Adherence to multidomain interventions for dementia prevention: Data from the FINGER and MAPT trials

Effects of a multidomain intervention against cognitive decline on dementia risk profiles - Results from the AgeWell.de trial

INTRODUCTION

Dementia risk scores constitute promising surrogate outcomes for lifestyle interventions targeting cognitive function. We investigated whether dementia risk, assessed using the LIfestyle for BRAin health (LIBRA) index, was reduced by the AgeWell.de intervention.

METHODS

Secondary analyses of the AgeWell trial, testing a multicomponent intervention (including optimization of nutrition, medication, and physical, social, and cognitive activity) in older adults with increased dementia risk. We analyzed data from n = 461 participants with complete information on risk/protective factors comprised by LIBRA at the 24-month follow-up. Intervention effects on LIBRA and LIBRA components were assessed using generalized linear models.

RESULTS

The intervention reduced LIBRA scores, indicating decreased dementia risk at follow-up (b = -0.63, 95% confidence interval [CI]: -1.14, -0.12). Intervention effects were particularly due to improvements in diet (odds ratio [OR]: 1.60, 95% CI: 1.16, 2.22) and hypertension (OR: 1.61, 95% CI: 1.19, 2.18).

DISCUSSION

The AgeWell.de intervention reduced dementia risk. However, several risk factors did not improve, possibly requiring more intensive interventions.

HIGHLIGHTS

The AgeWell.de intervention reduced dementia risk according to LIfestyle for BRAin health (LIBRA) scores. Beneficial effects on LIBRA are mainly due to changes in diet and blood pressure. A pragmatic lifestyle intervention is apt to reduce dementia risk in an at-risk population.

Combined healthy lifestyle behaviours and incident dementia: A systematic review and dose-response meta-analysis of cohort studies

BACKGROUND

The associations of combined healthy lifestyle behaviours and incident dementia have not been systematically reviewed and the dose-response relationship was uncertain.

OBJECTIVES

To evaluate the associations of combined healthy lifestyle behaviours with incident dementia and other cognitive outcomes, assess the dose-response relationship between the number of lifestyle behaviours and incident dementia, and summarise the adherence to healthy lifestyle behaviours.

DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, EMBASE, Web of Science and PsycINFO were searched from inception to 20 Jan 2024. Cohort studies reporting associations of combined healthy lifestyle behaviours with incident dementia or other cognitive outcomes were included. We used the random-effects meta-analysis to pool the risk estimates and the robust error meta-regression method to examine the dose-response relationship. The methodological quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

A total of 22 articles including 25 cohort studies mostly from high-income economics were included, with all assessed as high methodological quality. Adherence to a healthy lifestyle was associated with a decreased risk of incident dementia, either per healthy lifestyle behaviour increase (pooled hazard ratio 0.89, 95 % confidence interval 0.85-0.94) or the highest level versus the lowest level (pooled hazard ratio 0.61, 95 % confidence interval 0.49-0.76). An inverse, linear dose-response relationship (Pnon-linear = 0.845) between the number of healthy lifestyle behaviours and incident dementia was observed, with an 11 % risk reduction for each healthy behaviour increase. A relatively limited number of included studies indicated that adherence to a healthy lifestyle combination could yield benefits for cognitive decline, global cognition, memory and executive function. In addition, the adherence rates typically decreased as the number of healthy lifestyle behaviours increased.

CONCLUSIONS

Adherence to a healthy lifestyle was associated with a lower risk of incident dementia and other cognitive outcomes. It is important to find a subtle balance between the benefits and adherence. Further large cohort studies for combined lifestyle behaviours with specific cognitive outcomes and dose-response relationships are required, especially based on middle- and low-income populations.

REGISTRATION

The study was registered in PROSPERO (CRD42023418509).

TWEETABLE ABSTRACT

Engaging in a greater number of healthy lifestyle behaviours yields increased benefits in preventing dementia, albeit with lower adherence rates as a trade-off. Finding a delicate balance between the benefits and adherence is crucial.

Adherence to a lifestyle intervention - just a question of self-efficacy? Analysis of the AgeWell.de-intervention against cognitive decline

BACKGROUND

Aim of this study was to detect predictors of better adherence to the AgeWell.de-intervention, a two-year randomized multi-domain lifestyle intervention against cognitive decline.

METHODS

Data of 317 intervention group-participants comprising a risk group for dementia (Cardiovascular Risk Factors, Ageing and Dementia (CAIDE) score of  ≥ 9; mean age 68.9 years, 49.5% women) from the AgeWell.de intervention study were analysed. Regression models with four blocks of predictors (sociodemographic, cognitive and psychosocial, lifestyle factors and chronic conditions) were run on adherence to the components of nutrition, enhancement of social and physical activity and cognitive training. Adherence to each component was operationalised by assessing the degree of goal achievement per component at up to seven time points during the intervention period, measured using a 5-point Likert scale (mean score of goal achievement).

RESULTS

Increasing age was negatively associated with adherence, while higher education positively predicted adherence. Participants with better mental state (Montreal Cognitive Assessment (MoCA)-score > 25) at baseline and higher self-efficacy adhered better. Diabetes and cardiovascular conditions were not associated with adherence, whereas smoking negatively affected adherence. Highest education and quitting smoking in the past were the only predictors associated with all four intervention components.

CONCLUSION

Results identified predictors for better and worse adherence. Particularly self-efficacy seems to be of considerable influence on adherence. This should be considered when designing future intervention trials.

TRIAL REGISTRATION

German Clinical Trials Register (ref. number: DRKS00013555).

Value-based motivational strategies combined with technology to encourage a lifestyle that helps to prevent dementia

Lifestyles aimed at reducing dementia risk typically combine physical and cognitive training, nutritional adaptations, and, potentially, an augmentation in social interactions. Interventions at the population level are essential but should be complemented by individual efforts. For efficacy, lasting changes to an individual's lifestyle are needed, necessitating robust motivation and volition. Acting in accordance with one's values is assumed to be rewarding, leading to improved motivation and volition, and produces stable behaviour-outcome relationships. To this end, future preventive endeavours might first evaluate an individual's extant lifestyle, preferences, and values, including considerations of age-related changes to ensure these values remain a motivational source. Digital technology can support lifestyle goals and be targeted to support an individual's values. A digital platform could implement situation-specific, sensing-based feedback to alert users to a target situation (eg, opportunity for exercise) coupled with (smartphone-based) feedback on the extent of accomplished behavioural change to support individually set goals and facilitate their adjustment depending on whether these goals are achieved. This use of the motivational impetus of values, coupled with interpersonal techniques, such as motivational interviewing and SMART goal setting, in combination with sensor technology and just-in-time adaptive interventions, is assumed to hold high potential for dementia prevention.

Integrating a multimodal lifestyle intervention with medical food in prodromal Alzheimer's disease: the MIND-ADmini randomized controlled trial

BACKGROUND

The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) showed cognitive benefits from a multidomain lifestyle intervention in at-risk older people. The LipiDiDiet trial highlighted benefits of medical food in prodromal Alzheimer's disease (AD). However, the feasibility and impact of multimodal interventions combining lifestyle with medical food in prodromal AD is unclear.

METHODS

MIND-ADmini was a 6-month multinational (Sweden, Finland, Germany, France) proof-of-concept randomized controlled trial (RCT). Participants were 60-85 years old, had prodromal AD (International Working Group-1 criteria), and vascular/lifestyle risk factors. The parallel-group RCT had three arms: multimodal lifestyle intervention (nutritional guidance, exercise, cognitive training, vascular/metabolic risk management and social stimulation); multimodal lifestyle intervention + medical food (Fortasyn Connect); and regular health advice/care (control). Participants were randomized 1:1:1 (computer-generated allocation at each site). Outcome evaluators were blinded to randomization. Primary outcome was feasibility of the multimodal intervention, evaluated by recruitment rate during a 6-month recruitment phase, overall adherence in each intervention arm, and 6-month retention rate. Successful adherence was pre-specified as attending ≥ 40% of sessions/domain in ≥ 2/4 domains (lifestyle intervention), and consuming ≥ 60% of the medical food (lifestyle intervention + medical food). The secondary outcomes included adherence/participation to each intervention component and overall adherence to healthy lifestyle changes, measured using a composite score for healthy lifestyle. Cognitive assessments were included as exploratory outcomes, e.g. Clinical Dementia Rating scale.

RESULTS

During September 2017-May 2019, 93 individuals were randomized (32 lifestyle intervention, 31 lifestyle + medical food, and 30 control group). Overall recruitment rate was 76.2% (64.8% during the first 6 months). Overall 6-month retention rate was 91.4% (lifestyle intervention 87.5%; lifestyle + medical food 90.3%; control 96.7%). Domain-specific adherence in the lifestyle intervention group was 71.9% to cognitive training, 78.1% exercise, 68.8% nutritional guidance, and 81.3% vascular risk management; and in the lifestyle + medical food group, 90.3% to cognitive training, 87.1% exercise, 80.7% nutritional guidance, 87.1% vascular risk management, and 87.1% medical food. Compared with control, both intervention arms showed healthy diet improvements (βLifestyle×Time = 1.11, P = 0.038; βLifestyle+medical food×Time = 1.43, P = 0.007); the lifestyle + medical food group also showed vascular risk reduction (P = 0.043) and less cognitive-functional decline (P < 0.05, exploratory analysis). There were 5 serious adverse events (control group: 1; lifestyle intervention: 3; lifestyle + medical food: 1) unrelated to interventions.

CONCLUSIONS

The multidomain lifestyle intervention, alone or combined with medical food, had good feasibility and adherence in prodromal AD. Longer-term cognitive and other health benefits should be further investigated in a larger-scale trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03249688.

Multidomain interventions based on a life-course model to prevent dementia in at-risk Chinese older adults: A randomized controlled trial

BACKGROUND

Due to the time-dependent effect of specific risk factors for dementia, multidomain interventions based on a life-course model might achieve optimal preventive effects against dementia.

OBJECTIVE

The purpose of this study was to investigate the effectiveness of multidomain interventions based on a life-course model of modifiable risk factors for dementia in at-risk Chinese older adults.

DESIGN

This was a two-arm, proof-of-concept, randomized controlled trial.

