Individualized clinical management of patients at risk for Alzheimer's dementia

Prevalence and population attributable fractions of potentially modifiable risk factors for dementia in Canada: A cross-sectional analysis of the Canadian Longitudinal Study on Aging

OBJECTIVES

We investigated the prevalence and population attributable fraction (PAF) of 12 potentially modifiable risk factors for dementia in middle-aged and older Canadians.

METHODS

We conducted a cross-sectional study of 30,097 adults aged 45 to 85 with baseline data from the Canadian Longitudinal Study on Aging (2011‒2015). Risk factors and associated relative risks were taken from a highly cited systematic review. We calculated the prevalence of each risk factor using sampling weights. Individual PAFs were calculated both crudely and weighted for communality, and combined PAFs were calculated using both multiplicative and additive assumptions. Analyses were stratified by household income and repeated at CLSA's first follow-up (2015‒2018).

RESULTS

The most prevalent risk factors were physical inactivity (63.8%; 95% CI, 62.8-64.9), hypertension (32.8%; 31.7-33.8), and obesity (30.8%; 29.7-31.8). The highest crude PAFs were physical inactivity (19.9%), traumatic brain injury (16.7%), and hypertension (16.6%). The highest weighted PAFs were physical inactivity (11.6%), depression (7.7%), and hypertension (6.0%). We estimated that the 12 risk factors combined accounted for 43.4% (37.3‒49.0) of dementia cases assuming weighted multiplicative interactions and 60.9% (55.7‒65.5) assuming additive interactions. There was a clear gradient of increasing prevalence and PAF with decreasing income for 9 of the 12 risk factors.

CONCLUSION

The findings of this study can inform individual- and population-level dementia prevention strategies in Canada. Differences in the impact of individual risk factors between this study and other international and regional studies highlight the importance of tailoring national dementia strategies to the local distribution of risk factors.

Bibliometric analysis of research trends on factors affecting older adults with mild cognitive impairment

Background

In recent years, the problem of cognitive impairment in the elderly has become increasingly prominent. Understanding the research trend of influencing factors of mild cognitive impairment, and provide reference for medical staff to early screening of the elderly with mild cognitive impairment.

Objective

Through the visual analysis of the influence factors of the elderly with mild cognitive impairment, the current research status was discussed.

Methods

The relevant literature in the field of influencing factors of mild cognitive impairment in the elderly included in the Web of Science core collection database from 2013 to 2022 was searched. Using software such as Cite Space and VOS viewer to visually analyze literature citations, country, keywords, and development trends.

Results

A total of 547 relevant literatures were included, and the number of publications showed an increasing trend in the past ten years. The United States ranked first in both the number of published papers (157) and centrality (0.34), and the United States and China had a greater influence on the influencing factors of mild cognitive impairment. Alzheimer's disease, cognitive decline, the elderly, risk factors, are the research hotspot in this field.

Conclusion

Cognitive decline will affect the autonomy of the elderly. Cognitive frailty, MRI is the forefront of MCI research, to understand the research hotspots and frontiers in this field, to conduct early screening and intervention guidance for people with mild cognitive impairment, so as to delay the occurrence of Alzheimer's disease, and reduce the pressure on family caregivers and society.

Toolkit to Examine Lifelike Language v.2.0: Optimizing Speech Biomarkers of Neurodegeneration

INTRODUCTION

The Toolkit to Examine Lifelike Language (TELL) is a web-based application providing speech biomarkers of neurodegeneration. After deployment of TELL v.1.0 in over 20 sites, we now introduce TELL v.2.0.

METHODS

First, we describe the app's usability features, including functions for collecting and processing data onsite, offline, and via videoconference. Second, we summarize its clinical survey, tapping on relevant habits (e.g., smoking, sleep) alongside linguistic predictors of performance (language history, use, proficiency, and difficulties). Third, we detail TELL's speech-based assessments, each combining strategic tasks and features capturing diagnostically relevant domains (motor function, semantic memory, episodic memory, and emotional processing). Fourth, we specify the app's new data analysis, visualization, and download options. Finally, we list core challenges and opportunities for development.

RESULTS

Overall, TELL v.2.0 offers scalable, objective, and multidimensional insights for the field.

CONCLUSION

Through its technical and scientific breakthroughs, this tool can enhance disease detection, phenotyping, and monitoring.

Association between Multi-Domain Lifestyle and Objective Cognitive Impairment in Elderly People with SCD and MCI in Chinese Communities

OBJECTIVES

Controlling the lifestyle associated with dementia risk can delay the process of cognitive decline. Subjective cognitive decline (SCD) and mild cognitive impairment (MCI) are early states in the development of dementia and are also the window period for early intervention in dementia. The purpose of this study was to explore the association between multi-domain lifestyle and objective cognitive impairment in elderly people with SCD and MCI in Chinese communities and to provide reference for effective implementation of precise health management measures to reduce the risk of dementia.

METHODS

A total of 265 middle-aged and elderly volunteers recruited from the community were divided into SCD group (107 cases), MCI group (80 cases), and healthy control (HC) group (78 cases). All participants received clinical interview, examination, and cognitive assessments.

RESULTS

The total Dementia Risk Reduction Lifestyle Scale (DRRLS) scores in the HC, SCD, and MCI groups [110.00 (11.25) vs. 101.00 (10.00) vs. 79.50 (20.75)] exhibited statistically significant differences among them. The total score of the DRRLS showed a significant negative correlation with the Trail-Making Test (TMT), and significant positive correlations with both the Verbal Fluency Test (VFT) and Auditory Verbal Learning Test (AVLT) scores (p < 0.05). After adjusting for confounding factors, such as age and years of education, multiple linear regression analysis revealed several points. In the SCD group, brain-strengthening exercise and interpersonal relationship scores were negatively correlated with TMT scores (β = -11.257, -15.077; all p < 0.05), while health responsibility, smoking control behavior, and interpersonal relationship scores were positively correlated with AVLT scores (β = 0.485, 0.344, and 0.406; all p < 0.05). In the MCI Group, brain-strengthening exercise, brain-healthy diet, and interpersonal relationship were negatively correlated with TMT (β = -22.011, -16.206, -11.696; all p < 0.01), whereas health responsibility, mental activity, smoking control behavior, interpersonal relationship, and stress management were positively correlated with AVLT (β = 0.450, 0.435, 0.308, 0.256, 0.607; all p < 0.05).

CONCLUSIONS

In Chinese communities, the unhealthy lifestyle of elderly individuals with SCD and MCI is significantly associated with cognitive function impairment. The greater their unhealthy lifestyle habits, the more pronounced the scope and severity of cognitive function impairment becomes. Furthermore, different dimensions of lifestyle have varying impacts on cognitive domains.

Pregnancy as a window of opportunity for dementia prevention: a narrative review

Dementia is a debilitating condition with a disproportionate impact on women. While sex differences in longevity contribute to the disparity, the role of the female sex as a biological variable in disease progression is not yet fully elucidated. Metabolic dysfunctions are drivers of dementia etiology, and cardiometabolic diseases are among the most influential modifiable risk factors. Pregnancy is a time of enhanced vulnerability for metabolic disorders. Many dementia risk factors, such as hypertension or blood glucose dysregulation, often emerge for the first time in pregnancy. While such cardiometabolic complications in pregnancy pose a risk to the health trajectory of a woman, increasing her odds of developing type 2 diabetes or chronic hypertension, it is not fully understood how this relates to her risk for dementia. Furthermore, structural and functional changes in the maternal brain have been reported during pregnancy suggesting it is a time of neuroplasticity for the mother. Therefore, pregnancy may be a window of opportunity to optimize metabolic health and support the maternal brain. Healthy dietary patterns are known to reduce the risk of cardiometabolic diseases and have been linked to dementia prevention, yet interventions targeting cognitive function in late life have largely been unsuccessful. Earlier interventions are needed to address the underlying metabolic dysfunctions and potentially reduce the risk of dementia, and pregnancy offers an ideal opportunity to intervene. This review discusses current evidence regarding maternal brain health and the potential window of opportunity in pregnancy to use diet to address neurological health disparities for women.

