Association of Neighborhood-Level Disadvantage With Alzheimer Disease Neuropathology

Impact of the Adverse Social Exposome on Survival in Individuals With Amyotrophic Lateral Sclerosis

BACKGROUND AND OBJECTIVES

An adverse social exposome negatively affects many diseases, but its association with amyotrophic lateral sclerosis (ALS) survival is unknown. This study examined the association between the social exposome measure Area Deprivation Index (ADI) and ALS survival.

METHODS

This is a retrospective analysis of patients with ALS at the University of Michigan Pranger ALS Clinic diagnosed after January 1, 2012. Extracted data included age, sex, race, residential address, disease characteristics, and survival. National ADI ranking was assigned to each patient's geocoded address. Accelerated failure time survival analysis determined association between the ADI group and survival with adjustment for clinicodemographic covariates.

RESULTS

1,085 patients (median age at diagnosis, 72 years; 45% female) met inclusion criteria. The highest ADI decile (most disadvantaged neighborhood group) was associated with 37.0% shorter survival time (95% CI -50.4% to -20.1%). Results were similar when grouping patients by ADI ranking (as opposed to decile) or including only those with a classical ALS phenotype.

DISCUSSION

Exposure to adverse social exposome, as measured by ADI, associates with poorer ALS survival. Because this is a single-center study, replication in other cohorts is encouraged. Further research is needed to understand the underlying mechanisms, which could influence ALS clinical care.

Factors Associated With Physical Activity in Alzheimer's Disease: A Cross-Sectional Study of Individuals and Their Caregivers

INTRODUCTION

Physical activity (PA) is associated with better outcomes in individuals living with Alzheimer's and related dementia (ADRD). We examined environmental, intra-, and interpersonal correlates of PA for persons living with ADRD.

METHODS

PA (accelerometry), cognitive function, physical function, and sociodemographic factors were collected in adults with ADRD and their caregivers. Spearman's correlations and generalized linear models were used to evaluate factors associated with PA of persons living with ADRD.

RESULTS

Valid data were obtained from 65 pairs of adults living with ADRD (73.6 ± 8.4 years, 39.4% female) and caregivers (69.4 ± 9.4 years, 69.2% female, 93.8% spouse). Moderate-to-vigorous PA (MVPA) and light PA of persons living with ADRD were correlated with upper and lower body strength, aerobic fitness, and agility. MVPA and sedentary time of persons living with ADRD were associated with that of their caregiver.

CONCLUSION

Physical function and caregiver PA may be targets for interventions in those living with ADRD.

Social determinants of health and mild cognitive impairment in a diverse community sample

BACKGROUND

The associations between community-wide social determinants of health and mild cognitive impairment (MCI) among individuals warrant investigation.

METHODS

Among 2830 dementia-free individuals aged 65+ years in a community-based US study, we examined cross-sectional associations of MCI (Clinical Dementia Rating = 0.5) with the following potential social determinants of health: at the census tract or block group level obtained from public sources: neighborhood disadvantage (Area Deprivation Index, ADI), air pollution with fine particulate matter (PM2.5), greenspace, Walkability Index, ambulatory healthcare availability per square mile, homicide rate; and at the individual participant level, birth/schooling in a southern US state.

RESULTS

Unadjusted logistic regression models found higher odds ratios (OR, 95% CI) for MCI with higher ADI (1.01, 1.003-1.02), higher PM2.5 (1.16, 1.07-1.26), higher homicide rate (1.007, 1.001-1.012), lesser greenspace (0.99, 0.90-0.99), and southern schooling (2.06, 1.6-3.54). Adjusting for age, race, sex, and educational level, ADI remained statistically significant (1.04, 1.01-1.06), while PM2.5 and Southern state schooling interacted significantly with race and were more strongly affected in Black participants than in White participants.

CONCLUSIONS

In this cohort, several community-wide social/environmental factors were associated with MCI. While clinicians should continue to encourage older adults to modify their individual risk factors, policy changes are needed to mitigate social determinants of health in the community.

The Role of the Neural Exposome as a Novel Strategy to Identify and Mitigate Health Inequities in Alzheimer's Disease and Related Dementias

With the continuous increase of the elderly population, there is an urgency to understand and develop relevant treatments for Alzheimer's disease and related dementias (ADRD). In tandem with this, the prevalence of health inequities continues to rise as disadvantaged communities fail to be included in mainstream research. The neural exposome poses as a relevant mechanistic approach and tool for investigating ADRD onset, progression, and pathology as it accounts for several different factors: exogenous, endogenous, and behavioral. Consequently, through the neural exposome, health inequities can be addressed in ADRD research. In this paper, we address how the neural exposome relates to ADRD by contributing to the discourse through defining how the neural exposome can be developed as a tool in accordance with machine learning. Through this, machine learning can allow for developing a greater insight into the application of transferring and making sense of experimental mouse models exposed to health inequities and potentially relate it to humans. The overall goal moving beyond this paper is to define a multitude of potential factors that can increase the risk of ADRD onset and integrate them to create an interdisciplinary approach to the study of ADRD and subsequently translate the findings to clinical research.

"Rest of the folks are tired and weary": The impact of historical lynchings on biological and cognitive health for older adults racialized as Black

Childhood structural racism may lead to poorer health and longevity for individuals racialized as Black. Racism-related stress cumulatively taxes the body resulting in worsening biological and cognitive health. This study examines the association between state-level exposure to historical lynchings (adverse childhood racism for modern older adults), with C-reactive protein (CRP, a marker of systemic inflammation), and global cognitive performance (modified TICS). We linked the percentage of lynchings of people racialized as Black at the state-level between 1882 and 1968 from the Archives at Tuskegee Institute with repeated CRP and cognitive test scores at baseline (2006/2008), year 4 (2010/2012), and year 8 (2014/2016) for a national sample of older adults in the Health and Retirement Study (N = 10,500, aged >50). In multivariable generalized estimating equation models, we compared participants (by racialized group) living in states with high lynching proportions (>50th percentile) on changes in CRP and cognitive test scores adjusting for demographics, health conditions, and behaviors. Mean age was 69 (SD = 9.9) and most participants were cisgender women (59%). On average participants racialized as non-LatinX Black living in states with high lynching proportions experienced 18.5% (95% CI 3%, 36%) higher CRP levels and -0.92 (95% CI -1.34, -0.50) lower cognitive test scores than participants racialized as non-LatinX Black that lived in states with lower lynching proportions. As artist Marvin Gaye sang in Flyin' High (in the Friendly Sky), "Rest of the folks are tired and weary," which describes how adverse childhood racism is associated with inflammation and dementia risk for people racialized as Black.

Neighborhood disadvantage is associated with working memory and hippocampal volumes among older adults

It is not well understood how neighborhood disadvantage is associated with specific domains of cognitive function and underlying brain health within older adults. Thus, the objective was to examine associations between neighborhood disadvantage, brain health, and cognitive performance, and examine whether associations were more pronounced among women. The study included 136 older adults who underwent cognitive testing and MRI. Neighborhood disadvantage was characterized using the Area Deprivation Index (ADI). Descriptive statistics, bivariate correlations, and multiple regressions were run. Multiple regressions, adjusted for age, sex, education, and depression, showed that higher ADI state rankings (greater disadvantage) were associated with poorer working memory performance (p < .01) and lower hippocampal volumes (p < .01), but not total, frontal, and white matter lesion volumes, nor visual and verbal memory performance. There were no significant sex interactions. Findings suggest that greater neighborhood disadvantage may play a role in working memory and underlying brain structure.

Changes in neighborhood disadvantage over the course of 22 years among community-living older persons

BACKGROUND

Among older persons, neighborhood disadvantage is a granular and increasingly used social determinant of health and functional well-being. The frequency of transitions into or out of a disadvantaged neighborhood over time is not known. These transitions may occur when a person moves from one location to another or when the Neighborhood Atlas, the data source for the area deprivation index (ADI) that is used to identify disadvantaged neighborhoods at the census-block level, is updated.

METHODS

From a prospective longitudinal study of community-living persons, aged 70 years or older in South Central Connecticut, neighborhood disadvantage was ascertained every 18 months for 22 years (from March 1998 to March 2020). ADI scores higher than the 80th state percentile were used to distinguish neighborhoods that were disadvantaged (81-100) from those that were not (1-80).

RESULTS

At baseline, 205 (29.3%) of the 699 participants were living in a disadvantaged neighborhood. Changes in neighborhood disadvantage during 14 consecutive 18-month intervals were relatively uncommon, ranging from 1.5% to 11.8%. Nearly 80% of participants had no change in neighborhood disadvantage and less than 4% had more than one change over a median follow-up of more than 9 years. Overall, the rate of transitions into or out of neighborhood disadvantage was only 2.7 per 100 person-years. These transitions were most common when the Neighborhood Atlas was updated (2013, 2015, 2018, and 2020). Comparable results were observed when decile changes in ADI scores during the 18-month intervals were evaluated.

CONCLUSIONS

In longitudinal studies of older persons with extended follow-up, it may not be necessary to update information on disadvantaged neighborhoods in circumstances when it is possible, and the degree of misclassification of neighborhood disadvantage should be relatively low in circumstances when updated information cannot be obtained.

Comparison of sample characteristics of Wisconsin Alzheimer's Disease Research Center participants with the Wisconsin state population-An evaluation of the recruitment effort

INTRODUCTION

Understanding how a research sample compares to the population from which it is drawn can help inform future recruitment planning. We compared the Wisconsin Alzheimer's Disease Research Center (WADRC) participant sample to the Wisconsin state population (WI-pop) on key demographic, social exposome, and vascular risk measures.

