Identifying dementia cases with routinely collected health data: A systematic review

Increasing goals of care conversations in primary care: Study protocol for a cluster randomized, pragmatic, sequential multiple assignment randomized trial

BACKGROUND

Goals of care conversations explore seriously ill patients' values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations.

METHODS

We plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders.

CONCLUSION

This study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings.

Shift work effects on incident neuropsychiatric disorders and shift work tolerance

BACKGROUND

Shift work is associated with susceptibility to several neuropsychiatric disorders. This study aims to investigate the effect of shift work on the incidence of neuropsychiatric disorders, and highlighting how individual variability may influence the association.

METHODS

UK Biobank participants with employment information were included. Cox survival was conducted in main and subgroup analyses. Correlation analyses explored the impact of shift work on brain structures, and mediation analyses were performed to elucidate the shared underlying mechanisms. Shift work tolerance was evaluated through survival analyses contrasting the risks associated with five neuropsychiatric disorders in shift versus non-shift workers across different demographic or occupational strata.

RESULTS

The analysis encompassed 254,646 participants. Shift work was associated with higher risk of dementia (HR 1.29, 95 % CI 1.10-1.52), anxiety (1.08, 1.01-1.15), depression (1.29, 1.22-1.36), and sleep disorders (1.18, 1.09-1.28), but not stroke (p = 0.20). Shift work was correlated with decreasing volume of various brain regions, particularly in thalamus, lateral orbitofrontal, and middle temporal. Mediation analysis revealed that increased immune response and glucose levels are common pathways linking shift work to these disorders. We observed diversity in shift work tolerance across different individual characteristics, among which socioeconomic status and length of working hours were the most essential.

LIMITATIONS

Self-reported employment information may cause misclassification and recall bias. And since we focused on the middle-aged population, the conclusions may not be representative of younger or older populations.

CONCLUSIONS

Our findings indicated the need to monitor shift worker health and provide personalized management to help adapt to shift work.

Associations between concussion and more severe TBIs, mild cognitive impairment, and early-onset dementia among military retirees over 40 years

Background and objectives

As the population of U.S. service members (SMs) who have sustained concussions and more severe traumatic brain injuries (TBIs) during military service ages, understanding the long-term outcomes associated with such injuries will provide critical information that may promote long-term assessment, support, and rehabilitation following military service. The objective of this research was to examine whether concussion and more severe TBIs are associated with greater risk of precursors to dementia (i.e., mild cognitive impairment, memory loss), early-onset dementia, and any dementia.

Methods

This study used a retrospective cohort design wherein archival medical and career records from 1980 to 2020 identified U.S. military personnel who retired from military service and their corresponding Tricare-reimbursable medical encounters in inpatient and/or outpatient settings in military treatment facilities and/or purchased care settings both before and after retirement. All military personnel who served on active duty between 1980 and 2020 and were at least 45 years of age by 2020 were eligible for inclusion (N = 6,092,432). Those who were discharged from military service with a retirement designation, and were thus eligible for Tricare for Life, were included in the analytic sample (N = 1,211,972). Diagnoses of concussion and more severe TBI during active duty service recorded in inpatient settings between 1980 and 2020 and in outpatient settings from 2001 to 2020 were identified. Focal outcomes of interest included memory loss, mild cognitive impairment, Alzheimer's, Lewy Body dementia, frontotemporal dementia, and vascular dementia. Dementia diagnoses before age 65 were labeled early-onset.

Results

Those with (vs. without) concussion diagnoses during military service were significantly more likely to be diagnosed with memory loss and mild cognitive impairment and any of the dementias examined. However, they were not at greater risk of being diagnosed with early-onset dementia.

Discussion

Military SMs diagnosed with concussion may be at elevated risk for long-term neurodegenerative outcomes including memory loss, mild cognitive impairment, and dementia. As the population of SMs who sustained TBI during the Global War on Terror continue to age, the prevalence of dementia will increase and may bring a unique burden to the VHA.

Comparative effectiveness and safety of direct oral anticoagulants and warfarin in atrial fibrillation patients with dementia

INTRODUCTION

Developing an effective stroke prevention strategy is crucial for elderly atrial fibrillation (AF) patients with dementia. This is due to the limited and inconsistent evidence available on this topic. In this nationwide, population-based cohort study, we aim to compare the effectiveness and safety of direct oral anticoagulants (DOACs) and warfarin in AF patients with dementia.

PATIENTS AND METHODS

We identified AF patients with dementia, aged 50 years or older, from Taiwan's National Health Insurance Research Database between 2010 and 2019. The primary outcome was a composite of hospitalizations due to ischemic stroke, acute myocardial infarction, intracranial hemorrhage, or major bleeding, as well as all-cause mortality. We used 1:1 propensity score matching and Cox proportional hazard models to adjust for confounding factors when comparing outcomes between warfarin and DOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) users or warfarin and each individual DOAC.

RESULTS

There were 2952 patients in the DOAC-warfarin matched cohort. The apixaban-, dabigatran-, edoxaban-, and rivaroxaban-warfarin matched cohorts had 2346, 2554, 1684, and 2938 patients, respectively. The DOAC group, when compared to warfarin, was associated with a lower risk of both the composite outcome (hazard ratio (HR), 0.81; 95% confidence interval (CI) 0.69-0.95) and ischemic stroke (HR 0.65; 95% CI 0.48-0.87). Apixaban (HR 0.79; 95% CI 0.66-0.94), dabigatran (HR 0.64; 95% CI 0.53-0.77), and rivaroxaban (HR 0.82; 95% CI 0.70-0.97) were also associated with a lower risk of the composite outcome.

DISCUSSION AND CONCLUSION

Compared to warfarin, DOACs, whether as a group or apixaban, dabigatran, or rivaroxaban individually, were associated with a reduced risk of the composite outcome in elderly patients with concurrent AF and dementia.

Post-Acute Care Rehabilitation for Persons Living With Dementia: A Systematic Review

OBJECTIVES

To identify the results of post-acute care (PAC) rehabilitation for persons living with dementia (PLWD).

DESIGN

Systematic review of published literature without date restrictions through April 2023.

SETTING AND PARTICIPANTS

PLWD undergoing rehabilitation in PAC facilities after an acute care hospitalization.

METHODS

A systematic search was carried out in PubMed, Scopus, Google Scholar, Embase, Medline, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Included studies were peer-reviewed, available in English, and focused on PLWD admitted to rehabilitation facilities following hospitalization in the US and international settings. Studies on long-term care and acute inpatient rehabilitation units were excluded. Two reviewers independently screened articles and conducted a quality appraisal of selected studies. A narrative synthesis approach was used for analysis of results with rehabilitation themes encompassing "outcomes" and "experiences."

RESULTS

Forty-one articles met inclusion criteria, with a heterogeneity of study designs including observational (n = 33), randomized clinical trials (n = 3), and qualitative studies (n = 5). Narrative synthesis demonstrated that PAC rehabilitation for PLWD contained themes of "outcomes," including health service utilization and physical and cognitive function, providing evidence for a lower likelihood to return home and achieving less functional improvement compared to individuals without cognitive impairment. The second theme, "experiences," included health care transitions, knowledge and education, goal alignment, and care models. Findings detailed poor communication around care transitions, lack of dementia knowledge among health care workers, goal alignment strategies, and innovative rehabilitation models specific for PLWD.

CONCLUSIONS AND IMPLICATIONS

Overall, this systematic review covers a breadth of literature across time and international settings on PAC rehabilitation for PLWD. The findings highlight the importance of rehabilitation models specific for dementia care, with a need for personalized approaches around care transitions, goal setting, and increased dementia education. Addressing these aspects of rehabilitative care for PLWD may enhance the delivery of PAC and improve health care outcomes and experiences.

Latent profiles of modifiable dementia risk factors in later midlife: relationships with incident dementia, cognition, and neuroimaging outcomes

In 2020, the Lancet Commission identified 12 modifiable factors that increase population-level dementia risk. It is unclear if these risk factors co-occur among individuals in a clinically meaningful way. Using latent class analysis, we identified profiles of modifiable dementia risk factors in dementia-free adults aged 60-64 years from the UK Biobank. We then estimated associations between these profiles with incident dementia, cognition, and neuroimaging outcomes, and explored the differences across profiles in the effects of a polygenic risk score for Alzheimer's disease on outcomes. In 55,333 males and 63,063 females, three sex-specific latent profiles were identified: cardiometabolic risk, substance use-related risk, and low risk. The cardiometabolic risk profile in both males and females was associated with greater incidence of all-cause dementia (male: OR [95% CI] = 2.33 [2.03, 2.66]; female: OR [95% CI] = 1.44 [1.24, 1.68]), poorer cognitive performance, greater brain atrophy, and greater white matter hyperintensity volume compared to the low risk profile. The substance use-related risk profile in males was associated with poorer cognitive performance and greater white matter hyperintensities compared to the low risk profile, but no difference in all-cause dementia incidence was observed (OR [95% CI] = 1.00 [0.95, 1.06]). In females, the substance use-related risk profile demonstrated increased dementia incidence (OR [95% CI] = 1.58 [1.57, 1.58]) and greater brain atrophy but smaller white matter hyperintensity volume compared to the low risk profile. The polygenic risk score had larger effects among females, and differentially influenced outcomes across profiles; for instance, there were larger effects of the polygenic risk score on atrophy in the cardiometabolic profile vs. the low risk profile among males, and larger effects of the polygenic risk score on loss of white matter integrity in the cardiometabolic profile vs. the low risk profile among females. These results reveal three modifiable dementia risk profiles, their unique cognitive/neuroimaging outcomes, and their interactions with genetic risk for Alzheimer's disease. These differences highlight the need to consider population heterogeneity in risk prediction tools and in planning personalized prevention strategies.

CSF1R-Related Disorder: Prevalence of CSF1R Variants and Their Clinical Significance in the UK Population

Background and Objectives

CSF1R-related disorder (CSF1R-RD) is a devastating neurodegenerative disorder caused by variants in the colony stimulating factor-1 receptor (CSF1R) gene. CSF1R-RD leads to a variable combination of cognitive impairment, movement disorders, upper motor neuron signs, and spasticity with associated imaging abnormalities in brain white matter. Although increasingly recognized, there is evidence that it is significantly underdiagnosed or misdiagnosed, and its true prevalence is unknown. We leveraged the large data set of the UK Biobank to determine the prevalence of CSF1R mutations in the UK population and identify clinical phenotypes associated with these variants.

Methods

Pathogenic and likely pathogenic CSF1R variants were identified in UK Biobank whole-exome sequencing data (N = 470,000). Medical history, including neurologic and psychiatric disease, were determined from self-reported and hospital collected codes, and the volume of MRI white matter hyperintensities were compared between variant carriers and controls.

