The Effect of a 2-Year Intervention Consisting of Diet, Physical Exercise, Cognitive Training, and Monitoring of Vascular Risk on Chronic Morbidity-the FINGER Randomized Controlled Trial

Nutrition for the older adult - Current concepts. Report from an ESPEN symposium

BACKGROUND & AIMS

In view of the global demographic shift, a scientific symposium was organised by the European Society for Clinical Nutrition and Metabolism (ESPEN) to address nutrition-related challenges of the older population and provide an overview of the current state of knowledge.

METHODS

Eighteen nutrition-related issues of the ageing global society were presented by international experts during the symposium and summarised in this report.

RESULTS

Anorexia of ageing, dysphagia, malnutrition, frailty, sarcopenia, sarcopenic obesity, and the metabolic syndrome were highlighted as major nutrition-related geriatric syndromes. Great progress has been made in recent years through standardised definitions of some but not all syndromes. Regarding malnutrition, the GLIM approach has shown to be suitable also in older adults, justifying its continuous implementation. For anorexia of ageing, a consensus definition is still required. Intervention approaches should be integrated and person-centered with the aim of optimizing intrinsic capacity and maintaining functional capacity. Landmark studies like EFFORT and FINGER have impressively documented the potential of individualised and multifactorial interventions for functional and health benefits. Combining nutritional intervention with physical training seems particularly important whereas restrictive diets and drug treatment should generally be used with caution because of undesirable risks. Obesity management in older adults should take into account the risk of promoting sarcopenia.

CONCLUSIONS

In the future, even more individualised approaches like precision nutrition may enable better nutritional care. Meanwhile all stakeholders should focus on a better implementation of currently available strategies and work closely together to improve nutritional care for older adults.

Embracing complexity of (brain) aging

Aging is a multifactorial process occurring in a pathophysiological continuum which leads to organ and system functional loss. While aging is not a disease, its pathophysiological continuum predisposes to illness and multimorbidity clusters which share common biomolecular mechanisms-the pillars of aging. Brain aging and neurodegeneration share many hallmarks with other age-related diseases. The central nervous system is often the weakest link susceptible to the aging process and its deterioration, resulting in cognitive impairment and other symptoms; the aging process is associated with proteostasis collapse, stem cell exhaustion, repair mechanisms, altered brain nutrient sensing, endothelial changes, inflammation, oxidative distress, and energy unbalance, as well as other disturbances. These mechanisms are highly interwoven, and considerable research is aimed at their disentanglement and detection of their clinically relevant impact, particularly in order to identify pharmacological and non-pharmacological preventive and therapeutic strategies.

Somatic disease burden and depression risk in late life: a community-based study

AIMS

Co-occurring somatic diseases exhibit complex clinical profiles, which can differentially impact the development of late-life depression. Within a community-based cohort, we aimed to explore the association between somatic disease burden, both in terms of the number of diseases and their patterns, and the incidence of depression in older people.

METHODS

We analysed longitudinal data of depression- and dementia-free individuals aged 60+ years from the population-based Swedish National Study on Aging and Care in Kungsholmen. Depression diagnoses were clinically ascertained following the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision over a 15-year follow-up. Somatic disease burden was assessed at baseline through a comprehensive list of chronic diseases obtained by combining information from clinical examinations, medication reviews and national registers and operationalized as (i) disease count and (ii) patterns of co-occurring diseases from latent class analysis. The association of somatic disease burden with depression incidence was investigated using Cox models, accounting for sociodemographic, lifestyle and clinical factors.

RESULTS

The analytical sample comprised 2904 people (mean age, 73.2 [standard deviation (SD), 10.5]; female, 63.1%). Over the follow-up (mean length, 9.6 years [SD, 4 years]), 225 depression cases were detected. Each additional disease was associated with the occurrence of any depression in a dose-response manner (hazard ratio [HR], 1.16; 95% confidence interval [CI]: 1.08, 1.24). As for disease patterns, individuals presenting with sensory/anaemia (HR, 1.91; 95% CI: 1.03, 3.53), thyroid/musculoskeletal (HR, 1.90; 95% CI: 1.06, 3.39) and cardiometabolic (HR, 2.77; 95% CI: 1.40, 5.46) patterns exhibited with higher depression hazards, compared to those without 2+ diseases (multimorbidity). In the subsample of multimorbid individuals (85%), only the cardiometabolic pattern remained associated with a higher depression hazard compared to the unspecific pattern (HR, 1.71; 95% CI: 1.02, 2.84).

CONCLUSIONS

Both number and patterns of co-occurring somatic diseases are associated with an increased risk of late-life depression. Mental health should be closely monitored among older adults with high somatic burden, especially if affected by cardiometabolic multimorbidity.