SETTING AND PARTICIPANTS

We randomly assigned 96 community-dwelling at-risk adults aged 60 years or older in a 1:1 ratio to either the 6-month multidomain intervention group (dementia literacy, physical activity, cognitive training, social activity and optional modules) or the control group (health education).

METHODS

The primary outcomes were the dementia risk score and cognitive composite Z score. The secondary outcomes included the individual components of the dementia risk score (protective and risk factors) and cognitive composite Z score (global cognition, memory, executive function and language), social isolation (loneliness, social contact, and social participation), dementia literacy and prevention belief. Linear mixed models with maximum likelihood estimation were used to calculate the outcomes between the groups over time.

RESULTS

The primary analyses showed that the dementia risk score was significantly lower (p < 0.001) and that the cognitive composite Z score was significantly higher (p = 0.013) in the multidomain intervention group than in the control group. Baseline characteristics did not modify the effects of the multidomain interventions (p value for interaction > 0.05). For secondary outcomes, statistically significant group × time interactions were observed for the protective (p = 0.001) and risk factors (p = 0.049), as well as in executive function (p = 0.020), loneliness (p = 0.029), dementia literacy (p < 0.001) and prevention belief (p < 0.001).

CONCLUSIONS

Multidomain interventions based on a life-course model are feasible and have the potential to reduce dementia risk and improve cognitive function in at-risk Chinese older adults.

REGISTRATION

The trial was registered at the Chinese Clinical Trials Registry (ChiCTR2100053417).

GOIZ ZAINDU study: a FINGER-like multidomain lifestyle intervention feasibility randomized trial to prevent dementia in Southern Europe

BACKGROUND

GOIZ ZAINDU ("caring early" in Basque) is a pilot study to adapt the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) methodology to the Basque population and evaluate the feasibility and adherence to a FINGER-like multidomain intervention program. Additional aims included the assessment of efficacy on cognition and data collection to design a large efficacy trial.

METHOD

GOIZ ZAINDU is a 1-year, randomized, controlled trial of a multidomain intervention in persons aged 60+ years, with Cardiovascular Risk Factors, Aging and Dementia (CAIDE) risk score ≥ 6, no diagnosis of dementia, and below-than-expected performance in at least one of three cognitive screening tests. Randomization to a multidomain intervention (MD-Int) or regular health advice (RHA) was stratified by sex, age (>/≤ 75), and cognitive status (mild cognitive impairment (MCI)/normal cognition). MD-Int included cardiovascular risk factor control, nutritional counseling, physical activity, and cognitive training. The primary outcomes were retention rate and adherence to the intervention program. Exploratory cognitive outcomes included changes in the Neuropsychological Test Battery z-scores. Analyses were performed according to the intention to treat.

RESULTS

One hundred twenty-five participants were recruited (mean age: 75.64 (± 6.46); 58% women). The MD-Int (n = 61) and RHA (n = 64) groups were balanced in terms of their demographics and cognition. Fifty-two (85%) participants from the RHA group and 56 (88%) from the MD-Int group completed the study. More than 70% of the participants had high overall adherence to the intervention activities. The risk of cognitive decline was higher in the RHA group than in the MD-Int group in terms of executive function (p =.019) and processing speed scores (p =.026).

CONCLUSIONS

The GOIZ-ZAINDU study proved that the FINGER methodology is adaptable and feasible in a different socio-cultural environment. The exploratory efficacy results showed a lower risk of decline in executive function and processing speed in the intervention group. These results support the design of a large-scale efficacy trial.

TRIAL REGISTRATION

GOIZ ZAINDU feasibility trial was approved and registered by the Euskadi Drug Research Ethics Committee (ID: PI2017134) on 23 January 2018. Retrospectively registered in ClinicalTrials.gov (NCT06163716) on 8 December 2023.

Effects of engagement, persistence and adherence on cognitive training outcomes in older adults with and without cognitive impairment: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Limited understanding exists regarding the influences of engagement, persistence and adherence on the efficacy of cognitive training for age-related cognitive decline and neurodegenerative cognitive impairment.

METHODS

This study conducted a meta-analysis of randomised controlled trials (RCTs). We systematically searched MEDLINE, PubMed, Web of Science, Embase and CINAHL databases from 1 January 2012 to 13 June 2023, and included RCTs assessing the effects of cognitive training in older adults, both with and without cognitive impairment. Hedges' g with a 95% confidence interval (CI) was used to synthesise cognitive training effect sizes on various neuropsychological tests. Subgroup analyses were conducted based on variables including engagement, persistence, adherence and cognitive conditions of normal cognition, mild cognitive impairment (MCI) or neurodegenerative dementia.

RESULTS

This meta-analysis included 55 RCTs with 4,455 participants with cognitive conditions spanning normal cognition, MCI and neurodegenerative dementia. The mean age of participants was 73.9 (range: 65.7-84.5) years. Overall, cognitive training showed a significant cross-domain effect (Hedges' g = 0.286, 95% CI: 0.224-0.348). Training effects are significant when engagement or persistence rates exceed 60% or when adherence rates exceed 80%. Higher levels of persistence are required to achieve significant training effects in memory, visuospatial ability and reasoning than in executive function and attention and language. Higher persistence is also required for older adults with normal cognition to achieve significant training gains compared to those with cognitive impairment.

CONCLUSIONS

This systematic review highlights the critical roles of engagement, persistence and adherence in augmenting the efficacy of cognitive training.

Profiles of lifestyle health behaviors and cognitive decline in older adults

INTRODUCTION

We aimed to identify profiles of modifiable, late-life lifestyle health behaviors related to subsequent maintenance of cognition and explore sociodemographics and health characteristics as effect modifiers.

METHODS

Analyses used data from 715 older adults without baseline dementia from the Rush Memory and Aging Project and with lifestyle health behaviors (physical activity, cognitive activity, healthy diet, social activity) at baseline and ≥ 2 annual assessments of cognition. We used latent profile analysis to group participants based on behavior patterns and assessed change in cognition by group.

RESULTS

Three latent profiles were identified: high (n = 183), moderate (n = 441), and low (n = 91) engagement in health behaviors. Compared to high engagement, the moderate (mean difference [MD] = -0.02, 95% CI = [-0.03;-0.0002], p = 0.048) and low (MD = -0.06, 95% CI = [-0.08;-0.03], p < 0.0001) groups had faster annual rates of decline in global cognition, with no significant effects modifiers (vascular risk factors, apolipoprotein E [APOE] ε4, motor function).

DISCUSSION

Avoiding low levels of lifestyle health behaviors may help maintain cognition.

HIGHLIGHTS

Latent profile analysis (LPA) captures lifestyle health behaviors associated with cognitive function. Such behavior include physical activity, cognitive activity, healthy diet, social activity. We used LPA to examine associations of behaviors and cognitive function over time. Older adults with low lifestyle health behaviors showed more rapid decline. To a lesser degree, so did those with moderate lifestyle health behaviors. Vascular conditions and risks, APOEε4, or motor function did not modify the effect.

Optimizing the Implementation of a Lifestyle Dementia Prevention Intervention for Older Patients in an Academic Healthcare System

Background

Interventions that promote healthy lifestyles are critical for the prevention of Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD). However, knowledge of the best practices for implementing AD/ADRD prevention in healthcare settings remains limited.

Objective

We aimed to qualitatively identify barriers and facilitators to implementing a clinical trial of a novel lifestyle intervention (My Healthy Brain) in our medical center for older patients with subjective cognitive decline who are at-risk for AD/ADRD.

Methods

We conducted focus groups with 26 healthcare professionals (e.g., physicians, psychology, nursing) from 5 clinics that treat older patients (e.g., memory care, psychiatry). Our qualitative analysis integrated two implementation frameworks to systematically capture barriers and facilitators to AD/ADRD prevention (Consolidated Framework for Implementation Science Research) that impact implementation outcomes of acceptability, appropriateness, and feasibility (Proctor's framework).

Results

We found widespread support for an RCT of My Healthy Brain and AD/ADRD prevention. Participants identified barriers related to patients (stigma, technological skills), providers (dismissiveness of "worried well," doubting capacity for behavior change), clinics (limited time and resources), and the larger healthcare system (underemphasis on prevention). Implementation strategies guided by Expert Recommendations for Implementing Change (ERIC) included: developing tailored materials, training staff, obtaining buy-in from leadership, addressing stigmatized language and practices, identifying "champions," and integrating with workflows and resources.

Conclusions

The results will inform our recruitment, enrollment, and retention procedures to implement the first randomized clinical trial of My Healthy Brain. Our study provides a blueprint for addressing multi-level barriers to the implementation of AD/ADRD prevention for older patients in medical settings.

Understanding Health Beliefs and Health Behaviors in Older Adults at Risk for Alzheimer's Disease

Background

There are significant public health benefits to delaying the onset of Alzheimer's disease (AD) in individuals at risk. However, adherence to brain healthy behaviors is low. The Health Belief Model proposes that specific beliefs are mediators of behavior change.

Objective

To characterize health belief measures from the Science of Behavior Change Research Network (SBCRN) in an older adult population and associations between health beliefs, AD risk, and current health behaviors.

Methods

A total of 172 individuals from the Rhode Island AD Prevention Registry participated. SBCRN health belief measures included assessments of future time perspective, self-efficacy, deferment of gratification, and consideration of future consequences. Outcome measures included individual AD risk index score, dementia risk awareness, and lifestyle behaviors including physical, cognitive, and social activity.

Results

Participants who were older had higher scores for AD risk, lower future time perspective, and lower generalized self-efficacy (all at p < 0.001). Higher generalized self-efficacy was related to increased physical activity (p < 0.010). Higher future time perspective (p < 0.001) and generalized self-efficacy (p = 0.48) were associated with lower AD risk score. Subjective cognitive decline (SCD) was associated with lower self-efficacy, ability to delay gratification, and a less expansive future time perspective.

Conclusions

Greater self-efficacy and perceived future time remaining were associated with lower AD risk and greater engagement in physical activity. SCD was associated with health beliefs that may negatively affect engagement in positive brain health behaviors. Assessment of and psychoeducation about these intrapersonal health belief constructs may be important targets for behavioral interventions to reduce AD risk.