Results

We identified 25 individuals carrying 18 unique pathogenic variants and 107 individuals carrying 44 unique likely pathogenic variants-combined prevalence 132 (∼1 in 3,500). Pathogenic CSF1R variant carriers had increased risk of psychiatric disease (OR: 5.15, p = 0.0079), depression (OR: 10.52, p = 0.0015), and Parkinson disease (OR: 19.80, p = 0.0038). Using algorithmically defined diagnosis data, pathogenic or likely pathogenic variants (the combined group) carriers were at higher risk for both dementia (OR: 2.50, p = 0.046) and vascular dementia (OR: 4.72, p = 0.032).

Discussion

Damaging variants in CSF1R are more common than expected in the general population and are associated with cognitive, psychiatric, and movement disorder diagnoses, which may reflect clinical manifestation of the disease. This study suggests that CSF1R-RD is either underreported, not diagnosed because of lack of genetic screening or that there is reduced penetrance.

Glycated Hemoglobin A1c Time in Range and Dementia in Older Adults With Diabetes

Importance

Individuals with diabetes commonly experience Alzheimer disease and related dementias (ADRD). Factors such as hypoglycemia, hyperglycemia, and glycemic variability have been associated with increased risk of ADRD. Traditional glycemic measures, such as mean glycated hemoglobin A1c (HbA1c), may not identify the dynamic and complex pathophysiologic factors in the association between diabetes and ADRD. The HbA1c time in range (TIR) is a previously developed measure of glycemic control that expresses HbA1c stability over time within specific ranges. This measure may inform the current understanding of the association between glucose levels over time and ADRD incidence.

Objective

To examine the association between HbA1c TIR and incidence of ADRD in older veterans with diabetes.

Design, Setting, and Participants

The study sample for this cohort study was obtained from administrative and health care utilization data from the Veterans Health Administration and Medicare from January 1, 2004, to December 31, 2018. Veterans 65 years or older with diabetes were assessed. Participants were required to have at least 4 HbA1c tests during the 3-year baseline period, which could start between January 1, 2005, and December 31, 2014. Data analysis was conducted between July and December 2023.

Main Outcomes and Measures

Hemoglobin A1c TIR was calculated as the percentage of days during baseline in which HbA1c was in individualized target ranges based on clinical characteristics and life expectancy, with higher HbA1c TIR viewed as more favorable. The association between HbA1c TIR and ADRD incidence was estimated. Additional models considered ADRD incidence in participants who were above or below HbA1c target ranges most of the time.

Results

The study included 374 021 veterans with diabetes (mean [SD] age, 73.2 [5.8] years; 369 059 [99%] male). During follow-up of up to 10 years, 41 424 (11%) developed ADRD. Adjusted Cox proportional hazards regression models showed that lower HbA1c TIR was associated with increased risk of incident ADRD (HbA1c TIR of 0 to <20% compared with ≥80%: hazard ratio, 1.19; 95% CI, 1.16-1.23). Furthermore, the direction of out-of-range HbA1c levels was associated with incident ADRD. Having greater time below range (≥60%, compared with ≥60% TIR) was associated with significantly increased risk (hazard ratio, 1.23; 95% CI, 1.19-1.27). Findings remained significant after excluding individuals with baseline use of medications associated with hypoglycemia risk (ie, insulin and sulfonylureas) or with hypoglycemia events.

Conclusions and Relevance

In this study of older adults with diabetes, increased HbA1c stability within patient-specific target ranges was associated with a lower risk of ADRD. Lower HbA1c TIR may identify patients at increased risk of ADRD.

Promoting serious illness conversations in primary care through telehealth among persons living with cognitive impairment

BACKGROUND

serious illness conversations (SIC), particularly for persons living with cognitive impairment (PLCI), inconsistently happen in primary care. Pragmatic, scalable strategies are needed to promote SIC for PLCI.

DESIGN

Pragmatic, prospective single-arm pilot study that occurred between July 1, 2021 and May 30, 2022 across seven primary care practices in North Carolina.

PARTICIPANTS

Community-dwelling patients aged 65 and older with known or probable mild cognitive impairment or dementia (with decision-making capacity) and their care partners (if available).

INTERVENTION

SIC telehealth intervention (TeleVoice) via video or telephone to assist PLCI in discussing their current goals, values, and future medical preferences, while facilitating documentation within the EHR.

MAIN OUTCOMES

Main feasibility outcomes included reach/enrollment, intervention completion, and adoption rates at the clinic and provider level. Primary effectiveness outcomes included SIC documentation and quality within the EHR and usage of advance care planning billing (ACP) codes.

RESULTS

Of the 163 eligible PLCI approached, 107 (66%) enrolled (mean age 83.7 years, 68.2% female, 16.8% Black, 22% living in a geographic area of high socioeconomic disadvantage) and 81 (76%) completed the SIC telehealth intervention; 45 care partners agreed to participate (mean age 71.5 years, 80% female). Adoption at clinic level was 50%, while 75% of providers within these clinics participated. Among PLCI that completed the intervention, SIC documentation and usage of ACP billing codes was 100% and 96%, respectively, with 96% (n = 78) having high-quality SIC documentation. No significant differences were observed between telephone and video visits.

CONCLUSION

These findings provide preliminary evidence to support the feasibility of conducting SICs through telehealth to specifically meet the needs of community-dwelling PLCI. Further investigation of the sustainability of the intervention and its long-term impact on patient and caregiver outcomes is needed.

Association of Terazosin, Doxazosin, or Alfuzosin Use and Risk of Dementia With Lewy Bodies in Men

BACKGROUND AND OBJECTIVES

Terazosin, doxazosin, and alfuzosin (Tz/Dz/Az) are α-1 adrenergic receptor antagonists that also bind to and activate a key adenosine triphosphate (ATP)-producing enzyme in glycolysis. It is hypothesized that the increase in energy availability in the brain may slow or prevent neurodegeneration, potentially by reducing the accumulation of alpha-synuclein. Recent work has suggested a potentially neuroprotective effect of the use of Tz/Dz/Az in Parkinson disease in both animal and human studies. We investigated the neuroprotective effects of Tz/Dz/Az in a closely related disease, dementia with Lewy bodies (DLB).

METHODS

We used a new-user active comparator design in the Merative Marketscan database to identify men with no history of DLB who were newly started on Tz/Dz/Az or 2 comparator medications. Our comparator medications were other drugs commonly used to treat benign prostatic hyperplasia that do not increase ATP: the α-1 adrenergic receptor antagonist tamsulosin or 5α-reductase inhibitor (5ARI). We matched the cohorts on propensity scores and duration of follow-up. We followed up the matched cohorts forward to estimate the hazard of developing DLB using Cox proportional hazards regression.

RESULTS

Men who were newly started on Tz/Dz/Az had a lower hazard of developing DLB than matched men taking tamsulosin (n = 242,716, 728,256 person-years, hazard ratio [HR] 0.60, 95% CI 0.50-0.71) or 5ARI (n = 130,872, 399,316 person-years, HR 0.73, 95% CI 0.57-0.93). while the hazard in men taking tamsulosin was similar to that of men taking 5ARI (n = 159,596, 482,280 person-years, HR 1.17, 95% CI 0.96-1.42). These results were robust to several sensitivity analyses.

DISCUSSION

We find an association in men who are taking Tz/Dz/Az and a lower hazard of DLB compared with similar men taking other medications. When combined with the literature of Tz/Dz/Az on Parkinson disease, our findings suggest that glycolysis-enhancing drugs may be broadly protective in neurodegenerative synucleinopathies. A future randomized trial is required to assess these associations for causality.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that Tz/Dz/Az use reduces the rate of developing DLB in adult men.

The Association of Ancillary Diagnostic Tests With Outcome in Dementia

OBJECTIVES

Dementia is a clinical diagnosis without curative treatment. It is uncertain whether ancillary testing is beneficial for patients. This study investigates the association between use of diagnostic tests and time to poor outcome and health care costs.

DESIGN

Nationwide register-based cohort study using health care reimbursement data in the Netherlands.

SETTING AND PARTICIPANTS

All Dutch hospitals, including 13,312 patients diagnosed with dementia in 2018.

METHODS

Diagnostic testing included computed tomography or magnetic resonance imaging (CT/MRI), neuropsychological examination (NPE), nuclear imaging (PET/SPECT), electroencephalography (EEG), and cerebrospinal fluid (CSF) testing. We compared time to poor outcome (institutionalization or death) and costs per month from 2018 to 2021 between those who underwent a specific diagnostic test in previous years to controls, propensity score matched for age, sex, type of hospital, and comorbidity.

RESULTS

Time to poor outcome in those who underwent CT/MRI, EEG, or CSF testing was similar to those who did not, but was longer for those who underwent NPE. Time to poor outcome was shorter in patients who underwent PET/SPECT. Patients who underwent CSF testing or PET/SPECT had higher mean total health care costs as compared to controls (CSF €248, 95% CI 64-433; PET/SPECT: €315, 95% CI 179-451). NPE during the diagnostic trajectory was associated with lower total health care cost (-€127, 95% CI -62, -193).

CONCLUSION AND IMPLICATIONS

NPE was associated with longer time to poor outcome and lower health care costs, potentially due to confounding by indication. Patients who underwent neuroimaging (CT, MRI, SPECT/PET), CSF testing, or EEG for dementia diagnostics did not experience a longer time to poor outcome or lower health care costs. This emphasizes the importance of clinical examination as anchor for the diagnosis of dementia.

Epidemiology of Faecal Incontinence for People with Dementia Living in the Community in New Zealand: A Retrospective Cohort Study Using interRAI Home Care Assessment Data

INTRODUCTION

Globally, there are few studies but wide variation in the epidemiology of faecal incontinence (FI) for people living with dementia in the community. Our objectives are to identify 1-year period prevalence, 5-year incidence, and risks for FI for people living with dementia.

METHODS

A retrospective cohort study comprising the International Residential Assessment Instrument Home Care version (interRAI-HC) assessments in a 5-year period in New Zealand (N = 109,964). For prevalence analysis, we selected a dementia cohort for a 1-year period from August 1, 2020, to July 31, 2021 (n = 7,775). For the incidence analysis, participants in the dementia cohort were followed up from the day of the first dementia diagnosis during the period August 1, 2016, and July 31, 2021. Dementia was identified by combining diagnosis of "Alzheimer's disease" and "Dementia other than Alzheimer's disease." Participants were coded with faecal incontinence if they were continent with a stoma, seldom incontinent, occasionally incontinent, often incontinent and incontinent.

