Cognitive impairment in persons with rheumatoid arthritis

Prevalence of neurocognitive impairment in patients with rheumatoid arthritis - a systematic review and meta-analysis

ObjectiveThis study aimed to evaluate prevalence rates (PRs) of neurocognitive impairment and its potential moderators among patients with rheumatoid arthritis (RA). MethodA systematic review of the available literature and data extraction was undertaken on 6 August 2021, with the update by 14 September 2023, by two reviewers independently. Literature was screened for reported rates of prevalence of neurocognitive impairment in RA patients. The meta-analysis was performed using RStudio with the "meta" library. ResultsTwenty-two studies that fulfilled all selection criteria were carefully analyzed. The PR of neurocognitive impairment was 0.49 [0.38-0.61] across all studies included in the review; 0.75 [0.54-0.88] for the MoCA; 0.56 [0.40-0.72] for the MMSE; and 0.26 [0.16-0.38] for comprehensive batteries. The meta-regression results indicated that, depending on the measurement method, the percentage of subjects with positive rheumatoid factor, women ratio, mean age of participants, mean duration of RA, and percentage of domains that had to be impaired to diagnose neurocognitive impairment turned out to be statistically significant moderators. ConclusionsNeurocognitive impairment is a clinically relevant condition in many RA patients, and its prevalence is alarming high.

Impact of inflammation on cognitive function in patients with highly inflammatory rheumatoid arthritis

OBJECTIVE

To evaluate cognitive function in patients with rheumatoid arthritis (RA) and inflammatory activity.

PATIENTS AND METHODS

We performed a cross-sectional study of a cohort of patients with RA initiating their first biological treatment due to moderate-to-high inflammation and a healthy control group (no inflammatory diseases) matched for age, sex and educational level. All participants underwent a comprehensive neuropsychological assessment, with cognitive impairment defined as a Montreal Cognitive Assessment (MoCA) score<26. Additional assessments included various cognitive tests (STROOP, forward and backward digit spans), anxiety and depression scales (Hospital Anxiety and Depression Scale), quality of life measures (Quality of Life-Rheumatoid Arthritis) and average inflammatory activity according to the 28-joint Disease Activity Score (DAS28)-C-reactive protein (CRP) into high activity (DAS28≥3.2) and low activity (DAS28<3.2) groups, also CRP levels and interleukin 6 (IL-6) levels were measured using an ELISA.

RESULTS

The study population comprised 140 participants, 70 patients with RA and 70 controls. Patients more frequently experienced cognitive impairment than controls (60% vs 40%; p=0.019) and had lower mean (SD) values in the MoCA (23.6 (3.9) vs 25.1 (3.4); p=0.019. As for subtests of the MoCA, involvement was more marked in patients than in controls for the visuospatial-executive (p=0.030), memory (p=0.026) and abstraction (p=0.039) domains. Additionally, patients scored lower on executive function, as assessed by the backward digit span test (4.0 (1.7) vs 4.7 (1.9); p=0.039). Cognitive impairment is associated with age and a lower educational level in the general population, and among patients with RA with educational level, obesity and average inflammatory activity (DAS28, CRP, and IL-6).

CONCLUSIONS

Patients with RA with high inflammatory activity are more susceptible to cognitive impairment, which specifically affects the domains of visuospatial, memory, abstraction and executive function.

Causality between rheumatoid arthritis and the risk of cognitive impairment: a Mendelian randomization study

BACKGROUND

There is mounting proof that rheumatoid arthritis (RA) and cognitive decline are related. These studies, however, have not all been uniform, and others have not discovered such a correlation. It is essential to investigate the link between RA and cognitive decline.

METHOD

We conducted a Mendelian randomization analysis utilizing three different publicly accessible RA GWAS summary datasets and a variety of meticulously verified instrumental variables. We mostly used inverse variance weighting (IVW), as well as MR-Egger, weighted median, MR-PRESSO, and several sensitivity analyses, to figure out the link between RA and cognitive impairment (CI).

RESULTS

Our MR study identified the causality between RA and declining cognitive performance (β = - 0.010, 95% CI of - 0.017 to - 0.003, P = 4.33E-03) and cognitive function (β = - 0.029, 95% CI of - 0.053 to - 0.005, P = 1.93E-02). The consistent direction of the connection is revealed by sensitivity analysis utilizing the weighted median and the MR-Egger method. Furthermore, we reproduced our findings across two additional RA datasets and found identical outcomes, strengthening the validity of our findings.

CONCLUSION

This study offers proof of causality between RA and an increased risk of CI. Our findings highlight the importance of examining RA patients for cognitive ability, which may open up fresh ideas for the prevention of CI.

The Work Experience Survey - Rheumatic conditions (United Kingdom): Psychometric properties and identifying the workplace barriers of employed people with inflammatory arthritis receiving vocational rehabilitation

OBJECTIVE

The aims were to: revise the Work Experience Survey-Rheumatic Conditions (WES-RC- UK), a work assessment listing 142 workplace barriers; investigate content validity, reliability, and concurrent validity; update the accompanying WES-RC and WORKWELL Solutions Manuals; and investigate workplace barriers of people with inflammatory arthritis.

METHODS

Rheumatology therapists, following vocational rehabilitation (VR) training, assessed participants in the WORKWELL VR trial using the WES-RC. Data were extracted from the WES-RC to identify the frequency of workplace barriers, and from trial baseline questionnaires (e.g., Work Limitations Questionnaire-25 (WLQ-25). Barriers reported by ≤5 participants were considered for removal. WES-RC content validity was assessed by linking to the International Classification of Functioning, Health, and Disability Core Set for VR (ICF-VR). Reliability was assessed using Cronbach's α and concurrent validity by correlating the total number of workplace barriers reported with WLQ-25 scores.

RESULTS

WES-RCs were completed with 116 employed participants: 79% women, age 48.72 (SD 9.49) years, and 57% working full-time. The WES-RC was reduced to 121 barriers. Content validity was good, with 73/90 ICF-VR items linked. Cronbach's α = 0.92, that is, suitable for individual use. Concurrent validity was moderate: WLQ-25 (rs  = 0.40). The three most common barriers were Physical Job Demands (100%: e.g., mobility 99%; hand use 74%), Mental, Time, Energy, Emotional Job Demands (91%, e.g., concentration 47%, remembering 41%); Getting Ready for and Travel to Work (87%, e.g., driving 60%).

CONCLUSION

The WES-RC (UK) has good content validity, reliability, and concurrent validity. The wide range of barriers emphasises the need for biopsychosocial work rehabilitation.

Enhanced activity of the left precuneus as a predictor of visuospatial dysfunction correlates with disease activity in rheumatoid arthritis

OBJECTIVE

To identify the potential diagnostic biomarkers of rheumatoid arthritis (RA) and assess the relation between visuospatial dysfunction and disease activity in RA patients using mental rotation task (MRT)-based functional magnetic resonance imaging (fMRI).

METHODS

A total of 27 RA patients (11 in remission, 16 in active) and 27 well-matched controls were enrolled. The visuospatial function of the subjects was measured by MRT. Brain activity data were collected using blood oxygen level dependent fMRI technique under MRT. Disease activity score 28 (DAS28) was used to evaluate the disease severity of RA patients. An analysis of the correlations between abnormal visuospatial-related brain regions, MRT performance, and DAS28 was conducted.

RESULTS

RA patients performed worse on MRT than controls. Compared to the control group, RA patients showed enhanced activation in the left precuneus, left superior frontal gyrus and right cingulate gyrus during the rotation task, with left hemisphere dominance. RA patients in active showed enhanced activation in the left precuneus, left middle frontal gyrus and right cingulate gyrus compared to the patients in remission. The left precuneus activation was negatively correlated with MRT accuracy (r = -0.621, p = 0.01) and positively correlated with DAS28 (r = 0.710, p = 0.002), and MRT accuracy was negatively correlated with DAS28 in RA patients (r = -0.702, p = 0.002).

CONCLUSION

Enhanced activation of the left precuneus in RA patients affects visuospatial function and is closely related to disease activity. These changes may provide a valuable diagnostic neuroimaging biomarker of RA.

Gliosis, misfolded protein aggregation, and neuronal loss in a guinea pig model of pulmonary tuberculosis

Tuberculosis, caused by Mycobacterium tuberculosis infection, is an ongoing epidemic with an estimated ten million active cases of the disease worldwide. Pulmonary tuberculosis is associated with cognitive and memory deficits, and patients with this disease are at an increased risk for Parkinson's disease and dementia. Although epidemiological data correlates neurological effects with peripheral disease, the pathology in the central nervous system is unknown. In an established guinea pig model of low-dose, aerosolized Mycobacterium tuberculosis infection, we see behavior changes and memory loss in infected animals. We correlate these findings with pathological changes within brain regions related to motor, cognition, and sensation across disease progression. This includes microglial and astrocytic proliferation and reactivity. These cellular changes are followed by the aggregation of neurotoxic amyloid β and phosphorylated tau and, ultimately, neuronal degeneration in the hippocampus. Through these data, we have obtained a greater understanding of the neuropathological effects of a peripheral disease that affects millions of persons worldwide.