Association between experiencing low healthcare quality and developing dementia

BACKGROUND

Low healthcare quality has been found to predict the development of a number of illnesses in older adults. However, it has not been investigated as a determinant of dementia. Thus, the goal of this study was to assess whether experiencing low healthcare quality is associated with developing dementia in people aged 60 and older.

METHODS

Participants in the Health and Retirement Study, without dementia and aged 60 and older at baseline, were followed from 2006 to 2019. Experiencing low healthcare quality was assessed at baseline through questions about healthcare discrimination and dissatisfaction with healthcare services. The outcome, development of new cases of dementia, was determined through physician diagnosis or a cognition score compatible with dementia (assessed by the Telephone Interview for Cognitive Status). Cox regression was used to estimate the hazard ratio (HR) of dementia, adjusting for participants' demographic, health, and socioeconomic factors.

RESULTS

Among the 3795 participants included in the cohort, 700 developed dementia. Experiencing low healthcare quality was associated with increased dementia risk over 12 years (unadjusted HR: 1.68, 95% CI: 1.27-2.21, p-value <0.001; fully adjusted HR: 1.50, 95% CI: 1.12-2.01, p-value: 0.006). Healthcare discrimination and dissatisfaction with the healthcare quality received were independently associated with increased dementia risk.

CONCLUSIONS

As predicted, experiencing low healthcare quality was associated with greater dementia risk. To date, most measures to reduce dementia have focused on individual-level behaviors. Our findings suggest that implementing structural changes to improve healthcare quality delivery for older persons could reduce dementia prevalence.

Detecting mild cognitive impairment remotely with the modified memory impairment screen by telephone

The original Memory Impairment Screen by Telephone (MIST) was designed to identify individuals with dementia but was relatively ineffective for identification of less severe impairment observed in mild cognitive impairment (MCI). We expanded the original MIST to create a modified instrument (mMIST) with greater sensitivity to less severe memory impairment. Older men and women with subjective cognitive decline were assessed by phone with the mMIST and subsequently classified independently with MCI or non-pathological cognitive decline. Participants with MCI produced lower scores on the mMIST than did participants without MCI, 10.8 ± 2.7 vs 13.3 ± 1.3, t = 5.68, p < 0.001, and performance on the mMIST predicted performances on the California Verbal Learning Test (CVLT), Verbal Paired Associate Learning Test (VPAL), Montreal Cognitive Assessment (MoCA) total score, and MoCA memory index score, p < 0.001. Receiver operating characteristic (ROC) analyses identified the optimal cut score on the mMIST to distinguish participants with and without MCI with Sensitivity = 73.1%, Specificity = 79.1%, and AUC = 0.79. Predictive values for distinguishing the amnestic form of MCI (aMCI) from non-amnestic MCI were Sensitivity = 81.8%, Specificity = 30%, and AUC = 0.82. These findings indicate that the mMIST is a valid screening instrument for identifying MCI. It can be administered remotely at low cost and low participant burden. Also, the mMIST has potential utility for remote cross-sectional and longitudinal evaluation in research and clinical contexts. Further investigation is indicated to corroborate its utility for assessment of aging patients and research participants.

Toolkit to Examine Lifelike Language (TELL): An app to capture speech and language markers of neurodegeneration

Automated speech and language analysis (ASLA) is a promising approach for capturing early markers of neurodegenerative diseases. However, its potential remains underexploited in research and translational settings, partly due to the lack of a unified tool for data collection, encryption, processing, download, and visualization. Here we introduce the Toolkit to Examine Lifelike Language (TELL) v.1.0.0, a web-based app designed to bridge such a gap. First, we outline general aspects of its development. Second, we list the steps to access and use the app. Third, we specify its data collection protocol, including a linguistic profile survey and 11 audio recording tasks. Fourth, we describe the outputs the app generates for researchers (downloadable files) and for clinicians (real-time metrics). Fifth, we survey published findings obtained through its tasks and metrics. Sixth, we refer to TELL's current limitations and prospects for expansion. Overall, with its current and planned features, TELL aims to facilitate ASLA for research and clinical aims in the neurodegeneration arena. A demo version can be accessed here:  https://demo.sci.tellapp.org/ .

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).

Neurocognitive Effects of an Online Brain Health Program and Weekly Telehealth Support Group in Older Adults with Subjective Memory Loss: A Pilot Study

INTRODUCTION

Adopting healthy lifestyle behaviors has the potential to slow cognitive decline in older adults by reducing risks associated with dementia. Curriculum-based group health coaching may aid in establishing behavior change centered for dementia risk factors.

METHODS

In this pilot clinical care patient group study (n = 6), we examined the effects of a six-month online Cognitive Health Program combined with a weekly telehealth support group led by the course creator, and personalized health optimization by a collaborating physician, in older adults with subjective cognitive decline. Cognition was assessed at baseline and post-intervention using a computerized battery.

RESULTS

Cognitive changes were estimated with nonparametric tests and effect sizes (Cohen's d). Results showed significant improvements in global cognition (p < 0.03, d = 1.6), spatial planning (p < 0.01, d = 2.3), and visuospatial processing (p < 0.05, d = 1.1) compared to baseline. Participants reported high levels of satisfaction with the virtual group format and online curriculum.

CONCLUSIONS

This small pilot study suggests that a virtual six-month personalized health coaching group with self-paced online health education is feasible and potentially efficacious for improving cognition in participants with subjective cognitive complaints. This format may facilitate behavior change to slow cognitive decline. Future studies should include a control group, a larger, more diverse sample as well as assessing mood and other subjective measures.

The need for systems thinking to advance Alzheimer's disease research

Despite extensive research efforts to mechanistically understand late-onset Alzheimer's disease (LOAD) and other complex mental health disorders, curative treatments remain elusive. We emphasize the multiscale multicausality inherent to LOAD, highlighting the interplay between interconnected pathophysiological processes and risk factors. Systems thinking methods, such as causal loop diagrams and systems dynamic models, offer powerful means to capture and study this complexity. Recent studies developed and validated a causal loop diagram and system dynamics model using multiple longitudinal data sets, enabling the simulation of personalized interventions on various modifiable risk factors in LOAD. The results indicate that targeting factors like sleep disturbance and depressive symptoms could be promising and yield synergistic benefits. Furthermore, personalized interventions showed significant potential, with top-ranked intervention strategies differing significantly across individuals. We argue that systems thinking approaches can open new prospects for multifactorial precision medicine. In future research, systems thinking may also guide structured, model-driven data collection on the multiple interactions in LOAD's complex multicausality, facilitating theory development and possibly resulting in effective prevention and treatment options.

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.