RESULTS

One year period (1 August 2020-31 July 2021) prevalence of FI was 26.7% (2,082/7,775) of people with dementia. 5-Year incident FI rate was 19.0 per 100 person-years for people with dementia and 12.3 per 100 person-years for people without dementia. Controlling for risk factors for FI in both groups the hazard ratio for FI was 1.7 for people with dementia.

CONCLUSION

FI affects a significant proportion of people with dementia in New Zealand. interRAI-HC data could facilitate global epidemiological studies to estimate service or intervention needs for people with dementia to redress or manage FI.

Predicting the onset of Alzheimer's disease and related dementia using Electronic Health Records: Findings from the Cache County Study on Memory in Aging (1995-2008)

Introduction

Clinical notes, biomarkers, and neuroimaging have been proven valuable in dementia prediction models. Whether commonly available structured clinical data can predict dementia is an emerging area of research. We aimed to predict Alzheimer's disease (AD) and Alzheimer's disease related dementias (ADRD) in a well-phenotyped, population-based cohort using a machine learning approach.

Methods

Administrative healthcare data (k=163 diagnostic features), in addition to Census/vital record sociodemographic data (k = 6 features), were linked to the Cache County Study (CCS, 1995-2008).

Results

Among successfully linked UPDB-CCS participants (n=4206), 522 (12.4%) had incident AD/ADRD as per the CCS "gold standard" assessments. Random Forest models, with a 1-year prediction window, achieved the best performance with an Area Under the Curve (AUC) of 0.67. Accuracy declined for dementia subtypes: AD/ADRD (AUC = 0.65); ADRD (AUC = 0.49).

DISCUSSION

Commonly available structured clinical data (without labs, notes, or prescription information) demonstrate modest ability to predict AD/ADRD, corroborated by prior research.

Physical Activity Intensity and Risk of Dementia

INTRODUCTION

Regular participation in aerobic physical activity is associated with a reduced risk of dementia. It is currently unclear whether this association is due to the total volume or intensity of physical activity.

METHODS

This prospective cohort study analyzed 386,486 adults from the UK Biobank who were free of dementia and self-reported >0 minutes of moderate-to-vigorous intensity physical activity (MVPA) at baseline (2007-2010). Participants were categorized as performing 0%, >0%-30%, or >30% of their total MVPA in vigorous activity (VPA). Cox proportional hazards regression models were used to examine the associations between categories of VPA and incident dementia while adjusting for sociodemographic and lifestyle factors including total MVPA. Analyses were performed in 2022.

RESULTS

Over an average follow-up of 12.0 (1.7) years, there were 5,177 (1.3%) cases of dementia. Compared to the group reporting 0% VPA, the hazard ratios (95% confidence intervals) of dementia for the groups reporting >0%-30% and >30% VPA were 0.73 (0.68-0.78) and 0.81 (0.75-0.87), respectively, in the fully adjusted model. In a joint analysis, reporting some VPA was associated with a reduced risk of dementia regardless of meeting the aerobic physical activity guidelines (HR=0.78 [0.72-0.85]) or not (HR=0.76 [0.60-0.98]), while meeting the aerobic physical activity guidelines alone without VPA was not associated with incident dementia (HR=0.98 [0.90-1.07]), compared to the group that did not meet the guidelines and reported no VPA.

CONCLUSIONS

These results suggest that engaging in VPA as part of MVPA is associated with a lower risk of dementia.

Population incidence and associated mortality of urinary tract infection in people living with dementia

OBJECTIVES

Urinary tract infections (UTIs) frequently cause hospitalisation and death in people living with dementia (PLWD). We examine UTI incidence and associated mortality among PLWD relative to matched controls and people with diabetes and investigate whether delayed or withheld treatment further impacts mortality.

METHODS

Data were extracted for n = 2,449,814 people aged ≥ 50 in Wales from 2000-2021, with groups matched by age, sex, and multimorbidity. Poisson regression was used to estimate incidences of UTI and mortality. Cox regression was used to study the effects of treatment timing.

RESULTS

UTIs in dementia (HR=2.18, 95 %CI [1.88-2.53], p < .0) and diabetes (1.21[1.01-1.45], p = .035) were associated with high mortality, with the highest risk in individuals with diabetes and dementia (both) (2.83[2.40-3.34], p < .0) compared to matched individuals with neither dementia nor diabetes. 5.4 % of untreated PLWD died within 60 days of GP diagnosis-increasing to 5.9 % in PLWD with diabetes.

CONCLUSIONS

Incidences of UTI and associated mortality are high in PLWD, especially in those with diabetes and dementia. Delayed treatment for UTI is further associated with high mortality.

Specification curve analysis to identify heterogeneity in risk factors for dementia: findings from the UK Biobank

BACKGROUND

In 2020, the Lancet Commission identified 12 risk factors as priorities for prevention of dementia, and other studies identified APOE e4/e4 genotype and family history of Alzheimer's disease strongly associated with dementia outcomes; however, it is unclear how robust these relationships are across dementia subtypes and analytic scenarios. Specification curve analysis (SCA) is a new tool to probe how plausible analytical scenarios influence outcomes.

METHODS

We evaluated the heterogeneity of odds ratios for 12 risk factors reported from the Lancet 2020 report and two additional strong associated non-modifiable factors (APOE e4/e4 genotype and family history of Alzheimer's disease) with dementia outcomes across 450,707 UK Biobank participants using SCA with 5357 specifications across dementia subtypes (outcomes) and analytic models (e.g., standard demographic covariates such as age or sex and/or 14 correlated risk factors).

RESULTS

SCA revealed variable dementia risks by subtype and age, with associations for TBI and APOE e4/e4 robust to model specification; in contrast, diabetes showed fluctuating links with dementia subtypes. We found that unattributed dementia participants had similar risk factor profiles to participants with defined subtypes.

CONCLUSIONS

We observed heterogeneity in the risk of dementia, and estimates of risk were influenced by the inclusion of a combination of other modifiable risk factors; non-modifiable demographic factors had a minimal role in analytic heterogeneity. Future studies should report multiple plausible analytic scenarios to test the robustness of their association. Considering these combinations of risk factors could be advantageous for the clinical development and evaluation of novel screening models for different types of dementia.

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.

Traumatic Brain Injury Characteristics Are Not Related to Neurocognitive Decline in Older Adults: A Nationwide Longitudinal Cohort Study

OBJECTIVE

Evaluate whether traumatic brain injury (TBI) characteristics, age of injury, or recency of injury predicts the course of neurocognitive decline and/or increases conversion rates to mild cognitive impairment (MCI) or dementia.

METHODS

Data were obtained from the National Alzheimer's Coordinating Center for participants 50-85 years old with 3-5 visits from 2015 to 2022, with or without TBI history (TBI+ = 508; TBI- = 2,382). Groups were stratified by self-reported TBI history (i.e., single TBI without loss of consciousness [LOC], single TBI with LOC, multiple TBI without LOC, and multiple TBI with LOC), age of most recent TBI, and recency of TBI. Mixed linear models compared neuropsychological composite trajectories (executive functioning/attention/speed, language, memory, and global), co-varying for age, gender, education, apolipoprotein E4 status, race/ethnicity, and baseline diagnosis (normal aging n = 1,720, MCI n = 749, or dementia n = 417). Logistic binary regression examined MCI/dementia conversion rates.

RESULTS

There was a slightly higher frequency of MCI/dementia in those with multiple TBIs (50% to 60% with and without LOC, compared to 39% with no TBI) at baseline, but longitudinal trajectories were similar. TBI history, age of injury, or recency of injury did not impact neurocognitive trajectories or conversion rates to MCI/dementia (all p's > .01).

CONCLUSIONS

TBI history, regardless of injury characteristics, age of injury, or recency of injury, did not worsen neurocognitive decline or MCI/dementia conversion. Additional longitudinal research in more diverse cohorts with a wider range of TBI severity is needed to evaluate the specific factors and possible mechanisms in which TBI may increase dementia risk.

Role of cardiovascular health factors in mediating social inequalities in the incidence of dementia in the UK: two prospective, population-based cohort studies

Background

The contribution of modifiable risk factors to social inequalities in dementia, observed in longitudinal studies, remains unclear. We aimed to quantify the role of cardiovascular health factors, assessed using Life's Essential 8 (LE8) score, in mediating social inequalities in incidence of dementia and, for comparison, in incidence of stroke, coronary heart disease, and mortality.

Methods

In this prospective, population-based cohort study, we collected data from the UK Whitehall II Study and UK Biobank databases. Participants were included if data were available on SEP, outcomes and LE8 (smoking, physical activity, diet, body mass index, blood pressure, fasting blood glucose, lipid levels, sleep duration). The primary outcome was incident dementia and secondary outcomes were stroke, coronary heart disease, and mortality. Outcomes were derived from electronic healthcare records. Socioeconomic position (SEP) was measured by occupation in Whitehall II and education in UK Biobank. Counterfactual mediation analysis was used to quantify the extent to which LE8 score explained the associations of SEP with all outcomes. Analyses involved Cox regression, accelerated failure time models, and linear regression; and were adjusted for age, sex, and ethnicity.

Findings

Between 10.09.1985 and 29.03.1988, a total of 9688 participants (mean age ± SD 44.9 ± 6.0; 67% men) from the Whitehall II study, and between 19.12.2006 and 01.10.2010, 278,215 participants (mean age ± SD 56.0 ± 8.1; 47% men) from the UK Biobank were included. There were 606 and 4649 incident dementia cases over a median (interquartile range) follow-up of 31.7 (31.1-32.7) and 13.5 (12.7-14.1) years respectively in Whitehall II and UK Biobank. In Whitehall II, the hazard ratio was 1.85 [95% CI 1.42, 2.32] for the total effect of SEP on dementia and 1.20 [1.12, 1.28] for the indirect effect via the LE8, the proportion mediated being 36%. In UK Biobank, the total effect of SEP on dementia was 1.65 [1.54, 1.78]; the indirect effect was 1.11 [1.09, 1.12], and the proportion mediated was 24%. The proportions mediated for stroke, coronary heart disease, and mortality were higher, ranging between 34% and 63% in Whitehall II and between 36% and 50% in UK Biobank.

Interpretation

In two well-characterised cohort studies, up to one third of the social inequalities in incidence of dementia was attributable to cardiovascular health factors. Promotion of cardiovascular health in midlife may contribute to reducing social inequalities in risk of dementia, in addition to cardiovascular diseases and all-cause mortality. This study used adult measures of SEP, further research is warranted using lifecourse measures of SEP.

Funding

NIH (RF1AG062553).