Prevalence of cognitive impairment in patients with rheumatoid arthritis: a cross sectional study

OBJECTIVE

To explore the role of chronic inflammation in rheumatoid arthritis (RA) on cognition.

METHODS AND ANALYSIS

Six hundred sixty-one men and women aged ≥55 years who fulfilled the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria for RA were recruited from three healthcare trusts in the United Kingdom (UK) between May 2018 and March 2020. Study participants took part in interviews which captured sociodemographic information, followed by an assessment of cognition. RA specific clinical characteristics were obtained from hospital medical records. Participants were cognitively assessed using the Montreal Cognitive Assessment (MoCA) and were classified as cognitively impaired if they scored ≤27/30 points. Linear regression analyses were conducted to identify which demographic and clinical variables were potential predictors of cognitive impairment.

RESULTS

The average age of participants was 67.6 years and 67% (444/661) were women. 72% (458/634; 95% CI 0.69 to 0.76) of participants were classified as cognitively impaired (MoCA≤27). Greater cognitive impairment was associated with older age (p = .006), being male (p = .041) and higher disease activity score (DAS28) (with moderate (DAS28 > 3.1) (p = 0.008) and high (DAS28 > 5.1) (p = 0.008)) compared to those in remission (DAS28 ≤ 2.6). There was no association between MoCA score and education, disease duration, RF status, anti-cyclic citrullinated peptide (anti-CCP) status, RA medication type or use of glucocorticoids or non-steroidal anti-inflammatory drugs (p > 0.05).

CONCLUSION

This study suggests that cognitive impairment is highly prevalent in older adults with RA. This impairment appears to be associated with higher RA disease activity and supports the concept that chronic systemic inflammation might accelerate cognitive decline. This underlines the importance of controlling the inflammatory response.

Identifying latent comorbidity patterns in adults with perceived cognitive impairment: Network findings from the behavioral risk factor surveillance system

Background

People with cognitive impairment may be exposed to an increased risk of comorbidities; however, the clustering of comorbidity patterns in these patients is unclear.

Objective

To explore the network structure of chronic comorbidity in a U.S. national sample spanning all 50 U.S. states with more than 170,000 participants reporting perceived cognitive impairment.

Methods

This is a cross-sectional study conducted using Behavioral Risk Factor Surveillance System (BRFSS) secondary data collected in 2019 and covering 49 U.S. states, the District of Columbia, Guam, and the Commonwealth of Puerto Rico. A total of 15,621 non-institutionalized U.S. adult participants who reported "yes" to the subjective cognitive impairment question were considered, of whom 7,045 were men and 8,576 were women. All participants were aged 45 years or older. A statistical graphical model was used that included clustering algorithms and factorization of variables in a multivariate network relationship system [exploratory graphical analysis (EGA)].

Results

The results of the EGA show associations between the comorbid conditions evaluated. These associations favored the clustering of various comorbidity patterns. In fact, three patterns of comorbidities have been identified: (1) arthritis, asthma, respiratory diseases, and depression, (2) obesity, diabetes, blood pressure high, and blood cholesterol high, and (3) heart attack, coronary heart disease, stroke, and kidney disease.

Conclusion

These results suggest the development of interdisciplinary treatment strategies in patients with perceived cognitive impairment, which could help to design an integrated prevention and management of the disease and other related health problems, such as Alzheimer's disease and related dementias.

Longitudinal Study of Cognitive Functioning in Adults with Juvenile Idiopathic Arthritis

Objective: To prospectively evaluate possible decline of cognitive functions in adult patients with juvenile idiopathic arthritis (JIA) and identify associated factors. Patients and methods: We performed a 24-month prospective observational study of adults (≥16 years) with JIA. The primary outcome measure was decline in cognitive function defined as a worsening of ≥2 points on the scales of the subsets administered to evaluate the different cognitive areas using the Wechsler Adult Intelligence Scale (WAIS) after 24 months: attention/concentration (digit span); verbal function (vocabulary); visual-spatial organization (block design); working memory (letter-number sequencing); and problem solving (similarities). Other variables included average inflammatory activity using C-reactive protein and composite activity indexes, comorbidity, and treatment. Logistic regression was performed to identify factors associated with cognitive decline. Results: The study population comprised 52 patients with JIA. Of these, 15 (28.8%) had cognitive decline at V24. The most affected functions were working memory (17.3%), attention/concentration (9.6%), verbal function (7.7%), visual-spatial organization (7.7%), and problem solving (3.8%). There were no significant differences in the median direct or scale scores for the cognitive functions evaluated between V0 and V24 for the whole sample. The factors associated with cognitive decline in patients with JIA were average C-reactive protein (OR [95% CI], 1.377 [1.060–1.921]; p = 0.039), depression (OR [95% CI], 3.691 [1.294–10.534]; p = 0.015), and treatment with biologics (OR [95% CI], 0.188 [0.039–0.998]; p = 0.046). Conclusion: Cognitive decline was detected in almost one third of adults with JIA after 24 months of follow-up. Systemic inflammatory activity in JIA patients was related to cognitive decline. Patients treated with biologics had a lower risk of decline in cognitive functions.

Cognitive impairment in patients with psoriatic arthritis

BACKGROUND

Psoriatic arthritis (PsA) is an inflammatory rheumatic disorder associated with cutaneous psoriasis. Neurological manifestations are not uncommon in rheumatic diseases and recent studies point to a possible underestimation of cognitive impairment in this group of diseases. Our aim was to assess the cognitive impairment in patients with PsA.

METHODS

We carried out a cross-sectional case-control study with consecutive patients with PsA. Trained interviewers conducted structured and standardized in-person assessments. At baseline, functional limitations were characterized using the Health Assessment Questionnaire (HAQ). Cognitive function was evaluated with the Montreal Cognitive Assessment (MoCA) and neuropsychiatric symptoms were investigated with the Hospital Anxiety and Depression Scale (HADS). Using a proper statistical analysis, we compared the differences in the neurological outcomes between cases and controls.

RESULTS

A total of 37 patients with PsA and 36 healthy controls were included in our study. Patients with PsA had a worse MoCA score when compared to controls (p = 0.01). The proportion of patients with cognitive impairment according to MoCA between cases and controls was also statistically significant (91.9% vs 58.3%, p = 0.002). Executive skills, naming, language, and abstraction were the most affected domains. There was no statistical difference between the prevalence of neuropsychiatric symptoms between the two groups. Patients with increased functional limitations are associated with poor cognitive performance (p < 0.05).

CONCLUSION

Cognitive impairment might be a neurological manifestation of PsA.

Real-world effectiveness of dimethyl fumarate versus fingolimod in a cohort of patients with multiple sclerosis using standardized, quantitative outcome metrics

Background

Prior studies suggest comparable effectiveness of dimethyl fumarate (DMF) and fingolimod (FTY) in multiple sclerosis (MS) using relapse, Expanded Disability Status Score (EDSS), and magnetic resonance imaging (MRI) lesion metrics.

Objective

Compare the real-world effectiveness of DMF versus FTY using quantitative, validated neuroperformance tests, MRI, and serum neurofilament light chain (sNfL) outcomes while controlling for between-group differences.

Methods

Patients were eligible if on DMF or FTY when first enrolled in the MS Partners Advancing Technology and Health Solutions (MS PATHS) network and had ≥1-year follow-up in MS PATHS. Sensitivity analysis included a subgroup who started DMF/FTY ≤2 years from enrolment. After propensity score weighting, differences in means and in mean 1-year change of neuroperformance and MRI outcomes were compared. sNfL levels were assessed. This was a non-randomized comparison.

Results

In the overall cohort, no significant differences were observed between DMF (n = 702) and FTY (n = 600) in neuroperformance or MRI outcomes including brain volume loss; mean time (SD) since treatment initiation was 1.98 (0.68) years for DMF and 2.02 (0.75) years for FTY. A sensitivity analysis controlling for DMF and FTY treatment duration yielded similar results.

Conclusion

In this study, DMF and FTY demonstrated similar effects on physical and cognitive neuroperformance and MRI outcomes. Direct comparisons to other fumarates and S1P receptor modulators were not conducted.