A how-to guide for a precision medicine approach to the diagnosis and treatment of Alzheimer's disease

Article purpose

The clinical approach to Alzheimer's disease (AD) is challenging, particularly in high-functioning individuals. Accurate diagnosis is crucial, especially given the significant side effects, including brain hemorrhage, of newer monoclonal antibodies approved for treating earlier stages of Alzheimer's. Although early treatment is more effective, early diagnosis is also more difficult. Several clinical mimickers of AD exist either separately, or in conjunction with AD pathology, adding to the diagnostic complexity. To illustrate the clinical decision-making process, this study includes de-identified cases and reviews of the underlying etiology and pathology of Alzheimer's and available therapies to exemplify diagnostic and treatment subtleties.

Problem

The clinical presentation of Alzheimer's is complex and varied. Multiple other primary brain pathologies present with clinical phenotypes that can be difficult to distinguish from AD. Furthermore, Alzheimer's rarely exists in isolation, as almost all patients also show evidence of other primary brain pathologies, including Lewy body disease and argyrophilic grain disease. The phenotype and progression of AD can vary based on the brain regions affected by pathology, the coexistence and severity of other brain pathologies, the presence and severity of systemic comorbidities such as cardiac disease, the common co-occurrence with psychiatric diagnoses, and genetic risk factors. Additionally, symptoms and progression are influenced by an individual's brain reserve and cognitive reserve, as well as the timing of the diagnosis, which depends on the demographics of both the patient and the diagnosing physician, as well as the availability of biomarkers.

Methods

The optimal clinical and biomarker strategy for accurately diagnosing AD, common neuropathologic co-morbidities and mimickers, and available medication and non-medication-based treatments are discussed. Real-life examples of cognitive loss illustrate the diagnostic and treatment decision-making process as well as illustrative treatment responses.

Implications

AD is best considered a syndromic disorder, influenced by a multitude of patient and environmental characteristics. Additionally, AD existing alone is a unicorn, as there are nearly always coexisting other brain pathologies. Accurate diagnosis with biomarkers is essential. Treatment response is affected by the variables involved, and the effective treatment of Alzheimer's disease, as well as its prevention, requires an individualized, precision medicine strategy.

Sex-based differences in effector cells of the adaptive immune system during Alzheimer's disease and related dementias

Neurological conditions such as Alzheimer's disease (AD) and related dementias (ADRD) present with many challenges due to the heterogeneity of the related disease(s), making it difficult to develop effective treatments. Additionally, the progression of ADRD-related pathologies presents differently between men and women. With two-thirds of the population affected with ADRD being women, ADRD has presented itself with a bias toward the female population. However, studies of ADRD generally do not incorporate sex-based differences in investigating the development and progression of the disease, which is detrimental to understanding and treating dementia. Additionally, recent implications for the adaptive immune system in the development of ADRD bring in new factors to be considered as part of the disease, including sex-based differences in immune response(s) during ADRD development. Here, we review the sex-based differences of pathological hallmarks of ADRD presentation and progression, sex-based differences in the adaptive immune system and how it changes with ADRD, and the importance of precision medicine in the development of a more targeted and personalized treatment for this devastating and prevalent neurodegenerative condition.

Diet and lifestyle impact the development and progression of Alzheimer's dementia

Dementia is a growing public health concern, with an estimated prevalence of 57 million adults worldwide. Alzheimer's disease (AD) accounts for 60-80% of the cases. Clinical trials testing potential drugs and neuroprotective agents have proven futile, and currently approved drugs only provide symptomatic benefits. Emerging epidemiological and clinical studies suggest that lifestyle changes, including diet and physical activity, offer an alternative therapeutic route for slowing and preventing cognitive decline and dementia. Age is the single most common risk factor for dementia, and it is associated with slowing cellular bioenergetics and metabolic processes. Therefore, a nutrient-rich diet is critical for optimal brain health. Furthermore, type 2 diabetes (T2D) is a risk factor for AD, and diets that reduce the risk of T2D may confer neuroprotection. Foods predominant in Mediterranean, MIND, and DASH diets, including fruits, leafy green vegetables, fish, nuts, and olive oil, may prevent or slow cognitive decline. The mechanisms by which these nutrients promote brain health, however, are not yet completely understood. Other dietary approaches and eating regimes, including ketogenic and intermittent fasting, are also emerging as beneficial for brain health. This review summarizes the pathophysiology, associated risk factors, and the potential neuroprotective pathways activated by several diets and eating regimes that have shown promising results in promoting brain health and preventing dementia.

Simulating the multicausality of Alzheimer's disease with system dynamics

INTRODUCTION

In Alzheimer's disease (AD), cognitive decline is driven by various interlinking causal factors. Systems thinking could help elucidate this multicausality and identify opportune intervention targets.

METHODS

We developed a system dynamics model (SDM) of sporadic AD with 33 factors and 148 causal links calibrated with empirical data from two studies. We tested the SDM's validity by ranking intervention outcomes on 15 modifiable risk factors to two sets of 44 and 9 validation statements based on meta-analyses of observational data and randomized controlled trials, respectively.

RESULTS

The SDM answered 77% and 78% of the validation statements correctly. Sleep quality and depressive symptoms yielded the largest effects on cognitive decline with which they were connected through strong reinforcing feedback loops, including via phosphorylated tau burden.

DISCUSSION

SDMs can be constructed and validated to simulate interventions and gain insight into the relative contribution of mechanistic pathways.

Urinary dysfunction in patients with vascular cognitive impairment

Vascular cognitive impairment (VCI) is caused by vascular pathologies, with the spectrum of cognitive disorders ranging from subjective cognitive dysfunction to dementia. Particularly among older adults, cognitive impairment is often complicated with urinary dysfunction (UD); some patients may present with UD before cognitive impairment owing to stroke or even when there are white matter hyperintensities on imaging studies. Patients with cognitive impairment often have both language and movement dysfunction, and thus, UD in patients with VCI can often be underdiagnosed and remain untreated. UD has an impact on the quality of life of patients and caregivers, often leading to poor outcomes. Medical history is an important aspect and should be taken from both patients and their caregivers. Clinical assessment including urinalysis, voiding diary, scales on UD and cognitive impairment, post-void residual volume measurement, uroflowmetry, and (video-) urodynamics should be performed according to indication. Although studies on UD with VCI are few, most of them show that an overactive bladder (OAB) is the most common UD type, and urinary incontinence is the most common symptom. Normal urine storage and micturition in a specific environment are complex processes that require a sophisticated neural network. Although there are many studies on the brain-urinary circuit, the specific circuit involving VCI and UD remains unclear. Currently, there is no disease-modifying pharmacological treatment for cognitive impairment, and anti-acetylcholine drugs, which are commonly used to treat OAB, may cause cognitive impairment, leading to a vicious circle. Therefore, it is important to understand the complex interaction between UD and VCI and formulate individualized treatment plans. This review provides an overview of research advances in clinical features, imaging and pathological characteristics, and treatment options of UD in patients with VCI to increase subject awareness, facilitate research, and improve diagnosis and treatment rates.