The feasibility of a multidomain dementia risk reduction randomised controlled trial for people experiencing cognitive decline: the Body, Brain, Life for Cognitive Decline (BBL-CD)

OBJECTIVES

To evaluate the feasibility of a proof-of-concept multidomain dementia risk reduction intervention.

METHOD

An 8-week, parallel-group RCT, focused on increasing adherence to lifestyle domains of Mediterranean diet (MeDi), Physical Activity (PA), and Cognitive Engagement (CE). Feasibility was evaluated against the Bowen Feasibility Framework objectives of: Acceptability of the intervention, compliance with the protocol, and efficacy of the intervention to change behaviour in the three domains of interest.

RESULTS

High acceptability of the intervention was demonstrated through a participant retention rate of 80.7% (Intervention: 84.2%; Control: 77.4%). Compliance to the protocol was strong with 100% of participants completing all educational modules and all MeDi and PA components, with 20% compliance for CE. Linear mixed models demonstrated efficacy to change behaviour through significant effects of adherence to MeDi (χ2 = 16.75, df = 3, p < .001) and CE (χ2 = 9.83, df = 3, p =.020), but not PA (χ2 = 4.48, df = 3, p =.211).

CONCLUSION

Overall the intervention was shown to be feasible. Recommendations for future trials in this area are: The implementation of practical, one-on-one sessions as they are more effective than passive education at eliciting behaviour change; use of booster sessions to increase likelihood of lifestyle changes being sustained; and collection of qualitative data to identify barriers to change.

Predictive ability of the clock drawing test to detect mild cognitive impairment and dementia over time: Results from the HELIAD study

Objective: We investigated the diagnostic accuracy of the Clock Drawing Test (CDT) in discriminating Mild Cognitive Impairment (MCI) and dementia from normal cognition. Additionally, its clinical utility in predicting the transition from normal cognition to MCI and dementia over the course of several years was explored. Method: In total, 1037 older adults (633 women) who completed the CDT in a baseline assessment were drawn from the population-based HELIAD cohort. Among these, 848 participants were identified as cognitively normal, 142 as having MCI and 47 with dementia during the baseline assessment. Of these individuals, 565 attended the follow-up assessment (mean interval: 3.21 years). ROC curve and binary logistic regression analyses were performed. Results: The CDT exhibited good diagnostic accuracy for the discrimination between dementia and normal cognition (AUC = .879, SN = .813, SP = .778, LR+ = 3.66, LR- = .240, < .001, d = 1.655) and acceptable diagnostic accuracy for the discrimination between dementia and MCI (AUC=.761, SN= .750, SP= .689, LR+ = 2.41, LR- = .362, p < .001, d = 1.003). We found limited diagnostic accuracy, however, for the discrimination between MCI and normal cognition (AUC = .686, SN = .764, SP = .502, LR+ = 1.53, LR- = .470, p < .001, d = .685). Moreover, the CDT significantly predicted the transition from normal cognition to dementia [Exp(B)= 1.257, p = .022], as well as the transition from MCI to normal cognition [Exp(B) = 1.334, p = .023] during the longitudinal investigation. Conclusions: The CDT is a neuropsychological test with acceptable diagnostic accuracy for the discrimination of dementia from MCI and normal cognition. Furthermore, it has an important predictive value for the transition from normal cognition to dementia and from MCI to normal cognition.

Exploring the potential impact of multi-factor precision interventions in Alzheimer's disease with system dynamics

Numerous clinical trials based on a single-cause paradigm have not resulted in efficacious treatments for Alzheimer's disease (AD). Recently, prevention trials that simultaneously intervened on multiple risk factors have shown mixed results, suggesting that careful design is necessary. Moreover, intensive pilot precision medicine (PM) trial results have been promising but may not generalize to a broader population. These observations suggest that a model-based approach to multi-factor precision medicine (PM) is warranted. We systematically developed a system dynamics model (SDM) of AD for PM using data from two longitudinal studies (N=3660). This method involved a model selection procedure in identifying interaction terms between the SDM components and estimating individualized parameters. We used the SDM to explore simulated single- and double-factor interventions on 14 modifiable risk factors. We quantified the potential impact of double-factor interventions over single-factor interventions as 1.5 [95% CI: 1.5-2.6] and of SDM-based PM over a one-size-fits-all approach as 3.5 [3.1, 3.8] ADAS-cog-13 points in 12 years. Although the model remains to be validated, we tentatively conclude that multi-factor PM could come to play an important role in AD prevention.

Impact of transcranial direct current stimulation on white matter microstructure integrity in mild cognitive impairment patients according to effect modifiers as risk factors for Alzheimer's disease

Background

Little research exists on how individual risk factors for Alzheimer's disease (AD) affect the intermediate phenotype after transcranial direct current stimulation (tDCS), despite the importance of precision medicine-based therapeutic approaches.

Objective

To determine how an application of sequential tDCS (2 mA/day, left dorsolateral prefrontal cortex, 10 sessions) affects changes in white matter (WM) microstructure integrity in 63 mild cognitive impairment (MCI) patients with effect modifiers such as Aβ deposition, APOE ε4 carrier status, BDNF Val66Met polymorphism status, and sex.

Methods

We examined individual effect modifier-by-tDCS interactions and multiple effect modifiers-by-tDCS interactions for diffusion metrics. We also evaluated the association between baseline Aβ deposition and changes in WM microstructure integrity following tDCS.

Results

We found that APOE ε4 carrier status and sex had a significant interaction with tDCS, resulting in increased fractional anisotropy (FA) in the right uncinate fasciculus (UF) after stimulation. Additionally, we observed multiple effect modifiers-by-tDCS interactions on WM integrity of the right UF, leading to a more pronounced increase in FA values in APOE ε4 carriers and females with Val66 homozygotes. Finally, baseline Aβ deposition was positively associated with a difference in FA of the left cingulum in the hippocampal area, which showed a positive association with the changes in the score for delayed memory.

Conclusion

Our study shows the differential impact of individual AD risk factors on changes in the early intermediate phenotype after sequential tDCS in MCI patients. This research emphasizes the importance of precision medicine approaches in tDCS for the prodromal stages of AD.

Investigating the Role of Individual Differences in Adherence to Cognitive Training

Consistent with research across several domains, intervention adherence is associated with desired outcomes. Our study investigates adherence, defined by participants' commitment to, persistence with, and compliance with an intervention's regimen, as a key mechanism underlying cognitive training effectiveness. We examine this relationship in a large and diverse sample comprising 4,775 adults between the ages of 18 and 93. We test the predictive validity of individual difference factors, such as age, gender, cognitive capability (i.e., fluid reasoning and working memory), grit, ambition, personality, self-perceived cognitive failures, socioeconomic status, exercise, and education on commitment to and persistence with a 20-session cognitive training regimen, as measured by the number of sessions completed. Additionally, we test the relationship between compliance measures: (i) spacing between training sessions, as measured by the average time between training sessions, and (ii) consistency in the training schedule, as measured by the variance in time between training sessions, with performance trajectories on the training task. Our data suggest that none of these factors reliably predict commitment to, persistence with, or compliance with cognitive training. Nevertheless, the lack of evidence from the large and representative sample extends the knowledge from previous research exploring limited, heterogenous samples, characterized by older adult populations. The absence of reliable predictors for commitment, persistence, and compliance in cognitive training suggests that nomothetic factors may affect program adherence. Future research will be well served to examine diverse approaches to increasing motivation in cognitive training to improve program evaluation and reconcile the inconsistency in findings across the field.

Modifiable cardiovascular risk factors and genetics for targeted prevention of dementia

Dementia is a major global challenge for health and social care in the 21st century. A third of individuals >65 years of age die with dementia, and worldwide incidence numbers are projected to be higher than 150 million by 2050. Dementia is, however, not an inevitable consequence of old age; 40% of dementia may theoretically be preventable. Alzheimer's disease (AD) accounts for approximately two-thirds of dementia cases and the major pathological hallmark of AD is accumulation of amyloid-β. Nevertheless, the exact pathological mechanisms of AD remain unknown. Cardiovascular disease and dementia share several risk factors and dementia often coexists with cerebrovascular disease. In a public health perspective, prevention is crucial, and it is suggested that a 10% reduction in prevalence of cardiovascular risk factors could prevent more than nine million dementia cases worldwide by 2050. Yet this assumes causality between cardiovascular risk factors and dementia and adherence to the interventions over decades for a large number of individuals. Using genome-wide association studies, the entire genome can be scanned for disease/trait associated loci in a hypothesis-free manner, and the compiled genetic information is not only useful for pinpointing novel pathogenic pathways but also for risk assessments. This enables identification of individuals at high risk, who likely will benefit the most from a targeted intervention. Further optimization of the risk stratification can be done by adding cardiovascular risk factors. Additional studies are, however, highly needed to elucidate dementia pathogenesis and potential shared causal risk factors between cardiovascular disease and dementia.

Physical Activity for Cognitive Health: A Model for Intervention Design for People Experiencing Cognitive Concerns and Symptoms of Depression or Anxiety

BACKGROUND

People experiencing cognitive concerns and symptoms of depression or anxiety are at risk for Alzheimer's disease and dementia. We know physical activity can benefit cognition but understanding how to best support engagement is an ongoing challenge. Evidence-based conceptual models of factors underpinning physical activity engagement in target populations can inform intervention tailoring to address this challenge.

OBJECTIVE

This study (part of a pragmatic physical activity implementation trial) aimed to develop a specified model of physical activity engagement in people experiencing depressive or anxiety symptoms and cognitive concerns, to enable optimized dementia risk reduction intervention tailoring.

METHODS

We employed a qualitative design, triangulating data from three sources: semi-structured individual interviews with people experiencing cognitive concerns and mild to moderate depressive or anxiety symptoms; review of published evidence; and the Capability, Opportunity and Motivation system of behavior, an existing behavioral science model. Findings were integrated to develop a contextualized model of mechanisms of action for optimizing engagement.

RESULTS

Twenty-one participants were interviewed, and 24 relevant papers included. Convergent and complementary themes extended understanding of intervention needs. Findings highlighted emotional regulation, capacities to enact intentions despite barriers, and confidence in existing skills as areas of population-specific need that have not previously been emphasized. The final model provides specificity, directionality, and linked approaches for intervention tailoring.