Successful Discharge to Community From Home Health Less Likely for People in Late Stages of Dementia

BACKGROUND AND PURPOSE

Several studies have established the efficacy of home health in meeting the health care needs of people with Alzheimer disease and related dementias (ADRD) and helping them to remain at home. However, transitioning to the community after discharge from home health presents challenges to patient safety and quality of life. The severity of an individual's functional impairments, cognitive limitations, and behavioral and psychological symptoms may compound these challenges. The purpose of this study was to examine the association between dementia severity and successful discharge to community (DTC) from home health.

METHODS

This was a retrospective study of 142 376 Medicare beneficiaries with ADRD. Successful DTC was defined as having no unplanned hospitalization or death within 30 days of DTC from home health. Successful DTC rates were calculated, and multilevel logistic regression was used to estimate the relative risk (RR) of successful DTC, by dementia severity category, adjusted for patient and clinical characteristics. Six dementia severity categories were identified using a crosswalk between items on the Outcome and Assessment Information Set and the Functional Assessment Staging Tool.

RESULTS AND DISCUSSION

Successful DTC occurred in 71.2% of beneficiaries. Beneficiaries in the 2 most severe dementia categories had significantly lower risk of successful DTC (category 6: RR = 0.90, 95% CI = 0.889-0.910; category 7: RR = 0.737, 95% CI = 0.704-0.770) than those in the least severe dementia category. The RR of successful DTC for people with ADRD decreased as the level of independence with oral medication management decreased and when there was an overall greater need for caregiver assistance.

CONCLUSIONS

Patient status at the time of admission to home health is associated with outcomes after discharge from home health. Early identification of people in advanced stages of ADRD provides an opportunity to implement strategies to facilitate successful DTC while people are still receiving home care services. The severity of ADRD and availability of caregiver assistance should be key considerations in planning for successful DTC for people with ADRD.

Delirium and incident dementia in hospital patients in New South Wales, Australia: retrospective cohort study

OBJECTIVES

To determine the strength and nature of the association between delirium and incident dementia in a population of older adult patients without dementia at baseline.

DESIGN

Retrospective cohort study using large scale hospital administrative data.

SETTING

Public and private hospitals in New South Wales, Australia between July 2001 and March 2020.

PARTICIPANTS

Data were extracted for 650 590 hospital patients aged ≥65 years. Diagnoses of dementia and delirium were identified from ICD-10 (international classification of diseases, 10th revision) codes. Patients with dementia at baseline were excluded. Delirium-no delirium pairs were identified by matching personal and clinical characteristics, and were followed for more than five years.

MAIN OUTCOME MEASURES

Cox proportional hazards models and Fine-Gray hazard models were used to estimate the associations of delirium with death and incident dementia, respectively. Delirium-outcome dose-response associations were quantified, all analyses were performed in men and women separately, and sensitivity analyses were conducted.

RESULTS

The study included 55 211 matched pairs (48% men, mean age 83.4 years, standard deviation 6.5 years). Collectively, 58% (n=63 929) of patients died and 17% (n=19 117) had a newly reported dementia diagnosis during 5.25 years of follow-up. Patients with delirium had 39% higher risk of death (hazard ratio 1.39, 95% confidence interval 1.37 to 1.41) and three times higher risk of incident dementia (subdistribution hazard ratio 3.00, 95% confidence interval 2.91 to 3.10) than patients without delirium. The association with dementia was stronger in men (P=0.004). Each additional episode of delirium was associated with a 20% increased risk of dementia (subdistribution hazard ratio 1.20, 95% confidence interval 1.18 to 1.23).

CONCLUSIONS

The study findings suggest delirium was a strong risk factor for death and incident dementia among older adult patients. The data support a causal interpretation of the association between delirium and dementia. The clinical implications of delirium as a potentially modifiable risk factor for dementia are substantial.

Sex matters in the association between cardiovascular health and incident dementia: evidence from real world data

BACKGROUND

Cardiovascular health has been associated with dementia onset, but little is known about the variation of such association by sex and age considering dementia subtypes. We assessed the role of sex and age in the association between cardiovascular risk and the onset of all-cause dementia, Alzheimer's disease, and vascular dementia in people aged 50-74 years.

METHODS

This is a retrospective cohort study covering 922.973 Catalans who attended the primary care services of the Catalan Health Institute (Spain). Data were obtained from the System for the Development of Research in Primary Care (SIDIAP database). Exposure was the cardiovascular risk (CVR) at baseline categorized into four levels of Framingham-REGICOR score (FRS): low (FRS < 5%), low-intermediate (5% ≤ FRS < 7.5%), high-intermediate (7.5% ≤ FRS < 10%), high (FRS ≥ 10%), and one group with previous vascular disease. Cases of all-cause dementia and Alzheimer's disease were identified using validated algorithms, and cases of vascular dementia were identified by diagnostic codes. We fitted stratified Cox models using age parametrized as b-Spline.

RESULTS

A total of 51,454 incident cases of all-cause dementia were recorded over a mean follow-up of 12.7 years. The hazard ratios in the low-intermediate and high FRS groups were 1.12 (95% confidence interval: 1.08-1.15) and 1.55 (1.50-1.60) for all-cause dementia; 1.07 (1.03-1.11) and 1.17 (1.11-1.24) for Alzheimer's disease; and 1.34 (1.21-1.50) and 1.90 (1.67-2.16) for vascular dementia. These associations were stronger in women and in midlife compared to later life in all dementia types. Women with a high Framingham-REGICOR score presented a similar risk of developing dementia - of any type - to women who had previous vascular disease, and at age 50-55, they showed three times higher risk of developing dementia risk compared to the lowest Framingham-REGICOR group.

CONCLUSIONS

We found a dose‒response association between the Framingham-REGICOR score and the onset of all dementia types. Poor cardiovascular health in midlife increased the onset of all dementia types later in life, especially in women.

On the Dependence of the Critical Success Index (CSI) on Prevalence

The critical success index (CSI) is an established metric used in meteorology to verify the accuracy of weather forecasts. It is defined as the ratio of hits to the sum of hits, false alarms, and misses. Translationally, CSI has gained popularity as a unitary outcome measure in various clinical situations where large numbers of true negatives may influence the interpretation of other, more traditional, outcome measures, such as specificity (Spec) and negative predictive value (NPV), or when unified interpretation of positive predictive value (PPV) and sensitivity (Sens) is needed. The derivation of CSI from measures including PPV has prompted questions as to whether and how CSI values may vary with disease prevalence (P), just as PPV estimates are dependent on P, and hence whether CSI values are generalizable between studies with differing prevalences. As no detailed study of the relation of CSI to prevalence has been undertaken hitherto, the dataset of a previously published test accuracy study of a cognitive screening instrument was interrogated to address this question. Three different methods were used to examine the change in CSI across a range of prevalences, using both the Bayes formula and equations directly relating CSI to Sens, PPV, P, and the test threshold (Q). These approaches showed that, as expected, CSI does vary with prevalence, but the dependence differs according to the method of calculation that is adopted. Bayesian rescaling of both Sens and PPV generates a concave curve, suggesting that CSI will be maximal at a particular prevalence, which may vary according to the particular dataset.

Variability in Alzheimer's disease mortality from European vital statistics, 2012-2020

OBJECTIVE

Data regarding the trends in Alzheimer's disease (AD) mortality in the modern European Union (EU-27) member states are lacking. We assess the sex- and age-specific trends in AD mortality in the EU-27 member states between years 2012 and 2020.

METHODS

Data on cause-specific deaths and population numbers by sex for each country of the EU-27 were retrieved through publicly available European Statistical Office (EUROSTAT) dataset from 2012 to 2020. AD-related deaths were ascertained when the ICD-10 code G30 was listed as the primary cause of death in the medical death certificate. To calculate annual trends, we assessed the average annual percent change (AAPC) with relative 95% confidence intervals (CIs) using Joinpoint regression.

RESULTS

During the study period, 751,493 deaths (1.7%, 233,271 males and 518,222 females) occurred in the EU-27 because of AD. Trends in the proportion of AD-related deaths per 1000 total deaths slightly increased from 16.8% to 17.5% (p for trend <0.001). The age-adjusted mortality rate was higher in women over the entire study period. Joinpoint regression analysis revealed a stagnation in age-adjusted AD-related mortality from 2012 to 2020 among EU-27 Member States (AAMR: -0.1% [95% CI: -1.8-1.79], p = 0.94). Stratification by Country showed relevant regional disparities, especially in the Northern and Eastern EU-27 member states.

CONCLUSIONS

Over the last decade, the age-adjusted AD-related mortality rate has plateaued in EU-27. Important disparities still exist between Western and Eastern European countries.

Metabolomics and Risk of Dementia: A Systematic Review of Prospective Studies

BACKGROUND

The projected increase in the prevalence of dementia has sparked interest in understanding the pathophysiology and underlying causal factors in its development and progression. Identifying novel biomarkers in the preclinical or prodromal phase of dementia may be important for predicting early disease risk. Applying metabolomic techniques to prediagnostic samples in prospective studies provides the opportunity to identify potential disease biomarkers.

OBJECTIVE

The objective of this systematic review was to summarize the evidence on the associations between metabolite markers and risk of dementia and related dementia subtypes in human studies with a prospective design.

DESIGN

We searched PubMed, PsycINFO, and Web of Science databases from inception through December 8, 2023. Thirteen studies (mean/median follow-up years: 2.1-21.0 y) were included in the review.

RESULTS

Several metabolites detected in biological samples, including amino acids, fatty acids, acylcarnitines, lipid and lipoprotein variations, hormones, and other related metabolites, were associated with risk of developing dementia. Our systematic review summarized the adjusted associations between metabolites and dementia risk; however, our findings should be interpreted with caution because of the heterogeneity across the included studies and potential sources of bias. Further studies are warranted with well-designed prospective cohort studies that have defined study populations, longer follow-up durations, the inclusion of additional diverse biological samples, standardization of techniques in metabolomics and ascertainment methods for diagnosing dementia, and inclusion of other related dementia subtypes.

CONCLUSIONS

This study contributes to the limited systematic reviews on metabolomics and dementia by summarizing the prospective associations between metabolites in prediagnostic biological samples with dementia risk. Our review discovered additional metabolite markers associated with the onset of developing dementia and may help aid in the understanding of dementia etiology. The protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (https://www.crd.york.ac.uk/prospero/; registration ID: CRD42022357521).

Alerting providers to hospitalized persons with dementia using the electronic health record

BACKGROUND

While patients with dementia entering the hospital have worse outcomes than those without dementia, early detection of dementia in the inpatient setting is less than 50%. We developed and assessed the positive predictive value (PPV) and feasibility of a novel electronic health record (EHR) banner to identify patients with dementia who present to the inpatient setting using data from the medical record.

METHODS

We developed and implemented an EHR algorithm to flag hospitalized patients age ≥65 years with potential cognitive impairment in the Epic EHR system using dementia ICD-10 codes, FDA-approved medications, and the use of the term "dementia" in the emergency department physician note. Medical records were reviewed for all patients who were flagged with an EHR banner from October 2022 to May 2023.