Rationale for a Multi-Factorial Approach for the Reversal of Cognitive Decline in Alzheimer's Disease and MCI: A Review

Alzheimer's disease (AD) is a multifactorial, progressive, neurodegenerative disease typically characterized by memory loss, personality changes, and a decline in overall cognitive function. Usually manifesting in individuals over the age of 60, this is the most prevalent type of dementia and remains the fifth leading cause of death among Americans aged 65 and older. While the development of effective treatment and prevention for AD is a major healthcare goal, unfortunately, therapeutic approaches to date have yet to find a treatment plan that produces long-term cognitive improvement. Drugs that may be able to slow down the progression rate of AD are being introduced to the market; however, there has been no previous solution for preventing or reversing the disease-associated cognitive decline. Recent studies have identified several factors that contribute to the progression and severity of the disease: diet, lifestyle, stress, sleep, nutrient deficiencies, mental health, socialization, and toxins. Thus, increasing evidence supports dietary and other lifestyle changes as potentially effective ways to prevent, slow, or reverse AD progression. Studies also have demonstrated that a personalized, multi-therapeutic approach is needed to improve metabolic abnormalities and AD-associated cognitive decline. These studies suggest the effects of abnormalities, such as insulin resistance, chronic inflammation, hypovitaminosis D, hormonal deficiencies, and hyperhomocysteinemia, in the AD process. Therefore a personalized, multi-therapeutic program based on an individual's genetics and biochemistry may be preferable over a single-drug/mono-therapeutic approach. This article reviews these multi-therapeutic strategies that identify and attenuate all the risk factors specific to each affected individual. This article systematically reviews studies that have incorporated multiple strategies that target numerous factors simultaneously to reverse or treat cognitive decline. We included high-quality clinical trials and observational studies that focused on the cognitive effects of programs comprising lifestyle, physical, and mental activity, as well as nutritional aspects. Articles from PubMed Central, Scopus, and Google Scholar databases were collected, and abstracts were reviewed for relevance to the subject matter. Epidemiological, pathological, toxicological, genetic, and biochemical studies have all concluded that AD represents a complex network insufficiency. The research studies explored in this manuscript confirm the need for a multifactorial approach to target the various risk factors of AD. A single-drug approach may delay the progression of memory loss but, to date, has not prevented or reversed it. Diet, physical activity, sleep, stress, and environment all contribute to the progression of the disease, and, therefore, a multi-factorial optimization of network support and function offers a rational therapeutic strategy. Thus, a multi-therapeutic program that simultaneously targets multiple factors underlying the AD network may be more effective than a mono-therapeutic approach.

Research gaps and opportunities in precision nutrition: an NIH workshop report

Precision nutrition is an emerging concept that aims to develop nutrition recommendations tailored to different people's circumstances and biological characteristics. Responses to dietary change and the resulting health outcomes from consuming different diets may vary significantly between people based on interactions between their genetic backgrounds, physiology, microbiome, underlying health status, behaviors, social influences, and environmental exposures. On 11-12 January 2021, the National Institutes of Health convened a workshop entitled "Precision Nutrition: Research Gaps and Opportunities" to bring together experts to discuss the issues involved in better understanding and addressing precision nutrition. The workshop proceeded in 3 parts: part I covered many aspects of genetics and physiology that mediate the links between nutrient intake and health conditions such as cardiovascular disease, Alzheimer disease, and cancer; part II reviewed potential contributors to interindividual variability in dietary exposures and responses such as baseline nutritional status, circadian rhythm/sleep, environmental exposures, sensory properties of food, stress, inflammation, and the social determinants of health; part III presented the need for systems approaches, with new methods and technologies that can facilitate the study and implementation of precision nutrition, and workforce development needed to create a new generation of researchers. The workshop concluded that much research will be needed before more precise nutrition recommendations can be achieved. This includes better understanding and accounting for variables such as age, sex, ethnicity, medical history, genetics, and social and environmental factors. The advent of new methods and technologies and the availability of considerably more data bring tremendous opportunity. However, the field must proceed with appropriate levels of caution and make sure the factors listed above are all considered, and systems approaches and methods are incorporated. It will be important to develop and train an expanded workforce with the goal of reducing health disparities and improving precision nutritional advice for all Americans.

BDNF Val66Met Moderates the Effects of Hypertension on Executive Functioning in Older Adults Diagnosed With aMCI

OBJECTIVE

To investigate whether the BDNF Val66Met polymorphism influences the associations of hypertension, executive functioning and processing speed in older adults diagnosed with amnestic Mild Cognitive Impairment (aMCI).

DESIGN

Secondary data analysis using moderation modeling.

SETTING

Veterans Affairs Hospital, Palo Alto, CA.

PARTICIPANTS

Sample included 108 community-dwelling volunteers (mean age 71.3 ± 9.2 years) diagnosed with aMCI.

MEASUREMENTS

Cognitive performance was evaluated from multiple baseline assessments (Trail Making Test; Stroop Color-Word Test; Symbol Digit Modality Test) and grouped into standardized composite scores representing executive function and processing speed domains. BDNF genotypes were determined from whole blood samples. Hypertension was assessed from resting blood pressures or by self-report.

RESULTS

Controlling for age, BDNF Val66Met moderated the effects of hypertension on executive functioning, but added no significant variance to processing speed scores. Specifically, hypertensive carriers of the BDNF Met allele performed significantly below the sample mean on tasks of executive functioning, and evidenced significantly lower scores when compared to Val-Val homozygotes and normotensive participants.

CONCLUSIONS

Results posit that the executive functioning of non-demented older adults may be susceptible to interactions between BDNF genotype and hypertension, and Val-Val homozygotes and normotensive older adults may be more resilient to these effects of cognitive change. Further research is needed to understand the underlying processes and to implement strategies that target modifiable risk factors and promote cognitive resilience.

Cognitive performance protects against Alzheimer's disease independently of educational attainment and intelligence

Mendelian-randomization (MR) studies using large-scale genome-wide association studies (GWAS) have identified causal association between educational attainment and Alzheimer's disease (AD). However, the underlying mechanisms are still required to be explored. Here, we conduct univariable and multivariable MR analyses using large-scale educational attainment, cognitive performance, intelligence and AD GWAS datasets. In stage 1, we found significant causal effects of educational attainment on cognitive performance (beta = 0.907, 95% confidence interval (CI): 0.884-0.930, P < 1.145E-299), and vice versa (beta = 0.571, 95% CI: 0.557-0.585, P < 1.145E-299). In stage 2, we found that both increase in educational attainment (odds ratio (OR) = 0.72, 95% CI: 0.66-0.78, P = 1.39E-14) and cognitive performance (OR = 0.69, 95% CI: 0.64-0.75, P = 1.78E-20) could reduce the risk of AD. In stage 3, we found that educational attainment may protect against AD dependently of cognitive performance (OR = 1.07, 95% CI: 0.90-1.28, P = 4.48E-01), and cognitive performance may protect against AD independently of educational attainment (OR = 0.69, 95% CI: 0.53-0.89, P = 5.00E-03). In stage 4, we found significant causal effects of cognitive performance on intelligence (beta = 0.907, 95% CI: 0.877-0.938, P < 1.145E-299), and vice versa (beta = 0.957, 95% CI: 0.937-0.978, P < 1.145E-299). In stage 5, we identified that cognitive performance may protect against AD independently of intelligence (OR = 0.74, 95% CI: 0.61-0.90, P = 2.00E-03), and intelligence may protect against AD dependently of cognitive performance (OR = 1.17, 95% CI: 0.40-3.43, P = 4.48E-01). Collectively, our univariable and multivariable MR analyses highlight the protective role of cognitive performance in AD independently of educational attainment and intelligence. In addition to the intelligence, we extend the mechanisms underlying the associations of educational attainment with AD.