CONCLUSION

This study demonstrated that people experiencing cognitive concerns and symptoms of depression or anxiety require different interventions to improve physical activity engagement. The novel model can enable more precise intervention tailoring, and, ultimately, benefits for a key at-risk population.

A qualitative study to inform adaptations to a brain health intervention for older adults with type 2 diabetes living in rural regions of Ireland

AIMS

Type 2 diabetes is a risk factor for late-life dementia, but dementia prevention strategies have yet to be comprehensively evaluated in people with diabetes. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) demonstrated cognitive benefits of a 2-year multidomain lifestyle intervention. However, given the intensive nature of FINGER, there is uncertainty about whether it can be implemented in other high-risk populations. Our aim was to explore attitudes towards dementia risk, and barriers to an intervention based on the FINGER model in older adults with type 2 diabetes living in rural areas of Ireland.

METHODS

Focus groups were conducted with 21 adults (11 men and 10 women) aged 60+ years with type 2 diabetes living in border regions of north and south Ireland. Data were analysed using thematic analysis.

RESULTS

There was limited understanding of diabetes as a risk factor for late-life dementia. The main barriers to engagement with the multidomain intervention were eating foods that were not compatible with cultural norms, time and travel constraints, and perceived lack of self-efficacy and self-motivation for adopting the desired diet, exercise and computerised cognitive training (CCT) behaviours. Facilitators for intervention acceptability included the provision of culturally tailored and personalised education, support from a trusted source, and inclusion of goal setting and self-monitoring behavioural strategies.

CONCLUSIONS

While there was high acceptability for a brain health intervention, several barriers including cultural food norms and low self-efficacy for adopting the diet, exercise and CCT components would need to be considered in the intervention design. Findings from this study will be used to inform local decisions regarding the adaptation of FINGER for people with type 2 diabetes. The feasibility of the adapted multidomain intervention will then be evaluated in a future pilot trial.

Older Adults and Three-Dimensional Exergaming: Motivators and Barriers to Participation and Retention

Background: Cognitive and physical activity are important for daily functioning. However, limited research exists on the motivators and barriers associated with older adults participating and adhering to exergame studies that promote physical and cognitive activity. Our objective was to examine older adults' motivators and barriers to joining and completing a three-dimensional exergame study. Methods: Fourteen older adults who participated in the exergame study contributed to one of three focus group discussions. Inductive and deductive methods were used to analyze the qualitative data. Results: Motivators for joining were generativity, peer referrals, self-improvement, and curiosity. Accomplishment, immersion, and exercise were motivators for retention. Participants also cited the structured schedule and adaptive difficulty features as motivators for retention. Barriers to participation included frustration due to lack of level advancement and fatigue/pain during gameplay. Some (n = 3) reported camera tracking issues as a barrier. Unanticipated gender-based trends arose when examining perceptions of the study team's role and motivators for retention. Conclusion: These findings will inform future research strategies for participant recruitment, enrollment, and retention, in addition to providing insights into the design of motivating, enjoyable, and sustainable exergames for older adults.

Cognitive Benefit of a Multidomain Intervention for Older Adults at Risk of Cognitive Decline: A Cluster-Randomized Controlled Trial

OBJECTIVE

We sought to assess cognitive benefits of a community-based multidomain intervention for improving cognition among older adults at risk of cognitive decline (COMBAT).

DESIGN

A two-armed cluster-randomized controlled trial.

SETTING AND PARTICIPANTS

Community-dwelling older adults aged 60 years or older and were at risk of cognitive decline (n = 209).

INTERVENTION

In this 9-month intervention study, 10 community hospitals in Beijing, China, were randomized (1:1) to receive either a multidomain intervention of meditation, cognitive training, exercise, and nutrition counseling or usual care. The intervention was delivered with weekly 1-hour group training sessions and weekly home homework.

MEASUREMENTS

Primary outcome was change in cognition as measured by a composite Z score of seven cognitive tests. Secondary outcomes included subjective cognitive abilities, positive and negative affective experiences, physical activity, and dietary habits. Assessments were administered at baseline, end of the intervention, and 1 year after completing the intervention (1-year follow-up).

RESULTS

Immediately after the intervention, the intervention group showed significant enhancement in cognitive performance (p = 0.026). The between-group difference in the Z score of change of cognition was 0.20 (95% CI: 0.053, 0.35), with a Hedges' g of 0.40 (95% CI: 0.29, 0.50). However, this cognitive benefit was not significant at 1-year follow-up.

CONCLUSION

This multidomain intervention was effective to improve cognition for at-risk individuals. Long-term effects on cognitive function and individual differences in response to the intervention deserve further investigation.

Factors Associated with Participation in a Multidomain Web-Based Dementia Prevention Trial: Evidence from Maintain Your Brain (MYB)

BACKGROUND

The Maintain Your Brain (MYB) trial aims to prevent cognitive decline and dementia through multidomain, web-based risk-reduction. To facilitate translation, it is important to understand drivers of participation.

OBJECTIVE

To describe characteristics associated with participation in MYB.

METHODS

This was an observational ancillary study of MYB, a randomized controlled trial nested within the 45 and Up Study in New South Wales, Australia. We linked 45 and Up Study survey and MYB participation data. The study cohort comprised 45 and Up Study participants, aged 55-77 years at 1 January 2018, who were invited to participate in MYB. 45 and Up Study participant characteristics and subsequent MYB consent and participation were examined.

RESULTS

Of 98,836 invited, 13,882 (14%) consented to participate and 6,190 participated (6%). Adjusting for age and sex, a wide range of factors were related to participation. Higher educational attainment had the strongest relationship with increased MYB participation (university versus school non-completion; AdjOR = 5.15; 95% CI:4.70-5.64) and lower self-rated quality of life with reduced participation (Poor versus Excellent: AdjOR = 0.19; 95% CI:0.11-0.32). A family history of Alzheimer's disease was related to increased participation but most other dementia risk factors such as diabetes, obesity, stroke, high blood pressure, and current smoking were associated with reduced participation.

CONCLUSION

Higher socio-economic status, particularly educational attainment, is strongly associated with engagement in online dementia prevention research. Increasing population awareness of dementia risk factors, and better understanding the participation barriers in at-risk groups, is necessary to ensure online interventions are optimally designed to promote maximum participation.

Randomised controlled trials for the prevention of cognitive decline or dementia: A systematic review

Dementia prevention research has progressed rapidly in recent years, with publication of several large lifestyle intervention trials, and renewed interest in pharmacological interventions, notably for individuals with Alzheimer's disease biomarkers, warranting an updated review of results and methodology. We identified 112 completed trials testing the efficacy of single-domain pharmacological (n = 33, 29%), nutritional (n = 27, 24%), physical activity (n = 18, 16%) and cognitive stimulation (n = 13, 12%), or multidomain (n = 22, 20%) interventions on incident dementia, or a relevant intermediate marker (e.g. cognitive function, biomarkers or dementia risk scores) in people without dementia. The earliest trials tested pharmacological interventions or nutritional supplements, but lifestyle interventions predominated in the last decade. In total, 21 (19%) trials demonstrated a clear beneficial effect on the pre-specified primary outcome (or all co-primary outcomes), but only two (10%) were large-scale (testing blood pressure lowering (Syst-Eur) or multidomain (FINGER) interventions on incident dementia and cognitive change in cognitive function, respectively). Of the 116 ongoing trials, 40% (n = 46) are testing multidomain interventions. Recent methodological shifts concern target populations, primary outcome measures, and intervention design, but study design remains constant (parallel group randomised controlled trial). Future trials may consider using adaptive trials or interventions, and more targeted approaches, since certain interventions may be more effective in certain subgroups of the population, and at specific times in the life-course. Efforts should also be made to increase the representativeness and diversity of prevention trial populations.

Telephone and Smartphone-Based Interventions for Cognitive and Cardio-Metabolic Health in Middle-Aged and Older Adults: A Systematic Review

PURPOSE

Dementia and cardio-metabolic diseases share many risk factors. Management of these risk factors could contribute to successful aging, including the prevention of cardio-metabolic disease and dementia. The increasing use of smartphones offers an opportunity for remote preventive interventions. We provided a systematic review of telephone and smartphone-based interventions targeting the prevention of cognitive decline, dementia cardio-metabolic diseases or their risk factors among adults aged over 50 years.

PATIENTS AND METHODS

We searched Pubmed and the International Clinical Trials Registry Platform for experimental studies. We used the Cochrane risk-of-bias tool (Version 2) for randomized trials or TREND (Transparent Reporting of Evaluations with Nonrandomized Designs) checklists to assess study quality for completed studies.

RESULTS

We analyzed 21 completed (3 for cognition, 18 for cardio-metabolic outcomes) and 50 ongoing studies (23 for cognition, 27 for cardio-metabolic outcomes). Smartphone interventions were used in 26 studies (3 completed, 23 ongoing). Other interventions involved telephone vocal support and text messaging. Few studies were at low risk of bias. There were heterogeneous cognitive and cardio-metabolic outcomes. The highest quality studies found no significant effects on cognition, and inconsistent results for HbA1c, blood pressure or physical activity. The lower quality-studies found effects on global cognition, working memory, memory and language and inconsistent results for clinical, biological or behavioral cardio-metabolic outcomes.

CONCLUSION AND IMPLICATIONS

Despite the large number of commercially available mobile health applications, the magnitude of the scientific evidence base remains very limited. Based on published studies, the added value of telephone and smartphone tools for the prevention of cardio-metabolic diseases, cognitive decline or dementia is currently uncertain, but, there are several ongoing studies expected to be completed in the coming years.

Is more always better? Dose effect in a multidomain intervention in older adults at risk of dementia

BACKGROUND

Little is known regarding the dose-response function in multidomain interventions for dementia prevention.

METHOD

The Multidomain Alzheimer Preventive Trial is a 3-year randomized controlled trial comprising cognitive training, physical activity, nutrition, and omega-3 polyunsaturated fatty acids for at-risk older adults. The dose delivered (number of sessions attended) was modeled against global cognition, memory, and fluency in 749 participants. Interaction effects were assessed for age, sex, education, dementia score (CAIDE), frailty score, and apolipoprotein E (APOE) ε4 status.

RESULTS

The dose-response models were non-linear functions indicating benefits up to about 12 to 14 training hours or 15 to 20 multidomain sessions followed by a plateau. Participants who benefited from a higher dose included women, younger participants, frail individuals, and those with lower education or lower risk of dementia.

