those with the highest social vulnerability (adjusted hazard ratio 2.5, 95% CI: 1.5-4.3, P = 0.001).

CONCLUSIONS

a 22% absolute mortality difference in the fittest older adults is of considerable clinical and public health importance. Routine assessment of social vulnerability by clinicians could have value in predicting the risk of adverse health outcomes in older adults.

Cardiorespiratory fitness as a predictor of dementia mortality in men and women

There is evidence that physical activity may reduce the risk of developing Alzheimer disease and dementia. However, few reports have examined the physical activity-dementia association with objective measures of physical activity. Cardiorespiratory fitness (hereafter called fitness) is an objective reproducible measure of recent physical activity habits.

PURPOSE

We sought to determine whether fitness is associated with lower risk for dementia mortality in women and men.

METHODS

We followed 14,811 women and 45,078 men, age 20-88 yr at baseline, for an average of 17 yr. All participants completed a preventive health examination at the Cooper Clinic in Dallas, TX, during 1970-2001. Fitness was measured with a maximal treadmill exercise test, with results expressed in maximal METs. The National Death Index identified deaths through 2003. Cox proportional hazards models were used to examine the association between baseline fitness and dementia mortality, adjusting for age, sex, examination year, body mass index, smoking, alcohol use, abnormal ECGs, and health status.

RESULTS

There were 164 deaths with dementia listed as the cause during 1,012,125 person-years of exposure. Each 1-MET increase in fitness was associated with a 14% lower adjusted risk of dementia mortality (95% confidence interval (CI) = 6%-22%). With fitness expressed in tertiles, adjusted hazard ratios (HRs) for those in the middle- and high-fitness groups suggest their risk of dementia mortality was less than half that of those in the lowest fitness group (HR = 0.44, CI = 0.26-0.74 and HR = 0.49, CI = 0.26-0.90, respectively).

CONCLUSIONS

Greater fitness was associated with lower risk of mortality from dementia in a large cohort of men and women.

Less exercise and more TV: leisure-time physical activity trends of Shanghai elders, 1998-2008

BACKGROUND

Surveillance of physical activity trends in older adults is limited in developing nations. This study examined 10-year leisure-time physical activity trends of elderly residents of Shanghai, the largest Chinese city with the nation's highest proportion of senior citizens.

METHODS

The study used panel data from the Shanghai Longitudinal Survey of Elderly Life and Opinion (1998, 2003, 2005 and 2008). Leisure-time physical activity questions included (i) 16 major leisure-time habitual activities and (ii) regular exercise in the previous 6 months.

RESULTS

In comparison to 1998, for Shanghai elders, the trend for engaging in leisure-time habits not related to physical activity increased over time, becoming statistically significant in 2005 and 2008 (e.g. OR for watching TV in 2003, 2005 and 2008 is 1.04 [0.91, 1.19], 1.17 [1.00, 1.38] and 1.78 [1.51, 2.09], respectively). Simultaneously, the trend for engaging in regular exercise declined significantly in each observation year in comparison to 1998 (OR in 2003, 2005 and 2008 is 0.70 [0.61, 0.80], 0.36 [0.30, 0.42] and 0.28 [0.24, 0.33], respectively). Discussion An increasingly sedentary lifestyle has evolved over the past decade in Shanghai. This highlights a need for public health agencies to develop effective active lifestyle interventions and physical activity promotion programs for local elders.

Reversal of glial and neurovascular markers of unhealthy brain aging by exercise in middle-aged female mice

Healthy brain aging and cognitive function are promoted by exercise. The benefits of exercise are attributed to several mechanisms, many which highlight its neuroprotective role via actions that enhance neurogenesis, neuronal morphology and/or neurotrophin release. However, the brain is also composed of glial and vascular elements, and comparatively less is known regarding the effects of exercise on these components in the aging brain. Here, we show that aerobic exercise at mid-age decreased markers of unhealthy brain aging including astrocyte hypertrophy, a hallmark of brain aging. Middle-aged female mice were assigned to a sedentary group or provided a running wheel for six weeks. Exercise decreased hippocampal astrocyte and myelin markers of aging but increased VEGF, a marker of angiogenesis. Brain vascular casts revealed exercise-induced structural modifications associated with improved endothelial function in the periphery. Our results suggest that age-related astrocyte hypertrophy/reactivity and myelin dysregulation are aggravated by a sedentary lifestyle and accompanying reductions in vascular function. However, these effects appear reversible with exercise initiated at mid-age. As this period of the lifespan coincides with the appearance of multiple markers of brain aging, including initial signs of cognitive decline, it may represent a window of opportunity for intervention as the brain appears to still possess significant vascular plasticity. These results may also have particular implications for aging females who are more susceptible than males to certain risk factors which contribute to vascular aging.