Dementia Prevention in Clinical Practice

Over 55 million people globally are living with dementia and, by 2050, this number is projected to increase to 131 million. This poses immeasurable challenges for patients and their families and a significant threat to domestic and global economies. Given this public health crisis and disappointing results from disease-modifying trials, there has been a recent shift in focus toward primary and secondary prevention strategies. Approximately 40% of Alzheimer's disease (AD) cases, which is the most common form of dementia, may be prevented or at least delayed. Success of risk reduction studies through addressing modifiable risk factors, in addition to the failure of most drug trials, lends support for personalized multidomain interventions rather than a "one-size-fits-all" approach. Evolving evidence supports early intervention in at-risk patients using individualized interventions directed at modifiable risk factors. Comprehensive risk stratification can be informed by emerging principals of precision medicine, and include expanded clinical and family history, anthropometric measurements, blood biomarkers, neurocognitive evaluation, and genetic information. Risk stratification is key in differentiating subtypes of dementia and identifies targetable areas for intervention. This article reviews a clinical approach toward dementia risk stratification and evidence-based prevention strategies, with a primary focus on AD.

Precision Medicine Approach to Alzheimer’s Disease: Successful Pilot Project

Background:

Effective therapeutics for Alzheimer’s disease are needed. However, previous clinical trials have pre-determined a single treatment modality, such as a drug candidate or therapeutic procedure, which may be unrelated to the primary drivers of the neurodegenerative process. Therefore, increasing data set size to include the potential contributors to cognitive decline for each patient, and addressing the identified potential contributors, may represent a more effective strategy.

Objective:

To determine whether a precision medicine approach to Alzheimer’s disease and mild cognitive impairment is effective enough in a proof-of-concept trial to warrant a larger, randomized, controlled clinical trial.

Methods:

Twenty-five patients with dementia or mild cognitive impairment, with Montreal Cognitive Assessment (MoCA) scores of 19 or higher, were evaluated for markers of inflammation, chronic infection, dysbiosis, insulin resistance, protein glycation, vascular disease, nocturnal hypoxemia, hormone insufficiency or dysregulation, nutrient deficiency, toxin or toxicant exposure, and other biochemical parameters associated with cognitive decline. Brain magnetic resonance imaging with volumetrics was performed at baseline and study conclusion. Patients were treated for nine months with a personalized, precision medicine protocol, and cognition was assessed at t = 0, 3, 6, and 9 months.

Results:

All outcome measures revealed improvement: statistically significant improvement in MoCA scores, CNS Vital Signs Neurocognitive Index, and Alzheimer’s Questionnaire Change score were documented. No serious adverse events were recorded. MRI volumetrics also improved.

Conclusion:

Based on the cognitive improvements observed in this study, a larger, randomized, controlled trial of the precision medicine therapeutic approach described herein is warranted.

Blood copper excess is associated with mild cognitive impairment in elderly Chinese

BACKGROUND

Copper is associated with mild cognitive impairment (MCI). However, there is a lack of relevant population studies with large sample sizes.

AIMS

This study used baseline data from a cohort study to determine the distribution characteristics of MCI in the elderly and to estimate the association between whole blood copper concentrations and MCI.

METHODS

MCI status was screened by the Mini-Mental State Examination (MMSE) scale and Activities of Daily Living (ADL) scale. The concentration of copper in whole blood was determined by Inductively Coupled Plasma Mass Spectrometer (ICP-MS).

RESULTS

A total of 1057 subjects with an average age of 71.82 ± 6.45 years were included in this study. There were 215 patients with MCI, and the prevalence of MCI was 20.34%. After adjusting for general demographic variables, logistic regression analysis showed that the risk of MCI in the elderly with high copper level was 1.354 times higher than that in the elderly with low copper level (OR 1.354, 95% CI 1.047-1.983, P = 0.034).

CONCLUSION

In this study, it was found that the prevalence of MCI was different in gender, age, education level and other aspects, and a higher copper level in the elderly was significantly related to the occurrence of MCI. The association was stronger in older adults and men.

Blueberry Supplementation in Midlife for Dementia Risk Reduction

Late-life dementia typically develops over a period of many years beginning in midlife. Prevalence of metabolic disturbance also accelerates in middle age and is a prominent risk factor for dementia. Preliminary studies indicate that blueberry supplementation can improve cognitive performance and influence metabolism and brain function and therefore may have a role in early intervention to prevent neurodegeneration. In a randomized controlled trial, we investigated the effects of daily blueberry supplementation in a middle-aged sample of insulin-resistant participants with elevated risk for future dementia. We enrolled overweight men and women, aged 50 to 65 years, with subjective cognitive decline (SCD) and performed pre- and post-intervention assessments of cognition and metabolism and exploratory measures of peripheral mitochondrial function. We observed improved performances for the blueberry group on measures of lexical access, p = 0.003, and memory interference, p = 0.04, and blueberry-treated participants reported reduced memory encoding difficulty in daily life activities, p = 0.03. The blueberry-treated group also exhibited correction of peripheral hyperinsulinemia, p = 0.04, and a modest trend for increased mitochondrial uncoupling, p = 0.11. The cognitive findings indicated improved executive ability in this middle-aged sample. In addition, the changes in metabolic and bioenergetic measures imply potential mechanistic factors associated with anthocyanin and proanthocyanidin actions. The demonstration of these benefits in middle-aged individuals with insulin resistance and SCD suggests that ongoing blueberry supplementation may contribute to protection against cognitive decline when implemented early in at-risk individuals.

Stratification of the Gut Microbiota Composition Landscape across the Alzheimer's Disease Continuum in a Turkish Cohort

Alzheimer's disease (AD) is a heterogeneous disorder that spans a continuum with multiple phases, including preclinical, mild cognitive impairment, and dementia. Unlike for most other chronic diseases, human studies reporting on AD gut microbiota in the literature are very limited. With the scarcity of approved drugs for AD therapies, the rational and precise modulation of gut microbiota composition using diet and other tools is a promising approach to the management of AD. Such an approach could be personalized if an AD continuum can first be deconstructed into multiple strata based on specific microbiota features by using single or multiomics techniques. However, stratification of AD gut microbiota has not been systematically investigated before, leaving an important research gap for gut microbiota-based therapeutic approaches. Here, we analyze 16S rRNA amplicon sequencing of stool samples from 27 patients with mild cognitive impairment, 47 patients with AD, and 51 nondemented control subjects by using tools compatible with the compositional nature of microbiota. To stratify the AD gut microbiota community, we applied four machine learning techniques, including partitioning around the medoid clustering and fitting a probabilistic Dirichlet mixture model, the latent Dirichlet allocation model, and we performed topological data analysis for population-scale microbiome stratification based on the Mapper algorithm. These four distinct techniques all converge on Prevotella and Bacteroides stratification of the gut microbiota across the AD continuum, while some methods provided fine-scale resolution in stratifying the community landscape. Finally, we demonstrate that the signature taxa and neuropsychometric parameters together robustly classify the groups. Our results provide a framework for precision nutrition approaches aiming to modulate the AD gut microbiota. IMPORTANCE The prevalence of AD worldwide is estimated to reach 131 million by 2050. Most disease-modifying treatments and drug trials have failed, due partly to the heterogeneous and complex nature of the disease. Recent studies demonstrated that gut dybiosis can influence normal brain function through the so-called "gut-brain axis." Modulation of the gut microbiota, therefore, has drawn strong interest in the clinic in the management of the disease. However, there is unmet need for microbiota-informed stratification of AD clinical cohorts for intervention studies aiming to modulate the gut microbiota. Our study fills in this gap and draws attention to the need for microbiota stratification as the first step for microbiota-based therapy. We demonstrate that while Prevotella and Bacteroides clusters are the consensus partitions, the newly developed probabilistic methods can provide fine-scale resolution in partitioning the AD gut microbiome landscape.

Primary prevention recommendations to reduce the risk of cognitive decline

Introduction

Few resources address steps clinicians can take to help patients reduce their risk of dementia, despite growing recognition that brain health can be optimized and that risk reduction for cognitive decline can be accomplished by lifestyle modifications.