METHODS

The WADRC sample included 930 participants. Population statistics were estimated using several national and state data sources. We compared WADRC to WI-pop for two age groups, 45-64 years and ≥65 years, separately.

RESULTS

Compared to WI-pop, WADRC participants were older and included more women, more Black and American Indian individuals, and fewer Hispanic and Asian individuals. WADRC participants had higher levels of educational attainment, consisted of smaller proportions living in rural areas and disadvantaged neighborhoods, and showed lower vascular risks. Greater differences between WADRC and WI-pop were found for most metrics in the ≥65 group compared to the 45-64 group.

DISCUSSION

The findings revealed opportunities to increase enrollment from the Hispanic/Latino and Asian American populations, to include participants from a broader range of educational backgrounds, and to enroll more residents from rural areas and disadvantaged neighborhoods, which may lead to a broader distribution of cardiovascular risk factors. Expanding sociodemographic and health profiles represented in the participant candidate pool for study selection and including those who are underrepresented in research may potentially reduce selection bias but not eliminate it. Statistical approaches can be applied to address bias and generalize findings from a study sample to its target population by adjusting for their differences in the joint distribution of covariates. Although research centers have different regional populations and specific recruitment focuses for scientific reasons, evaluating their participant characteristics may help plan engagement efforts to improve the inclusion of underrepresented groups and collaboratively support generalizable research nationwide.

Highlights

We compared the characteristics of Wisconsin Alzheimer's Disease Research Center (WADRC) participants with the Wisconsin population.Metrics of comparison included demographics, social exposomes, and vascular risks.WADRC participants are different from the Wisconsin population.We explored the implications and causes of the differences.We discussed strategies for engaging and recruiting underrepresented groups.

Implication of Neighborhood Deprivation Index on Pelvic Organ Prolapse Management

IMPORTANCE

Differences in the rate of diagnosis of POP have been described based on race and ethnicity; however, there are few data available on the management and treatment patterns of POP based on multiple factors of socioeconomic status and deprivation.

OBJECTIVE

The objective of this study was to investigate the association between pelvic organ prolapse (POP) management and the Neighborhood Deprivation Index (NDI), a standardized multidimensional measure of socioeconomic status.

STUDY DESIGN

This retrospective cohort study included female members of a large integrated health care delivery system who were 18 years or older and had ≥4 years of continuous health care membership from January 1, 2015, to December 31, 2019. Demographic, POP diagnosis, urogynecology consultation, and surgical treatment of POP were obtained from the electronic medical record. Neighborhood Deprivation Index data were extrapolated via zip code and were reported in quartiles, with higher quartiles reflecting greater deprivation. Descriptive, bivariate, and logistic regression analyses were conducted by NDI.

RESULTS

Of 1,087,567 patients identified, 34,890 (3.2%) had a POP diagnosis. Q1, the least deprived group, had the highest prevalence of POP (26.3%). Most patients with POP identified as White (57.3%) and represented approximately a third of Q1. Black patients had the lowest rate of POP (5.8%) and comprised almost half of Q4, the most deprived quartile. A total of 13,730 patients (39.4%) had a urogynecology consultation, with rates ranging from 23.6% to 26.4% ( P < 0.01). Less than half (12.8%) of patients with POP underwent surgical treatment, and the relative frequencies of procedure types were similar across NDI quartiles except for obliterative procedures ( P = 0.01). When controlling for age, no clinically significant difference was demonstrated.

CONCLUSIONS

Differences in urogynecology consultation, surgical treatment, and surgical procedure type performed for prolapse across NDI quartiles were not found to be clinically significant. Our findings suggest that equitable evaluation and treatment of prolapse can occur through a membership-based integrated health care system.

The effect of socioeconomic status on clinical outcomes and implant survivorship after primary anatomic and reverse total shoulder arthroplasty

BACKGROUND

Low socioeconomic status has been shown to contribute to poor outcomes in patients undergoing joint replacement surgery. However, there is a paucity of studies investigating shoulder arthroplasty. The purpose of this study was to evaluate the effect of socioeconomic status on baseline and postoperative outcome scores and implant survivorship after anatomic and reverse primary total shoulder arthroplasty (TSA).

METHODS

A retrospective review of a prospectively collected single-institution database was performed to identify patients who underwent primary TSA. Zip codes were collected and converted to Area Deprivation Index (ADI) scores. We performed a correlation analysis between national ADI scores and preoperative, postoperative, and preoperative to postoperative improvement in range of motion (ROM), shoulder strength, and functional outcome scores in patients with minimum 2-year follow-up. Patients were additionally grouped into groups according to their national ADI. Achievement of the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) and revision-free survivorship were compared between groups.

RESULTS

A total of 1148 procedures including 415 anatomic and 733 reverse total shoulder arthroplasties with a mean age of 64 ± 8.2 and 69.9 ± 8.0 years, respectively, were included. The mean follow-up was 6.3 ± 3.6 years for anatomic and 4.9 ± 2.7 years for reverse total shoulder arthroplasty. We identified a weak negative correlation between national ADI and most functional outcome scores and ROM preoperatively (R range 0.07-0.16), postoperatively (R range 0.09-0.14), and preoperative to postoperative improvement (R range 0.01-0.17). Thus, greater area deprivation was weakly associated with poorer function preoperatively, poorer final outcomes, and poorer improvement in outcomes. There was no difference in the proportion of each ADI group achieving MCID, SCB, and PASS in the anatomic total shoulder arthroplasty cohort. However, in the reverse total shoulder arthroplasty cohort, the proportion of patients achieving MCID, SCB, and PASS decreased with greater deprivation. There was no difference in survivorship between ADI groups.

CONCLUSIONS

We found a negative effect of low socioeconomic status on baseline and postoperative patient outcomes and ROM; however, the correlations were relatively weak. Patients that reside in socioeconomically deprived areas have poorer functional outcomes before and after TSA and achieve less improvement from surgery. We should strive to identify modifiable factors to improve the success of TSA in socioeconomically deprived areas.

Behavioral Health Workforce Distribution in Socially Disadvantaged Communities

This study sought to understand the geographic distribution of three behavioral health clinician (BHC) types in disadvantaged communities in the U.S. across a standardized index of area disadvantage. CMS National Plan and Provider Enumeration System's data were used to identify BHC practice addresses. Addresses were geocoded and mapped to census block groups across Area Disadvantage Index (ADI) scores. Differences in the proportion of BHCs per 100k people in a block group by ADI, clinician type, and rurality were compared. Zero-inflated negative binomial models assessed associations between ADI score with any amount, and expected count, of BHC type in a block group. The sample included 836,780 BHCs (51.5% counselors, 34.5% social workers, 14.0% psychologists). Results indicated there were fewer BHCs in areas of high disadvantage with 351 BHCs in the lowest need versus 267 BHCs in highest need areas, per 100k people. BHC type was differently associated with the rate of clinicians per 100k by ADI and block groups that were both rural and high ADI had the least BHCs located. Findings suggest the maldistribution of BHCs by ADI underscores how some BHCs may be better positioned to meet the needs of vulnerable communities. Increasing access to behavioral health care requires a workforce equitably positioned in high-need areas. Reforms to payment and practice regulations may support BHCs to deliver services in socially disadvantaged neighborhoods.

Area Deprivation Index and Frailty Among Older People With HIV

We evaluated the relationship between neighborhood disadvantage (measured by the Area Deprivation Index [ADI]) and frailty. We performed a secondary analysis, pooling cross-sectional data collected from 209 people with HIV (PWH) aged ≥50 years enrolled in studies in Colorado (CO) and Missouri (MO). MO participants (N = 137) had a higher ADI (µ= 70, ơ2 = 25) compared to CO (µ= 32, ơ2 = 15; p < .001). No significant differences in ADI were observed between frailty categories when cohorts were examined either separately or combined; however, when comparing individual frailty criteria, the most apparent differences by neighborhood disadvantage were seen among those with limited physical activity (μ = 67, ơ2 = 28) compared to those without (μ = 55, ơ2 = 29, p = .03). Neighborhood disadvantage was associated with low physical activity but not with overall frailty status. Future research should examine how access to physical activity spaces varies based on ADI, as this could be crucial in preventing frailty.

Measuring the association between diagnostic errors and neighborhood disadvantage

Patients who reside in areas of high neighborhood disadvantage have poorer health outcomes; the mechanisms for this disparity are complex. We sought to determine if there was an association between neighborhood disadvantage and diagnostic error among a cohort of adult inpatients who experienced either an ICU transfer or in-hospital death. Using a sample of 527 patients from seven geographically diverse academic medical systems, we compared diagnostic error rates to patients' neighborhood disadvantage levels as measured by the Area Deprivation Index, a validated composite measure of socioeconomic status. In contrast to previous studies that found differences in hospital care based on socioeconomic status, we found no difference in diagnostic error rate between patients based on neighborhood disadvantage. Once a patient reaches the hospital, their risk of diagnostic error is not related to the neighborhood in which they live.