A multi-state model for the analysis of changes in cognitive scores over a fixed time interval

In this article, we present the novel approach of using a multi-state model to describe longitudinal changes in cognitive test scores. Scores are modelled according to a truncated Poisson distribution, conditional on survival to a fixed endpoint, with the Poisson mean dependent upon the baseline score and covariates. The model provides a unified treatment of the distribution of cognitive scores, taking into account baseline scores and survival. It offers a simple framework for the simultaneous estimation of the effect of covariates modulating these distributions, over different baseline scores. A distinguishing feature is that this approach permits estimation of the probabilities of transitions in different directions: improvements, declines and death. The basic model is characterised by four parameters, two of which represent cognitive transitions in survivors, both for individuals with no cognitive errors at baseline and for those with non-zero errors, within the range of test scores. The two other parameters represent corresponding likelihoods of death. The model is applied to an analysis of data from the Canadian Study of Health and Aging (1991-2001) to identify the risk of death, and of changes in cognitive function as assessed by errors in the Modified Mini-Mental State Examination. The model performance is compared with more conventional approaches, such as multivariate linear and polytomous regressions. This model can also be readily applied to a wide variety of other cognitive test scores and phenomena which change with age.

A prospective cohort study of long-term cognitive changes in older Medicare beneficiaries

Background

Promoting cognitive health and preventing its decline are longstanding public health goals, but long-term changes in cognitive function are not well-documented. Therefore, we first examined long-term changes in cognitive function among older Medicare beneficiaries in the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD), and then we identified the risk factors associated with those changes in cognitive function.

Methods

We conducted a secondary analysis of a prospective, population-based cohort using baseline (1993-1994) interview data linked to 1993-2007 Medicare claims to examine cognitive function at the final follow-up interview which occurred between 1995-1996 and 2006-2007. Besides traditional risk factors (i.e., aging, age, race, and education) and adjustment for baseline cognitive function, we considered the reason for censoring (entrance into managed care or death), and post-baseline continuity of care and major health shocks (hospital episodes). Residual change score multiple linear regression analysis was used to predict cognitive function at the final follow-up using data from telephone interviews among 3,021 to 4,251 (sample size varied by cognitive outcome) baseline community-dwelling self-respondents that were ≥ 70 years old, not in managed Medicare, and had at least one follow-up interview as self-respondents. Cognitive function was assessed using the 7-item Telephone Interview for Cognitive Status (TICS-7; general mental status), and the 10-item immediate and delayed (episodic memory) word recall tests.

Results

Mean changes in the number of correct responses on the TICS-7, and 10-item immediate and delayed word recall tests were -0.33, -0.75, and -0.78, with 43.6%, 54.9%, and 52.3% declining and 25.4%, 20.8%, and 22.9% unchanged. The main and most consistent risks for declining cognitive function were the baseline values of cognitive function (reflecting substantial regression to the mean), aging (a strong linear pattern of increased decline associated with greater aging, but with diminishing marginal returns), older age at baseline, dying before the end of the study period, lower education, and minority status.

Conclusions

In addition to aging, age, minority status, and low education, substantial and differential risks for cognitive change were associated with sooner vs. later subsequent death that help to clarify the terminal drop hypothesis. No readily modifiable protective factors were identified.

Physical activity and cognition in women with vascular conditions

BACKGROUND

Individuals with vascular disease or risk factors have substantially higher rates of cognitive decline, yet little is known about means of maintaining cognition in this group.