RESULTS

A total of 344 individuals were identified who had a banner on their chart of which 280 (81.4%) were either diagnosed with dementia or were on an FDA-approved dementia medication. Forty-three individuals who had confirmed dementia were identified by a medication only (15.4%). Of the patients without confirmed dementia, the majority (N = 33, 9.6%) had a diagnosis of altered mental status, cognitive dysfunction, or mild cognitive impairment. Only 31 individuals (9.0%) had no indication of dementia or cognitive decline in their problem list, past medical history, or medication list.

CONCLUSIONS

We found that it was feasible to implement an EHR algorithm for prospective dementia identification with a high PPV. These types of algorithms provide an opportunity to accurately identify hospitalized older individuals for inclusion in quality improvement projects, clinical trials, pay-for-performance programs, and other initiatives.

Impaired 24-h activity patterns are associated with an increased risk of Alzheimer's disease, Parkinson's disease, and cognitive decline

BACKGROUND

Sleep-wake regulating circuits are affected during prodromal stages in the pathological progression of both Alzheimer's disease (AD) and Parkinson's disease (PD), and this disturbance can be measured passively using wearable devices. Our objective was to determine whether accelerometer-based measures of 24-h activity are associated with subsequent development of AD, PD, and cognitive decline.

METHODS

This study obtained UK Biobank data from 82,829 individuals with wrist-worn accelerometer data aged 40 to 79 years with a mean (± SD) follow-up of 6.8 (± 0.9) years. Outcomes were accelerometer-derived measures of 24-h activity (derived by cosinor, nonparametric, and functional principal component methods), incident AD and PD diagnosis (obtained through hospitalization or primary care records), and prospective longitudinal cognitive testing.

RESULTS

One hundred eighty-seven individuals progressed to AD and 265 to PD. Interdaily stability (a measure of regularity, hazard ratio [HR] per SD increase 1.25, 95% confidence interval [CI] 1.05-1.48), diurnal amplitude (HR 0.79, CI 0.65-0.96), mesor (mean activity; HR 0.77, CI 0.59-0.998), and activity during most active 10 h (HR 0.75, CI 0.61-0.94), were associated with risk of AD. Diurnal amplitude (HR 0.28, CI 0.23-0.34), mesor (HR 0.13, CI 0.10-0.16), activity during least active 5 h (HR 0.24, CI 0.08-0.69), and activity during most active 10 h (HR 0.20, CI 0.16-0.25) were associated with risk of PD. Several measures were additionally predictive of longitudinal cognitive test performance.

CONCLUSIONS

In this community-based longitudinal study, accelerometer-derived metrics were associated with elevated risk of AD, PD, and accelerated cognitive decline. These findings suggest 24-h rhythm integrity, as measured by affordable, non-invasive wearable devices, may serve as a scalable early marker of neurodegenerative disease.

Identifying Functional Status Impairment in People Living With Dementia Through Natural Language Processing of Clinical Documents: Cross-Sectional Study

BACKGROUND

Assessment of activities of daily living (ADLs) and instrumental ADLs (iADLs) is key to determining the severity of dementia and care needs among older adults. However, such information is often only documented in free-text clinical notes within the electronic health record and can be challenging to find.

OBJECTIVE

This study aims to develop and validate machine learning models to determine the status of ADL and iADL impairments based on clinical notes.

METHODS

This cross-sectional study leveraged electronic health record clinical notes from Mass General Brigham's Research Patient Data Repository linked with Medicare fee-for-service claims data from 2007 to 2017 to identify individuals aged 65 years or older with at least 1 diagnosis of dementia. Notes for encounters both 180 days before and after the first date of dementia diagnosis were randomly sampled. Models were trained and validated using note sentences filtered by expert-curated keywords (filtered cohort) and further evaluated using unfiltered sentences (unfiltered cohort). The model's performance was compared using area under the receiver operating characteristic curve and area under the precision-recall curve (AUPRC).

RESULTS

The study included 10,000 key-term-filtered sentences representing 441 people (n=283, 64.2% women; mean age 82.7, SD 7.9 years) and 1000 unfiltered sentences representing 80 people (n=56, 70% women; mean age 82.8, SD 7.5 years). Area under the receiver operating characteristic curve was high for the best-performing ADL and iADL models on both cohorts (>0.97). For ADL impairment identification, the random forest model achieved the best AUPRC (0.89, 95% CI 0.86-0.91) on the filtered cohort; the support vector machine model achieved the highest AUPRC (0.82, 95% CI 0.75-0.89) for the unfiltered cohort. For iADL impairment, the Bio+Clinical bidirectional encoder representations from transformers (BERT) model had the highest AUPRC (filtered: 0.76, 95% CI 0.68-0.82; unfiltered: 0.58, 95% CI 0.001-1.0). Compared with a keyword-search approach on the unfiltered cohort, machine learning reduced false-positive rates from 4.5% to 0.2% for ADL and 1.8% to 0.1% for iADL.

CONCLUSIONS

In this study, we demonstrated the ability of machine learning models to accurately identify ADL and iADL impairment based on free-text clinical notes, which could be useful in determining the severity of dementia.

Incident dementia risk among patients with type 2 diabetes receiving metformin versus alternative oral glucose-lowering therapy: an observational cohort study using UK primary healthcare records

INTRODUCTION

4.2 million individuals in the UK have type 2 diabetes, a known risk factor for dementia and mild cognitive impairment (MCI). Diabetes treatment may modify this association, but existing evidence is conflicting. We therefore aimed to assess the association between metformin therapy and risk of incident all-cause dementia or MCI compared with other oral glucose-lowering therapies (GLTs).

RESEARCH DESIGN AND METHODS

We conducted an observational cohort study using the Clinical Practice Research Datalink among UK adults diagnosed with diabetes at ≥40 years between 1990 and 2019. We used an active comparator new user design to compare risks of dementia and MCI among individuals initially prescribed metformin versus an alternative oral GLT using Cox proportional hazards regression controlling for sociodemographic, lifestyle and clinical confounders. We assessed for interaction by age and sex. Sensitivity analyses included an as-treated analysis to mitigate potential exposure misclassification.

RESULTS

We included 211 396 individuals (median age 63 years; 42.8% female), of whom 179 333 (84.8%) initiated on metformin therapy. Over median follow-up of 5.4 years, metformin use was associated with a lower risk of dementia (adjusted HR (aHR) 0.86 (95% CI 0.79 to 0.94)) and MCI (aHR 0.92 (95% CI 0.86 to 0.99)). Metformin users aged under 80 years had a lower dementia risk (aHR 0.77 (95% CI 0.68 to 0.85)), which was not observed for those aged ≥80 years (aHR 0.95 (95% CI 0.87 to 1.05)). There was no interaction with sex. The as-treated analysis showed a reduced effect size compared with the main analysis (aHR 0.90 (95% CI 0.83 to 0.98)).

CONCLUSIONS

Metformin use was associated with lower risks of incident dementia and MCI compared with alternative GLT among UK adults with diabetes. While our findings are consistent with a neuroprotective effect of metformin against dementia, further research is needed to reduce risks of confounding by indication and assess causality.

Critical success index or F measure to validate the accuracy of administrative healthcare data identifying epilepsy in deceased adults in Scotland

BACKGROUND

Methods to undertake diagnostic accuracy studies of administrative epilepsy data are challenged by lack of a way to reliably rank case-ascertainment algorithms in order of their accuracy. This is because it is difficult to know how to prioritise positive predictive value (PPV) and sensitivity (Sens). Large numbers of true negative (TN) instances frequently found in epilepsy studies make it difficult to discriminate algorithm accuracy on the basis of negative predictive value (NPV) and specificity (Spec) as these become inflated (usually >90%). This study demonstrates the complementary value of using weather forecasting or machine learning metrics critical success index (CSI) or F measure, respectively, as unitary metrics combining PPV and sensitivity. We reanalyse data published in a diagnostic accuracy study of administrative epilepsy mortality data in Scotland.

METHOD

CSI was calculated as 1/[(1/PPV) + (1/Sens) - 1]. F measure was calculated as 2.PPV.Sens/(PPV + Sens). CSI and F values range from 0 to 1, interpreted as 0 = inaccurate prediction and 1 = perfect accuracy. The published algorithms were reanalysed using these and their accuracy re-ranked according to CSI in order to allow comparison to the original rankings.

RESULTS

CSI scores were conservative (range 0.02-0.826), always less than or equal to the lower of the corresponding PPV (range 39-100%) and sensitivity (range 2-93%). F values were less conservative (range 0.039-0.905), sometimes higher than either PPV or sensitivity, but were always higher than CSI. Low CSI and F values occurred when there was a large difference between PPV and sensitivity, e.g. CSI was 0.02 and F was 0.039 in an instance when PPV was 100% and sensitivity was 2%. Algorithms with both high PPV and sensitivity performed best in terms of CSI and F measure, e.g. CSI was 0.826 and F was 0.905 in an instance when PPV was 90% and sensitivity was 91%.

CONCLUSION

CSI or F measure can combine PPV and sensitivity values into a convenient single metric that is easier to interpret and rank in terms of diagnostic accuracy than trying to rank diagnostic accuracy according to the two measures themselves. CSI or F prioritise instances where both PPV and sensitivity are high over instances where there are large differences between PPV and sensitivity (even if one of these is very high), allowing diagnostic accuracy thresholds based on combined PPV and sensitivity to be determined. Therefore, CSI or F measures may be helpful complementary metrics to report alongside PPV and sensitivity in diagnostic accuracy studies of administrative epilepsy data.

Lower mental health related quality of life precedes dementia diagnosis: findings from the EPIC-Norfolk prospective population-based study

Lower Health Related Quality of Life (HRQoL) precedes dementia in older adults in the USA. We explore prospective associations between HRQoL and dementia in British adults in mid and late-life, when interventions to optimise cognitive ageing may provide benefit. 7,452 community-dwelling participants (57% women; mean age 69.3 ± 8.3 years) attended the European Prospective Investigation of Cancer-Norfolk study's third health check (3HC) and reported their HRQoL using Short-Form 36 (SF-36). Cox Proportional Hazard regression models explored associations between standard deviation differences in baseline Physical Component (PCS) and Mental Component Summary (MCS) scores, as well as eight SF-36 sub-scales (physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, mental health), and incident dementia over ten years. Logistic regression models explored cross-sectional relationships at the 3HC between HRQoL and objective global cognitive function (n = 4435; poor cognition = lowest performance decile). The cohort was examined as a whole and by age-group (50-69, ≥ 70), considering socio-demographics and co-morbidity. Higher MCS scores were associated with lower chance of incident dementia (Hazard Ratio [HR] = 0.74, 95% CI 0.68-0.81) and lower odds of poor cognition (Odds Ratio [OR] = 0.82, 0.76-0.89), with findings similar by age-group. Higher PCS scores were not associated with dementia in the whole cohort (HR = 0.93, 0.84-1.04) or considering age-groups; and were only associated with poor cognition in younger participants (OR = 0.81, 0.72-0.92). Similarly, associations between higher scores on subscales pertaining to mental, but not physical, HRQoL and lower dementia incidence were observed. Lower mental HRQoL precedes dementia diagnosis in middle-aged and older British adults.