Tofacitinib improved peripheral endothelial dysfunction and brain-derived neurotrophic factor levels in the rat adjuvant-induced arthritis model

This study aimed to explore the effect of Tofacitinib on endothelial dysfunction and cerebral levels of brain-derived neurotrophic factor (BDNF) in the adjuvant-induced arthritis (AIA) rat model. Tofacitinib (10 mg/kg twice a day) or vehicle was administered from the first signs of inflammation. Arthritis scores were daily monitored while other parameters including endothelial function assessed from aortic rings, radiographic scores, blood pressure, heart rate, circulating levels of triglycerides, cholesterol, and interleukin (IL)-1β, tumor necrosis factor-α (TNF-α), IL-17A, and cerebral BDNF levels were determined after 3 weeks of treatment. A group of non-AIA rats served as controls. In AIA rats, as compared with vehicle, Tofacitinib significantly reduced arthritis and radiographic scores, decreased total cholesterol and low-density lipoprotein cholesterol (LDL-C), but changed neither blood pressure nor heart rate and proinflammatory cytokines levels. It also fully restored acetylcholine (Ach)-induced relaxation (p < 0.05) through increased nitric oxide (NO) synthase activity, reduced BH₄ deficiency and O₂ ^-° production, decreased cyclo-oxygenase-2 (COX-2)/arginase activities, and enhanced endothelium-derived hyperpolarizing factor (EDHF) production. These effects translated into a decrease in atherogenic index and an elevation of BDNF levels in the prefrontal cortex (p < 0.05) and hippocampus (p < 0.001). The present study identified Tofacitinib as an efficient therapeutic option to reduce cardiovascular risk and improve BDNF-dependent cognition in arthritis.

No association between rheumatoid arthritis and cognitive impairment in a cross-sectional national sample of older U.S. adults

BACKGROUND

Studies suggest an increased prevalence of cognitive impairment (CI) among people with rheumatoid arthritis (RA). However, most prior studies have used convenience samples which are subject to selection biases or have failed to adjust for key confounding variables. We thus examined the association between CI and RA in a large national probability sample of older US adults.

METHODS

Data were from interviews with 4462 participants in the 2016 wave of the nationally representative U.S. Health and Retirement Study with linked Medicare claims. RA diagnoses were identified via a minimum of two ICD-9CM or ICD-10 codes in Medicare billing records during the prior 2 years. The Langa-Weir Classification was used to classify cognitive status as normal, cognitively impaired non-dementia (CIND), or dementia based on a brief neuropsychological battery for self-respondents and informant reports for proxy respondents. We compared the odds of CI between older adults with and without RA using logistic regression, adjusted for age, education, gender, and race.

RESULTS

Medicare records identified a 3.36% prevalence of RA (150/4462). While age, gender, education, and race independently predicted CI status, controlling for these covariates we found no difference in CI prevalence according to RA status (prevalent CI in 36.7% of older adults with RA vs. 34.0% without RA; adjusted OR = 1.08, 95% CI 0.74-1.59, p = .69).

CONCLUSION

There was no association between RA and CI in this national sample of older U.S. adults.

Reduced cognitive ability in people with rheumatoid arthritis compared with age-matched healthy controls

Objective

The aim was to compare the cognitive ability of people with RA with healthy controls (HCs).

Methods

People with RA were recruited from the Norfolk Arthritis Register (NOAR), a population-based cohort study of people with inflammatory arthritis. Data on aged-matched HCs (people with no cognitive impairment) came from the comparison arm of The Dementia Research and Care Clinic Study (TRACC). People with RA and HCs performed a range of cognitive ability tasks to assess attention, memory, verbal fluency, language, visuospatial skills, emotional recognition, executive function and theory of mind. A score of <88 on the Addenbrooke’s Cognitive Examination III was considered cognitive impairment. Scores were compared using linear regression adjusting for age, sex, smoking status, education, BMI, anxiety and depression.

Results

Thirty-eight people with RA [mean (S.D.) age: 69.1 (8.0) years; 25 (65.8%) women] were matched with 28 HCs [mean (S.D.) age: 68.2 (6.4) years; 15 (53.6%) women]. Twenty-three (60.5%) people with RA were considered to have mild cognitive impairment [mean (S.D.) Addenbrooke’s Cognitive Examination III: RA = 85.2 (7.4), HC = 96.0 (2.5)]. People with RA had impairments in memory, verbal fluency, visuospatial functioning, executive function and emotional recognition in faces compared with HCs, after adjustment for confounders.

Conclusion

People with RA had cognitive impairments in a range of domains. People with RA might benefit from cognitive impairment screening to allow for early administration of appropriate interventions.

Attentional function in fibromyalgia and rheumatoid arthritis

Concentration difficulties, forgetfulness and mental slowness are common in fibromyalgia syndrome (FMS); initial findings suggest that rheumatoid arthritis (RA) may also be accompanied by cognitive impairments. This study aimed to compare attentional performance between patients with FMS and RA. Attention was quantified in the domains of alerting, orienting and executive control using the Attentional Network Test-Interaction (ANT-I) in 56 women with FMS, 41 women with RA and 50 healthy women. Pain severity was statistically controlled in the group comparison. While FMS patients exhibited longer reaction times and made more errors on the ANT-I than RA patients and healthy women, performance did not differ between RA patients and healthy women. The magnitude of group differences did not vary by the experimental conditions of the ANT-I, suggesting a general attentional deficit in FMS rather than specific impairments in the domains of alerting, orienting and executive control. Differences between patient groups may relate to the different pathogenetic mechanisms involved in the disorders, i.e. inflammatory processes in RA and central nervous sensitization in FMS. In FMS, heightened activity in the pain neuromatrix may interfere with attention, because it requires enhanced neural resources in brain areas that are involved in both pain and attentional processing.

Cognitive Decline in Rheumatoid Arthritis: Insight into the Molecular Pathogenetic Mechanisms

Cognitive decline refers to a deterioration of intellectual and learning abilities and related memory problems, and is often associated with behavioral alterations, which prevents sufferers from carrying out the most common daily activities, such as maintaining normal productive interpersonal relationships, communicating, and leading an autonomous life. Numerous studies have highlighted the association between cognitive decline and autoimmune disorders, including rheumatoid arthritis (RA). RA is a chronic, inflammatory, autoimmune disease that involves systems and organs other than the bones and joints, with varying severity among patients. Here, we review the studies investigating the link between cognitive decline and RA, focusing on the main molecular pathogenetic mechanisms involved. The emerging body of data suggests that clinical, psychological, and biological factors may contribute to the pathogenesis of cognitive decline in RA, including cardiovascular complications, chronic pain, depression, inflammatory factors, changes in hormone levels, drug side effects, and genetics. Further studies are warranted in order to fully clarify the basis underlying the association between cognitive decline and RA and to find new possible diagnostic strategies and therapeutic targets for RA patients.

Endothelial Dysfunction and Extra-Articular Neurological Manifestations in Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory autoimmune disease that affects about 1% of the global population, with a female–male ratio of 3:1. RA preferably affects the joints, with consequent joint swelling and deformities followed by ankylosis. However, evidence has accumulated showing that patients suffering from RA can also develop extra-articular manifestations, including cardiovascular disease states, neuropathies, and multiorgan dysfunction. In particular, peripheral nerve disorders showed a consistent impact in the course of the disease (prevalence about 20%) mostly associated to vasculitis of the nerve vessels leading to vascular ischemia, axonal degeneration, and neuronal demyelination. The pathophysiological basis of this RA-associated microvascular disease, which leads to impairment of assonal functionality, is still to be better clarified. However, endothelial dysfunction and alterations of the so-called brain-nerve barrier (BNB) seem to play a fundamental role. This review aims to assess the potential mechanisms underlying the impairment of endothelial cell functionality in the development of RA and to identify the role of dysfunctional endothelium as a causative mechanism of extra-articular manifestation of RA. On the other hand, the potential impact of lifestyle and nutritional interventions targeting the maintenance of endothelial cell integrity in patients with RA will be discussed as a potential option when approaching therapeutic solutions in the course of the disease.

The Joint-Brain Axis: Insights From Rheumatoid Arthritis on the Crosstalk Between Chronic Peripheral Inflammation and the Brain

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by erosive polyarthritis. Beyond joint pathology, RA is associated with neuropsychiatric comorbidity including depression, anxiety, and an increased risk to develop neurodegenerative diseases in later life. Studies investigating the central nervous system (CNS) in preclinical models of RA have leveraged the understanding of the intimate crosstalk between peripheral and central immune responses. This mini review summarizes the current knowledge of CNS comorbidity in RA patients and known underlying cellular mechanisms. We focus on the differential regulation of CNS myeloid and glial cells in different mouse models of RA reflecting different patterns of peripheral immune activation. Moreover, we address CNS responses to anti-inflammatory treatment in human RA patients and mice. Finally, to illustrate the bidirectional communication between the CNS and chronic peripheral inflammation, we present the current knowledge about the impact of the CNS on arthritis. A comprehensive understanding of the crosstalk between the CNS and chronic peripheral inflammation will help to identify RA patients at risk of developing CNS comorbidity, setting the path for future therapeutic approaches in both RA and neuropsychiatric diseases.