DISCUSSION

The non-linear function indicates that a higher dose is not necessarily better in multidomain interventions. The optimal dose was about half of the potentially available sessions.

Combining elements of the CO-OP Approach™ with education to promote healthy eating among older adults: A pilot study

This paper describes an exploratory study developing the Baycrest Brain-healthy Eating Approach (BBEA). Poor diet is a modifiable risk factor for many health problems including dementia. Mediterranean type diets, high in plant-based foods, rich in poly- and mono- unsaturated fatty acids with minimal consumption of saturated fat, red meat, and processed foods, are considered brain healthful. While several dementia prevention trials randomized controlled trials have included nutritional counselling in favor of these diets as one component of their interventions, the extent to which dietary change occurred is not known. Based on observations that a strategy training approach, the Cognitive Orientation to daily Occupational Performance (CO-OP) Approach, was beneficial for promoting lifestyle changes in older adults with complaints of cognitive changes, we undertook to develop the BBEA combining elements of CO-OP with didactic nutrition education. This exploratory, descriptive study assesses the feasibility and acceptability of the BBEA. Healthy community dwelling older adults (n = 5) were recruited using convenience sampling. Participants received five, 2 h, group sessions. During these sessions participants were supported in adopting dietary practices consistent with brain healthy eating. Each participant set specific dietary goals important to them. Feasibility of the intervention was demonstrated through high levels of attendance and by the findings that at each session, all participants set personally meaningful goals and received education on selected brain healthy eating topics. Acceptability was demonstrated through participants' positive reports of their experiences and perspectives obtained via semi-structured interviews. Thus, the BBEA appears to be feasible and acceptable.

A Multimodal Intervention to Improve Cognition in Community-dwelling Older Adults

OBJECTIVE

To examine the effects of a multimodal intervention composed of cognitive training, physical exercise, and group counseling on cognitive function in community-dwelling older adults.

DESIGN

A four-armed, quasi-experimental intervention study.

SETTING AND PARTICIPANTS

Community-dwelling adults aged 60 years and older (n = 153).

INTERVENTION

Participants were allocated into multimodal intervention, cognitive training plus Taichi exercise, cognitive training, or control group. The multimodal intervention included 18 sessions of cognitive training, 18 sessions of Taichi, and 6 sessions of group reminiscence over six weeks.

MEASUREMENTS

Cognitive function, depressive symptoms, and psychological well-being were assessed at the baseline, postintervention, and three-month follow-up. The primary outcome was the change in overall cognition measured by the Montreal Cognitive Assessment (MoCA) and a composite cognitive score derived from a battery of neuropsychological tests.

RESULTS

For MoCA, there was no significant difference between any of the three intervention groups and controls. For composite cognition, all three intervention groups showed improvements at the three-month follow-up, with a large effect size in the cognitive training plus Taichi group (change difference 0.37, 95% CI 0.18-0.56, Hedge's g = 0.92), and medium effect sizes in the multimodal intervention group (change difference 0.23, 95% CI 0.0 -0.42, g = 0.58) and cognitive training group (change difference 0.22, 95% CI 0.03-0.42, g = 0.55).

CONCLUSIONS

Multimodal intervention, cognitive training plus Taichi, and cognitive training could foster cognitive function in community-dwelling older adults. The combination of cognitive training and Taichi showed greater efficacy than the other two interventions.

Lifestyle modification and cognitive function among individuals with resistant hypertension: cognitive outcomes from the TRIUMPH trial

BACKGROUND

Resistant hypertension is associated with increased risk of cognitive decline, stroke, and dementia. Lifestyle modification has been suggested to improve cognitive function through its salutary effects on vascular function.

METHODS

Participants included 140 patients with resistant hypertension participating in the TRIUMPH trial. Participants were randomized to a cardiac rehabilitation-based lifestyle program (C-LIFE) or a standardized education and physician advice condition (SEPA). Participants completed a 45-min cognitive test battery consisting of tests of Executive Functioning and Learning, Memory, and Processing Speed. Biomarkers of vascular [flow mediated dilation of the brachial artery (FMD)], microvascular, and cerebrovascular function were also collected, in addition to weight, fitness, and ambulatory blood pressure.

RESULTS

Participants averaged 63 years of age, 48% women, 59% black, and obese [mean BMI = 36 kg/m 2 (SD = 4)]. Cognitive performance improved across the entire cohort during the 4-month trial [ t -scores pretreatment = 48.9 (48, 50) vs. posttreatment = 50.0 (49, 51), P  < 0.001]. Postintervention Executive Function/Learning composite performance was higher for participants in C-LIFE compared to SEPA ( d  = 0.37, P  = 0.039). C-LIFE intervention effects on Memory and Processing Speed were moderated by sex and baseline stroke risk, respectively ( P  = 0.026 and P  = 0.043 for interactions), such that males and participants with greater stroke risk showed the greatest cognitive changes. FMD [C-LIFE: +0.3% (-0.3, 1.0) vs. SEPA: -1.4% (-2.5, -0.3), P  = 0.022], and microvascular function [C-LIFE: 97 (65, 130) vs. SEPA: 025 (-75, 23), P  < 0.001] were improved in C-LIFE compared with SEPA, whereas cerebrovascular reactivity was not [C-LIFE: -0.2 (-0.4, 0) vs. SEPA: 0.1 (-0.2, 0.4), P  = 0.197). Mediation analyses suggested that increased executive function/learning was associated with reduced ambulatory SBP levels secondary to weight loss [indirect effect: B  = 0.25 (0.03, 0.71)].

CONCLUSION

Lifestyle modification individuals with resistant hypertension improves cognition, which appeared to be associated with reduced ambulatory SBP changes through weight loss. Cognitive improvements were accompanied by parallel improvements in endothelial and microvascular function.

The effectiveness of a motivational enhancement smartphone application promoting lifestyle improvement for brain health: A randomized controlled trial

Multidomain lifestyle modification is considered an effective intervention for dementia prevention due to its multifactorial nature. Recognizing that participants’ activity adherence is crucial for successful lifestyle modification, our team developed a smartphone application to enhance motivation toward brain health behavior based on gamification theory, which influences behaviors by enhancing motivation. The developed smartphone application has two main functions: delivering supporting videos from family, friends, and medical staff, and self-evaluation. We assessed the effectiveness of this smartphone application with regard to brain health behavior. In this eight-week randomized controlled trial, 40 participants were randomly assigned to the smartphone application intervention group or control group. The primary outcome reflected participants’ brain health behavior in three categories: physical activity, cognitive activity, and healthy diet. Each brain health behavior was measured by the Korean version of the Global Physical Activity Questionnaire, Cognitive Activity Score, and Mediterranean DASH Intervention for Neurodegenerative Delay Diet Score. Furthermore, we investigated the change in motivation, measured by the Situational Motivation Scale. Additionally, we reviewed participants’ self-record diary during the first, fourth, and eighth week of intervention for evaluation of adherence. The intervention group was found to have a positive association with moderate metabolic equivalent activities (P = 0.01) and intrinsic motivation change (P = 0.01). There was a significant difference between the intervention and control groups regarding average physical activity at week 8 (P = 0.037). An eight-week intervention with the smartphone application induced physical activity of moderate intensity through intrinsic motivation enhancement. We suggest that the motivation enhancement application could be an efficient option for maintaining and promoting psychosocial health behavior. This smartphone application can be applied to any other disease that needs behavioral change. Through the application, a broader spectrum of the population, regardless of time, space, and human resources, can benefit from community health services.

Trial registration: Korean National Clinical Trial Registry CRIS identifier: KCT0005231.

Correlates of Adherence of Multimodal Non-pharmacological Interventions in Older Adults With Mild Cognitive Impairment: A Cross-Sectional Study

Background

Non-pharmacological interventions are promising for delaying cognitive decline in older adults with mild cognitive impairment (MCI). Although some studies have demonstrated adherence rates and factors influencing participation in single modality non-pharmacological interventions, little is known about the level and correlates of adherence to multimodal non-pharmacological interventions (MNPIs) in older adults with MCI.

Objective

This study aimed to explore the adherence level and the correlates of adherence to MNPIs in older adults with MCI.

Methods

A cross-sectional design was employed. Community-dwelling older adults aged 60 years and over were recruited from senior community centers and healthcare centers in Huzhou from March 2019 to December 2020. Data were collected by a general information questionnaire and the adherence scale of cognitive dysfunction management (AS-CDM) in older adults with MCI. Hierarchical regression analyses were applied to explore the correlates of adherence to MNPIs.

Results

A total of 216 completed questionnaires were finally analyzed. Of these, 68.52% were female, and 45.4% of the participants had no less than 6 years of education. The overall mean score for adherence was 117.58 (SD = 10.51) out of 160, equivalent to 73.49 in the hundred-mark system, indicating a medium-level adherence to MNPIs in older adults with MCI. Of the five dimensions of adherence (AS-CDM), self-efficacy scored the highest, and the lowest was perceived barriers. The univariate analysis showed that the factors associated with the adherence to MNPIs were: regular physical exercise, meat-vegetable balance, absence of multimorbidity, high level of education, living alone, and living in urban (p < 0.05). In the hierarchical regression analysis, the final model explained 18.8% of variance in overall adherence (p < 0.01), which high school (Beta = 0.161, p < 0.05), college and above more (Beta = 0.171, p < 0.05), meat-vegetarian balance (Beta = 0.228, p < 0.05), regular physical exercise (Beta = 0.234, p < 0.05), and presence of multimorbidity (Beta = -0.128, p < 0.05) significantly contributed to adherence. In addition, nearly 80% of older adults with MCI preferred MNPIs.

Conclusion

Early assessment and management of adherence to MNPIs were essential in older adults with MCI. Furthermore, the findings shed light on several critical areas of intervention to improve adherence to MNPIs in older adults with MCI.

Clinical Trial Registration

http://www.chictr.org.cn/showproj.aspx?proj=35363, ChiCTR1900020950 (Registered on January 23, 2019).