Association of Cancer History with Lifetime Risk of Dementia and Alzheimer's Disease

Background

The literature presents conflicting results regarding the potential protective effect of prevalent cancer on the development of dementia and Alzheimer's disease (AD).

Objective

Association between cancer and subsequent risk of dementia and/or AD was reported previously, but survival bias has been of concern. Here, we aimed to calculate the lifetime risk of dementia and AD and evaluate the association of cancer history with these two conditions.

Methods

In this retrospective analysis, we included 292,654 participants aged 60+ y during the follow-up and free of dementia at baseline, within the UK Biobank cohort. Lifetime risks of dementia and AD were estimated in individuals with and without cancer history, and different durations of cancer exposure and cancer types.

Results

During a median of 12.5 follow-up years, 5,044 new dementia and 2,141 AD cases were reported. Lifetime risks of dementia and AD were lower in cancer survivors compared to those without cancer, and this effect was more pronounced in participants with cancer history exposure≥5 years. Similar relationship was observed in individual cancer types, except for breast cancer.

Conclusions

Results suggested an inverse association between cancer history and lifetime risk of dementia and AD, which may be modified by different cancer types and cancer exposure time.

Association Between Long-Term Exposure to Ambient Air Pollution and the Risk of Mild Cognitive Impairment in a Chinese Urban Area: A Case-Control Study

Background

As a prodromal stage of dementia, significant emphasis has been placed on the identification of modifiable risks of mild cognitive impairment (MCI). Research has indicated a correlation between exposure to air pollution and cognitive function in older adults. However, few studies have examined such an association among the MCI population inChina.

Objective

We aimed to explore the association between air pollution exposure and MCI risk from the Hubei Memory and Aging Cohort Study.

Methods

We measured four pollutants from 2015 to 2018, 3 years before the cognitive assessment of the participants. Logistic regression models were employed to calculate odds ratios (ORs) to assess the relationship between air pollutants and MCI risk.

Results

Among 4,205 older participants, the adjusted ORs of MCI risk for the highest quartile of PM2.5, PM10, O3, and SO2 were 1.90 (1.39, 2.62), 1.77 (1.28, 2.47), 0.56 (0.42, 0.75), and 1.18 (0.87, 1.61) respectively, compared with the lowest quartile. Stratified analyses indicated that such associations were found in both males and females, but were more significant in older participants.

Conclusions

Our findings are consistent with the growing evidence suggesting that air pollution increases the risk of mild cognitive decline, which has considerable guiding significance for early intervention of dementia in the older population. Further studies in other populations and broader geographical areas are warranted to validate these findings.

Associations Between Neuroinflammation-Related Conditions and Alzheimer's Disease: A Study of US Insurance Claims Data

Background

Early detection of Alzheimer's disease (AD) is a key component for the success of the recently approved lecanemab and aducanumab. Patients with neuroinflammation-related conditions are associated with a higher risk for developing AD.

Objective

Investigate the incidence of AD among patients with neuroinflammation-related conditions including epilepsy, hemorrhage stroke, multiple sclerosis (MS), and traumatic brain injury (TBI).

Methods

We used Optum's de-identified Clinformatics Data Mart Database (CDM). We derived covariate-matched cohorts including patients with neuroinflammation-related conditions and controls without the corresponding condition. The matched cohorts were: 1) patients with epilepsy and controls (N = 67,825 matched pairs); 2) patients with hemorrhage stroke and controls (N = 81,510 matched pairs); 3) patients with MS and controls (N = 9,853 matched pairs); and 4) patients TBI and controls (N = 104,637 matched pairs). We used the Cox model to investigate the associations between neuroinflammation-related conditions and AD.

Results

We identified that epilepsy, hemorrhage stroke, and TBI were associated with increased risks of AD in both males and females (hazard ratios [HRs]≥1.74, p < 0.001), as well as in gender- and race-conscious subpopulations (HRs≥1.64, p < 0.001). We identified that MS was associated with increased risks of AD in both males and females (HRs≥1.47, p≤0.004), while gender- and race-conscious subgroup analysis shown mixed associations.

Conclusions

Patients with epilepsy, hemorrhage stroke, MS, and/or TBI are associated with a higher risk of developing AD. More attention on cognitive status should be given to older patients with these conditions.

Analysis of the Association Between Pathogen Exposure and the Risk of Dementia

Background

Previous research has suggested that pathogen infections may serve as potential contributors to dementia.

Objective

Consequently, the study aimed to evaluate whether pathogen exposure heightens the risk of dementia.

Methods

Between 2006 and 2010, a total of 8,144 individuals from the UK Biobank had data on pathogen antibodies and were included in the baseline assessment. Cox proportional hazard models were employed for the analysis.

Results

Out of the 8,144 participants, 107 eventually developed dementia, while 55 participants were diagnosed with Alzheimer's disease (AD). Multivariate Cox regression analysis revealed that the levels of pathogen antibody titers of EBV and C. trachomatis were associated with an increased risk of dementia/AD. The highest quartile of EBV EBNA-1 and EBV VCA p18, and the second quartile of H. pylori VacA significantly increased the risk of dementia compared lower quartile (EBV EBNA-1: HR = 1.938, p = 0.018; EBV VCA p18: HR = 1.824, p = 0.040; H. pylori VacA: HR = 1.890, p = 0.033). Besides, the highest quartile of EBV VCA p18 had a higher risk of AD compared lower quartile (HR = 2.755, p = 0.029).

Conclusions

The study demonstrated that exposure to EBV, H. pylori, and C. trachomatis substantially elevated the risk of dementia/AD. Despite the relatively widespread occurrence of EBV infection in the population, elevated pathogen antibody titers were still found to increase the risk of dementia/AD. Besides, since C. trachomatis and C. pneumoniae are quite homologous, this study found that trachomatis (C. trachomatis/C. pneumoniae) may be significantly associated with the risk of AD/dementia.

Use of Electronic Medical Records (EMR) in Gerontology: Benefits, Considerations and a Promising Future

Electronic medical records (EMRs) have many benefits in clinical research in gerontology, enabling data analysis, development of prognostic tools and disease risk prediction. EMRs also offer a range of advantages in clinical practice, such as comprehensive medical records, streamlined communication with healthcare providers, remote data access, and rapid retrieval of test results, ultimately leading to increased efficiency, enhanced patient safety, and improved quality of care in gerontology, which includes benefits like reduced medication use and better patient history taking and physical examination assessments. The use of artificial intelligence (AI) and machine learning (ML) approaches on EMRs can further improve disease diagnosis, symptom classification, and support clinical decision-making. However, there are also challenges related to data quality, data entry errors, as well as the ethics and safety of using AI in healthcare. This article discusses the future of EMRs in gerontology and the application of AI and ML in clinical research. Ethical and legal issues surrounding data sharing and the need for healthcare professionals to critically evaluate and integrate these technologies are also emphasized. The article concludes by discussing the challenges related to the use of EMRs in research as well as in their primary intended use, the daily clinical practice.

Artificial intelligence for dementia-Applied models and digital health

INTRODUCTION

The use of applied modeling in dementia risk prediction, diagnosis, and prognostics will have substantial public health benefits, particularly as "deep phenotyping" cohorts with multi-omics health data become available.

METHODS

This narrative review synthesizes understanding of applied models and digital health technologies, in terms of dementia risk prediction, diagnostic discrimination, prognosis, and progression. Machine learning approaches show evidence of improved predictive power compared to standard clinical risk scores in predicting dementia, and the potential to decompose large numbers of variables into relatively few critical predictors.

RESULTS

This review focuses on key areas of emerging promise including: emphasis on easier, more transparent data sharing and cohort access; integration of high-throughput biomarker and electronic health record data into modeling; and progressing beyond the primary prediction of dementia to secondary outcomes, for example, treatment response and physical health.

DISCUSSION

Such approaches will benefit also from improvements in remote data measurement, whether cognitive (e.g., online), or naturalistic (e.g., watch-based accelerometry).

Physical and brain frailty in ischaemic stroke or TIA: Shared occurrence and outcomes. A cohort study

BACKGROUND

There is increasing interest in the concept of frailty in stroke, including both physical frailty and imaging-evidence of brain frailty. We aimed to establish the prevalence of brain frailty in stroke survivors as well as the concurrent and predictive validity of various frailty measures against long-term cognitive outcomes.

METHODS

We included consecutively admitted stroke or transient ischaemic attack (TIA) survivors from participating stroke centres. Baseline CT scans were used to generate an overall brain frailty score for each participant. We measured frailty via the Rockwood frailty index, and a Fried frailty screening tool. Presence of major or minor neurocognitive disorder at 18-months following stroke or TIA was established via a multicomponent assessment. Prevalence of brain frailty was established based upon observed percentages within groups defined by frailty status (robust, pre-frail, frail). We assessed the concurrent validity of brain frailty and frailty scales via Spearman's rank correlation. We conducted multivariable logistic regression analyses, controlling for age, sex, baseline education and stroke severity, to evaluate association between each frailty measure and 18-month cognitive impairment.

RESULTS

Three-hundred-forty-one stroke survivors participated. Three-quarters of people who were frail had moderate-severe brain frailty and prevalence increased according to frailty status. Brain frailty was weakly correlated with Rockwood frailty (Rho: 0.336; p < 0.001) and with Fried frailty (Rho: 0.230; p < 0.001). Brain frailty (OR: 1.64, 95% CI = 1.17-2.32), Rockwood frailty (OR: 1.05, 95% CI = 1.02-1.08) and Fried frailty (OR: 1.93, 95% CI = 1.39-2.67) were each independently associated with cognitive impairment at 18 months following stroke.

CONCLUSIONS

There appears to be value in the assessment of both physical and brain frailty in patients with ischaemic stroke and TIA. Both are associated with adverse cognitive outcomes and physical frailty remains important when assessing cognitive outcomes.

Change in lipids before onset of dementia, coronary heart disease, and mortality: A 28-year follow-up Whitehall II prospective cohort study

INTRODUCTION

The association of lipids with dementia remains a subject of debate. Using data from 7,672 participants of the Whitehall II prospective cohort study, we examined whether timing of exposure, length of follow-up, or sex modifies this association.