Evaluation of cognitive function in adult patients with juvenile idiopathic arthritis

OBJECTIVE

To evaluate cognitive function in adult patients with juvenile idiopathic arthritis (JIA) and associated factors.

PATIENTS AND METHODS

We performed a cross-sectional observational study of adult patients with JIA and a healthy control group (no inflammatory diseases) matched for age, gender, and educational level. Cognitive function was assessed using Wechsler Adult Intelligence Scale-III. The cognitive domains measured were attention/concentration, verbal function, visuospatial organization, working memory, and problem solving (Similarities). Other measures included clinical-epidemiological characteristics, comorbid conditions, and treatment. We performed a descriptive bivariate analysis and logistic regression to identify factors associated with visuospatial involvement.

RESULTS

The study population comprised 104 subjects (52 with JIA and 52 healthy controls). Patients with JIA had poorer results for visuospatial function, with a lower median scaled score on the Block Design test (5.0 [4.0-8.0] vs 8.0 [5.0-10.0]; P = .014). The number of patients with scaled scores below the average range (<8) in visuospatial organization was significantly greater in the JIA group (67.3% vs 40.4%; P = .006). The multivariate analysis revealed time since diagnosis (odds ratio [95% CI], 1.03 [1.01-1.06]), inflammatory activity according to Juvenile Arthritis Disease Activity Score 27-joint count (1.94 [1.01-3.75]), and educational level (0.28 [0.08-0.94]) to be factors associated with visuospatial function.

CONCLUSION

Cognitive function in adult patients with JIA is poorer than in healthy controls at the expense of visuospatial function. Visuospatial function in JIA patients was inversely associated with disease duration, inflammatory activity, and lower educational level.

Rheumatoid Arthritis: The Impact of Mental Health on Disease: A Narrative Review

Over 60% of rheumatoid arthritis (RA) patients achieve a good response after 12 months of treatment when following the European league against rheumatism (EULAR) guidelines for treatment. However, almost half of patients still suffer from moderate to severe disease activity despite this. In addition, mental health problems may remain despite reduced measures of inflammation systemically and within joints. Depression is two times more common in RA patients than in the general population, and intriguingly a bi-directional relationship with RA has been shown in cross-sectional studies. Chronic inflammation impairs the physiological responses to stress including effective coping behaviours, resulting in depression, which leads to a worse long-term outcome in RA. In RA patients, the pain score is not always solely related to inflammatory arthritis and immunological disease activity by Bąk et al. (Patient Prefer Adherence 13:223-231, [1]). Non-inflammatory pain secondary to anxiety, depression, sleep disturbance and the psychosocial situation needs to be considered whilst fibromyalgia, mechanical pain and neuropathic pain can also contribute to overall pain scores by Chancay et al. (Women's Midlife Health 5:3, [2]). Hence, the UK National Institute for Health and Care Excellence (NICE) guideline for the management of RA included psychological interventions for fatigue, low mood and social well-being (NICE NG100, 2018) [3], and the NICE clinical guidelines (CG91) [4] suggest managing mental health and depression in chronic medical conditions to improve treatment outcomes. This is a narrative review of the impact of mental health on RA disease activity in terms of patient-reported outcomes (PROs).

Cognitive impairment in elderly patients with rheumatic disease and the effect of disease-modifying anti-rheumatic drugs

Recent development of biologic disease-modifying anti-rheumatic drugs (DMARDs) has led to better control of disease activity among patients with chronic rheumatological diseases. Many patients with rheumatic disease are living longer, adding to the growing elderly population. Rheumatic diseases, most notably rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE), are known to increase the risk of cognitive impairment. Systemic inflammation associated with chronic rheumatological diseases has been postulated to be key driver of cognitive decline. Recent development of classic and biologic DMARDs have led to better control of disease activity among patients with rheumatic conditions. It is proposed that strict control of systemic inflammation will significantly lower the risk of cognitive impairment among patients with rheumatic disease. The impact of classic DMARDs on cognitive function appears to be variable. On the other hand, biologic DMARDs, specifically antitumor necrosis factor (TNF) drugs (i.e., etanercept), have been shown to significantly lower the risk of dementia. Experimental studies on IL-1, IL-6, and B and T cell blockade are promising. However, clinical data is limited. Preclinical studies on targeted therapies, specifically JAK/STAT inhibitors, also show promising results. Additional studies are necessary to better understand the impact of these newer biologic agents on cognitive function in elderly patients with rheumatic disease. Key points • Patients with chronic rheumatic conditions are beginning to live longer, adding to the elderly population. • Patients with chronic rheumatologic disease are at increased risk of cognitive impairment compared to the general population. • Recent development of biologic (i.e., TNF, IL-1, IL-6) and targeted drugs (i.e., Janus kinase inhibitors) have led to better control of disease activity. • Current evidence suggests that TNF inhibitors may have beneficial effects on cognitive function. However, evidence on newer biologic and targeted therapies is limited.

A Computerized Assessment of Verbal and Visuospatial Memory (Dys)functions in Patients with Rheumatoid Arthritis

Purpose

Rheumatoid arthritis (RA) is a chronic inflammatory systemic disease associated with various degrees of impairment across different cognitive domains. We aimed to provide a detailed computerized investigation of verbal and visuospatial short-term and working memory (dys)functions in RA patients, assessing both accuracy and response speed, while relating them to age, disease-related activity, affective problems, psychomotor speed and other clinical parameters.

Patients and Methods

The study included 29 RA patients (mean age 50.6 ± 12.3 years, 79% female) and 30 controls (matched according to age, gender and education), assessed with short-term and working memory tasks from the Cambridge Neuropsychological Test Automated Battery (CANTAB) and the Automated Working Memory Assessment (AWMA).

Results

RA patients were significantly slower on the basic processing speed test (Motor Screening Test, p =0.003). Their short-term information storage (verbal and visuospatial) was comparable to controls, yet this similar accuracy came at the expense of a longer response time to retain information correctly (on spatial span, p = 0.04). On tasks with higher executive demands, both visuospatial and verbal working memory were compromised, as RA patients took longer (p = 0.004) and had a higher number of total errors (p = 0.02) when conducting a strategic memory-guided search (Spatial Working Memory), and had a significantly lower verbal working memory span on the backwards digit recall test (p = 0.02).

Conclusion

The findings of this study emphasize the usefulness of performing computerized tests to detect subtle signs of cognitive impairment and of intact performance, which can inform memory training protocols for this vulnerable population.

Factors Affecting Vision and Visio-Spatial Intelligence (VSI) in Sport: A Review of the Literature

: Sport has become increasingly competitive, prompting the need to determine, as far as possible, any likely performance advantage. While the focus of athletic research, testing, and training is on the physiological and physical characteristics of the sport, visual abilities not only affect sport performance directly, but also affect the acquisition of motor skills. Vision, and visual-spatial intelligence (VSI), are a relatively new and underexplored area of athletic performance. As with physiological and physical parameters, a range of factors affect vision and VSI in sporting activities. This review of the literature is a first attempt to summarize and compile an overview of the factors affecting vision and VSI in athletes, covering those previously connected with sport, as well as those hitherto not associated with athletic activities, but that could also play a part in sports performance. The evidence from this review suggests that while current research still tends to focus on single factors affecting vision and VSI, a large number of such factors have been identified that could affect vision and VSI. This offers new opportunities for researchers to investigate the effects of a combination of factors, and for conditioning and/or sports vision specialists to explore further possibilities for competitive advantage.

Effect of depression on attentional network system among rheumatoid arthritis patients-A cross-sectional study

Rheumatoid arthritis (RA) is a chronic, painful and debilitating musculoskeletal condition with depression being its common co-morbidity. It is associated with symptoms of fatigue, pain, and sleep disturbances that can overlap with or mimic symptoms of depression. It may occur with at least mild severity is up to 42% of RA patients. Basically, depression refers to a constellation of experience including not only mood but also physical, mental and behavioral experiences. The fact that rates of depression are higher in samples of patients with RA than in the normal population is well documented. The present study was conducted in order to examine the effect of depression on attentional functioning with diagnosed RA patients. Twenty RA patients out of which 10 patients with depression and 10 patients without depression participated in the study. The Beck Depression Inventory was administered for the assessment of depression and the attentional network task was used to measure the attentional performance of the RA patients. Results revealed that there was a significant difference in depressive symptoms among RA patients on accuracy and reaction time (P < 0.01) and orienting effect (P < 0.05). The findings would also imply intervention and rehabilitation of depression among RA patients.