Methods

To address this gap, UsAgainstAlzheimer's convened a risk reduction workgroup (RRWG) to review existing evidence and develop recommendations for primary care clinicians discussing cognitive decline and risk reduction with their patients. 

Results

The RRWG produced 11 consensus‐based recommendations and implementation strategies across six topics: neurovascular risk management, physical activity, sleep, nutrition, social isolation, and cognitive stimulation. 

Discussion

These recommendations are a first step for clinicians to address brain health with patients and potentially help them prevent cognitive decline. To ensure there is routine care for brain health, proper incentives and policies must be instituted and more education for consumers should be provided.

Association of Reproductive History With Brain MRI Biomarkers of Dementia Risk in Midlife

BACKGROUND AND OBJECTIVES

To examine associations between indicators of estrogen exposure from women's reproductive history and brain MRI biomarkers of Alzheimer disease (AD) in midlife.

METHODS

We evaluated 99 cognitively normal women 52 ± 6 years of age and 29 men 52 ± 7 years of age with reproductive history data, neuropsychological testing, and volumetric MRI scans. We used multiple regressions to examine associations among reproductive history indicators, voxel-wise gray matter volume (GMV), and memory and global cognition scores, adjusting for demographics and midlife health indicators. Exposure variables were menopause status, age at menarche, age at menopause, reproductive span, hysterectomy status, number of children and pregnancies, and use of menopause hormonal therapy (HT) and hormonal contraceptives (HC).

RESULTS

All menopausal groups exhibited lower GMV in AD-vulnerable regions compared to men, with perimenopausal and postmenopausal groups also exhibiting lower GMV in temporal cortex compared to the premenopausal group. Reproductive span, number of children and pregnancies, and use of HT and HC were positively associated with GMV, chiefly in temporal cortex, frontal cortex, and precuneus, independent of age, APOE ε4 status, and midlife health indicators. Although reproductive history indicators were not directly associated with cognitive measures, GMV in temporal regions was positively associated with memory and global cognition scores.

DISCUSSION

Reproductive history events signaling more estrogen exposure such as premenopausal status, longer reproductive span, higher number of children, and use of HT and HC were associated with larger GMV in women in midlife. Further studies are needed to elucidate sex-specific biological pathways through which reproductive history influences cognitive aging and AD risk.

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.

Feasibility of a wearable biosensor device to characterize exercise and sleep in neurology residents

BACKGROUND

Research suggests optimizing sleep, exercise and work-life balance may improve resident physician burnout. Wearable biosensors may allow residents to detect and correct poor sleep and exercise habits before burnout develops. Our objectives were to evaluate the feasibility of a wearable biosensor to characterize exercise/sleep in neurology residents and examine its relationship to self-reported, validated survey measures. We also assessed the device's impact on well-being and barriers to use.

METHODS

This prospective cohort study evaluated the WHOOP Strap 2.0 in neurology residents. Participants completed regular online surveys, including self-reported hours of sleep/exercise, and validated sleep/exercise scales at 3-month intervals. Autonomic, exercise, and sleep measures were obtained from WHOOP. Changes were evaluated over time via linear regression. Survey and WHOOP metrics were compared using Pearson correlations.

RESULTS

Sixteen (72.7%) of 22 eligible participants enrolled. Eleven (68.8%) met the minimum usage requirement (6+ months) and were classified as 'consecutive wearers.' Significant increases were found in sleep duration and exercise intensity. Moderate-to-low correlations were found between survey responses and WHOOP measures. Most (73%) participants reported a positive impact on well-being. Barriers to use included 'Forgetting to wear' (20%) and 'not motivational' (23.3%).

CONCLUSION

Wearable biosensors may be a feasible tool to evaluate sleep/exercise in residents.

Case Study: A Precision Medicine Approach to Multifactorial Dementia and Alzheimer's Disease

We report a case of a patient with mixed dementia successfully treated with a personalized multimodal therapy. Monotherapeutics are inadequate for the treatment of Alzheimer's disease (AD) and mixed dementia; therefore, we approach treatment through an adaptive personalized multimodal program. Many multimodal programs are pre-determined, and thus may not address the underlying contributors to cognitive decline in each particular individual. The combination of a targeted, personalized, precision medicine approach using a multimodal program promises advantages over monotherapies and untargeted multimodal therapies for multifactorial dementia. In this case study, we describe successful treatment for a patient diagnosed with AD, using a multimodal, programmatic, precision medicine intervention encompassing therapies targeting multiple dementia diastheses. We describe specific interventions used in this case that are derived from a comprehensive protocol for AD precision medicine. After treatment, our patient demonstrated improvements in quantitative neuropsychological testing, volumetric neuroimaging, PET scans, and serum chemistries, accompanied by symptomatic improvement over a 3.5-year period. This case outcome supports the need for rigorous trials of comprehensive, targeted combination therapies to stabilize, restore, and prevent cognitive decline in individuals with potentially many underlying causes of such decline and dementia. Our multimodal therapy included personalized treatments to address each potential perturbation to neuroplasticity. In particular, neuroinflammation and metabolic subsystems influence cognitive function and hippocampal volume. In this patient with a primary biliary cholangitis (PBC) multimorbidity component, we introduced a personalized diet that helped reduce liver inflammation. Together, all these components of multimodal therapy showed a sustained functional and cognitive benefit. Multimodal therapies may have systemwide benefits on all dementias, particularly in the context of multimorbidity. Furthermore, these therapies provide generalized health benefits, as many of the factors - such as inflammation - that impact cognitive function also impact other systems.

Opinion & Special Articles: Preventive Neurology: An Emerging Field Toward Brain Health

With the rapid aging of populations, neurological disorders have become among the leading causes of disability and mortality worldwide. Most neurological conditions have a prolonged prodromal phase - even if they tend to manifest with an acute syndrome such as stroke - and can lead to a relentless, often deleterious course creating a major burden on patients, caregivers, and society. This unique nature of neurological diseases signifies the strong need for equally effective primary and secondary prevention strategies and focus on brain health before brain diseases ensue. The field of preventive neurology applies both universal and selective primary prevention strategies to promote brain health both at the public and personal levels. The preventive neurology approach aims to identify and target high risk individuals and protect them from reaching a critical point where overt clinical symptoms are present and disease progression is irreversible. Universal and selective prevention training, along with dovetailed clinical and public health research, are three essential pillars of preventive neurology. The burgeoning field of preventive neurology aims to assess neurological care needs in a society, promote the participation of neurologists in restructuring of the health care policies to promote brain health, and to identify medium and high-risk individuals in order to prevent or delay future neurological events.

A systems-biology clinical trial of a personalized multimodal lifestyle intervention for early Alzheimer's disease

INTRODUCTION

There is an urgent need to develop effective interventional treatments for people with Alzheimer's disease (AD). AD results from a complex multi-decade interplay of multiple interacting dysfunctional biological systems that have not yet been fully elucidated. Epidemiological studies have linked several modifiable lifestyle factors with increased incidence for AD. Because monotherapies have failed to prevent or ameliorate AD, interventional studies should deploy multiple, targeted interventions that address the dysfunctional systems that give rise to AD.