Predictors of Retention in the 1Florida Alzheimer's Disease Research Center (ADRC) Over Two Waves

Background: Attrition is a significant methodological concern in longitudinal studies. Sample loss can limit generalizability and compromise internal validity. Methods: Wave one (n = 346) and wave two follow-ups (n = 196) of the 1Florida ADRC clinical core were examined using a 24-month visit window. Results: The sample (59% Hispanic) demonstrated retention rates of 77.2% and 86.2% in waves one and two, respectively. Predictors of lower retention in wave one included older age, amnestic MCI or dementia, and lower cognition and function scores. Completing a baseline MRI and lack of hippocampal atrophy were associated with higher retention in both waves. In wave two, a greater neighborhood disadvantage score was associated with attrition. Discussion: Predictors of retention changed over time, possibly due to the early withdrawal of the most vulnerable in the initial wave. Understanding predictors of retention can facilitate retention strategies, reduce attrition, and increase the validity of findings.

Neighborhood Disadvantage in a Nationally Representative Sample of Community-Living Older US Adults

Importance

Although neighborhood socioeconomic disadvantage has become the standard for evaluating contextual socioeconomic deprivation at the Census-block level, little is known about its prevalence or association with long-term mortality in nationally representative samples of older persons.

Objectives

To estimate the prevalence of neighborhood disadvantage among a nationally representative sample of community-living older adults; to identify how prevalence estimates differ based on relevant demographic, socioeconomic, geographic, clinical, and geriatric characteristics; and to evaluate the association between neighborhood disadvantage and all-cause mortality.

Design, Setting, and Participants

This cohort study analyzed linked data of community-living persons aged 65 years or older in the contiguous US participating in the National Health and Aging Trends Study (NHATS) from 2011 to 2021. Data on demographic, socioeconomic, geographic, clinical, and geriatric characteristics were obtained primarily from the baseline NHATS assessment. NHATS survey weights were used for all analyses. Data analysis was conducted from February to July 2024.

Main Outcomes and Measures

Neighborhood disadvantage-the main measure for each of the 3 objectives-was assessed using the area deprivation index, which was dichotomized at the worst quintile (defined as the worst 2 deciles). Ascertainment of mortality over 10 years was 100% complete.

Results

Among the 7505 participants, with a weighted mean (SD) age of 75.3 (7.4) years, 56.8% were female, 6.6% were Hispanic, 8.2% were non-Hispanic Black, and 81.7% were non-Hispanic White individuals. The prevalence of neighborhood disadvantage was 15.8% (95% CI, 14.9%-16.7%), but it differed greatly across multiple subgroups. The largest differences after adjustment for age and sex were observed for non-Hispanic Black compared with non-Hispanic White participants (rate ratio [RR], 3.11; 95% CI, 2.56-3.79); those with less than a high school diploma vs college degree or higher educational level (RR, 3.47; 95% CI, 2.75-4.39); and those in several Census divisions, with an RR as high as 7.31 (95% CI, 2.98-17.90) for West South Central vs Pacific. The mortality rates were 48.5% (95% CI, 44.6%-52.1%) and 43.5% (95% CI, 42.2%-44.7%) among participants in a disadvantaged and a nondisadvantaged neighborhood. Neighborhood disadvantage was associated with mortality after adjustment for demographic characteristics (hazard ratio [HR], 1.25; 95% CI, 1.11-1.40) but not after further adjustment for socioeconomic characteristics (HR, 1.11; 95% CI, 0.98-1.25).

Conclusions and Relevance

In this cohort study of community-living older adults, population-based estimates of neighborhood disadvantage differed greatly across multiple subgroups. This contextual indicator of socioeconomic deprivation was associated with long-term mortality, but the association was diminished and no longer significant after accounting for individual-level socioeconomic characteristics.

Neighborhood socioeconomic disadvantage does not predict need for manipulation under anesthesia or range of motion following total knee arthroplasty

Background

Studies have linked socioeconomic factors including lower income and minority race with worse functional outcomes following total knee arthroplasty (TKA). Arthrofibrosis is a common complication following TKA, and manipulation under anesthesia (MUA) is an effective treatment option for arthrofibrosis. This study aimed to determine if neighborhood-level socioeconomic disadvantage predicts need for MUA and postoperative range of motion (ROM) among patients undergoing primary elective TKA.

Methods

We performed a retrospective cohort study of primary TKAs performed at a single institution over a three-year duration. Area Deprivation Index (ADI) was used to determine each patient's level of socioeconomic disadvantage based on their home address. Patients were allocated into three groups based on ADI: least socioeconomic disadvantage (ADI 1-3), middle socioeconomic disadvantage (ADI 4-6), and most socioeconomic disadvantage (ADI 7-10). Demographic factors and comorbid conditions were recorded. Bivariate analysis was used to evaluate the relationship between degree of socioeconomic disadvantage and need for MUA and postoperative ROM.

Results

In total, 600 patients were included and 26.7 % were categorized as most disadvantaged. In comparison to the middle and least disadvantaged groups, these patients were more likely to be Women (71.2 vs. 67.9 and 58.6 %; p = 0.027), younger (60.7 vs. 62.9 and 66.3 years; p < 0.001) and have higher BMI (34.9 vs. 33 and 31.7; p < 0.001) (most disadvantaged vs. middle and least). Analysis revealed no difference in rate of MUA (6.3 vs. 2.5 vs. 4 %; p = 0.179) or postoperative ROM (98 vs. 98 vs. 100°; p = 0.753) between the three groups (most, middle, and least disadvantaged, respectively).

Conclusion

Neighborhood socioeconomic disadvantage does not predict rate of MUA or postoperative ROM following TKA. Patients residing in neighborhoods with higher ADI who underwent TKA were more likely to be younger, Women, and have higher BMI, consistent with previous literature. Our results support efforts to improve access to orthopaedic care, including TKA, to patients of all socioeconomic levels.

Assessing the Impact and Cost-Effectiveness of Exposome Interventions on Alzheimer's Disease: A Review of Agent-Based Modeling and Other Data Science Methods for Causal Inference

Background: The exposome (e.g., totality of environmental exposures) and its role in Alzheimer's Disease and Alzheimer's Disease and Related Dementias (AD/ADRD) are increasingly critical areas of study. However, little is known about how interventions on the exposome, including personal behavioral modification or policy-level interventions, may impact AD/ADRD disease burden at the population level in real-world settings and the cost-effectiveness of interventions. Methods: We performed a critical review to discuss the challenges in modeling exposome interventions on population-level AD/ADRD burden and the potential of using agent-based modeling (ABM) and other advanced data science methods for causal inference to achieve this. Results: We describe how ABM can be used for empirical causal inference modeling and provide a virtual laboratory for simulating the impacts of personal and policy-level interventions. These hypothetical experiments can provide insight into the optimal timing, targeting, and duration of interventions, identifying optimal combinations of interventions, and can be augmented with economic analyses to evaluate the cost-effectiveness of interventions. We also discuss other data science methods, including structural equation modeling and Mendelian randomization. Lastly, we discuss challenges in modeling the complex exposome, including high dimensional and sparse data, the need to account for dynamic changes over time and over the life course, and the role of exposome burden scores developed using item response theory models and artificial intelligence to address these challenges. Conclusions: This critical review highlights opportunities and challenges in modeling exposome interventions on population-level AD/ADRD disease burden while considering the cost-effectiveness of different interventions, which can be used to aid data-driven policy decisions.

Childhood Community Disadvantage and MRI-Derived Structural Brain Integrity After Age 65 Years

Importance

Prior studies associate late-life community disadvantage with worse brain health. It is relatively unknown if childhood community disadvantage associates with late-life brain health.

Objective

To test associations between childhood residence in an economically disadvantaged community, individual income and education, and late-life cortical brain volumes and white matter integrity.

Design, Setting, and Participants

This cohort study was conducted in the ongoing harmonized cohorts KHANDLE (Kaiser Healthy Aging and Diverse Life Experiences Study; initiated 2017) and STAR (Study of Healthy Aging in African Americans; initiated 2018) using all available data collected out of a regional integrated health care delivery network in California between cohort initiation and analysis initiation in June 2023. Eligible participants were Kaiser Permanente Northern California member ages 65 years or older. Data were analyzed between June and November 2023.

Exposure

Residence at birth was geocoded and linked to historical Area Deprivation Indices (ADI). ADI is a nationally ranked percentile; community disadvantage was defined as ADI of 80 or higher.

Main Outcomes and Measures

Regional brain volumes and white matter integrity measures were derived from a random subset of participants who underwent 3T magnetic resonance imaging. Models adjusted for race and ethnicity, sex, and parental education.

Results

Of a total 2161 individuals in the combined cohort, 443 individuals were eligible for imaging (mean [SD] age, 76.3 [6.5] years; 253 female [57.1%]; 56 Asian [12.6%], 212 Black [47.9%], 67 Latino [15.1%], 109 White [24.6%]). Imaging participants had a mean (SD) 15.0 (2.5) years of education, and 183 (41.3%) earned $55 000 to $99 999 annually. Fifty-four participants (12.2%) resided in a disadvantaged childhood community. Childhood community disadvantage was associated with smaller gray matter volumes overall (-0.39 cm3; 95% CI, -0.65 to -0.10 cm3) and in the cerebellum (-0.39 cm3; 95% CI, -0.66 to -0.09 cm3), hippocampus (-0.37 cm3; 95% CI, -0.68 to -0.04 cm3), and parietal cortex (-0.25 cm3; 95% CI, -0.46 to -0.04 cm3) and larger mean lateral ventricle (0.44 cm3; 95% CI, 0.12 to 0.74 cm3), third ventricle (0.28 cm3; 95% CI, 0.03 to 0.55 cm3), and white matter hyperintensity volume (0.31 cm3; 95% CI, 0.06 to 0.56 cm3). Educational attainment and late-life income did not mediate these associations.