Cognitive dysfunction in patients of rheumatoid arthritis

Rheumatoid Arthritis (RA) is a form of arthritis characterized by joint pain, stiffness, swelling and deformity. There has been plethora of researches in the area of rheumatoid arthritis which focused on immune system, genetic predisposition and newer treatment modalities. Researchers have also examined the cognitive decline, physical deficits and their interrelationship in patients with RA. Among several psychological aspects depression, anxiety and stress emerge as significant psychological co morbidity. RA is a multifactorial, chronic, inflammatory disease primarily affects physical functioning as well as psychological aspects. Pain, fatigue, duration of disease, disease activity and functional disability are very common in rheumatoid arthritis which is leading cause of psychological distress and functional disability. Various types of neuropsychological battery were used to assess the decline in specific areas like attention, executive functioning, visuo-spatial learning, verbal learning/memory etc. These functions were compared with other type of arthritis disease. Also, various other factors like depression, cardiovascular diseases, other systemic and chronic disease and concomitant drugs intake etc. also affected cognitive functioning in Rheumatoid Arthritis patients. The objective of this review was to identify and explore the rates and types of cognitive impairment in RA. This present review paper systematically examines and summarizes the cognition related decrement in arthritis patients. Multiple research articles between 1990 to 2018 were searched. These reviews were evaluated and synthesized using a narrative and descriptive approach.

Cognitive dysfunction in autoimmune rheumatic diseases

For people with chronic autoimmune rheumatic diseases (AIRD), such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) or systemic sclerosis (SSc), normal cognitive functions are essential for performing daily activities. These diseases may be associated with cognitive dysfunction (CD). In RA, CD has been associated with age, lower education and disease duration and activity. Great advances have been achieved in neuropsychiatric SLE in the identification of pathogenic pathways, assessment and possible treatment strategies. SSc rarely exerts direct effects on the brain and cognitive function. However, the psychological burden that includes depression, anxiety and social impact may be high. AIRD patients with sustained disease activity, organ damage or lower education should be evaluated for CD. The control of systemic inflammation together with tailored behavioural cognitive therapies may benefit these patients.

The Impact of Exercise, Lifestyle, and Clinical Factors on Perceived Cognitive Function in Patients with Rheumatoid Arthritis: Results from a Prospective Cohort Study

Objective

Lifestyle factors, such as inactivity and obesity, contribute to cognitive decline in the general population, but little is known about how these factors may affect individuals with a chronic inflammatory condition such as rheumatoid arthritis (RA). We studied the clinical and functional risk factors related to a worsening of perceived cognitive function in patients with RA.

Methods

We collected clinical and functional questionnaire data over 10 years in a prospective RA cohort including yearly self‐reported memory, concentration, and word‐finding difficulties graded from “never” to “often.” Generalized estimating equation models examined the role of exercise (defined as those meeting the Department of Health and Human Services physical activity guidelines of 75 minutes of vigorous or 150 minutes of moderate aerobic activity per week), body mass index (BMI), sleep, depression (Mental Health Index‐Depression), Disease Activity Score (DAS)28–c‐reactive protein (CRP)3 score, disease‐modifying antirheumatic drug, and corticosteroid use from the previous year as predictors of cognitive complaints that progressed to “often” compared with the previous year (the first year (T_i) progressed to “often” 1 year later (T_i+1)).

Results

Of 1219 RA subjects, 127 (10.4%) described either poor memory, concentration, or word‐finding difficulties as affecting them “often” at study entry. RA patients (n = 1092, mean age = 56.5 years, 82% female, 58% college educated) were less likely to report word‐finding difficulties, poor memory, and concentration as “often” if they were physically active (p = 0.0001, P = 0.01, P < 0.0001, respectively). Female RA patients developed more concentration complaints compared with males (P = 0.03); patients taking an anti–tumor necrosis factor therapy were less likely to complain of poor memory (P = 0.01). Sleep, BMI, fatigue, depression, DAS28‐CRP3, methotrexate, and corticosteroid use were not independently associated with a worsening of any cognitive complaints.

Conclusion

RA patients who are physically active are less likely to report cognitive difficulties. Our study suggests potential modifiable risk factors for the prevention of cognitive dysfunction in RA.

Assessment of cognitive function in female rheumatoid arthritis patients: associations with cerebrovascular pathology, depression and anxiety

We assessed cognitive function of female rheumatoid arthritis (RA) patients and analyze the determinants, with special focus on cerebrovascular morphology. Sixty methotrexate (MTX-) or biologic-treated RA patients and 39 healthy controls were included in a cross-sectional study. Smoking habits, alcohol intake and time spent in education were recorded. Standard measures were performed to assess cognitive function (Montreal Cognitive Assessment, MOCA; Trail Making Test, TMT; Victoria Stroop Test, VST; Wechsler Adult Intelligence Scale, WAIS; Benton Visual Retention test, BVRT), depression (Beck Depression Inventory, BDI), anxiety (State-Trait Anxiety Inventory, STAIT/S) and general health status (Short Form 36, SF-36). Mean disease activity (28-joint Disease Activity Score, mDAS28; erythrocyte sedimentation rate, mESR; C-reactive protein, mCRP) of the past 12 months was calculated; anti-cyclic citrullinated peptide (CCP) and rheumatoid factor (RF) were assessed. Cerebral vascular lesions and atrophy, carotid intima-media thickness (cIMT) and plaques, as well as median cerebral artery (MCA) circulatory reserve capacity (CRC) were assessed by brain magnetic resonance imaging (MRI), carotid ultrasound and transcranial Doppler, respectively. Cognitive function tests showed impairment in RA vs controls. Biologic- vs MTX-treated subgroups differed in TMT-A. Correlations were identified between cognitive function and depression/anxiety tests. WAIS, STAIS, STAIT and BDI correlated with most SF-36 domains. Numerous cognitive tests correlated with age and lower education. Some also correlated with disease duration, mESR and mDAS28. Regarding vascular pathophysiology, cerebral vascular lesions were associated with VST-A, carotid plaques with multiple cognitive parameters, while MCA and CRC with MOCA, BVRT and BDI. RA patients have significant cognitive impairment. Cognitive dysfunction may occur together with or independently of depression/anxiety. Older patients and those with lower education are at higher risk to develop cognitive impairment. Cognitive screening might be a useful tool to identify subgroups to be further investigated for cerebrovascular pathologies.

Disease activity is associated with cognitive impairment in patients with rheumatoid arthritis

OBJECTIVE

To investigate the association between disease activity and cognitive impairment in patients with rheumatoid arthritis (RA).

METHODS

A total of 464 patients from the rheumatoid arthritis registry of two academic centers, Siriraj and Phramongkutklao hospitals, were included. Demographic, clinical, and laboratory data related to disease activity and functional status were collected. Cognitive function was assessed using the Thai version of the Montreal Cognitive Assessment (MoCA-T). Subjects were classified as cognitively impaired if they scored less than 25.

RESULTS

Most subjects (85%) were female with a mean age ± SD of 59.2 ± 11.4 years old and a median (range) educational level of 9 (4-14) years. They were long-standing RA patients (median disease duration (range) of 9.9 (5.1-16.6) years) and had moderate cumulative disease activity (mean DAS28 ± SD of 3.5 ± 0.81) and mild functional impairment (median HAQ (range) 0.5 (0.13-1.10)). Seventy percent of the patients were classified as having cognitive impairment. The patients with cognitive impairment significantly impaired in all domains, especially in visuospatial/executive, language, and abstraction. In multiple logistic regression analyses, old age (RR 3.45, 95% CI 2-6, p < 0.001), low education (RR 10.8, 95% CI 5.3-22.1, p < 0.001), and high cumulative disease activity (RR 2.2, 95% CI 1.07-4.7, p = 0.033) were independently associated with cognitive impairment.

CONCLUSION

High cumulative RA disease activity is associated with cognitive impairment. Therefore, treat-to-target aimed at low disease activity or remission may be beneficial for preventing cognitive decline in RA patients.

Comorbid anxiety, depression, and cognition in MS and other immune-mediated disorders

OBJECTIVE

To determine whether anxiety and depression are associated with cognition in multiple sclerosis (MS), and whether these associations are similar in other immune-mediated inflammatory diseases (IMID; including inflammatory bowel disease [IBD] and rheumatoid arthritis [RA]) and in anxious/depressed individuals (ANX/DEP) without an IMID.