METHODS

This randomized controlled trial (RCT) will examine the efficacy of a 12-month personalized, multimodal, lifestyle intervention in 60 mild cognitive impairment (MCI) and early stage AD patients (aged 50+, amyloid positivity). Both groups receive data-driven, lifestyle recommendations designed to target multiple systemic pathways implicated in AD. One group receives these personalized recommendations without coaching. The other group receives personalized recommendations with health coaching, dietary counseling, exercise training, cognitive stimulation, and nutritional supplements. We collect clinical, proteomic, metabolomic, neuroimaging, and genetic data to fuel systems-biology analyses. We will examine effects on cognition and hippocampal volume. The overarching goal of the study is to longitudinally track biological systems implicated in AD to reveal the dynamics between these systems during the intervention to understand differences in treatment response.

RESULTS

We have developed and implemented a protocol for a personalized, multimodal intervention program for early AD patients. We began enrollment in September 2019; we have enrolled a third of our target (20 of 60) with a 95% retention and 86% compliance rate.

DISCUSSION

This study presents a paradigm shift in designing multimodal, lifestyle interventions to reduce cognitive decline, and how to elucidate the biological systems being targeted. Analytical efforts to explain mechanistic or causal underpinnings of individual trajectories and the interplay between multi-omic variables will inform the design of future hypotheses and development of effective precision medicine trials.

The Role of Nutrition in Individualized Alzheimer's Risk Reduction

PURPOSE OF REVIEW

Decades of research suggests nutritional interventions can be an effective tool for reducing risk of Alzheimer's disease (AD), especially as part of an individualized clinical management plan. This review aims to emphasize new findings examining how specific dietary changes may delay or possibly prevent AD onset, and highlight how interventions can be adopted in clinical practice based on emerging principles of precision medicine.

RECENT FINDINGS

Specific dietary patterns and varied nutrient combinations can have a protective effect on brain health, promote cognitive function, and mediate the comorbidity of chronic conditions associated with increased AD risk. Individuals at risk for AD may see a greater impact of evidence-based dietary changes when initiated earlier in the AD spectrum. Depending on individual clinical profiles, incorporation of nutrition strategies is an essential component of an AD risk reduction plan in clinical practice.

Precision Nutrition for Alzheimer's Prevention in ApoE4 Carriers

The ApoE4 allele is the most well-studied genetic risk factor for Alzheimer’s disease, a condition that is increasing in prevalence and remains without a cure. Precision nutrition targeting metabolic pathways altered by ApoE4 provides a tool for the potential prevention of disease. However, no long-term human studies have been conducted to determine effective nutritional protocols for the prevention of Alzheimer’s disease in ApoE4 carriers. This may be because relatively little is yet known about the precise mechanisms by which the genetic variant confers an increased risk of dementia. Fortunately, recent research is beginning to shine a spotlight on these mechanisms. These new data open up the opportunity for speculation as to how carriers might ameliorate risk through lifestyle and nutrition. Herein, we review recent discoveries about how ApoE4 differentially impacts microglia and inflammatory pathways, astrocytes and lipid metabolism, pericytes and blood–brain barrier integrity, and insulin resistance and glucose metabolism. We use these data as a basis to speculate a precision nutrition approach for ApoE4 carriers, including a low-glycemic index diet with a ketogenic option, specific Mediterranean-style food choices, and a panel of seven nutritional supplements. Where possible, we integrate basic scientific mechanisms with human observational studies to create a more complete and convincing rationale for this precision nutrition approach. Until recent research discoveries can be translated into long-term human studies, a mechanism-informed practical clinical approach may be useful for clinicians and patients with ApoE4 to adopt a lifestyle and nutrition plan geared towards Alzheimer’s risk reduction.

Validity of the MemTrax Memory Test Compared to the Montreal Cognitive Assessment in the Detection of Mild Cognitive Impairment and Dementia due to Alzheimer's Disease in a Chinese Cohort

BACKGROUND

A valid, reliable, accessible, engaging, and affordable digital cognitive screen instrument for clinical use is in urgent demand.

OBJECTIVE

To assess the clinical utility of the MemTrax memory test for early detection of cognitive impairment in a Chinese cohort.

METHODS

The 2.5-minute MemTrax and the Montreal Cognitive Assessment (MoCA) were performed by 50 clinically diagnosed cognitively normal (CON), 50 mild cognitive impairment due to AD (MCI-AD), and 50 Alzheimer's disease (AD) volunteer participants. The percentage of correct responses (MTx-% C), the mean response time (MTx-RT), and the composite scores (MTx-Cp) of MemTrax and the MoCA scores were comparatively analyzed and receiver operating characteristic (ROC) curves generated.

RESULTS

Multivariate linear regression analyses indicated MTx-% C, MTx-Cp, and the MoCA score were significantly lower in MCI-AD versus CON and in AD versus MCI-AD groups (all with p≤0.001). For the differentiation of MCI-AD from CON, an optimized MTx-% C cutoff of 81% had 72% sensitivity and 84% specificity with an area under the curve (AUC) of 0.839, whereas the MoCA score of 23 had 54% sensitivity and 86% specificity with an AUC of 0.740. For the differentiation of AD from MCI-AD, MTx-Cp of 43.0 had 70% sensitivity and 82% specificity with an AUC of 0.799, whereas the MoCA score of 20 had 84% sensitivity and 62% specificity with an AUC of 0.767.

CONCLUSION

MemTrax can effectively detect both clinically diagnosed MCI and AD with better accuracy as compared to the MoCA based on AUCs in a Chinese cohort.

Prevalence of Behavioral and Psychological Symptoms of Dementia in Community-Dwelling Dementia Patients: A Systematic Review

Background: Identifying the characteristics of behavioral and psychological symptoms of dementia (BPSD) associated with different dementia types may be a promising strategy to effectively deal with BPSD. We aimed to synthesize the prevalence rates of BPSD characteristics in community-dwelling dementia patients. Methods: We searched Medline, EMBASE, and PsycARTICLES databases for original clinical studies published until December 2020 that enrolled at least 300 community-dwelling dementia patients. The methodological qualities of prevalence studies were assessed using the Joanna Briggs Institute's critical appraisal checklist. Results: Thirty studies were included. The prevalence of the BPSD characteristic ranged from 4 (elation and mania) to 32% (apathy) in the pooled samples. The prevalence of delusions, anxiety, apathy, irritability, elation and mania, and aberrant motor behavior in Alzheimer's disease patients was 1.72-2.88 times greater than that in vascular dementia (VD) patients, while the prevalence of disinhibition in VD patients was 1.38 times greater. The prevalence of anxiety, irritability, and agitation and aggression, delusion, hallucinations, apathy, disinhibition, and aberrant motor behavior tended to increase as the severity of dementia increased, while that of depression, eating disorder, sleep disorders, and elation and mania tended to stable. In community-dwelling patients with dementia, the pooled prevalence of apathy, depression, anxiety, irritability, agitation and aggression, sleep disorders, and eating disorder was higher than 20%, while that of disinhibition and elation and mania was lower than 10%. Conclusion: Overall, the pooled prevalence of apathy, depression, anxiety, irritability, agitation and aggression, sleep disorders, and eating disorder was generally high in patients with dementia. Also, the prevalence of some BPSD characteristics differed according to the type and the severity of dementia. The methodological quality of the included studies is not the best, and high heterogeneity may affect the certainty of the findings. However, the results of this review can deepen our understanding of the prevalence of BPSD. Systematic Review Registration: https://osf.io/dmj7k, identifier: 10.17605/OSF.IO/DMJ7K.