Conclusions and Relevance

In this cohort study of racially and ethnically diverse health plan members, childhood community disadvantage was associated with worse late-life brain health independent of individual socioeconomic status. Future work should explore alternative pathways (eg, cardiovascular health) that may explain observed associations.

Association of Area Deprivation Index With Mortality in Critically Ill Adults With COVID-19

BACKGROUND

Various social determinants of health have been established as significant risk factors for COVID-19 transmission, prevalence, incidence, and mortality. Area deprivation index (ADI, a composite score made up of educational, housing, and poverty markers) is an accepted multidimensional social determinants of health measure. Little is known about how structural social determinants of health before hospitalization, including ADI, may affect mortality related to COVID-19 in critically ill patients.

OBJECTIVES

To examine the association of ADI with intensive care unit (ICU) mortality in patients with COVID-19 and compare its predictive power with that of clinical factors.

METHODS

This was a retrospective cohort study of critically ill adults with COVID-19 in 3 hospitals within a single health system. Multivariable logistic regression models (adjusted for demographic and clinical variables) were used to examine the association of ADI with ICU mortality.

RESULTS

Data from 1784 patients hospitalized from 2020 to 2022 were analyzed. In multivariable models, no association was found between national ADI and ICU mortality. Notable factors associated with ICU mortality included treatment year, age, van Walraven weighted score, invasive mechanical ventilation, and body mass index.

CONCLUSION

In this study, clinical factors were more predictive of mortality than ADI and other social determinants of health. The influence of ADI may be most relevant before hospital admission. These findings could serve as a foundation for shaping targeted public health strategies and hospital interventions, enhancing care delivery, and potentially contributing to better outcomes in future pandemics.

The impact of social deprivation on healthcare utilization patterns following rotator cuff repair

BACKGROUND

Disparities in social determinants of health have been linked to worse patient reported outcomes, higher pain, and increased risk of revision surgery following rotator cuff repair. Identification of perioperative predictors of increased healthcare utilization is of particular interest to surgeons to improve outcomes and mitigate the total cost of care. The effect of social deprivation on healthcare utilization has not been fully characterized.

METHODS

This is a retrospective review of a single institution's experience with primary rotator cuff repair between 2012 and 2020. Demographic variables (age, race, gender, American Society of Anesthesiologists (ASA) score) and healthcare utilization (hospital readmission, emergency department visits, follow-up visits, telephone calls) were recorded within 90 days of surgery. The Area Deprivation Index (ADI) was recorded, and patients were separated into terciles according to their relative level of social deprivation. Outcomes were then stratified based on ADI tercile and compared.

RESULTS

A total of 1695 patients were included. The upper, middle, and lower terciles of ADI consisted of 410, 767, and 518 patients, respectively. The most deprived tercile had greater emergency department visitation and office visitation within 90 days of surgery relative to the least and intermediate deprived terciles. Higher levels of social deprivation were independent risk factors for increased emergency department (ED) visitation and follow-up visitation. There was no difference in 90-day readmission rates or telephone calls made between the least, intermediate, and most deprived patients.

CONCLUSIONS

Patients with higher levels of deprivation demonstrated greater postoperative hospital utilization. We hope to use these results to identify risk factors for increased hospital use, guide clinical decision making, increase transparency, and manage patient outcomes following rotator cuff repair surgery.

Socioeconomic and medical determinants of state-level subjective cognitive decline in the United States

INTRODUCTION

It is important to understand the socioeconomic and medical determinants of subjective cognitive decline (SCD) at a population level in the United States.

METHODS

The primary outcomes are state-level rates of SCD and SCD-related functional impairment in adults aged ≥ 45, both measured in the Behavioral Risk Factor Surveillance System from 2016 to 2022. The exposures are state-level rates of poverty, unemployment, homelessness, college education, racial and ethnic minorities, uninsurance, smoking, hypertension, diabetes, and obesity as well as household income and physician density.

RESULTS

The strongest state-level associations with rates of SCD were the prevalence of diabetes (rho = 0.64), hypertension (rho = 0.59), and poverty (rho = 0.58; all p < 0.001), and with SCD-related functional impairment were prevalence of poverty (rho = 0.71), diabetes (rho = 0.68), and hypertension (rho = 0.53; all p < 0.001).

DISCUSSION

This study highlights critical links between SCD and socioeconomic and medical determinants in adults aged ≥ 45 in the United States, including the prevalence of poverty, diabetes, and hypertension.

HIGHLIGHTS

State-level analysis reveals socioeconomic and medical risk factors for subjective cognitive decline (SCD) at a population level. The prevalence of poverty is a critical contributor to the state-level prevalence of SCD. The prevalence of diabetes and hypertension are also strong state-level determinants of SCD. Addressing the burden of cognitive decline at the population level necessitates targeting socioeconomic and medical factors.

Impact of pre-existing dementia on neurosurgical intervention and outcomes in older patients with head injury: an analysis of a nationwide trauma registry in Japan

BACKGROUND

Dementia is a common comorbidity in older patients with traumatic brain injury (TBI), potentially affecting their care processes and outcomes. However, the impact of pre-existing dementia on TBI remains unclear as research on TBI often excludes older adults with comorbidities. This study aimed to investigate the association between pre-existing dementia and outcomes in older patients admitted to hospitals after TBI.

METHODS

This observational study included patients aged ≥ 65 years with TBI who were identified from the Japan Trauma Data Bank between January 1, 2019, and December 31, 2021. Associations between pre-existing dementia and outcomes were assessed using multivariable logistic regression analysis. The primary outcome was survival at discharge. Secondary outcomes were neurosurgical interventions and discharge to home.

RESULTS

In total, 16,270 patients from 175 hospitals were analyzed. Of these, 1,750 (10.8%) had pre-existing dementia, and 13,520 (83.1%) survived to discharge. No significant association was observed between pre-existing dementia and neurosurgical interventions and survival at discharge. In contrast, pre-existing dementia was associated with a significantly lower likelihood of being discharged to home. Subgroup analysis revealed interactions between pre-existing dementia and the subgroups, showing adverse impact in relatively younger patients and those without severe head injury.

CONCLUSIONS

Patients with pre-existing dementia had similar chances for neurosurgical intervention and survival at discharge than their counterparts without dementia. However, pre-existing dementia was associated with a significantly lower likelihood of being discharged to home, especially in relatively younger patients and those without severe head injury. Therefore, recognizing the risks within this population and taking measures to facilitate social reintegration is necessary.

Disparities in structural brain imaging in older adults from rural communities in Southern Nevada

Introduction

Identifying the associations between rural-living or neighborhood disadvantage and neurobiology may clarify rural-urban disparities in older adults with cognitive impairment related to Alzheimer's disease.

Methods

We examined rural-urban differences and neighborhood disadvantages in brain cortical thickness (CT) measures among 71 rural and 87 urban-dwelling older adults. Analysis of covariance was used to test each FreeSurfer-derived CT measures' associations with rural-urban living, clinical impairment status, and their interactions. Post-hoc linear regressions were used to test the association between CT measures and neighborhood disadvantage index.

Results

Rural-dwelling older adults had thinner cortices in temporal and inferior frontal regions compared to urban participants, especially among clinically normal participants, where the thinner temporal cortex further correlated with higher neighborhood disadvantage. Conversely, rural participants had thicker cortices in superior frontal, parietal and occipital regions.

Discussion

Our results suggest a complex interplay between community contexts and neurobiology. For memory-related regions, rural-living and neighborhood disadvantage might be negatively associated with subjects' brain structures.

Association of the Area Deprivation Index With Dementia Basic Workup and Diagnosis in Central and Western Virginia: A Cross-Sectional Study

Background and Objectives

The Area Deprivation Index (ADI) provides a validated and multidimensional metric of areal disadvantage. Our goals were to determine if the ADI influences the likelihood of receiving workup based on published guidelines and an etiologic diagnosis of dementia in Central and Western Virginia.

Methods

We collected deidentified data from the electronic health record of individuals aged 50-105 years diagnosed with dementia at the University of Virginia (UVA) Medical Center (2016-2021) and at Carillion Clinic (2018-2021). Visit-specific ICD-10 codes were used to classify each dementia diagnosis as "disease-specific" (e.g., Alzheimer disease) or "general" (e.g., unspecified dementia). Following the American Academy of Neurology guidelines, we considered the evaluation performed as "adequate" if patients had vitamin B12, thyroid-stimulating hormone, and brain CT or magnetic resonance imaging within 6 months of the initial diagnosis. Census tract ADI was linked to study participants using the unique census tract identifier derived from the participants' home addresses at the time of diagnosis. Statistical modeling occurred under a Bayesian paradigm implemented using a standard code in R.

Results

The study included 13,431 individuals diagnosed with dementia at UVA (n = 7,152) and Carillion Clinic (n = 6,279). Of those, 32.5% and 20.4% received "disease-specific" diagnoses at UVA and Carillion Clinic and 8.2% and 20.4% underwent "adequate" workup, respectively. The adjusted relationship between census tract ADI and the likelihood of a disease-specific diagnosis was U-shaped: Residence in moderately disadvantaged areas was associated with the lowest likelihood of disease-specific diagnosis.

Discussion

Most patients diagnosed with dementia did not receive an adequate evaluation or an etiologic diagnosis. Those living in locations just above the national median ADI levels had the lowest likelihood of receiving an etiologic diagnosis, lower than those in the least and most deprived areas. Renewed awareness efforts among providers are needed to increase compliance with diagnostic guidelines.