A multimodal precision-prevention approach combining lifestyle intervention with metformin repurposing to prevent cognitive impairment and disability: the MET-FINGER randomised controlled trial protocol

BACKGROUND

Combining multimodal lifestyle interventions and disease-modifying drugs (novel or repurposed) could provide novel precision approaches to prevent cognitive impairment. Metformin is a promising candidate in view of the well-established link between type 2 diabetes (T2D) and Alzheimer's Disease and emerging evidence of its potential neuro-protective effects (e.g. vascular, metabolic, anti-senescence). MET-FINGER aims to test a FINGER 2.0 multimodal intervention, combining an updated FINGER multidomain lifestyle intervention with metformin, where appropriate, in an APOE ε4-enriched population of older adults (60-79 years) at increased risk of dementia.

METHODS

MET-FINGER is an international randomised, controlled, parallel-group, phase-IIb proof-of-concept clinical trial, where metformin is included through a trial-within-trial design. 600 participants will be recruited at three sites (UK, Finland, Sweden). Participants at increased risk of dementia based on vascular risk factors and cognitive screening, will be first randomised to the FINGER 2.0 intervention (lifestyle + metformin if eligible; active arm) or to receive regular health advice (control arm). Participants allocated to the FINGER 2.0 intervention group at risk indicators of T2D will be additionally randomised to receive metformin (2000 mg/day or 1000 mg/day) or placebo. The study duration is 2 years. The changes in global cognition (primary outcome, using a Neuropsychological Test Battery), memory, executive function, and processing speed cognitive domains; functional status; lifestyle, vascular, metabolic, and other dementia-related risk factors (secondary outcomes), will be compared between the FINGER 2.0 intervention and the control arm. The feasibility, potential interaction (between-groups differences in healthy lifestyle changes), and disease-modifying effects of the lifestyle-metformin combination will be exploratory outcomes. The lifestyle intervention is adapted from the original FINGER trial (diet, physical activity, cognitive training, monitoring of cardiovascular/metabolic risk factors, social interaction) to be consistently delivered in three countries. Metformin is administered as Glucophage®XR/SR 500, (500 mg oral tablets). The metformin/placebo treatment will be double blinded.

CONCLUSION

MET-FINGER is the first trial combining a multimodal lifestyle intervention with a putative repurposed disease-modifying drug for cognitive impairment prevention. Although preliminary, its findings will provide crucial information for innovative precision prevention strategies and form the basis for a larger phase-III trial design and future research in this field.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05109169).

Association Between the Healthy Lifestyle Index and Risk of Multimorbidity in the Women's Health Initiative

BACKGROUND

Multimorbidity, defined as the presence of 2 or more chronic health conditions, is increasingly common among older adults. The combination of lifestyle characteristics such as diet quality, smoking status, alcohol intake, physical activity (PA), sleep duration, and body fat as assessed by body mass index (BMI) or waist circumference, and risk of multimorbidity are not well understood.

OBJECTIVES

We investigated the association between the healthy lifestyle index (HLI), generated by combining indicators of diet quality, smoking, alcohol, PA, sleep amount, and BMI, and risk of multimorbidity, a composite outcome that included cardiovascular disease (CVD), diabetes, cancer, and fracture.

METHODS

We studied 62 037 postmenopausal women aged 50-79 years at enrollment in the Women's Health Initiative, with no reported history of CVD, diabetes, cancer, or fracture at baseline. Lifestyle characteristics measured at baseline were categorized and a score (0-4) was assigned to each category. The combined HLI (0-24) was grouped into quintiles, with higher quintiles indicating a healthier lifestyle. Multivariable adjusted estimates of hazard ratios (HRs) and 95% confidence intervals (95% CIs) for the risk of developing multimorbidity were obtained using Cox proportional hazard models.

RESULTS

Over an average follow-up period of 16.3 years, 5 656 women developed multimorbidity. There was an inverse association between the HLI levels and risk of multimorbidity (compared to the HLI_1st quintile: HR_2nd quintile = 0.81 95% CI 0.74-0.83, HR_3rd quintile = 0.77 95% CI 0.71-0.83, HR_4th quintile = 0.70 95% CI 0.64-0.76, and HR_5th quintile = 0.60 95% CI 0.54-0.66; p trend < .001). Similar associations were observed after stratification by age or BMI categories.

CONCLUSIONS

Among postmenopausal women, higher levels of the HLI were associated with a reduced risk of developing multimorbidity.

Understanding barriers to and facilitators of clinician-patient conversations about brain health and cognitive concerns in primary care: a systematic review and practical considerations for the clinician

BACKGROUND

Primary care clinicians (PCCs) are typically the first practitioners to detect cognitive impairment in their patients, including those with Alzheimer's disease or related dementias (ADRD). However, conversations around cognitive changes can be challenging for patients, family members, and clinicians to initiate, with all groups reporting barriers to open dialogue. With the expanding array of evidence-based interventions for ADRD, from multidomain care management to novel biotherapeutics for early-stage AD, incorporating conversations about brain health into routine healthcare should become a standard of care. We conducted a systematic review to identify barriers to and facilitators of brain health conversations in primary care settings.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library for qualitative or quantitative studies conducted in the US between January 2000 and October 2022 that evaluated perceptions of cognition and provider-patient brain health conversations prior to formal screening for, or diagnosis of, mild cognitive impairment or ADRD. We assessed the quality of the included studies using the Mixed Methods Appraisal Tool.