Promoting Successful Cognitive Aging: A Ten-Year Update

A decade has passed since we published a comprehensive review in this journal addressing the topic of promoting successful cognitive aging, making this a good time to take stock of the field. Because there have been limited large-scale, randomized controlled trials, especially following individuals from middle age to late life, some experts have questioned whether recommendations can be legitimately offered about reducing the risk of cognitive decline and dementia. Despite uncertainties, clinicians often need to at least make provisional recommendations to patients based on the highest quality data available. Converging lines of evidence from epidemiological/cohort studies, animal/basic science studies, human proof-of-concept studies, and human intervention studies can provide guidance, highlighting strategies for enhancing cognitive reserve and preventing loss of cognitive capacity. Many of the suggestions made in 2010 have been supported by additional research. Importantly, there is a growing consensus among major health organizations about recommendations to mitigate cognitive decline and promote healthy cognitive aging. Regular physical activity and treatment of cardiovascular risk factors have been supported by all of these organizations. Most organizations have also embraced cognitively stimulating activities, a heart-healthy diet, smoking cessation, and countering metabolic syndrome. Other behaviors like regular social engagement, limiting alcohol use, stress management, getting adequate sleep, avoiding anticholinergic medications, addressing sensory deficits, and protecting the brain against physical and toxic damage also have been endorsed, although less consistently. In this update, we review the evidence for each of these recommendations and offer practical advice about behavior-change techniques to help patients adopt brain-healthy behaviors.

The fusiform gyrus exhibits an epigenetic signature for Alzheimer's disease

Background

Alzheimer’s disease (AD) is the most common type of dementia, and patients with advanced AD frequently lose the ability to identify family members. The fusiform gyrus (FUS) of the brain is critical in facial recognition. However, AD etiology in the FUS of AD patients is poorly understood. New analytical strategies are needed to reveal the genetic and epigenetic basis of AD in FUS.

Results

A complex of new analytical paradigms that integrates an array of transcriptomes and methylomes of normal controls, AD patients, and “AD-in-dish” models were used to identify genetic and epigenetic signatures of AD in FUS. Here we identified changes in gene expression that are specific to the FUS in brains of AD patients. These changes are closely linked to key genes in the AD network. Profiling of the methylome (5mC/5hmC/5fC/5caC) at base resolution identified 5 signature genes (COL2A1, CAPN3, COL14A1, STAT5A, SPOCK3) that exhibit perturbed expression, specifically in the FUS and display altered DNA methylome profiles that are common across AD-associated brain regions. Moreover, we demonstrate proof-of-principle that AD-associated methylome changes in these genes effectively predict the disease prognosis with enhanced sensitivity compared to presently used clinical criteria.

Conclusions

This study identified a set of previously unexplored FUS-specific AD genes and their epigenetic characteristics, which may provide new insights into the molecular pathology of AD, attributing the genetic and epigenetic basis of FUS to AD development.

Modifiable Risk Factors for Poor Cognitive Function in Former American-Style Football Players: Findings from the Harvard Football Players Health Study

Recent attention to consequences of head trauma among former professional American-style football players has increased the likelihood that former players and their healthcare providers attribute neurocognitive effects to these exposures. In addition to head trauma, however, many potentially modifiable risk factors are associated with cognitive impairment. We examined the association of self-reported risk factors for cognitive impairment (e.g., cardiovascular health, sleep, pain, depression, anxiety, smoking, physical impairment, and physical activity) with cognition-related quality of life, measured by the Quality of Life in Neurological Disorders, Applied Cognition-General Concerns (Neuro-QOL) among 3803 former National Football League (NFL) players. We examined the prevalence of risk factors among men who had experienced a high number of concussion symptoms during playing years, comparing men with good current cognition-related QOL, the "healthy concussed," to men with poor cognition-related QOL, the "unhealthy concussed." Physical functioning, pain, depression, and anxiety were very strongly associated with poor cognitive-related QOL (risk ratio range, 2.21-2.70, p < 0.0001 for all). Short sleep duration and low physical activity were also strongly associated (RR = 1.69 and 1.57, respectively, p < 0.0001 for both). The largest differences between healthy and unhealthy concussed were in chronic pain (72.0% vs. 21.2%), depressive symptoms (50.3% vs. 6.3%), anxiety symptoms (53.4% vs. 11.6%), and physical impairment (52.4% vs. 12.5%). Substantial differences also existed in prevalence of sleep apnea, short sleep duration, high-intensity exercise, weight training, high blood pressure, and body mass index ≥35 kg/m² (all differences >10 percentage points). We identified cognitive risk factors, including chronic pain, mood problems, sleep problems, obesity, and lack of exercise, that were commonly present in former football players with cognition-related impairment. Better treatment for these factors may reduce cognitive problems in this population.

Endosomal-lysosomal dysfunction in metabolic diseases and Alzheimer's disease

The endosomal-lysosomal pathways and related autophagic processes are responsible for proteostasis, involving complexes between lysosomes and autophagosomes. Lysosomes are a key component of homeostasis, involved in cell signaling, metabolism, and quality control, and they experience functional compromise in metabolic diseases, aging, and neurodegenerative diseases. Many genetic mutations and risk factor genes associated with proteinopathies, as well as with metabolic diseases like diabetes, negatively influence endocytic trafficking and autophagic clearance. In contrast, health-improving exercise induces autophagy-lysosomal degradation, perhaps promoting efficient digestion of injured organelles so that undamaged organelles ensure cellular healthiness. Reductions in lysosomal hydrolases are implicated in Alzheimer's, Parkinson's, and lysosomal storage diseases, as well as obesity-related pathology, and members of the cathepsin enzyme family are involved in clearing both Aβ42 and α-synuclein. Upregulation of cathepsin hydrolases improves synaptic and memory functions in models of dementia and in exercising humans, thus identifying lysosomal-related systems as vital for healthy cognitive aging.

Fast-food for thought: Retail food environments as resources for cognitive health and wellbeing among aging Americans?

In this exploratory sequential mixed-methods study, interviews with 125 adults aged 55-92 (mean age 71) living in the Minneapolis (Minnesota) metropolitan area suggested that eateries, including coffee shops and fast-food restaurants, represent popular neighborhood destinations for older adults and sources of wellbeing. Thematic analysis of how older adults perceived and utilized local eateries included sites of familiarity and comfort; physical and economic accessibility; sociability with friends, family, staff, and customers; and entertainment (e.g., destinations for outings and walks, free newspapers to read). To test the hypothesis that these sites, and the benefits they confer, are associated with cognitive welfare, we analyzed data from urban and suburban community-dwelling participants in the Reasons for Geographic And Racial Differences in Stroke (REGARDS) study, a national racially diverse sample of older Americans followed since 2003 (n = 16,404, average age at assessment 72 years). Results from multilevel linear regression models of these data demonstrated a positive association between kernel density of local eateries and cognitive functioning, which corroborated qualitative findings. Taken together, these results complicate our understanding of casual eatery settings as possible sites of wellbeing through social interaction and leisure activities. Results prompt further research investigating whether and how retail food environments can serve as community spaces for older adults that may help buffer against cognitive decline.

Exercise and dementia prevention

Ageing, genetic, medical and lifestyle factors contribute to the risk of Alzheimer’s disease and other dementias. Around a third of dementia cases are attributable to modifiable risk factors such as physical inactivity, smoking and hypertension. With the rising prevalence and lack of neuroprotective drugs, there is renewed focus on dementia prevention strategies across the lifespan. Neurologists encounter many people with risk factors for dementia and are frequently asked whether lifestyle changes may help. Exercise has emerged as a key intervention for influencing cognition positively, including reducing the risk of age-related cognitive decline and dementia. This article focuses on the current evidence for physical inactivity as a modifiable dementia risk factor and aims to support neurologists when discussing risk reduction.