METHODS

We examined the relation between physical activity and cognitive decline in participants of the Women's Antioxidant Cardiovascular Study, a cohort of women with prevalent vascular disease or at least 3 coronary risk factors. Recreational physical activity was assessed at baseline (October 1995 through June 1996) and every 2 years thereafter. Between December 1998 and July 2000, a total of 2809 women 65 years or older underwent a cognitive battery by telephone interview, including 5 tests of global cognition, verbal memory, and category fluency. Tests were administered 3 additional times over 5.4 years. We used multivariable-adjusted general linear models for repeated measures to compare the annual rates of cognitive score changes across levels of total physical activity and energy expended in walking, as assessed at Women's Antioxidant Cardiovascular Study baseline.

RESULTS

We found a significant trend (P < .001 for trend) toward decreasing rates of cognitive decline with increasing energy expenditure. Compared with the bottom quintile of total physical activity, significant differences in rates of cognitive decline were observed from the fourth quintile (P = .04 for the fourth quintile and P < .001 for the fifth quintile), or the equivalent of daily 30-minute walks at a brisk pace. This was equivalent to the difference in cognitive decline observed for women who were 5 to 7 years younger. Regularly walking for exercise was strongly related to slower rates of cognitive decline (P = .003 for trend).

CONCLUSION

Regular physical activity, including walking, was associated with better preservation of cognitive function in older women with vascular disease or risk factors.

Vascular cognitive impairment: Current concepts and Indian perspective

Cognitive impairment due to cerebrovascular disease is termed “Vascular Cognitive Impairment” (VCI) and forms a spectrum that includes Vascular Dementia (VaD) and milder forms of cognitive impairment referred to as Vascular Mild Cognitive Impairment (VaMCI). VCI represents a complex neurological disorder that occurs as a result of interaction between vascular risk factors such as hypertension, diabetes, obesity, dyslipidemia, and brain parenchymal changes such as macro and micro infarcts, haemorrhages, white matter changes, and brain atrophy occurring in an ageing brain. Mixed degenerative and vascular pathologies are increasingly being recognised and an interaction between the AD pathology, vascular risk factors, and strokes is now proposed. The high cardiovascular disease burden in India, increasing stroke incidence, and ageing population have contributed to large numbers of patients with VCI in India. Inadequate resources coupled with low awareness make it a problem that needs urgent attention, it is important identify patients at early stages of cognitive impairment, to treat appropriately and prevent progression to frank dementia.

Frailty in older women

It is a truth universally acknowledged that although men tend to have better health in old age, women live longer lives. Here, we briefly review the biological, social and behavioural factors that may contribute to women's greater longevity. We consider in particular factors that might result in a greater frailty burden in women, focusing on frailty being measured by a Frailty Index. The Frailty Index represents the burden of health deficits, expressed for an individual as the proportion of deficits present - from 0 (no deficits) to 1.0 (the theoretical maximum, if all deficits were expressed). A greater frailty burden in women might first represent a male "fitness-frailty pleiotropy", resulting in men having lower physiological reserves in old age so that health deficits are more lethal. In short, the price of more optimal physiological functioning during youth is a lower threshold for system failure in old age. Conversely, a female "fertility-frailty pleiotropy" might result in greater physiological reserves in women. Child birth and child rearing necessitate high levels of energetic and nutritional investment: women who have children live shorter lives. Women currently are limiting the number of children they bear and their life expectancies may be longer than predicted by evolutionary design. Third, though the Frailty Index captures physical, cognitive and psychological vulnerability, it may not include all factors that impact life expectancy in older people; these factors may be present more in men than in women. While these hypotheses seek to explain how frailty impacts men and women in different ways, there is clearly much to be done to understand frailty in older people.

Physical activity and Alzheimer disease course

OBJECTIVES

To examine the association between physical activity (PA) and Alzheimer disease (AD) course.

BACKGROUND

PA has been related to lower risk for AD. Whether PA is associated with subsequent AD course has not been investigated.

METHODS

In a population-based study of individuals aged 65 years and older in New York who were prospectively followed up with standard neurologic and neuropsychological evaluations (every ~1.5 years), 357 participants i) were nondemented at baseline and ii) were diagnosed with AD during follow-up (incident AD). PA (sum of participation in a variety of physical activities, weighted by the type of activity [light, moderate, and severe]) obtained 2.4 (standard deviation [SD], 1.9) years before incidence was the main predictor of mortality in Cox models and of cognitive decline in generalized estimating equation models that were adjusted for age, gender, ethnicity, education, comorbidities, and duration between PA evaluation and dementia onset.