Educating the masses to address a global public health priority: The Preventing Dementia Massive Open Online Course (MOOC)

Dementia is a global public health priority and risk reduction is an important pillar of the public health response. While 40% of cases are estimated to be attributable to modifiable health and lifestyle risk factors, public awareness of the evidence is low, limiting peoples’ opportunity to adopt risk-reducing behaviours. To address this gap, we designed, implemented, and evaluated an educational intervention, the Preventing Dementia Massive Open Online Course (PDMOOC). This mixed-methods study examined the reach and impact of the free and globally available PDMOOC, to assess its potential to provide effective dementia risk reduction education to a broad international audience. Over 100,000 individuals participated in the PDMOOC across seven iterations from 2016 to 2020, with 55,739 of these consenting to participate in research. Their mean age was 49 years (SD = 15), they came from 167 different countries, and the majority were female (86%), had completed post-secondary education (77%), lived in high-income countries (93%) and worked in health care and social assistance (63%). This demographic profile changed across time, with more men, people with higher education and people from low- and middle-income countries participating in recent course iterations. Two-thirds of participants completed the PDMOOC; completion was associated with being aged 50 to 70 years, residing in a high-income country, having tertiary education, and working in the health sector. Participants reported high levels of satisfaction with the PDMOOC, improved dementia risk reduction understanding and self-efficacy, increased motivation to maintain healthy lifestyles, and, importantly, application of their learning to health behaviour change with the potential to reduce their dementia risk. The PDMOOC educated a large global audience about dementia risk reduction, which contributed to participants making risk-reducing behaviour changes. This suggests MOOCs can be a successful public health strategy to improve dementia risk reduction understanding.

A Scoping Review for Usage of Telerehabilitation among Older Adults with Mild Cognitive Impairment or Cognitive Frailty

Older adults are vulnerable towards cognitive frailty that can lead to adverse health outcomes and telerehabilitation appears to be a potential platform to reverse cognitive frailty among older adults. The aim of this coping review is to identify the usage of telerehabilitation and its common platform of delivery among older adults with mild cognitive impairment (MCI) or cognitive frailty (CF). Articles published from January 2015 until October 2020 were selected. Out of the 1738 articles retrieved, six studies were identified. Two articles were randomized controlled trials, one was a pilot study and three were qualitative studies. The outcome suggests that telerehabilitation may improve the quality of life among participants as well as it can be a useful and supportive digital platform for health care. Some types of technologies commonly used were smartphones or telephones with internet, television-based assistive integrated technology, mobile application and videoconference. Telerehabilitation utilization in managing cognitive frailty among older adults is still limited and more research is required to evaluate its feasibility and acceptability. Although telerehabilitation appears to be implemented among older adults with MCI and CF, some social support is still required to improve the adherence and effectiveness of telerehabilitation. Future research should focus on the evaluation of acceptance and participants’ existing knowledge towards telerehabilitation to achieve its target.

Determinants of Adherence to a "GRADIOR" Computer-Based Cognitive Training Program in People with Mild Cognitive Impairment (MCI) and Mild Dementia

BACKGROUND

Computer-based programs have been implemented from a psychosocial approach for the care of people with dementia (PwD). However, several factors may determine adherence of older PwD to this type of treatment. The aim of this paper was to identify the sociodemographic, cognitive, psychological, and physical-health determinants that helped predict adherence or not to a "GRADIOR" computerized cognitive training (CCT) program in people with mild cognitive impairment (MCI) and mild dementia.

METHOD

This study was part of a randomized clinical trial (RCT) (ISRCTN: 15742788). However, this study will only focus on the experimental group (n = 43) included in the RCT. This group was divided into adherent people (compliance: ≥60% of the sessions and persistence in treatment up to 4 months) and non-adherent. The participants were 60-90 age and diagnosed with MCI and mild dementia. We selected from the evaluation protocol for the RCT, tests that evaluated cognitive aspects (memory and executive functioning), psychological and physical health. The CCT with GRADIOR consisted of attending 2-3 weekly sessions for 4 months with a duration of 30 min Data analysis: Phi and Biserial-point correlations, a multiple logical regression analysis was obtained to find the adherence model and U Mann-Whitney was used.

RESULTS

The adherence model was made up of the Digit Symbol and Arithmetic of Wechsler Adult Intelligence Scale (WAIS-III) and Lexical Verbal Fluency (LVF) -R tests. This model had 90% sensitivity, 50% specificity and 75% precision. The goodness-of-fit p-value of the model was 0.02.

CONCLUSIONS

good executive functioning in attention, working memory (WM), phonological verbal fluency and cognitive flexibility predicted a greater probability that a person would be adherent.

Associations of Depressive Symptoms and Cognition in the FINGER Trial: A Secondary Analysis of a Randomised Clinical Trial

Depression and cognition are associated, but the role of depressive symptoms in lifestyle interventions to prevent dementia needs further study. We investigated the intervention effect on depressive symptoms and their associations with cognition in the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER; NCT01041989), a two-year multidomain lifestyle trial. One thousand two-hundred and sixty individuals (60-77 years) at risk for dementia were randomised into a multidomain intervention (diet, exercise, cognitive training, and vascular/metabolic risk monitoring) or control group (regular health advice). Depressive symptoms (Zung scale) and cognition (modified Neuropsychological Test Battery) were evaluated at baseline, 12, and 24 months. One thousand one-hundred and twenty-five participants had baseline Zung data. Mean Zung score decreased 0.73 (SD 5.6) points in the intervention and 0.36 (5.6) points in the control group, with nonsignificant between-group difference (group × time coefficient -0.006, 95% CI -0.019 to 0.007). Overall, higher baseline Zung score was associated with less improvement in global cognition (-0.140, p = 0.005) and memory (-0.231, p = 0.005). Participants with clinically significant baseline depressive symptoms (Zung ≥ 40 points) had less intervention benefit to executive functioning (group × time × Zung -0.096, 95% CI -0.163 to -0.028). Change in Zung score was not associated with change in cognition. Clinically significant depressive symptoms warrant more attention when designing dementia-prevention interventions.

Psychosocial determinants for adherence to a healthy lifestyle and intervention participation in the FINGER trial: an exploratory analysis of a randomised clinical trial

Background and aims

Psychosocial factors may affect adherence to lifestyle interventions and lifestyle changes. The role of psychosocial factors in dementia prevention needs more research. We aimed at clarify the issue in the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER).

Methods

The population included 1260 participants aged 60–77 years at risk for cognitive decline, randomised to a multidomain lifestyle intervention or regular health advice for 2 years. Adherence was evaluated as participation in the provided activities and actual lifestyle changes, separately for each domain (diet, exercise, social/cognitive activity, vascular risk management) and combined into multidomain. Psychosocial factors were measured at trial baseline (depressive symptoms; study perception; health-related quality of life, HRQoL) and earlier life (hopelessness; satisfaction with family life, achievements, and financial situation).

Results

Depressive symptoms, hopelessness, and nonpositive study perception were negatively and HRQoL positively associated with participation in the multidomain intervention. Depressive symptoms, lower HRQoL, hopelessness and dissatisfaction with financial situation were associated with unhealthier lifestyles at baseline. Baseline depressive symptoms and lower HRQoL predicted less improvement in lifestyle, but did not modify the intervention effect on lifestyle change.

Discussion and conclusions

Several psychosocial factors were associated with participation in lifestyle intervention, while fewer of them contributed to lifestyle changes. Although the intervention was beneficial for lifestyle changes independent of psychosocial factors, those most in need of lifestyle improvement were less likely to be active. Tailoring lifestyle-modifying strategies based on the need for psychosocial support may add efficacy in future trials.

Trial Registry

ClinicalTrials.gov NCT01041989 2010-01-05

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-022-02088-x.

Trials and Treatments for Vascular Brain Health: Risk Factor Modification and Cognitive Outcomes

There is robust evidence linking vascular health to brain health, cognition, and dementia. In this article, we present evidence from trials of vascular risk factor treatment on cognitive outcomes. We summarize findings from randomized controlled trials of antihypertensives, lipid-lowering medications, diabetes treatments (including antidiabetic drugs versus placebo, and intensive versus standard glycemic control), and multidomain interventions (that target several domains simultaneously such as control of vascular and metabolic factors, nutrition, physical activity, and cognitive stimulation etc). We report that evidence on the efficacy of vascular risk reduction interventions is promising, but not yet conclusive, and several methodological limitations hamper interpretation. Evidence mainly comes from high-income countries and, as cognition and dementia have not been the primary outcomes of many trials, evaluation of cognitive changes have often been limited. As the cognitive aging process occurs over decades, it is unclear whether treatment during the late-life window is optimal for dementia prevention, yet older individuals have been the target of most trials thus far. Further, many trials have not been powered to explore interactions with modifiers such as age, race, and apolipoprotein E, even though sub-analyses from some trials indicate that the success of interventions differs depending on patient characteristics. Due to the complex multifactorial etiology of dementia, and variations in risk factors between individuals, multidomain interventions targeting several risk factors and mechanisms are likely to be needed and the long-term sustainability of preventive interventions will require personalized approaches that could be facilitated by digital health tools. This is especially relevant during the coronavirus disease 2019 (COVID-19) pandemic, where intervention strategies will need to be adapted to the new normal, when face-to-face engagement with participants is limited and public health measures may create changes in lifestyle that affect individuals’ vascular risk profiles and subsequent risk of cognitive decline.

Psychographic Segmentation: Another Lever for Precision Population Brain Health

Dementia prevention interventions that address modifiable risk factors for dementia require extensive lifestyle and behavior changes. Strategies are needed to enhance engagement and personalization of the experience at a population level. Precision Population Brain Health aims to improve brain health across the lifespan at a population level. Psychographic segmentation is a core component of Precision Population Brain Health with untapped potential. Psychographic segmentation applies behavioral and social sciences to understanding people's motivations, values, priorities, decision making, lifestyles, personalities, communication preferences, attitudes, and beliefs. Integrating psychographic segmentation into dementia care could provide a more personalized care experience and increased patient engagement, leading to improved health outcomes and reduced costs. Psychographic segmentation can enhance patient engagement for dementia and shift the clinical paradigm from "What is the matter?" to "What matters to you?" Similar benefits of psychographic segmentation can be provided for dementia caregivers. Developing dementia prevention programs that integrate psychographic segmentation could become the basis for creating a shared framework for prevention of non-communicable diseases and brain health disorders at a population level. Integrating psychographic segmentation into digital health tools for dementia prevention programs is especially critical to overcome current suboptimal approaches. Applying psychographic segmentation to dementia prevention has the potential to help people feel a sense of empowerment over their health and improve satisfaction with their health experience-creating a culture shift in the way brain health is approached and paving the way toward Precision Population Brain Health.