Impact of neighborhood disadvantage on cardiometabolic health and cognition in a community-dwelling cohort

INTRODUCTION

Neighborhood disadvantage may be an important determinant of cardiometabolic health and cognitive aging. However, less is known about relationships among individuals with mild cognitive impairment (MCI).

METHODS

The objective of this study is to investigate the relationship between neighborhood disadvantage measured by national Area Deprivation Index (ADI) rank with measures of cardiometabolic health and cognition among Wake Forest (WF) Alzheimer's Disease Research Center (ADRC) participants, with and without MCI.

RESULTS

ADI was positively associated with blood pressure and cardiometabolic index (CMI), and negatively associated with global and Preclinical Alzheimer's Cognitive Composite (PACC5) scores, in cognitively unimpaired (CU) individuals. ADI was only positively associated with hemoglobin A1c (HbA1c) in MCI.

DISCUSSION

Neighborhood disadvantage is associated more strongly with measures of cardiometabolic health and cognition among CU individuals rather than MCI. These findings demonstrate a need for structural solutions to address social determinants of health in an attempt to reduce cardiometabolic and cognitive risks.

The Potential of Social Policies in Preventing Dementia: An Ecological Study Using Systematic Review and Meta-Analysis

Social policies determine the distribution of factors (e.g. education, cardiovascular health) protecting against the development of dementia in Alzheimer's disease (AD). However, the association between social policies and the likelihood of AD without dementia (ADw/oD) has yet to be evaluated. We estimated this association in an ecological study using systematic review and meta-analysis. Four reference databases were consulted; 18 studies were included in the final analysis. ADw/oD was defined as death without dementia in people with clinically significant AD brain pathology. The indicators of social policy were extracted from the Organisation for Economic Co-operation and Development database (OECD). The probability of ADw/oD with moderate AD brain pathology was inversely associated with the Gini index for disposable income, poverty rate, and certain public expenditures on healthcare. ADw/oD with advanced AD brain pathology was only associated with public expenditures for long-term care. Social policies may play a role in maintaining and sustaining cognitive health among older people with AD.

Incident traumatic spinal cord injury and risk of Alzheimer's disease and related dementia: longitudinal case and control cohort study

STUDY DESIGN

Retrospective case/control longitudinal cohort study OBJECTIVES: Prevalent traumatic spinal cord injury (TSCI) is associated with Alzheimer's disease and related dementia (ADRD). We examined the hazard ratio for ADRD after incident TSCI and hypothesized that ADRD hazard is greater among adults with incident TSCI compared with their matched control of adults without TSCI.

SETTING

Using 2010-2020 U.S. national private administrative claims data, we identified adults aged 45 years and older with probable (likely and highly likely) incident TSCI (n = 657). Our controls included one-to-ten matched cohort of people without TSCI (n = 6553).

METHODS

We applied Cox survival models and adjusted them for age, sex, years of living with certain chronic conditions, exposure to six classes of prescribed medications, and neighborhood characteristics of place of residence. Hazard ratios were used to compare the results within a 4-year follow-up.

RESULTS

Our fully adjusted model without any interaction showed that incident TSCI increased the risk for ADRD (HR = 1.30; 95% CI, 1.01-1.67). People aged 45-64 with incident TSCI were at high risk for ADRD (HR = 5.14; 95% CI, 2.27-11.67) and no significant risk after age 65 (HR = 1.20; 95% CI, .92-1.55). Our sensitivity analyses confirmed a higher hazard ratio for ADRD after incident TSCI at 45-64 years of age compared with the matched controls.

CONCLUSIONS

TSCI is associated with a higher hazard of ADRD. This study informs the need to update clinical guidelines for cognitive screening after TSCI to address the heightened risk of cognitive decline and to shed light on the causality between TSCI and ADRD.

Neighborhood racial income inequality and cognitive health

INTRODUCTION

Neighborhood socioeconomic status (SES) has been linked to dementia, but the distribution of SES within a neighborhood may also matter.

METHODS

Data from 460 (47% Black, 46% White) older adults from the Michigan Cognitive Aging Project were linked to census tract-level data from the National Neighborhood Data Archive (NaNDA). Neighborhood SES included two composites reflecting disadvantage and affluence. Neighborhood racial income inequality was the ratio of median incomes for White versus Black residents. Generalized estimating equations examined associations between neighborhood factors and cognitive domains.

RESULTS

Neighborhood racial income inequality was uniquely associated with worse cognitive health, and these associations did not differ by participant race. Neighborhood disadvantage was only associated with worse cognitive health among Black participants.

DISCUSSION

Both the level and racial distribution of SES within a neighborhood may be relevant for dementia risk. Racial differences in the level and impact of neighborhood SES contribute to dementia inequalities.

HIGHLIGHTS

Black participants lived in neighborhoods with lower socioeconomic status (SES) than White participants, on average. Neighborhood SES and racial income inequality were associated with worse cognition. Effects of neighborhood racial income inequality did not differ across racial groups. Effects of neighborhood SES were only evident among Black participants.

Performance of the Modified Caregiver Strain Index in a Sample of Black and White Persons Living With Dementia and Their Caregivers

BACKGROUND AND OBJECTIVES

This study examined the performance of the Modified Caregiver Strain Index (MCSI) in a sample of Black and White caregivers of persons living with dementia.

RESEARCH DESIGN AND METHODS

Data on 153 dyads enrolled in the Care Ecosystem dementia care management program were analyzed, including sociodemographic variables, dementia severity, and caregiver burden and wellbeing. Factor structure, item-response patterns, and concurrent validity were assessed across racial groups.

RESULTS

Differences between Black and White caregivers included gender, dyad relation, and socioeconomic disadvantage. Factor structure and item loadings varied by racial cohort, with parameters supporting a 3-factor model. For Black caregivers, finances and work, emotional and physical strain, and family and personal adjustment items loaded together on individual factors. For White caregivers physical and emotional strain items loaded on separate factors, although personal and family adjustment items loaded with work and financial strain items. Item-level analysis revealed differences between groups, with Black caregivers endorsing physical strain to a greater degree (p = .003). Total MCSI scores were positively correlated with concurrent measures like the PHQ-9 (White: r = 0.67, Black: r = 0.54) and the GAD-2 (White: r = 0.47, Black: r = 0.4), and negatively correlated with self-efficacy ratings (White: r = -0.54, Black: r = -0.55), with a p < .001 for all validity analysis.

DISCUSSION AND IMPLICATIONS

The MCSI displayed acceptable statistical performance for Black and White caregivers of persons living with dementia and displayed a factor structure sensitive to cultural variations of the construct. Researchers results highlight the inherent complexity and the relevance of selecting inclusive measures to appropriately serve diverse populations.

Socioeconomic Disadvantage Predicts Decreased Likelihood of Maintaining a Functional Knee Arthroplasty Following Treatment for Prosthetic Joint Infection

BACKGROUND

Prosthetic joint infection (PJI) carries major morbidity and mortality as well as a complicated and lengthy treatment course. In patients who have high degrees of socioeconomic disadvantage, this may be a particularly devastating complication. Our study sought to evaluate the impact of socioeconomic deprivation on outcomes following treatment for PJI of the knee.

METHODS

We conducted a retrospective review of revision total knee arthroplasty (TKA) procedures performed for the treatment of initial PJI between 2008 and 2020 at a single tertiary care center in the United States. The Area Deprivation Index (ADI) was used to quantify socioeconomic deprivation. The primary outcome measure was presence of a functional knee joint at the time of most recent follow-up defined as TKA components or an articulating spacer. A total of 96 patients were included for analysis. The median follow-up duration was 26.5 months.

RESULTS

There was no significant difference in the rate of treatment failure (P = .63). However, the proportion of patients who had a functional knee arthroplasty (in contrast to having undergone arthrodesis, amputation, or retention of a static spacer) declined significantly with increasing ADI index (81.8% for the least disadvantaged group, 58.7% for the middle group, 42.9% for the most disadvantaged group, P = .021).

CONCLUSIONS

Patients who have a higher socioeconomic disadvantage as measured by ADI are less likely to maintain a functional knee arthroplasty following treatment for TKA PJI. These findings support continued efforts to improve access to care and optimize treatment plans for patients who have socioeconomic disadvantage.

Perceived but not objective measures of neighborhood safety and food environments are associated with longitudinal changes in processing speed among urban older adults

BACKGROUND

Although a growing body of literature documents the importance of neighborhood effects on late-life cognition, little is known about the relative strength of objective and subjective neighborhood measures on late-life cognitive changes. This study examined effects of objective and subjective neighborhood measures in three neighborhood domains (neighborhood safety, physical disorder, food environments) on longitudinal changes in processing speed, an early marker of cognitive aging and impairment.

METHODS

The analysis sample included 306 community-dwelling older adults enrolled in the Einstein Aging Study (mean age = 77, age range = 70 to 91; female = 67.7%; non-Hispanic White: 45.1%, non-Hispanic Black: 40.9%). Objective and subjective measures of neighborhood included three neighborhood domains (i.e., neighborhood safety, physical disorder, food environments). Processing speed was assessed using a brief Symbol Match task (unit: second), administered on a smartphone device six times a day for 16 days and repeated annually for up to five years. Years from baseline was used as the within-person time index.

RESULTS

Results from mixed effects models showed that subjective neighborhood safety (β= -0.028) and subjective availability of healthy foods (β= -0.028) were significantly associated with less cognitive slowing over time. When objective and subjective neighborhood measures were simultaneously examined, subjective availability of healthy foods remained significant (β= -0.028) after controlling for objective availability of healthy foods. Associations of objective neighborhood crime and physical disorder with processing speed seemed to be confounded by individual-level race and socioeconomic status; after controlling for these confounders, none of objective neighborhood measures showed significant associations with processing speed.