RESULTS

One hundred fifty incident AD cases (54%) died during the course of 5.2 (SD, 4.4) years of follow-up. When compared with incident AD cases who were physically inactive, those with some PA had lower mortality risk, whereas incident AD participants with much PA had an even lower risk. Additional adjustments for apolipoprotein genotype, smoking, comorbidity index, and cognitive performance did not change the associations. PA did not affect rates of cognitive or functional decline.

CONCLUSION

Exercise may affect not only risk for AD but also subsequent disease duration: more PA is associated with prolonged survival in AD.

Measuring the impact of exercise on cognitive aging: methodological issues

Physical exercise and fitness have been proposed as potential factors that promote healthy cognitive aging. Support for this hypothesis has come from cross sectional, longitudinal, and intervention studies. In the present review, we discuss several methodological problems that limit the conclusions of many studies. The lack of consensus on how to retrospectively measure exercise intensity is a major difficulty for all studies that attempt to estimate lifelong impact of exercise on cognitive performance in older adults. Intervention studies have a much better capacity to establish causality, but still suffer from difficulties arising from inadequate control groups and the choice and modality of administration of cognitive measures. We argue that, while the association between exercise and preserved cognition during aging is clearly demonstrated, the specific hypothesis that physical exercise is a cause of healthy cognitive aging has yet to be validated. A number of factors could mediate the exercise-cognition association, including depression, and social or cognitive stimulation. The complex interactions among these 3 factors and the potential impact of exercise on cognition remain to be systematically studied. At this time, the best prescription for lifestyle interventions for healthy cognitive aging would be sustained physical, social, and mental activities. What remains unknown is which type of activity might be most useful, and whether everyone benefits similarly from the same interventions.

Transitions in frailty status in older adults in relation to mobility: a multistate modeling approach employing a deficit count

OBJECTIVES

To investigate how changes in frailty status and mortality risk relate to baseline frailty state, mobility performance, age, and sex.

DESIGN

Cohort study.

SETTING

The Yale Precipitating Events Project, New Haven, Connecticut.

PARTICIPANTS

Seven hundred fifty-four community-dwelling people aged 70 and older at baseline followed up at 18, 36, and 54 months.

MEASUREMENTS

Frailty status, assessed at 18-month intervals, was defined using a frailty index (FI) as the number of deficits in 36 health variables. Mobility was defined as time in seconds on the rapid gait test, in which participants walked back and forth over a 20-foot course as quickly as possible. Multistate transition probabilities were calculated with baseline frailty, mobility, age, and sex estimated using Poisson and logistic regressions in survivors and those who died, respectively.

RESULTS

In multivariable analyses, baseline frailty status and age were significantly associated with changes in frailty status and risk of death, whereas mobility was significantly associated with the frailty but not with mortality. At all values of the FI, participants with better mobility were more likely than those with poor mobility to remain stable or to improve. For example, at 54 months, 20.6% (95% confidence interval (CI)=16-25.2) of participants with poor mobility had the same or fewer deficits, compared with 32.4% (95% CI=27.9-36.9) of those with better mobility.

CONCLUSION

A multistate transition model effectively measured the probability of change in frailty status and risk of death. Mobility, age, and baseline frailty were significant factors in frailty state transitions.

Is dementia preventable? Focus on Alzheimer's disease

The prevention of dementia, and particularly of Alzheimer's disease, is a major challenge for researchers and clinicians. In this article, the mixture of evidence, observations and hypotheses in the current literature is categorized into four avenues for possible preventive interventions, as suggested by the NIH State-of-the-Science Conference. The main categories are: antihypertensive medications; nutrition; cognitive engagement; and physical activity. There is, as yet, no conclusive evidence, but each category may hold promise for the prevention of dementia. The robust findings are as follows: cognitive engagement and regular physical activity may reduce the risk of Alzheimer's disease; the Mediterranean diet and consumption of omega-3 fatty acids deserves further elucidation; and the meticulous management of risk factors, and especially hypertension, is the infrastructure of Alzheimer's disease prevention.