METHODS

Twelve markers of lipid levels were measured from fasting blood and eight among them a further five times. We performed time-to-event as well as trajectory analyses.

RESULTS

No associations were observed in men; in women most lipids were associated with the risk of dementia, but only for events occurring after the first 20 years of follow-up. Differences in lipid trajectories in men emerged only in the years immediately before diagnosis whereas in women total cholesterol (TC), LDL-cholesterol (LDL-C), non-HDL-cholesterol (non-HDL-C), TC/HDL-C, and LDL-C/HDL-C were higher in midlife among dementia cases before declining progressively.

DISCUSSION

Abnormal lipid levels in midlife seem to be associated with a higher risk of dementia in women.

Protocol for validating an algorithm to identify neurocognitive disorders in Canadian Longitudinal Study on Aging participants: an observational study

INTRODUCTION

In population-based research, disease ascertainment algorithms can be as accurate as, and less costly than, performing supplementary clinical examinations on selected participants to confirm a diagnosis of a neurocognitive disorder (NCD), but they require cohort-specific validation. To optimise the use of the Canadian Longitudinal Study on Aging (CLSA) to understand the epidemiology and burden of NCDs, the CLSA Memory Study will validate an NCD ascertainment algorithm to identify CLSA participants with these disorders using routinely acquired study data.

METHODS AND ANALYSIS

Up to 600 CLSA participants with equal numbers of those likely to have no NCD, mild NCD or major NCD based on prior self-reported physician diagnosis of a memory problem or dementia, medication consumption (ie, cholinesterase inhibitors, memantine) and/or self-reported function will be recruited during the follow-up 3 CLSA evaluations (started August 2021). Participants will undergo an assessment by a study clinician who will also review an informant interview and make a preliminary determination of the presence or absence of an NCD. The clinical assessment and available CLSA data will be reviewed by a Central Review Panel who will make a final categorisation of participants as having (1) no NCD, (2) mild NCD or, (3) major NCD (according to fifth version of the Diagnostic and Statistical Manual of Mental Disorders criteria). These will be used as our gold standard diagnosis to determine if the NCD ascertainment algorithm accurately identifies CLSA participants with an NCD. Weighted Kappa statistics will be the primary measure of agreement. Sensitivity, specificity, the C-statistic and the phi coefficient will also be estimated.

ETHICS AND DISSEMINATION

Ethics approval has been received from the institutional research ethics boards for each CLSA Data Collection Site (Université de Sherbrooke, Hamilton Integrated Research Ethics Board, Dalhousie University, Nova Scotia Health Research Ethics Board, University of Manitoba, McGill University, McGill University Health Centre Research Institute, Memorial University of Newfoundland, University of Victoria, Élisabeth Bruyère Research Institute of Ottawa, University of British Columbia, Island Health (Formerly the Vancouver Island Health Authority, Simon Fraser University, Calgary Conjoint Health Research Ethics Board).The results of this work will be disseminated to public health professionals, researchers, health professionals, administrators and policy-makers through journal publications, conference presentations, publicly available reports and presentations to stakeholder groups.

Women with hearing loss show increased dementia risk and brain atrophy

Hearing loss is a modifiable risk factor for dementia. However, it is unknown whether risk differs by sex. Study 1 used Cox proportional hazard models to examine sex differences in the association between hearing loss (measured by speech-reception thresholds) and dementia risk. Study 2 examined how 2-year changes in hearing is associated with changes in brain volume in auditory-limbic regions. Both studies used UK Biobank data. Women with poor hearing had the greatest risk of dementia, whereas women and men with insufficient hearing were at similar risk. Men with poor hearing did not have increased risk. Presence of social isolation/depressed mood minimally contributed to dementia risk in men and women. Women, but not men, with hearing loss had greater atrophy in auditory and limbic regions compared to normal hearing women and men. Women with hearing loss show greater risk of dementia and brain atrophy, highlighting the need to examine sex-specific mechanisms.

Habitual glucosamine use, APOE genotypes, and risk of incident cause-specific dementia in the older population

BACKGROUND

The relationship of glucosamine use with incident dementia in the older population remains uncertain. We aimed to evaluate the longitudinal association between habitual glucosamine supplement and the risk of cause-specific dementia and examine the possible effect modifiers on this association.

METHODS

The study included 214,945 participants over the age of 60 who had available information on glucosamine use and did not have dementia at baseline in the UK Biobank. The APOE genotypes were determined by a combination variant of rs429358 and rs7412. The primary outcome was incident vascular dementia, incident Alzheimer's disease, and incident frontotemporal dementia, respectively.

RESULTS

Over a median follow-up duration of 12 years, 1039, 1774, and 122 participants developed vascular dementia, Alzheimer's disease, and frontotemporal dementia, respectively. Overall, habitual glucosamine use was significantly associated with a lower risk of incident vascular dementia (adjusted HR, 0.82; 95%CI, 0.70-0.96), but not significantly associated with incident Alzheimer's disease (adjusted HR, 1.02; 95%CI, 0.92-1.14) and incident frontotemporal dementia (adjusted HR, 0.95; 95%CI, 0.63-1.43). Moreover, the inverse association between habitual glucosamine use and incident vascular dementia was more pronounced in participants with concomitant supplement of calcium (P-interaction = 0.011), and those without concomitant supplement of zinc (P-interaction = 0.018). However, APOE ε4 dosage and baseline cognitive function did not significantly modify the relationships of glucosamine use with incident vascular dementia or Alzheimer's disease (All P-interactions > 0.05).

CONCLUSIONS

Regardless of APOE genotypes and baseline cognitive function, habitual glucosamine use was significantly inversely associated with incident vascular dementia in the older population.

Antipsychotic drug prescribing and mortality in people with dementia before and during the COVID-19 pandemic: a retrospective cohort study in Wales, UK

BACKGROUND

Concerns have been raised that antipsychotic drug prescribing, which has been associated with increased mortality in people with dementia, might have increased during the COVID-19 pandemic due to social restrictions imposed to limit the spread of SARS-CoV-2. We used multisource, routinely collected health-care data from Wales, UK to investigate prescribing and mortality variations in people with dementia before and during the COVID-19 pandemic.

METHODS

In this retrospective cohort study, we used individual-level, anonymised, population-scale linked health data to identify adults aged 60 years and older with a diagnosis of dementia in Wales, UK. We used the CVD-COVID-UK initiative to access Welsh routinely collected electronic health record data from the Secure Anonymised Information Linkage (SAIL) Databank. Patients who were alive and registered with a SAIL general practice on Jan 1, 2016, and who received a dementia diagnosis before the age of 60 years and before or during the study period were included. We explored antipsychotic drug prescribing rate changes over 67 months, between Jan 1, 2016, and Aug 1, 2021, overall and stratified by age and dementia subtype. We used time-series analyses to examine all-cause and myocardial infarction and stroke mortality over the study period and identified the leading causes of death in people with dementia between Jan 1, 2020, and Aug 1, 2021.

FINDINGS

Of 3 106 690 participants in SAIL between Jan 1, 2016 and Aug 1, 2021, 57 396 people (35 148 [61·2%] women and 22 248 [38·8%] men) met inclusion criteria for this study and contributed 101 428 person-years of follow-up. Of the 57 396 people with dementia, 11 929 (20·8%) were prescribed an antipsychotic drug at any point during follow-up. Accounting for seasonality, antipsychotic drug prescribing increased during the second half of 2019 and throughout 2020. However, the absolute difference in prescribing rates was small, ranging from 1253 prescriptions per 10 000 person-months in March, 2019, to 1305 per 10 000 person-months in September, 2020. All-cause mortality and stroke mortality increased throughout 2020, while myocardial infarction mortality declined. From Jan 1, 2020, to Aug 1, 2021, 1286 (17·1%) of 7508 participants who died had COVID-19 recorded as the underlying cause of death.

INTERPRETATION

During the COVID-19 pandemic, antipsychotic drug prescribing in people with dementia in the UK increased slightly; however, it is unlikely that this was solely related to the pandemic and this increase was unlikely to be a major factor in the substantial increase in mortality during 2020. The long-term increase in antipsychotic drug prescribing in younger people and in those with Alzheimer's disease warrants further investigation using resources with access to more granular clinical data. Although deprescribing antipsychotic medications remains an essential aspect of dementia care, the results of this study suggest that changes in prescribing and deprescribing practices as a result of the COVID-19 pandemic are not required.

FUNDING

British Heart Foundation (via the British Heart Foundation Data Science Centre led by Health Data Research UK), and the Scottish Neurological Research Fund.

Risk of All-Cause Dementia, Alzheimer Disease, and Vascular Dementia in Breast Cancer Survivors: A Longitudinal Register-Based Study

Background and Objectives

Now more than two-thirds of cancer survivors are aged 65 years or older, but evidence about their long-term health is thin. Cancer and its treatments have been linked to accelerated aging, so there is a concern that aging cancer survivors have an increased risk of age-related diseases, including dementia.

Methods

We examined the risk of dementia among 5-year breast cancer survivors using a matched cohort study design. We included breast cancer survivors aged 50 years and older at diagnosis (n = 26,741) and cancer-free comparison participants (n = 249,540). Women eligible for inclusion in the study were those born 1935-1975 and registered in the Swedish Total Population Register between January 1, 1991, and December 31, 2015. We defined breast cancer survivors as women with an initial breast cancer diagnosis between 1991 and 2005 who survived 5 or more years after their first diagnosis. We assessed all-cause dementia, Alzheimer disease (AD), and vascular dementia (VaD) using International Classification of Diseases codes. Survival analyses were conducted using age-adjusted subdistribution hazard models accounting for competing risk of death.

Results

We did not observe an association between breast cancer survivorship and risk of all-cause dementia, AD, or VaD. However, in models stratified by age at cancer diagnosis, women diagnosed with cancer after age 65 years had a higher risk of all-cause dementia (subdistribution hazard ratio [SHR] = 1.30, 95% CI 1.07-1.58), AD (SHR = 1.35, 95% CI 1.05-1.75), and VaD (SHR = 1.64, 95% CI 1.11-2.43) in models adjusted for age, education, and country of origin.

Discussion

Older breast cancer survivors who survive cancer have a higher risk for dementia than their peers without a cancer diagnosis, in contrast to earlier studies showing that prevalent or incident cancer is associated with a lower risk of dementia. With the older adult population growing rapidly and because cancer and dementia are 2 of the most common and debilitating diseases among older adults, it is critical that we understand the link between the 2.

Coding for Physical Restraint Status Among Hospitalized Patients: a 2019 National Inpatient Sample Analysis

BACKGROUND

The reduction of physical restraint utilization in the hospital setting is a key goal of high-quality care, but little is known about the rate of restraint use in general hospitals in the USA.