CONCLUSION

Subjective neighborhood safety and subjective availability of healthy foods, rather than objective measures, were associated with less cognitive slowing over time over a five-year period. Perception of one's neighborhood may be a more proximal predictor of cognitive health outcomes as it may reflect one's experiences in the environment. It would be important to improve our understanding of both objective and subjective neighborhood factors to improve cognitive health among older adults.

Investigating the relationships between motor skills, cognitive status, and area deprivation index in Arizona: a pilot study

Introduction

Previous studies highlight the negative impact of adverse socioeconomic conditions throughout life on motor skills and cognitive health. Factors such as cognitive activity, physical activity, lifestyle, and socioeconomic position significantly affect general health status and brain health. This pilot study investigates the relationships among the Area Deprivation Index (ADI)-a measure of neighborhood-level socioeconomic deprivation, brain structure (cortical volume and thickness), and cognitive status in adults in Arizona. Identifying measures sensitive to ADI could elucidate mechanisms driving cognitive decline.

Methods

The study included 22 adults(mean age = 56.2 ± 15.2) in Arizona, residing in the area for over 10 years(mean = 42.7 ± 15.8). We assessed specific cognitive domains using the NeuroTrax™ cognitive screening test, which evaluates memory, executive function, visual-spatial processing, attention, information processing speed, and motor function. We also measured cortical thickness and volume in 10 cortical regions using FreeSurfer 7.2. Linear regression tests were conducted to examine the relationships between ADI metrics, cognitive status, and brain health measures.

Results

Results indicated a significant inverse relationship between ADI metrics and memory scores, explaining 25% of the variance. Both national and state ADI metrics negatively correlated with motor skills and global cognition (r's < -0.40, p's < 0.05). In contrast, ADI metrics generally positively correlated with motor-related volumetric and cortical thickness measures (r's > 0.40, p's < 0.05).

Conclusion

The findings suggest that neighborhood-level social deprivation might influence memory and motor status, primarily through its impact on motor brain health.

Association of neighborhood disadvantage with cognitive function and cortical disorganization in an unimpaired cohort

Objective

Neighborhood disadvantage is associated with worse health and cognitive outcomes. Morphological similarity network (MSN) is a promising approach to elucidate cortical network patterns underlying complex cognitive functions. We hypothesized that MSNs could capture intricate changes in cortical patterns related to neighborhood disadvantage and cognitive function, potentially explaining some of the risk for later life cognitive impairment among individuals who live in disadvantaged contexts.

Methods

This cross-sectional study included cognitively unimpaired participants (n=524, age=62.96±8.377, gender (M:F)=181:343, ADI(L:H) =450,74) from the Wisconsin Alzheimer's Disease Research Center or Wisconsin Registry for Alzheimer's Prevention. Neighborhood disadvantage status was obtained using the Area Deprivation Index (ADI). Cognitive performance was assessed through six tests evaluating memory, executive functioning, and the modified preclinical Alzheimer's cognitive composite (mPACC). Morphological Similarity Networks (MSN) were constructed for each participant based on the similarity in distribution of cortical thickness of brain regions, followed by computation of local and global network features. We used linear regression to examine ADI associations with cognitive scores and MSN features. The mediating effect of MSN features on the relationship between ADI and cognitive performance was statistically assessed.

Results

Neighborhood disadvantage showed negative association with category fluency, implicit learning speed, story recall and mPACC scores, indicating worse cognitive function among those living in more disadvantaged neighborhoods. Local network features of frontal and temporal brain regions differed based on ADI status. Centrality of left lateral orbitofrontal region showed a partial mediating effect between association of neighborhood disadvantage and story recall performance.

Conclusion

Our findings suggest differences in local cortical organization by neighborhood disadvantage, which also partially mediated the relationship between ADI and cognitive performance, providing a possible network-based mechanism to, in-part, explain the risk for poor cognitive functioning associated with disadvantaged neighborhoods. Future work will examine the exposure to neighborhood disadvantage on structural organization of the brain.

Characterizing Neighborhood Vulnerabilities in Mild Cognitive Impairment using the Environmental Justice Index

Background

There is a need for integration and comprehensive characterization of environmental determinants of Alzheimer's disease. The Environmental Justice Index (EJI) is a new measure that consolidates multiple environmental health hazards.

Objective

This analysis aims to explore how environmental vulnerabilities vary by race/ethnicity and whether they predict cognitive outcomes in a clinical trial of mild cognitive impairment (MCI).

Methods

We used data from a clinical trial of 107 MCI participants (28% minorities). Using the EJI, we extracted 40 measures of neighborhood environmental and social vulnerability including air and water pollution, access to recreational spaces, exposure to coal and lead mines, and area poverty. We also examined the relationship of the EJI to the Area Deprivation Index (ADI). Data was analyzed using regressions, correlations, and t-tests.

Results

Environmental Burden Rank (EBR) across the sample (0.53±0.32) was near the 50th percentile nationally. When divided by race/ethnicity, environmental (p = 0.025) and social (p < 0.0001) vulnerabilities were significantly elevated for minorities, specifically for exposure to ozone, diesel particulate matter, carcinogenic air toxins, and proximity to treatment storage and disposal sites. ADI state decile was not correlated with the EBR. Neither EBR nor ADI were a significant predictor of cognitive decline.

Conclusions

To our knowledge, this is the first study to link the EJI to an MCI trial. Despite limitations of a relatively small sample size, the study illustrates the potential of the EJI to provide deeper phenotyping of the exposome and diversity in clinical trial subjects.

Dementia, dementia's risk factors and premorbid brain structure are concentrated in disadvantaged areas: National register and birth-cohort geographic analyses

INTRODUCTION

Dementia risk may be elevated in socioeconomically disadvantaged neighborhoods. Reasons for this remain unclear, and this elevation has yet to be shown at a national population level.

METHODS

We tested whether dementia was more prevalent in disadvantaged neighborhoods across the New Zealand population (N = 1.41 million analytic sample) over a 20-year observation. We then tested whether premorbid dementia risk factors and MRI-measured brain-structure antecedents were more prevalent among midlife residents of disadvantaged neighborhoods in a population-representative NZ-birth-cohort (N = 938 analytic sample).

RESULTS

People residing in disadvantaged neighborhoods were at greater risk of dementia (HR per-quintile-disadvantage-increase = 1.09, 95% confidence interval [CI]:1.08-1.10) and, decades before clinical endpoints typically emerge, evidenced elevated dementia-risk scores (CAIDE, LIBRA, Lancet, ANU-ADRI, DunedinARB; β's 0.31-0.39) and displayed dementia-associated brain structural deficits and cognitive difficulties/decline.

DISCUSSION

Disadvantaged neighborhoods have more residents with dementia, and decades before dementia is diagnosed, residents have more dementia-risk factors and brain-structure antecedents. Whether or not neighborhoods causally influence risk, they may offer scalable opportunities for primary dementia prevention.

Deriving life-course residential histories in brain bank cohorts: A feasibility study

INTRODUCTION

The exposome is theorized to interact with biological mechanisms to influence risk for Alzheimer's disease but is not well-integrated into existing Alzheimer's Disease Research Center (ADRC) brain bank data collection.

METHODS

We apply public data tracing, an iterative, dual abstraction and validation process rooted in rigorous historic archival methods, to develop life-course residential histories for 1254 ADRC decedents.

RESULTS

The median percentage of the life course with an address is 78.1% (IQR 24.9); 56.5% of the sample has an address for at least 75% of their life course. Archivists had 89.7% agreement at the address level. This method matched current residential survey methodology 97.4% on average.

DISCUSSION

This novel method demonstrates feasibility, reproducibility, and rigor for historic data collection. To our knowledge, this is the first study to show that public data tracing methods for brain bank decedent residential history development can be used to better integrate the social exposome with biobank specimens.

HIGHLIGHTS

Public data tracing compares favorably to survey-based residential history. Public data tracing is feasible and reproducible between archivists. Archivists achieved 89.7% agreement at the address level. This method identifies residences for nearly 80% of life-years, on average. This novel method enables brain banks to add social characterizations.

Ready for Discharge, but Are They Ready to Go Home? Examining Neighborhood-Level Disadvantage as a Marker of the Social Exposome and the Swallowing Care Process in a Retrospective Cohort of Inpatients With Dementia

PURPOSE

Socioeconomically disadvantaged areas are more resource poor, impacting adherence to swallowing care recommendations. Neighborhood-level disadvantage metrics, such as the Area Deprivation Index (ADI), allow for examination of social determinants of health (SDOH) in a precise region. We examined ADI in a cohort of persons living with dementia (PLWD) to determine representation of those residing in areas of socioeconomic disadvantage (high ADI), distribution of swallowing care provided, and frequency of SDOH-related counseling or resource linking prior to discharge.

METHOD

A retrospective chart abstraction was performed for all inpatients with a diagnosis of dementia (N = 204) seen by the Swallow Service at a large academic hospital in 2014. State ADI Deciles 1 (least) to 10 (most socioeconomic disadvantage) and decile groups (1-3, 4-7, and 8-10) were compared with the surrounding county. Frequency of videofluoroscopic swallowing evaluations (VFSEs) based on ADI deciles was recorded. To determine whether SDOH-related counseling or resource linking occurred for those in high ADI (8-10) neighborhoods, speech-language pathology notes, and discharge summaries were reviewed. Descriptive statistics, independent samples t tests, and one-way analysis of variance were calculated.