Frailty defined by deficit accumulation and geriatric medicine defined by frailty

As nonreplicative cells age, they commonly accumulate subcellular deficits that can compromise function. As people age, they too experience problems that can accumulate. As deficits (symptoms, signs, illnesses, disabilities) accumulate, people become more susceptible to adverse health outcomes, including worse health and even death. This state of increased risk of adverse health outcomes is indistinguishable from the idea of frailty, so deficit accumulation represents another way to define frailty. Counting deficits not only allows grades of frailty to be discerned but also provides insights into the complex problems of older adults. This process is potentially useful to geriatricians who need to be experts in managing complexity. A key to managing complexity is through instruments such as a comprehensive geriatric assessment, which can serve as the basis for routine clinical estimation of an individual's degree of frailty. Understanding people and their needs as deficits accumulate is an exciting challenge for clinical research on frailty and its management by geriatricians.

The impact of physical and mental activity on cognitive aging

With the aging of the population, there is continued emphasis on finding interventions that prevent or delay onset of cognitive disorders of aging. Pharmacological interventions have proven less effective than hoped in this capacity and a greater emphasis has therefore been placed on understanding behavioral interventions that will positively impact dementia risk. Building on a robust animal literature, a substantial volume of research has emerged, particularly over the last 5 years, to suggest that modifiable behaviors impact brain plasticity in both humans and animals. This chapter aims to provide a critical summary of this ever growing body of research, focusing specifically on participation in physical and cognitive activities among older adults and their impact on cognition, the brain, and cognitive aging outcomes. The animal literature on activity and cognition provides a series of hypotheses as to how exercise exerts its cognitive and brain benefits. Research in animals is briefly reviewed in the context of these hypotheses as it provides the groundwork for investigations in humans. The literature on physical and cognitive activity benefits to brain and cognition in humans is reviewed in more detail. The largely positive impact of physical and cognitive activities on cognition and brain health documented in epidemiological, cross sectional, and prospective randomized controlled studies are summarized. While most studies have targeted older adults in general, the implications of exercise and cognitive interventions in individuals with Alzheimer's disease (AD) or mild cognitive impairment (MCI) are also described as is the evidence supporting the ability for physical activity to modify genetic risk. The connection between activity levels and brain volume, white matter integrity, and improved functionality is reviewed. Practical recommendations regarding the nature, duration, intensity and age of onset of physical or mental activity necessary to reap cognitive and brain benefits are also detailed. Most studies have investigated a singular behavioral factor or intervention, but there is some research detailing the impact of combining both mental and physical activity to boost brain health; this emerging literature is also reviewed. Finally, we comment on the limitations of the extant literature and directions for future research, in particular the need for prospective trials of activity interventions in older adults.

Use it or lose it: environmental enrichment as a means to promote successful cognitive aging

Environmental enrichment has become increasingly utilized in rodent models of aging and neurodegenerative disease in order to prevent or reverse cognitive decline and neuronal dysfunction. However, the potential application of this body of work to human cognitive aging has rarely been discussed. The present article provides an overview of the rodent research that has tested the effects of environmental enrichment on hippocampal and neocortical function, and the types of memories mediated by these brain regions. Although data from models of neurodegenerative disease are presented, primary emphasis is given to studies of aging rodents and to methodological issues (e.g., age, treatment duration, treatment type) central to the mnemonic effectiveness of enrichment treatment. The implications of this work for human cognitive aging are discussed.

Physical activity, diet, and risk of Alzheimer disease

CONTEXT

Both higher adherence to a Mediterranean-type diet and more physical activity have been independently associated with lower Alzheimer disease (AD) risk but their combined association has not been investigated.

OBJECTIVE

To investigate the combined association of diet and physical activity with AD risk.

DESIGN, SETTING, AND PATIENTS

Prospective cohort study of 2 cohorts comprising 1880 community-dwelling elders without dementia living in New York, New York, with both diet and physical activity information available. Standardized neurological and neuropsychological measures were administered approximately every 1.5 years from 1992 through 2006. Adherence to a Mediterranean-type diet (scale of 0-9; trichotomized into low, middle, or high; and dichotomized into low or high) and physical activity (sum of weekly participation in various physical activities, weighted by the type of physical activity [light, moderate, vigorous]; trichotomized into no physical activity, some, or much; and dichotomized into low or high), separately and combined, were the main predictors in Cox models. Models were adjusted for cohort, age, sex, ethnicity, education, apolipoprotein E genotype, caloric intake, body mass index, smoking status, depression, leisure activities, a comorbidity index, and baseline Clinical Dementia Rating score.