Factors predicting engagement of older adults with a coach-supported eHealth intervention promoting lifestyle change, and associations between engagement and changes in cardiovascular and dementia risk: secondary analysis of an 18-month multinational randomized controlled trial

Background

Digital health interventions could help to prevent age-related diseases, but little is known about how older adults engage with such interventions, especially in the long term, or whether engagement is associated with changes in clinical, behavioral, or biological outcomes in this population. Disparities in engagement levels with digital health interventions may exist among older people and be associated with health inequalities.

Objective

This study aimed to describe older adults’ engagement with an eHealth intervention, identify factors associated with engagement, and examine associations between engagement and changes in cardiovascular and dementia risk factors (blood pressure, cholesterol, BMI, physical activity, diet, and cardiovascular and dementia risk scores).

Methods

This was a secondary analysis of the 18-month randomized controlled Healthy Ageing Through Internet Counselling in the Elderly trial of a tailored internet-based intervention encouraging behavior changes, with remote support from a lifestyle coach, to reduce cardiovascular and cognitive decline risk in 2724 individuals aged ≥65 years, recruited offline in the Netherlands, Finland, and France. Engagement was assessed via log-in frequency, number of lifestyle goals set, measurements entered and messages sent to coaches, and percentage of education materials read. Clinical and biological data were collected during in-person visits at baseline and 18 months. Lifestyle data were self-reported on a web-based platform.

Results

Of the 1389 intervention group participants, 1194 (85.96%) sent at least one message. They logged in a median of 29 times, and set a median of 1 goal. Higher engagement was associated with significantly greater improvement in biological and behavioral risk factors, with evidence of a dose-response effect. Compared with the control group, the adjusted mean difference (95% CI) in 18-month change in the primary outcome, a composite z-score comprising blood pressure, BMI, and cholesterol, was −0.08 (−0.12 to −0.03), −0.04 (−0.08 to 0.00), and 0.00 (−0.08 to 0.08) in the high, moderate, and low engagement groups, respectively. Low engagers showed no improvement in any outcome measures compared with the control group. Participants not using a computer regularly before the study engaged much less with the intervention than those using a computer up to 7 (adjusted odds ratio 5.39, 95% CI 2.66-10.95) or ≥7 hours per week (adjusted odds ratio 6.58, 95% CI 3.21-13.49). Those already working on or with short-term plans for lifestyle improvement at baseline, and with better cognition, engaged more.

Conclusions

Greater engagement with an eHealth lifestyle intervention was associated with greater improvement in risk factors in older adults. However, those with limited computer experience, who tended to have a lower level of education, or who had poorer cognition engaged less. Additional support or forms of intervention delivery for such individuals could help minimize potential health inequalities associated with the use of digital health interventions in older people.

Multi-domain interventions for the prevention of dementia and cognitive decline

BACKGROUND

Dementia is a worldwide concern. Its global prevalence is increasing. Currently, no effective medical treatment exists to cure or to delay the onset of cognitive decline or dementia. Up to 40% of dementia is attributable to potentially modifiable risk factors, which has led to the notion that targeting these risk factors might reduce the incidence of cognitive decline and dementia. Since sporadic dementia is a multifactorial condition, thought to derive from multiple causes and risk factors, multi-domain interventions may be more effective for the prevention of dementia than those targeting single risk factors.

OBJECTIVES

To assess the effects of multi-domain interventions for the prevention of cognitive decline and dementia in older adults, including both unselected populations and populations at increased risk of cognitive decline and dementia.

SEARCH METHODS

We searched ALOIS, the Cochrane Dementia and Cognitive Improvement Group's register, MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), CINAHL (EBSCOhost), Web of Science Core Collection (ISI Web of Science), LILACS (BIREME), and ClinicalTrials.gov on 28 April 2021. We also reviewed citations of reference lists of included studies, landmark papers, and review papers to identify additional studies and assessed their suitability for inclusion in the review.

SELECTION CRITERIA

We defined a multi-domain intervention as an intervention with more than one component, pharmacological or non-pharmacological, but not consisting only of two or more drugs with the same therapeutic target. We included randomised controlled trials (RCTs) evaluating the effect of such an intervention on cognitive functioning and/or incident dementia. We accepted as control conditions any sham intervention or usual care, but not single-domain interventions intended to reduce dementia risk. We required studies to have a minimum of 400 participants and an intervention and follow-up duration of at least 12 months.

DATA COLLECTION AND ANALYSIS

We initially screened search results using a 'crowdsourcing' method in which members of Cochrane's citizen science platform identify RCTs. We screened the identified citations against inclusion criteria by two review authors working independently. At least two review authors also independently extracted data, assessed the risk of bias and applied the GRADE approach to assess the certainty of evidence. We defined high-certainty reviews as trials with a low risk of bias across all domains other than blinding of participants and personnel involved in administering the intervention (because lifestyle interventions are difficult to blind). Critical outcomes were incident dementia, incident mild cognitive impairment (MCI), cognitive decline measured with any validated measure, and mortality. Important outcomes included adverse events (e.g. cardiovascular events), quality of life, and activities of daily living (ADL).  Where appropriate, we synthesised data in random-effects meta-analyses. We expressed treatment effects as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs).

MAIN RESULTS

We included nine RCTs (18.452 participants) in this review. Two studies reported incident dementia as an outcome; all nine studies reported a measure for cognitive functioning. Assessment of cognitive functioning was very heterogeneous across studies, ranging from complete neuropsychological assessments to short screening tests such as the mini-mental state examination (MMSE). The duration of the interventions varied from 12 months to 10 years. We compared multi-domain interventions against usual care or a sham intervention. Positive MDs and RRs <1 favour multi-domain interventions over control interventions. For incident dementia, there was no evidence of a difference between the multi-domain intervention group and the control group (RR 0.94, 95% CI 0.76 to 1.18; 2 studies; 7256 participants; high-certainty evidence). There was a small difference in composite Z-score for cognitive function measured with a neuropsychological test battery (NTB) (MD 0.03, 95% CI 0.01 to 0.06; 3 studies; 4617 participants; high-certainty evidence) and with the Montreal Cognitive Assessment (MoCA) scale (MD 0.76 point, 95% CI 0.05 to 1.46; 2 studies; 1554 participants), but the certainty of evidence for the MoCA was very low (due to serious risk of bias, inconsistency and indirectness) and there was no evidence of an effect on the MMSE (MD 0.02 point, 95% CI -0.06 to 0.09; 6 studies; 8697participants; moderate-certainty evidence). There was no evidence of an effect on mortality (RR 0.93, 95% CI 0.84 to 1.04; 4 studies; 11,487 participants; high-certainty evidence). There was high-certainty evidence for an interaction of the multi-domain intervention with ApoE4 status on the outcome of cognitive function measured with an NTB (carriers MD 0.14, 95% CI 0.04 to 0.25, noncarriers MD 0.04, 95% CI -0.02 to 0.10, P for interaction 0.09). There was no clear evidence for an interaction with baseline cognitive status (defined by MMSE-score) on cognitive function measured with an NTB (low baseline MMSE group MD 0.06, 95% CI 0.01 to 0.11, high baseline MMSE group MD 0.01, 95% CI -0.01 to 0.04, P for interaction 0.12), nor was there clear evidence for an effect in participants with a Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) score > 6 points (MD 0.07, 95%CI -0.00 to 0.15).

AUTHORS' CONCLUSIONS

We found no evidence that multi-domain interventions can prevent incident dementia based on two trials. There was a small improvement in cognitive function assessed by a NTB in the group of participants receiving a multi-domain intervention, although this effect was strongest in trials offering cognitive training within the multi-domain intervention, making it difficult to rule out a potential learning effect. Interventions were diverse in terms of their components and intensity.

The effect of adherence on cognition in a multidomain lifestyle intervention (FINGER)

INTRODUCTION

Lifestyle interventions may prevent cognitive decline, but the sufficient dose of intervention activities and lifestyle changes is unknown. We investigated how intervention adherence affects cognition in the FINGER trial (pre-specified subgroup analyses).

METHODS

FINGER is a multicenter randomized controlled trial examining the efficacy of multidomain lifestyle intervention (ClinicalTrials.gov NCT01041989). A total of 1260 participants aged 60 to 77 with increased dementia risk were randomized to a lifestyle intervention and control groups. Percentage of completed intervention sessions, and change in multidomain lifestyle score (self-reported diet; physical, cognitive, and social activity; vascular risk) were examined in relation to change in Neuropsychological Test Battery (NTB) scores.

RESULTS

Active participation was associated with better trajectories in NTB total and all cognitive subdomains. Improvement in lifestyle was associated with improvement in NTB total and executive function.

DISCUSSION

Multidomain lifestyle changes are beneficial for cognitive functioning, but future interventions should be intensive enough, and supporting adherence is essential.

Multidomain interventions: state-of-the-art and future directions for protocols to implement precision dementia risk reduction. A user manual for Brain Health Services-part 4 of 6

Although prevention of dementia and late-life cognitive decline is a major public health priority, there are currently no generally established prevention strategies or operational models for implementing such strategies into practice. This article is a narrative review of available evidence from multidomain dementia prevention trials targeting several risk factors and disease mechanisms simultaneously, in individuals without dementia at baseline. Based on the findings, we formulate recommendations for implementing precision risk reduction strategies into new services called Brain Health Services. A literature search was conducted using medical databases (MEDLINE via PubMed and SCOPUS) to select relevant studies: non-pharmacological multidomain interventions (i.e., combining two or more intervention domains), target population including individuals without dementia, and primary outcomes including cognitive/functional performance changes and/or incident cognitive impairment or dementia. Further literature searches covered the following topics: sub-group analyses assessing potential modifiers for the intervention effect on cognition in the multidomain prevention trials, dementia risk scores used as surrogate outcomes in multidomain prevention trials, dementia risk scores in relation to brain pathology markers, and cardiovascular risk scores in relation to dementia. Multidomain intervention studies conducted so far appear to have mixed results and substantial variability in target populations, format and intensity of interventions, choice of control conditions, and outcome measures. Most trials were conducted in high-income countries. The differences in design between the larger, longer-term trials that met vs. did not meet their primary outcomes suggest that multidomain intervention effectiveness may be dependent on a precision prevention approach, i.e., successfully identifying the at-risk groups who are most likely to benefit. One such successful trial has already developed an operational model for implementing the intervention into practice. Evidence on the efficacy of risk reduction interventions is promising, but not yet conclusive. More long-term multidomain randomized controlled trials are needed to fill the current evidence gaps, especially concerning low- and middle-income countries and integration of dementia prevention with existing cerebrovascular prevention programs. A precision risk reduction approach may be most effective for dementia prevention. Such an approach could be implemented in Brain Health Services.