METHODS

Participants (MS: n = 255; IBD: n = 247; RA: n = 154; ANX/DEP: n = 308) completed a structured psychiatric interview, the Hospital Anxiety and Depression Scale, and cognitive testing, including the Symbol Digit Modalities Test, the California Verbal Learning Test, and Letter Number Sequencing test. Test scores were converted to age-, sex-, and education-adjusted z scores. We evaluated associations of anxiety and depression with the cognitive z scores using multivariate linear models, adjusting for disease cohort.

RESULTS

All cohorts exhibited higher rates of impairment (i.e., z less than or equal to -1.5) in the domains of processing speed, verbal learning, and delayed recall memory relative to general population norms. Higher levels of anxiety symptoms were associated with slower processing speed, lower verbal learning, and lower working memory performance (all p < 0.001); higher levels of depression symptoms were associated with slower processing speed. These associations did not differ across cohorts.

CONCLUSION

Anxiety and depression are associated with lower cognitive function in MS, with a similar pattern observed in persons with other IMID, including IBD and RA, and persons without an IMID. Managing symptoms of anxiety and of depression in MS, as well as other IMIDs, is important to mitigate their effect on cognition.

Multiple chronic conditions: Implications for cognition - Findings from the Wisconsin Registry for Alzheimer's Prevention (WRAP)

INTRODUCTION

Several chronic illnesses have demonstrated relationships to cognitive decline in the context of aging. However, researchers have largely ignored the effects of multi-morbidity in the context of Alzheimer's disease and related dementias (ADRD) risk. The purpose of this study is to examine the relationship between multiple chronic conditions (MCC) and cognitive decline.

METHODS

Latent class analysis (LCA) was completed to identify different subgroups of the 1285 participants from the Wisconsin Registry for Alzheimer's Prevention who were recognized based on their self-reported chronic illnesses. Differences between variables of interest (i.e., biomarkers and depressive symptom scores) and each of the individual classes were then explored. Chi-square tests were used to examine the association between MCC and cognitive status.

RESULTS

LCA revealed a four-class model best fit solution. Participants in the sleep class had the highest incidence of new onset cognitive decline.

DISCUSSION

Findings offer evidence of an association between specific MCC groups and the development of cognitive decline. Nurses should monitor and screen for cognitive decline in the presence of MCC in order to better target self-management interventions.

Brain-derived neurotrophic factor secreted by the cerebral endothelium: A new actor of brain function?

Low cerebral levels of brain-derived neurotrophic factor (BDNF), which plays a critical role in many brain functions, have been implicated in neurodegenerative, neurological and psychiatric diseases. Thus, increasing BDNF levels in the brain is considered an attractive possibility for the prevention/treatment of various brain diseases. To date, BDNF-based therapies have largely focused on neurons. However, given the cross-talk between endothelial cells and neurons and recent evidence that BDNF expressed by the cerebral endothelium largely accounts for BDNF levels present in the brain, it is likely that BDNF-based therapies would be most effective if they also targeted the cerebral endothelium. In this review, we summarize the available knowledge about the biology and actions of BDNF derived from endothelial cells of the cerebral microvasculature and we emphasize the remaining gaps and shortcomings.

Proteomic analysis of plasma from rheumatoid arthritis patients with mild cognitive impairment

Rheumatoid arthritis (RA) patients may suffer from comorbid neuropsychiatric symptoms including mild cognitive impairment (MCI). Although comorbidity of MCI is common, there are currently no validated plasma biomarkers to aid MCI diagnosis. This study screened plasma from patients with RA with and without comorbid MCI to identify potential biomarkers useful in the differential diagnosis of comorbid MCI. Plasma samples were collected from patients with RA without comorbid MCI, with comorbid MCI, and from healthy controls. Plasma samples were examined by tandem mass tags (TMT) combined with two-dimensional liquid chromatography-tandem mass spectrometry (2D-LC-MSMS) to analyze protein expression. Differentially expressed proteins were identified by bioinformatics and validated by enzyme-linked immunosorbent assay (ELISA). A total of 746 reliable proteins and 158 differentially expressed proteins were identified. Fourteen patients with RA-MCI showed differential protein expression (six proteins upregulated and eight proteins downregulated) compared with those patients without MCI and with healthy controls. Bioinformatics analysis showed that the differentially expressed proteins were primarily involved in biological processes, such as cell adhesion, coagulation, apoptosis, and body fluid regulation. The results of the ELISA experiments, similar to those of the proteomic analysis, demonstrated that sonic hedgehog (SHH) was upregulated and serum paraoxonase (TTR) was downregulated in patients with RA-MCI. These results indicate that SHH and TTR may be candidate plasma biomarkers that could be used to distinguish patients with RA and comorbid MCI from those without comorbid MCI.

A Longitudinal Analysis of General Practitioner Service Use by Patients with Mild Cognitive Disorders in Australia

BACKGROUND

The aim of this study was to ascertain if participants diagnosed with any mild cognitive disorder (MCD) visited a general practitioner (GP) more than those without MCD and the effect of either depression or arthritis on GP use longitudinally.

METHODS

2,551 participants aged 60-64 years at baseline completed the Personality and Total Health Through Life (PATH) study in Canberra. Follow-up data were collected after 4 and 8 years. A cognitive screening battery was used to screen participants into a substudy of MCD.

RESULTS

Participants with any MCD had greater GP use than cognitively healthy participants across all three waves (wave 1, M = 7.35 vs. 5.59; wave 2, M = 7.77 vs. 5.86; wave 3, M = 9.01 vs. 6.81). After adjusting for demographic and health factors, MCD was a significant predictor of GP use at all three waves (p < 0.05, CI 0.84-0.99).

CONCLUSION

This study has shown that MCD is associated with a higher use of GP visits, especially if the patient has a comorbid condition.

Cognitive impairment in rheumatoid arthritis: role of lymphocyte subsets, cytokines and neurotrophic factors

To what extent the cognitive impairment of rheumatoid arthritis (RA) is modulated by autoimmune and/or inflammatory activity is largely unknown. The aim of this study was to investigate the role of peripheral inflammation on cognitive functions of patients with active (Ac-), controlled (Co-) RA and healthy controls. In a cross-sectional study, 102 RA patients and 30 matched healthy controls were recruited. B and T cell subsets were immunophenotyped by flow cytometry. Plasma cytokines and neurotrophins were measured by flow cytometry and ELISA, respectively. Cognitive performance, depression and stress were evaluated by structured clinical interviews. Generalized linear modeling (GzLM) was used to compare differences between groups and multiple linear regression models were used to explore the predictive value of immune variables on cognitive performance. RA patients had overall cognitive impairment. Of note, the Ac-RA had the poorest performance on digit span (DST) and N-back when compared to Co-RA and control group (DST 9.9 ± 2.1, 12.9 ± 4.2, 15.5 ± 4.7, respectively; N-back 49.2 ± 8.3, 55.5 ± 11.1, 60.8 ± 9.1, respectively, all p < 0.0001). RA patients had expansions of immature B cells (Ac-RA 11.2 ± 7.1, Co-RA: 9 ± 5.7, control 5.9 ± 2.1) and plasma cells (Ac-RA 5.2 ± 2.5, Co-RA 6.9 ± 3.7, control 2.8 ± 1.7) as compared to controls, all p < 0.05. RA patients (controlled and active disease) had higher plasma levels of TNF, IL-2, IL-4, IL-6 and IL-10 than controls (all p < 0.002). RA patients had higher BDNF levels (Ac-RA 17,354.4 ± 5357.3, Co-RA 13,841.2 ± 5953.7, control 11,543.3 ± 3772), but lower GDNF levels [median (interquartile range) Ac-RA 0 pg/ml (0.0), Co-RA 0 pg/ml (4.6) and control 4.7 pg/ml (18.1)] than controls (all p < 0.05). RA patients had global cognitive impairment, which was associated with disease activity and immune changes.

Effects of Psychiatric Comorbidity in Immune-Mediated Inflammatory Disease: Protocol for a Prospective Study

BACKGROUND

Immune-mediated inflammatory diseases (IMID), such as inflammatory bowel disease (IBD), multiple sclerosis (MS), and rheumatoid arthritis (RA), are highly prevalent in Canada and the United States and result in substantial personal and societal burden. The prevalence of psychiatric comorbidities, primarily depression and anxiety, in IMID exceeds those in the general population by two- to threefold, but remains underdiagnosed and undertreated. Furthermore, the effects of psychiatric comorbidity on IMID are not well understood.

OBJECTIVE

The objectives of this study were (1) to compare health-related quality of life and work ability in persons with IMID and psychiatric comorbidity with those of persons with IMID without psychiatric comorbidity and with those of persons with depression and anxiety disorders alone, and (2) to validate existing case identification tools for depression and anxiety in persons with IMID to facilitate improved identification of depression and anxiety by clinicians. To achieve these objectives, we designed a prospective 3-year longitudinal study. In this paper, we aim to describe the study rationale and design and the characteristics of study participants.