MAIN OUTCOME MEASURE

Time to incident AD.

RESULTS

A total of 282 incident AD cases occurred during a mean (SD) of 5.4 (3.3) years of follow-up. When considered simultaneously, both Mediterranean-type diet adherence (compared with low diet score, hazard ratio [HR] for middle diet score was 0.98 [95% confidence interval {CI}, 0.72-1.33]; the HR for high diet score was 0.60 [95% CI, 0.42-0.87]; P = .008 for trend) and physical activity (compared with no physical activity, the HR for some physical activity was 0.75 [95% CI, 0.54-1.04]; the HR for much physical activity was 0.67 [95% CI, 0.47-0.95]; P = .03 for trend) were associated with lower AD risk. Compared with individuals neither adhering to the diet nor participating in physical activity (low diet score and no physical activity; absolute AD risk of 19%), those both adhering to the diet and participating in physical activity (high diet score and high physical activity) had a lower risk of AD (absolute risk, 12%; HR, 0.65 [95% CI, 0.44-0.96]; P = .03 for trend).

CONCLUSION

In this study, both higher Mediterranean-type diet adherence and higher physical activity were independently associated with reduced risk for AD.

Impact of exercise in community-dwelling older adults

Background

Concern has been expressed that preventive measures in older people might increase frailty by increasing survival without improving health. We investigated the impact of exercise on the probabilities of health improvement, deterioration and death in community-dwelling older people.

Methods and Principal Findings

In the Canadian Study of Health and Aging, health status was measured by a frailty index based on the number of health deficits. Exercise was classified as either high or low/no exercise, using a validated, self-administered questionnaire. Health status and survival were re-assessed at 5 years. Of 6297 eligible participants, 5555 had complete data. Across all grades of frailty, death rates for both men and women aged over 75 who exercised were similar to their peers aged 65 to 75 who did not exercise. In addition, while all those who exercised had a greater chance of improving their health status, the greatest benefits were in those who were more frail (e.g. improvement or stability was observed in 34% of high exercisers versus 26% of low/no exercisers for those with 2 deficits compared with 40% of high exercisers versus 22% of low/no exercisers for those with 9 deficits at baseline).

Conclusions

In community-dwelling older people, exercise attenuated the impact of age on mortality across all grades of frailty. Exercise conferred its greatest benefits to improvements in health status in those who were more frail at baseline. The net effect of exercise should therefore be to improve health status at the population level.

Current Concepts in Vascular Cognitive Impairment and Pharmacotherapeutic Implications

Objective:

To review evolution of the vascular cognitive impairment (VCI) construct, including diagnosis, pharmacotherapeutic implications, and address challenges that will shape future developments.

Data Sources:

Literature retrieval was accessed through PubMed, from 1966 to December 2008, using the terms vascular cognitive impairment, vascular dementia, post-stroke dementia, vascular cognitive disorder, mild cognitive impairment, criteria, disease progression, outcomes, treatment, prevention, biomarkers, and neuroimaging.

Study Selection and Data Extraction:

All articles in published English identified from the data sources were evaluated for inclusion. Regarding pharmacotherapy, prospective double-blind, placebo-controlled studies were included as well as extensions or relevant post hoc analyses.

Data Synthesis:

In the 1970s, “senile dementia due to hardening of the arteries” was used to describe dementia due to vascular causes. This was a narrow view of what is now known to be a common form of cognitive impairment in older people. Multiple infarct dementia (MID) was first proposed to describe dementia attributable to multiple cerebral infarcts, followed by the vascular dementia (VaD) construct, itself meant to be an improvement over MID. The VaD construct had limitations, not the least of which was that, by the time a patient was diagnosed with VaD, the opportunity for prevention was lost. Thus arose the concept of VCI, representing a group of heterogeneous disorders that share presumed vascular causes. The importance of VCI is centered on the fact that vascular risk factors are treatable, and thus should lead to a reduction in the incidence of cognitive impairment due to vascular causes. There is evidence that treatment of hypertension can lead to a reduction in the incidence of cognitive impairment and dementia, and that treatment of VaD with acetylcholinesterase inhibitors may be beneficial.

Conclusions:

Careful attention needs to be given to controlling vascular risk factors in at-risk patients. Pharmacists should play an active role in this important area of geriatric pharmacotherapy.