RESULTS

ADI was significantly higher in this cohort (M = 3.84, SD = 2.58) than in the surrounding county (M = 2.79, SD = 1.88, p = .000). There was no significant difference in utilization of swallowing services across decile groups (p = .88). Although the majority (85%) in high ADI areas was recommended diet modifications or alternative nutrition likely requiring extra resources, there was no documentation indicating that additional SDOH resource linking or counseling was provided.

CONCLUSIONS

These findings raise important questions about the role and responsibility of speech-language pathologists in tailoring swallowing services to challenges posed by the lived environment, particularly in socioeconomically disadvantaged areas. This underscores the need for further research to understand and address gaps in postdischarge support for PLWD in high-ADI regions and advocate for more equitable provision of swallowing care.

The Effect of Social Deprivation on Hospital Utilization Following Distal Radius Fracture Treatment

Purpose

Social determinants of health disparities have been shown to adversely impact outcomes following distal radius fracture (DRF) treatment. Identifying risk factors for increased hospital use following DRF has been historically difficult; however, it is of utmost concern to orthopedic surgeons to improve outcomes and decrease the total cost of care. The effect of social deprivation following DRF has yet to be fully investigated.

Methods

This is a retrospective cohort analysis of a single institution's experience in treating DRF with either an operative or nonsurgical modality between 2005 and 2020. Patient demographic information and health care utilization (hospital readmission, emergency department [ED] visitation, office visits, and telephone use) were collected from within 90 days of treatment. Area Deprivation Index (ADI) national percentiles were recorded. Patients were stratified into terciles based on their relative level of deprivation, and their outcomes were compared. Secondary analyses included stratifying patients based on treatment modality, race, and legal sex.

Results

In total, 2,149 patients were included. The least, intermediate, and most deprived groups consisted of 552, 1,067, and 530 patients, respectively. Risk factors for hospital readmission included higher levels of relative deprivation. Identifying as Black or African American and nonsurgical management were risk factors for increased ED visitation. No differences in rate of hospital readmission, ED visitation, office visitation, or telephone use were seen based on deprivation level.

Conclusions

High levels of social deprivation, treatment modality, race, and legal sex disparities may influence the amount of hospital resource utilization following DRF treatment. Understanding and identifying risk factors for greater resource utilization can help to mitigate inappropriate use and decrease health care costs. We hope to use these findings to guide clinical decision making, educate patient populations, and optimize outcomes following DRF treatment.

Type of Study/Level of Evidence

Therapeutic III.

The Association of Neighborhood Socioeconomic Status with Executive Function and Processing Speed in Cognitively Normal Mexican American Elders from the Health and Aging Brains Study: Health Disparities Cohort

INTRODUCTION

Neighborhood socioeconomic status (NSES) has been linked with overall health, and this study will evaluate whether NSES is cross-sectionally associated with cognition in non-Hispanic whites (NHWs) and Mexican Americans (MAs) from the Health and Aging Brain: Health Disparities Study (HABS-HD).

METHODS

The HABS-HD is a longitudinal study conducted at the University of North Texas Health Science Center. The final sample analyzed (n = 1,312) were 50 years or older, with unimpaired cognition, and underwent an interview, neuropsychological examination, imaging, and blood draw. NSES was measured using the national area deprivation index (ADI) percentile ranking, which considered socioeconomic variables. Executive function and processing speed were assessed by the trail making tests (A and B) and the digit-symbol substitution test, respectively. Linear regression was used to assess the association of ADI and cognitive measures.

RESULTS

MAs were younger, more likely to be female, less educated, had higher ADI scores, performed worse on trails B (all p < 0.05), and had lower prevalence of APOE4 + when compared to NHWs (p < 0.0001). A higher percentage of MAs lived in the most deprived neighborhoods than NHWs. For NHWs, ADI did not predict trails B or DSS scores, after adjusting for demographic variables and APOE4. For MAs, ADI predicted trails A, trails B, and DSS after adjusting for demographic covariates and APOE4 status.

CONCLUSION

Our study revealed that living in an area of higher deprivation was associated with lower cognitive function in MAs but not in NHWs, which is important to consider in future interventions to slow cognitive decline.

Neighborhood disadvantage reduces cognitive reserve independent of neuropathologic change

INTRODUCTION

Individuals in socioeconomically disadvantaged neighborhoods exhibit increased risk for impaired cognitive function. Whether this association relates to the major dementia-related neuropathologies is unknown.

METHODS

This cross-sectional study included 469 autopsy cases from 2011 to 2023. The relationships between neighborhood disadvantage measured by Area Deprivation Index (ADI) percentiles categorized into tertiles, cognition evaluated by the last Mini-Mental State Examination (MMSE) scores before death, and 10 dementia-associated proteinopathies and cerebrovascular disease were assessed using regression analyses.

RESULTS

Higher ADI was significantly associated with lower MMSE score. This was mitigated by increasing years of education. ADI was not associated with an increase in dementia-associated neuropathologic change. Moreover, the significant association between ADI and cognition remained even after controlling for changes in major dementia-associated proteinopathies or cerebrovascular disease.

DISCUSSION

Neighborhood disadvantage appears to be associated with decreased cognitive reserve. This association is modified by education but is independent of the major dementia-associated neuropathologies.

Social and Behavior Factors of Alzheimer's Disease and Related Dementias: A National Study in the U.S

INTRODUCTION

Considerable research has linked many risk factors to Alzheimer's Disease and Related Dementias (ADRD). Without a clear etiology of ADRD, it is advantageous to rank the known risk factors by their importance and determine if disparities exist. Statistical-based ranking can provide insight into which risk factors should be further evaluated.

METHODS

This observational, population-based study assessed 50 county-level measures and estimates related to ADRD in 3,155 counties in the U.S. using data from 2010 to 2021. Statistical analysis was performed in 2022-2023. The machine learning method, eXtreme Gradient Boosting, was utilized to rank the importance of these variables by their relative contribution to the model performance. Stratified ranking was also performed based on a county's level of disadvantage. Shapley Additive exPlanations (SHAP) provided marginal contributions for each variable.

RESULTS

The top three ranked predictors at the county level were insufficient sleep, consuming less than one serving of fruits/vegetables per day among adults, and having less than a high school diploma. In both disadvantaged and non-disadvantaged counties, demographic variables such as sex and race were important in predicting ADRD. Lifestyle factors ranked highly in non-disadvantaged counties compared to more environmental factors in disadvantaged counties.

CONCLUSIONS

This ranked list of factors can provide a guided approach to ADRD primary prevention strategies in the U.S., as the effects of sleep, diet, and education on ADRD can be further developed. While sleep, diet, and education are important nationally, differing prevention strategies could be employed based on a county's level of disadvantage.

Promoting diverse perspectives: Addressing health disparities related to Alzheimer's and all dementias

Dementia research lacks appropriate representation of diverse groups who often face substantial adversity and greater risk of dementia. Current research participants are primarily well-resourced, non-Hispanic White, cisgender adults who live close to academic medical centers where much of the research is based. Consequently, the field faces a knowledge gap about Alzheimer's-related risk factors in those other groups. The Alzheimer's Association hosted a virtual conference on June 14-16, 2021, supported in part by the National Institute on Aging (R13 AG072859-01), focused on health disparities. The conference was held entirely online and consisted of 2 days of core programming and a day of focused meetings centered on American Indian and Alaska Natives and on LGBTQIA+ populations. Over 1300 registrants attended discussions focused on the structural and systemic inequities experienced across diverse groups, as well as ways to investigate and address these inequities.

Race, community disadvantage, and cognitive decline: Findings from KHANDLE and STAR

INTRODUCTION

Community disadvantage is associated with late-life cognition. Few studies examine its contribution to racial disparities in cognition/cognitive change.

METHODS

Inverse probability weighted models estimated expected mean differences in cognition/cognitive change attributed to residing in less advantaged communities, defined as cohort top quintile of Area Deprivation Indices (ADI): childhood 66-100; adulthood ADI 5-99). Interactions by race tested.

RESULTS

More Black participants resided in less advantaged communities. Semantic memory would be lower if all participants had resided in less advantaged childhood (b = -0.16, 95% confidence interval [CI] = -0.30, -0.03) or adulthood (b = -0.14, 95% CI = -0.22, -0.04) communities. Race interactions indicated that, among Black participants, less advantaged childhood communities were associated with higher verbal episodic memory (interaction p-value = 0.007) and less advantaged adulthood communities were associated with lower semantic memory (interaction p-value = 0.002).

DISCUSSION

Examining racial differences in levels of community advantage and late-life cognitive decline is a critical step toward unpacking community effects on cognitive disparities.

Association between military service and Alzheimer's disease neuropathology at autopsy

INTRODUCTION

Anti-amyloid therapies are at the forefront of efforts to treat Alzheimer's disease (AD). Identifying amyloid risk factors may aid screening and intervention strategies. While veterans face increased exposure to risk factors, whether they face a greater neuropathologic amyloid burden is not well understood.

METHODS

Male decedents donating to two Alzheimer's Disease Research Center (ADRC) brain banks from 1986 to 2018 with categorized neuritic plaque density and neurofibrillary tangles (n = 597) were included. Using generalized ordered logistic regression we modeled each outcome's association with military history adjusting for age and death year.