OBJECTIVE

This study reports the rate of physical restraint coding among acute care hospital discharges in the USA and explores associated demographic and diagnostic factors.

DESIGN

The National Inpatient Sample, a de-identified all-payors database of acute care hospital discharges in the USA, was queried for patients aged 18 and older with a diagnosis code for physical restraint status in 2019.

PARTICIPANTS

Hospitalized patients aged 18 and older.

MAIN MEASURES

Demographics, discharge diagnoses, in-hospital mortality, length of stay, total hospital charges.

KEY RESULTS

In total, 220,470 (95% CI: 208,114 to 232,826) hospitalizations, or 0.7% of overall hospitalizations, included a discharge code for physical restraint status. There was a 700-fold difference in coding for restraint utilization based on diagnosis, with 7.4% of patients with encephalitis receiving restraint diagnosis codes compared to < 0.01% of patients with uncomplicated diabetes. In an adjusted model, male sex was associated with an odds ratio of 1.4 (95% CI: 1.4 to 1.5) for restraint utilization coding, and Black race was associated with an odds ratio of 1.3 (95% CI: 1.2 to 1.4) relative to white race.

CONCLUSIONS

In the general hospital setting, there is variability in physical restraint coding by sex, race, and clinical diagnosis. More research is needed into the appropriate utilization of restraints in the hospital setting and possible inequities in restraint utilization.

Temporal characterization of Alzheimer's Disease with sequences of clinical records

BACKGROUND

Alzheimer's Disease (AD) is a complex clinical phenotype with unprecedented social and economic tolls on an ageing global population. Real-world data (RWD) from electronic health records (EHRs) offer opportunities to accelerate precision drug development and scale epidemiological research on AD. A precise characterization of AD cohorts is needed to address the noise abundant in RWD.

METHODS

We conducted a retrospective cohort study to develop and test computational models for AD cohort identification using clinical data from 8 Massachusetts healthcare systems. We mined temporal representations from EHR data using the transitive sequential pattern mining algorithm (tSPM) to train and validate our models. We then tested our models against a held-out test set from a review of medical records to adjudicate the presence of AD. We trained two classes of Machine Learning models, using Gradient Boosting Machine (GBM), to compare the utility of AD diagnosis records versus the tSPM temporal representations (comprising sequences of diagnosis and medication observations) from electronic medical records for characterizing AD cohorts.

FINDINGS

In a group of 4985 patients, we identified 219 tSPM temporal representations (i.e., transitive sequences) of medical records for constructing the best classification models. The models with sequential features improved AD classification by a magnitude of 3-16 percent over the use of AD diagnosis codes alone. The computed cohort included 663 patients, 35 of whom had no record of AD. Six groups of tSPM sequences were identified for characterizing the AD cohorts.

INTERPRETATION

We present sequential patterns of diagnosis and medication codes from electronic medical records, as digital markers of Alzheimer's Disease. Classification algorithms developed on sequential patterns can replace standard features from EHRs to enrich phenotype modelling.

FUNDING

National Institutes of Health: the National Institute on Aging (RF1AG074372) and the National Institute of Allergy and Infectious Diseases (R01AI165535).

Causal evidence that herpes zoster vaccination prevents a proportion of dementia cases

The root causes of dementia are still largely unclear, and the medical community lacks highly effective preventive and therapeutic pharmaceutical agents for dementia despite large investments into their development. There is growing interest in the question if infectious agents play a role in the development of dementia, with herpesviruses attracting particular attention. To provide causal as opposed to merely correlational evidence on this question, we take advantage of the fact that in Wales eligibility for the herpes zoster vaccine (Zostavax) for shingles prevention was determined based on an individual's exact date of birth. Those born before September 2 1933 were ineligible and remained ineligible for life, while those born on or after September 2 1933 were eligible to receive the vaccine. By using country-wide data on all vaccinations received, primary and secondary care encounters, death certificates, and patients' date of birth in weeks, we first show that the percentage of adults who received the vaccine increased from 0.01% among patients who were merely one week too old to be eligible, to 47.2% among those who were just one week younger. Apart from this large difference in the probability of ever receiving the herpes zoster vaccine, there is no plausible reason why those born just one week prior to September 2 1933 should differ systematically from those born one week later. We demonstrate this empirically by showing that there were no systematic differences (e.g., in pre-existing conditions or uptake of other preventive interventions) between adults across the date-of-birth eligibility cutoff, and that there were no other interventions that used the exact same date-of-birth eligibility cutoff as was used for the herpes zoster vaccine program. This unique natural randomization, thus, allows for robust causal, rather than correlational, effect estimation. We first replicate the vaccine's known effect from clinical trials of reducing the occurrence of shingles. We then show that receiving the herpes zoster vaccine reduced the probability of a new dementia diagnosis over a follow-up period of seven years by 3.5 percentage points (95% CI: 0.6 - 7.1, p=0.019), corresponding to a 19.9% relative reduction in the occurrence of dementia. Besides preventing shingles and dementia, the herpes zoster vaccine had no effects on any other common causes of morbidity and mortality. In exploratory analyses, we find that the protective effects from the vaccine for dementia are far stronger among women than men. Randomized trials are needed to determine the optimal population groups and time interval for administration of the herpes zoster vaccine to prevent or delay dementia, as well as to quantify the magnitude of the causal effect when more precise measures of cognition are used. Our findings strongly suggest an important role of the varicella zoster virus in the etiology of dementia.

Occupational characteristics and incident anxiety and depression: A prospective cohort study of 206,790 participants

BACKGROUND

This study aimed to analyze the impact of a wide spectrum of occupational characteristics on the incidence of anxiety and depression, and to determine the features affecting adaptation to specific characteristics.

METHODS

Participants in paid employment or self-employed at baseline in UKB were included, with occupational characteristics extracted from O*NET. Cox-proportional-hazard models were conducted in the main analyses and subgroup analyses.

RESULTS

Direct work with the public and exposure to disease/infections were first time demonstrated to be risk factors for both anxiety and depression, along with occupations involving more physical activities and dealing with unpleasant/physically aggressive people. Protective factors for both: time spent sitting, communication, decision making, creativity and reasoning, and responsibility in work. Protective factors for anxiety only: Coordinating/leading, fluency of ideas, originality, problem sensitivity, decision latitude, and time pressure. Risk factor for depression only: Exposure to contaminants. Females were found more sensitive to dealing with unpleasant/physically aggressive people. The impact of exposure to disease/infections was more significant among those with lower education levels. Those with BMI over 24 were more sensitive to the risk factors.

LIMITATIONS

The short-term effect of the above exposures remained unclear. The scores of occupational characteristics were based on self-reported questionnaires. There was the potential for undiagnosed anxiety or depression events. The participants included only those aged from 40 to 69. Participants included in this cohort were mainly White British.

CONCLUSIONS

Our findings advocate closer monitoring of the mental health of workers with risk work-related factors.

Cataract, Cataract Surgery, and Risk of Incident Dementia: A Prospective Cohort Study of 300,823 Participants

BACKGROUND

Visual impairment and interventions to preserve vision may impact dementia risk. Thus, we aimed to explore the associations of cataract and cataract surgery with the risk of dementia.

METHODS

Prospective data from 300,823 individuals in the UK Biobank were used. We used multivariate Cox proportional hazards regression models to estimate hazard ratios (HRs) and 95% confidence intervals for associations, with healthy control subjects as a reference. The same method was used to explore the effects of surgery on dementia outcomes of patients with cataract. One-way analysis of variance was performed to examine the associations between cataract and brain morphometric measures.

RESULTS

After a mean follow-up of 8.4 years, 3226 individuals were diagnosed with dementia. The nonsurgical cataract group had increased risk of all-cause dementia (HR, 1.214; 95% CI, 1.012-1.456; p = .037) and Alzheimer's disease (HR, 1.479; 95% CI, 1.105-1.981; p = .009). However, there was no difference in dementia risk between the cataract surgery group and the healthy control group. Cataract surgery was associated with decreased risk of all-cause dementia (HR, 0.632; 95% CI, 0.421-0.947; p = .026) and Alzheimer's disease (HR, 0.399; 95% CI, 0.196-0.812; p = .011) compared with the nonsurgical group. Additionally, cataract was negatively associated with cortical volumes, aging-related subcortical volumes, and fractional anisotropy of white matter fibers.

CONCLUSIONS

Cataract patients who did not receive surgical treatment had an increased risk of dementia. However, cataract surgery could reverse the risk of dementia. Our findings on brain structures and pathways in patients with cataract also provided evidence for the mechanism. Reversible visual impairment, such as cataract, is a promising modifiable risk factor for dementia.

Population-based discovery and Mendelian randomization analysis identify telmisartan as a candidate medicine for Alzheimer's disease in African Americans

INTRODUCTION

African Americans (AAs) and European Americans (EAs) differ in Alzheimer's disease (AD) prevalence, risk factors, and symptomatic presentation and AAs are less likely to enroll in AD clinical trials.

METHODS

We conducted race-conscious pharmacoepidemiologic studies of 5.62 million older individuals (age ≥60) to investigate the association of telmisartan exposure and AD outcome using Cox analysis, Kaplan-Meier analysis, and log-rank test. We performed Mendelian randomization (MR) analysis of large ethnically diverse genetic data to test likely causal relationships between telmisartan's target and AD.

RESULTS

We identified that moderate/high telmisartan exposure was significantly associated with a reduced incidence of AD in the AAs compared to low/no telmisartan exposure (hazard ratio [HR] = 0.77, 95% CI: 0.65-0.91, p-value = 0.0022), but not in the non-Hispanic EAs (HR = 0.97, 95% CI: 0.89-1.05, p-value = 0.4110). Sensitivity and sex-/age-stratified patient subgroup analyses identified that telmisartan's medication possession ratio (MPR) and average hypertension daily dosage were significantly associated with a stronger reduction in the incidence of both AD and dementia in AAs. Using MR analysis from large genome-wide association studies (GWAS) (over 2 million individuals) across AD, hypertension, and diabetes, we further identified AA-specific beneficial effects of telmisartan for AD.

DISCUSSION

Randomized controlled trials with ethnically diverse patient cohorts are warranted to establish causality and therapeutic outcomes of telmisartan and AD.

HIGHLIGHTS

Telmisartan is associated with lower risk of Alzheimer's disease (AD) in African Americans (AAs). Telmisartan is the only angiotensin II receptor blockers having PPAR-γ agonistic properties with beneficial anti-diabetic and renal function effects, which mitigate AD risk in AAs. Mendelian randomization (MR) analysis demonstrates the specificity of telmisartan's protective mechanism to AAs.