METHODS

Between November 2014 and July 2016, we recruited 982 individuals from multiple clinic and community sources; 18 were withdrawn due to protocol violations.

RESULTS

The final study sample included 247 participants with IBD, 255 with MS, 154 with RA, and 308 with depression or anxiety. The majority were white, with the proportion ranging from 85.4% (IBD [210/246]; MS [217/254]) to 74.5% (114/153, RA; P=.01). There was a female predominance in all groups, which was highest in the RA cohort (84.4%, 130/154) and least marked in the IBD cohort (62.7%, 155/247). Participants with depression or anxiety were more likely to be single (36.0%, 111/308) than participants in any other group (11.8% [30/255]-22.7% [56/247], P<.001).

CONCLUSIONS

This paper presents the rationale for this study, describes study procedures, and characterizes the cohort enrolled. Ultimately, the aim is improved care for individuals affected by IMID.

Discrepancy between subjective and objective measures of cognitive impairment in patients with rheumatoid arthritis

This study explored the discrepancy between perceived cognitive dysfunction and computerized neuropsychological test performance in Korean patients with RA. Individuals with RA were recruited by their rheumatologists during follow-up visits at one hospital in Korea. After getting signed consents, a trained research nurse assessed participants with a range of physical, psychosocial, and biological metrics. Subjective cognitive dysfunction was assessed using the Perceived Deficits Questionnaire (PDQ; range 0-20). Objective cognitive impairment was assessed using a set of 6 computerized neurocognitive tests yielding 12 indices covering a range of cognitive domains. Subjects were classified as 'impaired' if they performed 1 SD below age-based population norms on each test. A total cognitive function score was calculated by summing the transformed scores (range 0-12). Multiple linear regression analyses determined the relationship of total cognitive function score with PDQ score, controlling for disease activity, functional limitations, and psychological factors. Forty subjects (mean ± SD age: 63.1 ± 11.4 years) were included. Mean ± SD scores of total cognitive function and PDQ were 7.3 ± 2.7 (2-12) and 11.8 ± 5.1 (5-25), respectively. In multivariate analysis, there was no significant relationship between total cognitive function score and PDQ score. However, depression and sleep quality (β = 0.37, p = 0.025; β = 0.17, p = 0.034) were significantly associated with PDQ score. The findings emphasize the gap between subjective and objective measures of cognitive impairment and the importance of considering psychological factors within the context of cognitive complaints in clinical settings.

Gulf War illness (GWI) as a neuroimmune disease

Gulf War illness (GWI) is a chronic disease characterized by the involvement of several organs, including the brain (Christova et al., Exp Brain Res doi: 10.1007/s00221-017-5010-8 , 2017). In a previous study (Georgopoulos et al., J Neural Eng 4:349-355, 2015), we identified six protective alleles from Class II human leukocyte antigen (HLA) genes, and more recently, we investigated the brain correlates of this protection (James et al., EBioMedicine 13:72-79, 2016). Those and other studies (Israeli, Lupus, 21:190-194, 2012) suggested an involvement of the immune system in GWI. In a recent study (Engdahl et al., EBioMedicine doi: 10.1016/j.ebiom.2016.08.030 , 2016), we showed that the brain pattern of synchronous neural interactions (SNI; Georgopoulos et al., J Neural Eng 4:349-355, 2007) in GWI is distinctly different from that in healthy controls. Here we focused on the SNI itself, as a basic measure of neural communication (irrespective of specific connections) and compared it between GWI and seven other diseases that cover a broad spectrum of etiology and pathophysiology. Specifically, we sought to determine which, if any, of those diseases might resemble GWI SNI, overall and within the HLA protective domain, and thus gain further knowledge regarding the nature of GWI brain abnormality. We studied a total of 962 participants from a healthy control population (N = 583) and eight different diseases, including GWI (N = 40), schizophrenia (SZ; N = 21), Alzheimer's disease (AD; N = 66), posttraumatic stress disorder (PTSD; N = 159), major depressive disorder (MDD; N = 10), relapsing-remitting multiple sclerosis (RRMS; N = 43), Sjögren's syndrome (SS; N = 32), and rheumatoid arthritis (RA; N = 8). They all underwent a resting-state magnetoencephalographic (MEG) scan to calculate SNIs. Data were analyzed using analysis of covariance (ANCOVA) with disease as fixed factor, and sex and age as covariates. We found that GWI SNIs differed significantly from control SZ, AD, PTSD and MDD but not from RRMS, SS and RA. In addition, we compared GWI to RRMS, SS and RA with respect to SNIs of MEG sensor pairs that were related to the HLA alleles protective for GWI (James et al., EBioMedicine 13:72-79, 2016). We found that GWI SNIs did not differ significantly from any of these three diseases but they did so from control SZ, AD, PTSD and MDD. These findings indicate that (a) GWI brain synchronicity does not differ significantly from that of known immune-related diseases (RRMS, SS, RA), and (b) that this SNI similarity is present within the HLA-related SNIs. In contrast, GWI SNIs differed significantly from those of the other diseases. We conclude that altered brain communication in GWI likely reflects immune-related processes, as postulated previously (James et al., EBioMedicine 13:72-79, 2016). By extension, these findings also indicate that functional brain abnormalities in RRMS, SS and RA might be, in part, due to lack of protective HLA alleles as documented for GWI (Georgopoulos et al., EBioMedicine 3:79-85, 2015).

Autoantibodies against myelin sheath and S100β are associated with cognitive dysfunction in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) has been associated with cognitive impairment and peripheral production of autoantibodies. Autoantibodies against central nervous system (CNS) proteins and S100 calcium-binding β (S100β) were found increased in diseases characterized by cognitive impairment like Alzheimer disease and Neuropsychiatric Systemic Lupus Erythematosus (NPSLE). The aim of this study was to investigate the plasma levels of autoantibodies against myelin basic protein (anti-MBP), myelin oligodendrocyte glycoprotein (anti-MOG) and S100β, and their relationships with cognitive performance in RA patients. Twenty patients with active rheumatoid arthritis and 19 age-, sex-, and schooling-matched healthy controls were recruited. Multiple dimensions of cognitive function were evaluated by structured clinical questionnaires. Autoantibodies and S100β levels were assessed by ELISAs. Patients had significantly higher levels of anti-MBP IgG (17.51 ± 1.36 vs. 5.24 ± 0.53 ng/mL), anti-MOG IgG (5.68 ± 1.34 vs. 0.51 ± 0.49 ng/mL), and S100β protein (2.24 ± 0.50 vs. 0.47 ± 0.06) than controls (all p < 0.0001). After adjusting for potential confounders, RA group presented worse cognitive performance involving the working memory and executive functions such as inhibition, flexibility, and mental control in parallel to higher autoantibodies and S100β levels than healthy controls (all p < 0.001). Levels of anti-MBP were negatively associated with delayed verbal recall (DVR; r = -0.42, p = 0.005), Stroop Color-Word (r = -0.48, p = 0.004), and N-Back Total scores (r = -0.59, p < 0.0001) and positively with Trail Making Test B (TMB, r = 0.53, p = 0.001). Negative correlation was found between levels of anti-MOG and DVR (r = -0.64, p < 0.0001), N-Back Total scores (r = -0.35, p = 0.03), Stroop Color-Word (r = -0.51, p = 0.001), and positively with TMB (r = 0.50, p = 0.003). S100β levels were associated with DVR (r = -0.51, p = 0.002), TMB (r = 0.46, p = 0.008), Stroop Color-Word (r = -0.67, p < 0.0001), and N-Back Total (r = -0.52, p = 0.003). RA is associated with impaired cognitive performance associated with higher levels of CNS-related autoantibodies and S100β levels. Given the importance of myelin integrity to cognition, our data indicate that these autoantibodies may be harmful to proper cognitive function.

Arthritis and cognitive impairment in older adults

Adults aged 65 or older with arthritis may be at increased risk for cognitive impairment [cognitive impairment but not dementia (CIND) or dementia]. Studies have found associations between arthritis and cognition impairments; however, none have examined whether persons with arthritis develop cognitive impairments at higher rates than those without arthritis. Using data from the Health and Retirement Study, we estimated the prevalence of cognitive impairments in older adults with and without arthritis, and examined associations between arthritis status and cognitive impairments. We calculated incidence density ratios (IDRs) using generalized estimating equations to estimate associations between arthritis and cognitive impairments adjusting for age, sex, race/ethnicity, marital status, education, income, depression, obesity, smoking, the number of chronic conditions, physical activity, and birth cohort. The prevalence of CIND and dementia did not significantly differ between those with and without arthritis (CIND: 20.8%, 95% CI 19.7-21.9 vs. 18.3%, 95% CI 16.8-19.8; dementia: 5.2% 95% CI 4.6-5.8 vs. 5.1% 95% CI 4.3-5.9). After covariate control, older adults with arthritis did not differ significantly from those without arthritis for either cognitive outcome (CIND IDR: 1.6, 95% CI = 0.9-2.9; dementia IDR: 1.1, 95% CI = 0.4-3.3) and developed cognitive impairments at a similar rate to those without arthritis. Older adults with arthritis were not significantly more at risk to develop cognitive impairments and developed cognitive impairments at a similar rate as older adults without arthritis over 6 years.