The Japan-Multimodal Intervention Trial for Prevention of Dementia (J-MINT): The Study Protocol for an 18-Month, Multicenter, Randomized, Controlled Trial

Background/Objectives

The Japan-multimodal intervention trial for prevention of dementia (J-MINT) is intended to verify the effectiveness of multi-domain interventions and to clarify the mechanism of cognitive improvement and deterioration by carrying out assessment of dementia-related biomarkers, omics analysis and brain imaging analysis among older adults at high risk of dementia. Moreover, the J-MINT trial collaborates with partnering private enterprises in the implementation of relevant interventional measures. This manuscript describes the study protocol.

Design/Setting

Eighteen-month, multi-centered, randomized controlled trial.

Participants

We plan to recruit 500 older adults aged 65–85 years with mild cognitive impairment. Subjects will be centrally randomized into intervention and control groups at a 1:1 allocation ratio using the dynamic allocation method with all subjects stratified by age, sex, and cognition.

Intervention

The multi-domain intervention program includes: (1) management of vascular risk factors; (2) group-based physical exercise and self-monitoring of physical activity; (3) nutritional counseling; and (4) cognitive training. Health-related information will be provided to the control group every two months.

Measurements

The primary and secondary outcomes will be assessed at baseline, 6-, 12-, and 18-month follow-up. The primary outcome is the change from baseline to 18 months in a global composite score combining several neuropsychological domains. Secondary outcomes include: cognitive change in each neuropsychological test, incident dementia, changes in blood and dementia-related biomarkers, changes in geriatric assessment including activities of daily living, frailty status and neuroimaging, and number of medications taken.

Conclusions

This trial that enlist the support of private enterprises will lead to the creation of new services for dementia prevention as well as to verify the effectiveness of multi-domain interventions for dementia prevention.

Electronic Supplementary Material

Supplementary material is available for this article at 10.14283/jpad.2021.29 and is accessible for authorized users.

Disparities in the participation and adherence of older adults in lifestyle-based multidomain dementia prevention and the motivational role of perceived disease risk and intervention benefits: an observational ancillary study to a randomised controlled trial

Background

Preventive interventions for dementia are urgently needed and must be tested in randomised controlled trials (RCTs). Selection (volunteer) bias may limit efficacy, particularly in trials testing multidomain interventions and may also be indicative of disparities in intervention uptake in real-world settings. We identified factors associated with participation and adherence in a 3-year RCT of multidomain lifestyle intervention and/or omega-3 supplementation for prevention of cognitive decline and explored reasons for (non-) participation.

Methods

Ancillary study during recruitment and follow-up of the 3-year Multidomain Alzheimer Preventive Trial (MAPT) conducted in in 13 memory centres in France and Monaco, involving 1630 community-dwelling dementia-free individuals aged ≥ 70 who were pre-screened for MAPT (1270 participated in MAPT; 360 declined to participate).

Results

Response rates were 76% amongst MAPT participants and 53% amongst non-participants. Older individuals (odds ratio 0.94 [95% confidence interval 0.91–0.98] and those with higher anxiety (0.61 [0.47–0.79]) were less likely to participate in the trial. Those with higher income (4.42 [2.12–9.19]) and family history (1.60 [1.10–2.32]) or greater fear (1.73 [1.30–2.29]) of dementia were more likely to participate, as were those recruited via an intermediary (e.g. pension funds, local Alzheimer’s associations, University of the 3rd Age, sports clubs) (2.15 [1.45–3.20]). MAPT participants living in larger towns (0.71 [0.55–0.92]) and with higher depressive symptoms (0.94 [0.90–0.99]) were less likely to adhere to the interventions. Greater perceived social support (1.21 [1.03–1.43]) and cognitive function (1.37 [1.13–1.67]) predicted better adherence. Descriptively, the most frequent reasons for accepting and refusing to participate were, respectively, altruism and logistical constraints, but underlying motivations mainly related to (lack of) perceived benefits.

Conclusions

Disparities in uptake of health interventions persist in older age. Those most at risk of dementia may not participate in or adhere to preventive interventions. Barriers to implementing lifestyle changes for dementia prevention include lack of knowledge about potential benefits, lack of support networks, and (perceived) financial costs.

Trial registration

NCT00672685 (ClinicalTrials.gov)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13195-021-00904-6.

General population perspectives of dementia risk reduction and the implications for intervention: A systematic review and thematic synthesis of qualitative evidence

BACKGROUND

Evidence for the potential prevention of dementia through lifestyle risk factor modification is growing and has prompted examination of implementation approaches. Understanding the general population's perspectives regarding dementia risk reduction is key to implementation. This may provide useful insights into more effective and efficient ways to help people change relevant beliefs, motivations and behaviour patterns. We conducted a systematic review and thematic synthesis of qualitative evidence to develop an integrated model of general population dementia risk reduction perspectives and the implications for intervention in research and implementation contexts.

METHODS AND FINDINGS

We searched electronic databases, supplemented by lateral search techniques, to identify studies published since 1995 reporting qualitative dementia risk reduction perspectives of the non-expert general population who do not have dementia. Thematic synthesis, incorporating an expert panel discussion, was used to identify overarching themes and develop an integrated model to guide intervention to support individuals to adopt and maintain dementia risk reduction behaviour patterns. Quality of included studies and confidence in review findings were systematically appraised. We included 50 papers, reflecting the views of more than 4,500 individuals. Main themes were: 1) The need for effective education about a complex topic to prevent confusion and facilitate understanding and empowerment; 2) Personally relevant short- and long-term benefits of dementia risk reduction behaviour patterns can generate value and facilitate action; 3) Individuals benefit from trusted, reliable and sensitive support to convert understanding to personal commitment to relevant behaviour change; 4) Choice, control and relevant self-regulatory supports help individuals take-action and direct their own progress; 5) Collaborative and empowering social opportunities can facilitate and propagate dementia risk reduction behaviour change; 6) Individual behaviour patterns occur in social contexts that influence beliefs through heuristic processes and need to be understood. Findings indicate that, for intervention: 1) education is key, but both content and delivery need to be tailored; 2) complementary interventions to support self-regulation mechanisms and social processes will increase education effectiveness; 3) co-design principles should guide intervention design and delivery processes; 4) all interventions need to be supported by context-specific data.

CONCLUSIONS

This systematic review and thematic synthesis provides a comprehensive, integrated model of the dementia risk reduction perspectives of the general population and intervention approaches to support behaviour change that can be applied in clinical trial and real-world implementation settings. Findings extend existing knowledge and may assist more effective intervention design and delivery.

Facility-based and home-based multidomain interventions including cognitive training, exercise, diet, vascular risk management, and motivation for older adults: a randomized controlled feasibility trial

We aimed to evaluate the feasibility of multidomain intervention (MI) tailored to the Korean context. In an outcome assessor-blinded, randomized controlled trial, participants without dementia and with one or more modifiable dementia risk factors, aged 60-79 years, were randomly assigned to the facility-based MI (FMI; n=51), the home-based MI (HMI; n=51), or the control group receiving general health advice (n=50). The 24-week intervention comprised vascular risk management, cognitive training, social activity, physical exercise, nutrition guidance, and motivational enhancement. The FMI participants performed all intervention programs at a facility three times a week. The HMI participants performed some programs at a facility once every 1-2 weeks and performed others at home. The primary outcome was feasibility measured through retention, adherence, and at least no differences from the control group in the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). In the FMI and HMI groups, the retention rates were 88.2% and 96.1%, and adherence to the intervention was 94.5% and 96.8%, respectively. The RBANS total scale index score improved significantly in the FMI (5.46 ± 7.50, P = 0.004) and HMI (5.50 ± 8.14, P = 0.004) groups compared to the control group (-0.74 ± 11.51). The FMI and HMI are feasible and there are indicators of efficacy.

Impact of Transcranial Direct Current Stimulation on Cognitive Function, Brain Functional Segregation, and Integration in Patients with Mild Cognitive Impairment According to Amyloid-Beta Deposition and APOE ε4-Allele: A Pilot Study

Anodal transcranial direct current stimulation (anodal-tDCS) is known to improve cognition and normalize abnormal network configuration during resting-state functional magnetic resonance imaging (fMRI) in patients with mild cognitive impairment (MCI). We aimed to evaluate the impact of sequential anodal-tDCS on cognitive functions, functional segregation, and integration parameters in patients with MCI, according to high-risk factors for Alzheimer’s disease (AD): amyloid-beta (Aβ) deposition and APOE ε4-allele status. In 32 patients with MCI ([¹⁸ F] flutemetamol-: n = 10, [¹⁸ F] flutemetamol+: n = 22; APOE ε4-: n = 13, APOE ε4+: n = 19), we delivered anodal-tDCS (2 mA/day, five times/week, for 2 weeks) over the left dorsolateral prefrontal cortex and assessed the neuropsychological test battery and resting-state fMRI measurements before and after 2 weeks stimulation. We observed a non-significant impact of an anodal-tDCS on changes in neuropsychological battery scores between MCI patients with and without high-risk factors of AD, Aβ retention and APOE ε4-allele. However, there was a significant difference in brain functional segregation and integration parameters between MCI patients with and without AD high-risk factors. We also found a significant effect of tDCS-by-APOE ε4-allele interaction on changes in the functional segregation parameter of the temporal pole. In addition, baseline Aβ deposition significantly associated negatively with change in global functional integrity of hippocampal formation. Anodal-tDCS might help to enhance restorative and compensatory intrinsic functional changes in MCI patients, modulated by the presence of Aβ retention and the APOE ε4-allele.