RESULTS

Having served in the military (60% of sample) is associated with post mortem neuritic amyloid plaque (for each comparison of higher to lower C scores OR = 1.26; 95% confidence interval [CI] = 1.06-1.49) and tau pathology (B score OR = 1.10; 95% CI = 1.08-1.12).

DISCUSSION

This is the first study, to our knowledge, finding increased levels of verified AD neuropathology in those with military service. Targeted veteran AD therapies is a pressing need.

The Science of Precision Prevention: Research Opportunities and Clinical Applications to Reduce Cardiovascular Health Disparities

Precision prevention embraces personalized prevention but includes broader factors such as social determinants of health to improve cardiovascular health. The quality, quantity, precision, and diversity of data relatable to individuals and communities continue to expand. New analytical methods can be applied to these data to create tools to attribute risk, which may allow a better understanding of cardiovascular health disparities. Interventions using these analytic tools should be evaluated to establish feasibility and efficacy for addressing cardiovascular disease disparities in diverse individuals and communities. Training in these approaches is important to create the next generation of scientists and practitioners in precision prevention. This state-of-the-art review is based on a workshop convened to identify current gaps in knowledge and methods used in precision prevention intervention research, discuss opportunities to expand trials of implementation science to close the health equity gaps, and expand the education and training of a diverse precision prevention workforce.

Neuroprotective Effects of N-methyl-(2S, 4R)-trans-4-hydroxy-L-proline (NMP) against Amyloid-β-Induced Alzheimer's Disease Mouse Model

Alzheimer's disease (AD), is a progressive neurodegenerative disorder that involves the deposition of β-amyloid plaques and the clinical symptoms of confusion, memory loss, and cognitive dysfunction. Despite enormous progress in the field, no curative treatment is available. Therefore, the current study was designed to determine the neuroprotective effects of N-methyl-(2S, 4R)-Trans-4-hydroxy-L-proline (NMP) obtained from Sideroxylon obtusifolium, a Brazilian folk medicine with anti-inflammatory and anti-oxidative properties. Here, for the first time, we explored the neuroprotective role of NMP in the Aβ1-42-injected mouse model of AD. After acclimatization, a single intracerebroventricular injection of Aβ1-42 (5 µL/5 min/mouse) in C57BL/6N mice induced significant amyloidogenesis, reactive gliosis, oxidative stress, neuroinflammation, and synaptic and memory deficits. However, an intraperitoneal injection of NMP at a dose of (50 mg/kg/day) for three consecutive weeks remarkably decreased beta secretase1 (BACE-1) and Aβ, activated the astrocyte and microglia expression level as well as downstream inflammatory mediators such as pNF-ĸB, TNF-α, and IL-1β. NPM also strongly attenuated oxidative stress, as evaluated by the expression level of NRF2/HO-1, and synaptic failure, by improving the level of both the presynaptic (SNAP-25 and SYN) and postsynaptic (PSD-95 and SNAP-23) regions of the synapses in the cortexes and hippocampi of the Aβ1-42-injected mice, contributing to cognitive improvement in AD and improving the behavioral deficits displayed in the Morris water maze and Y-maze. Overall, our data suggest that NMP provides potent multifactorial effects, including the inhibition of amyloid plaques, oxidative stress, neuroinflammation, and cognitive deficits.

The Role of Place in Person- and Family-Oriented Long-Term Services and Supports

Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and well-being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state-level LTSS-relevant environmental characteristics stand to improve the health and well-being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions.

CONTEXT

Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them.

METHODS

We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status.

FINDINGS

We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations.

CONCLUSIONS

We present a framework and analyses describing the variable relationships between LTSS-relevant environmental factors and person-reported care experiences. LTSS-relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state- and community-based policies and practices that support aging in place.

The Impact of Neighborhood Socioeconomic Disadvantage on Operative Outcomes after Single-Level Lumbar Fusion

INTRODUCTION

The relationship between socioeconomic status and neurosurgical outcomes has been investigated with respect to insurance status or median household income, but few studies have considered more comprehensive measures of socioeconomic status. This study examines the relationship between Area Deprivation Index (ADI), a comprehensive measure of neighborhood socioeconomic disadvantage, and short-term postoperative outcomes after lumbar fusion surgery.

METHODS

1861 adult patients undergoing single-level, posterior-only lumbar fusion at a single, multihospital academic medical center were retrospectively enrolled. An ADI matching protocol was used to identify each patient's 9-digit zip code and the zip code-associated ADI data. Primary outcomes included 30- and 90-day readmission, emergency department visits, reoperation, and surgical complication. Coarsened exact matching was used to match patients on key demographic and baseline characteristics known to independently affect neurosurgical outcomes. Odds ratios (ORs) were computed to compare patients in the top 10% of ADI versus lowest 40% of ADI.

RESULTS

After matching (n = 212), patients in the highest 10% of ADI (compared to the lowest 40% of ADI) had significantly increased odds of 30- and 90-day readmission (OR = 5.00, P < 0.001 and OR = 4.50, P < 0.001), ED visits (OR = 3.00, P = 0.027 and OR = 2.88, P = 0.007), and reoperation (OR = 4.50, P = 0.039 and OR = 5.50, P = 0.013). There was no significant association with surgical complication (OR = 0.50, P = 0.63).

CONCLUSIONS

Among otherwise similar patients, neighborhood socioeconomic disadvantage (measured by ADI) was associated with worse short-term outcomes after single-level, posterior-only lumbar fusion. There was no significant association between ADI and surgical complications, suggesting that perioperative complications do not explain the socioeconomic disparities in outcomes.

Neuropsychiatric symptoms in people living with dementia receiving home health services

BACKGROUND

We sought to describe neuropsychiatric symptoms (NPS) among people living with dementia (PLWD) from diverse racial and ethnic groups receiving home health services while accounting for dementia severity, individual symptom prevalence, and neighborhood disadvantage.

METHODS

A prospective study using cross-sectional data from n = 192 PLWD receiving skilled home healthcare in New Jersey enrolled in the Dementia Symptom Management at Home Program trial. We prospectively measured symptom prevalence with the Neuropsychiatric Inventory Questionnaire and dementia severity using the Quick Dementia Rating System. A one-way ANOVA determined NPS prevalence by dementia severity (mild, moderate, severe). Fisher's exact tests were used to assess the association of individual symptom prevalence with race and ethnicity and cross tabs to descriptively stratify individual symptom prevalence by dementia severity among groups. A Pearson correlation was performed to determine if a correlation existed among neighborhood disadvantages measured by the Area Deprivation Index (ADI) state decile scores and NPS prevalence and severity.

RESULTS

Participants identified as non-Hispanic White (50%), non-Hispanic Black (30%), or Hispanic (13%). NPS were prevalent in 97% of participants who experienced 5.4 ± 2.6 symptoms with increased severity (10.8 ± 6.6) and care partner distress (13.8 ± 10.8). NPS increased with dementia severity (p = 0.004) with the greatest difference seen between individuals with mild dementia (4.3 ± 2.3) versus severe dementia (5.9 ± 2.3; p = 0.002). Few differences were found in symptom prevalence by racial and ethnic sub-groups. Nighttime behaviors were higher in non-Hispanic Black (78%), compared with non-Hispanic Whites (46%) with moderate dementia, p = 0.042. State ADI scores were not correlated with the number of NPS reported, or severity.

CONCLUSIONS

NPS were prevalent and increased with dementia severity with commonalities among racial and ethnic groups with varying levels of neighborhood disadvantage. There is a need for effective methods for improving NPS identification, assessment, and management broadly for homebound PLWD.

Estimating the prevalence of diagnosed Alzheimer disease in England across deprivation groups using electronic health records: a clinical practice research datalink study

OBJECTIVE

Estimate the prevalence of diagnosed Alzheimer's disease (AD) and early Alzheimer's disease (eAD) overall and stratified by age, sex and deprivation and combinations thereof in England on 1 January 2020.

DESIGN

Cross-sectional.

SETTING

Primary care electronic health record data, the Clinical Practice Research database linked with secondary care data, Hospital Episode Statistics (HES) and patient-level deprivation data, Index of Multiple Deprivation (IMD).

OUTCOME MEASURES

The prevalence per 100 000 of the population and corresponding 95% CIs for both diagnosed AD and eAD overall and stratified by covariates. Sensitivity analyses were conducted to assess the sensitivity of the population definition and look-back period.

RESULTS

There were 448 797 patients identified in the Clinical Practice Research Datalink that satisfied the study inclusion criteria and were eligible for HES and IMD linkage. For the main analysis of AD and eAD, 379 763 patients are eligible for inclusion in the denominator. This resulted in an estimated prevalence of diagnosed AD of 378.39 (95% CI, 359.36 to 398.44) per 100 000 and eAD of 292.81 (95% CI, 276.12 to 310.52) per 100 000. Prevalence estimates across main and sensitivity analyses for the entire AD study population were found to vary widely with estimates ranging from 137.48 (95% CI, 127.05 to 148.76) to 796.55 (95% CI, 768.77 to 825.33). There was significant variation in prevalence of diagnosed eAD when assessing the sensitivity with the look-back periods, as low as 120.54 (95% CI, 110.80 to 131.14) per 100 000, and as high as 519.01 (95% CI, 496.64 to 542.37) per 100 000.

CONCLUSIONS

The study found relatively consistent patterns of prevalence across both AD and eAD populations. Generally, the prevalence of diagnosed AD increased with age and increased with deprivation for each age category. Women had a higher prevalence than men. More granular levels of stratification reduced patient numbers and increased the uncertainty of point prevalence estimates. Despite this, the study found a relationship between deprivation and prevalence of AD.