Arthritis and Risk of Cognitive and Functional Impairment in Older Mexican Adults

OBJECTIVE

This study investigated the risk of cognitive and functional impairment in older Mexicans diagnosed with arthritis. Participants included 2,681 Mexicans, aged ≥60 years, enrolled in the Mexican Health and Aging Study cohort.

METHOD

Participants were categorized into arthritis and no arthritis exposure groups. Primary outcome included participants categorized into "cognitively impaired" or "cognitively normal" groups. Secondary outcomes included participants categorized into Normal, Functionally Impaired only, Cognitively Impaired only, or Dementia (both cognitively and functionally impaired) groups. Multivariable logistic and multinomial regression models were used to assess the relationships.

RESULTS

Overall, 16% or 7% were diagnosed with cognitive impairment or dementia. Compared with older Mexicans without arthritis, those who were diagnosed with arthritis had significantly increased risk of functional impairment (adjusted odds ratio [OR] 1.82, 95% confidence interval [CI] = [1.45, 2.29]), but not of dementia.

CONCLUSION

Arthritis is associated with increased risk of functional impairment, but not with dementia after 11 years in older Mexicans.

Brain Correlates of Human Leukocyte Antigen (HLA) Protection in Gulf War Illness (GWI)

BACKGROUND

We recently reported that six alleles from class II genes of the Human Leukocyte Antigen (HLA) confer protection from Gulf War Illness (GWI) (Georgopoulos et al., 2015). The most significant effect is exerted on Neurological-Cognitive-Mood (NCM), Pain, and Fatigue symptoms, such that higher number of copies of the protective alleles are associated with lower symptom severity. Here we tested the hypothesis that this effect is exerted by modulating the strength of neural synchronicity.

METHODS

Eighty-one Gulf War veterans (65 with GWI and 16 healthy controls) underwent a magnetoencephalography (MEG) scan to assess the strength of brain synchronicity by computing zero-lag crosscorrelations (and their Fisher z transforms) between prewhitened MEG time series. A high-resolution HLA genotyping determined the number of copies, k, of the 6 protective alleles above in each participant. We tested the hypothesis above by regressing NCM, Pain and Fatigue symptom severity against the interaction term, k×z (HLA-related effect), while including z (non-HLA-related effect), gender and age as covariates. The k×z and z terms assessed HLA- and non-HLA-related effects, respectively, of neural synchronicity on symptom severity. The distributions of these effects in sensor space were visualized using statistical heatmaps.

FINDINGS

We found significant, graded HLA- and non-HLA-related effects: (a) NCM>Pain>Fatigue for HLA-related effects, (b) NCM>Fatigue>Pain for non-HLA-related effects, and (c) HLA-related>non-HLA-related effects for all symptoms. These effects had widespread but distinct distributions in sensor space that allowed the orderly separation of the 6 terms (3 symptom domains×2 HLA factors) in a multidimensional plot, where one dimension separated the symptoms and the other the HLA relation.

INTERPRETATION

These findings demonstrate the presence of substantial, widespread, distinct and orderly HLA- and non-HLA-related neural influences on NCM, Pain and Fatigue symptom severity in GWI.

FUNDING

U.S. Department of Veterans Affairs and University of Minnesota.

The challenging interplay between rheumatoid arthritis, ageing and comorbidities

Background

The incidence of rheumatoid arthritis (RA) is expected to increase over the next 10 years in the European Union because of the increasing proportion of elderly people. As both RA and ageing are associated with emerging comorbidities such as cardiovascular disease, malignancies and osteoporosis, these factors will have a profound effect on the management of RA. In addition, both increasing age and comorbidities may independently alter commonly used RA-specific outcome measures.

Discussion

Age-related decline in immune cell functions (immunosenescence), such as a decrease in T-cell function, may contribute to the development of RA, as well as comorbidity. The chronic immune stimulation that occurs in RA may also lead to premature ageing and comorbidity. The interplay between RA, ageing and (emerging) comorbidities is interesting but complex. Cardiovascular disease, lung disease, malignancies, bone and muscle wasting and neuropsychiatric disease all occur more frequently in RA patients as compared to the general population. It is unclear how RA should be managed in ‘today’s world of multiple comorbidities’. Evidence that treatment of RA improves comorbidities is currently lacking, although some promising indirect observations are available. On the other hand, there is limited evidence that medication regularly prescribed for comorbidities, such as statins, might improve RA disease activity. Both ageing and comorbidity have an independent effect on commonly used outcome measures in the RA field, such as the Health Assessment Questionnaire (HAQ) and the clinical disease activity index (CDAI). Prospective studies, that also account for the presence of comorbidity in (elderly) RA patients are therefore urgently needed. To address gaps in knowledge, future research should focus on the complex interdependencies between RA, ageing and comorbidity. In addition, these findings should be integrated into daily clinical practice by developing and testing integrated and coordinated health care services. Adaptation of management recommendations is likely required.

Summary

The elderly RA patient who also deals with (emerging) comorbidities presents a unique challenge to treating clinicians. A paradigm shift from disease-centered to goal-oriented approach is needed to develop adequate health care services for these patients.

Multimorbidity, cognitive function, and physical activity

Previous research demonstrates that both physical activity and multimorbidity are associated with cognitive function. However, the extent to which physical activity may moderate the relationship between multimorbidity and cognitive function has not been thoroughly evaluated. Data from the 1999-2002 NHANES were used (60+ years; N = 2157). A multimorbidity index variable was created based on physician diagnosis of a multitude of chronic diseases. Physical activity was self-reported and cognitive function was evaluated from the digit symbol substitution test. Multimorbidity was inversely associated with cognitive function for the unadjusted and adjusted models. However, generally, multimorbidity was no longer associated with cognitive function for the majority of older adults who achieved the minimum recommended physical activity level (≥2000 MET-min-month), as issued by the United States Department of Health and Human Services. In this national sample of older adults, there was some evidence to suggest that physical activity moderates the relationship between multimorbidity and cognitive function.

HIV-associated neurocognitive disorders: the relationship of HIV infection with physical and social comorbidities

The prevalence of HIV (human immunodeficiency virus) associated neurocognitive disorders (HAND) will undoubtedly increase with the improved longevity of HIV-infected persons. HIV infection, itself, as well as multiple physiologic and psychosocial factors can contribute to cognitive impairment and neurologic complications. These comorbidities confound the diagnosis, assessment, and interventions for neurocognitive disorders. In this review, we discuss the role of several key comorbid factors that may contribute significantly to the development and progression of HIV-related neurocognitive impairment, as well as the current status of diagnostic strategies aimed at identifying HIV-infected individuals with impaired cognition and future research priorities and challenges.

Premature immunosenescence is associated with memory dysfunction in rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) has been associated with premature immunosenescence and an increased prevalence of age-related morbidities including poor cognitive function.

OBJECTIVE

We explored the relationships among lymphocyte subsets and memory in RA.

METHODS

Thirty patients with RA and 19 age-matched healthy controls took part in this study. Cognitive function stress and depression scores were evaluated by structured clinical questionnaires. Lymphocytes were isolated and immunophenotyped by flow cytometry to investigate the following subsets: B cells, activated and naïve/memory T cells, regulatory FoxP3+ T (Treg) cells, Th17+ cells, NK cells and senescence-associated CD28- T cells.

RESULTS

RA patients were more depressed than controls, but stress levels were similar in the 2 groups. Patients had impaired memory performance compared to controls, demonstrated by lower Mini-Mental State Examination scores and logical and working memories (all p < 0.0001). These group effects remained significant after correcting for depression and age. Patients had expansion of regulatory T cells, naïve CD4+ T cells and CD8+CD28- cells but reduced percentages of B cells and memory CD8+CD45RO+ T cells compared to controls. CD8+CD28- and CD8+CD45RO+ T cells were found to be negatively associated with memory.

CONCLUSION

RA patients had reduced memory performance compared to healthy controls. Expansion of activated and senescence-associated T cells was correlated with poor memory performance.