RESULTS

In total, 5547 unique abstracts were screened and 22 articles describing 19 studies were included. The studies explored perceptions of cognition among laypersons or clinicians, or provider-patient interactions in the context of a patient's cognitive concerns. We identified 4 main themes: (1) PCCs are hesitant to discuss brain health and cognitive concerns; (2) patients are hesitant to raise cognitive concerns; (3) evidence to guide clinicians in developing treatment plans that address cognitive decline is often poorly communicated; and (4) social and cultural context influence perceptions of brain health and cognition, and therefore affect clinical engagement.

CONCLUSIONS

Early conversations about brain health between PCCs and their patients are rare, and effective tools, processes, and strategies are needed to make these vital conversations routine.

Dementia-related disability in the population aged 90 years and over: differences over time and the role of comorbidity in the vitality 90 + study

BACKGROUND

The burden of dementia, multimorbidity, and disability is high in the oldest old. However, the contribution of dementia and comorbidities to functional ability in this age group remains unclear. We examined the combined effects of dementia and comorbidities on ADL and mobility disability and differences between dementia-related disability between 2001, 2010, and 2018.

METHODS

Our data came from three repeated cross-sectional surveys in the population aged 90 + in the Finnish Vitality 90 + Study. The associations of dementia with disability and the combined effects of dementia and comorbidity on disability adjusted for age, gender, occupational class, number of chronic conditions, and study year were determined by generalized estimating equations. An interaction term was calculated to assess differences in the effects of dementia on disability over time.

RESULTS

In people with dementia, the odds of ADL disability were almost five-fold compared to people with three other diseases but no dementia. Among those with dementia, comorbidities did not increase ADL disability but did increase mobility disability. Differences in disability between people with and without dementia were greater in 2010 and 2018 than in 2001.

CONCLUSION

We found a widening gap in disability between people with and without dementia over time as functional ability improved mainly in people without dementia. Dementia was the main driver of disability and among those with dementia, comorbidities were associated with mobility disability but not with ADL disability. These results imply the need for strategies to maintain functioning and for clinical updates, rehabilitative services, care planning, and capacity building among care providers.

[Prevention and health promotion in dementia: motivation for change within preventive interventions-Empirical results]

BACKGROUND

Aging healthily and prevention of diseases are statutory and a national health target. There is convincing evidence that describes the modifiable risk factors, which are principally suitable for preventive measures.

OBJECTIVE

Definition of terms, presentation of the roots of prevention in laws, strategies and guidelines. Presentation of the risk factors for dementia, outline of effective preventive measures and their promising components.

MATERIAL AND METHODS

Prevention is systematically described. The available evidence on risk factors, health behavior and preventive measures is analyzed. A multimodal intervention is presented and the influence of motivation on a change in behavior is outlined, exemplified by physical activity.

RESULTS AND DISCUSSION

Aging healthily is a national health target and prevention of disease is rooted and defined in both the legislation and guidelines. The current evidence on modifiable risk factors for dementia originates from 12 factors. These include behavior-associated factors, such as inactivity, diabetes and smoking. The efficacy of preventive measures can be described by their effectiveness, the utilization when available and the principal availability for all people for whom they are indicated. Changing a health behavior is complex and dependent among other things on the motivation to want to change a behavior. Currently, multimodal prevention programs appear to be very promising for the prevention of cognitive disorders and dementia.

Metabolome-wide association study on ABCA7 indicates a role of ceramide metabolism in Alzheimer's disease

Genome-wide association studies (GWASs) have identified genetic loci associated with the risk of Alzheimer's disease (AD), but the molecular mechanisms by which they confer risk are largely unknown. We conducted a metabolome-wide association study (MWAS) of AD-associated loci from GWASs using untargeted metabolic profiling (metabolomics) by ultraperformance liquid chromatography-mass spectrometry (UPLC-MS). We identified an association of lactosylceramides (LacCer) with AD-related single-nucleotide polymorphisms (SNPs) in ABCA7 (P = 5.0 × 10^-5 to 1.3 × 10^-44). We showed that plasma LacCer concentrations are associated with cognitive performance and genetically modified levels of LacCer are associated with AD risk. We then showed that concentrations of sphingomyelins, ceramides, and hexosylceramides were altered in brain tissue from Abca7 knockout mice, compared with wild type (WT) (P = 0.049-1.4 × 10^-5), but not in a mouse model of amyloidosis. Furthermore, activation of microglia increases intracellular concentrations of hexosylceramides in part through induction in the expression of sphingosine kinase, an enzyme with a high control coefficient for sphingolipid and ceramide synthesis. Our work suggests that the risk for AD arising from functional variations in ABCA7 is mediated at least in part through ceramides. Modulation of their metabolism or downstream signaling may offer new therapeutic opportunities for AD.

Lifestyle Interventions for the Prevention of Parkinson Disease: A Recipe for Action

The prevalence of Parkinson disease (PD) is growing fast, amplifying the quest for disease-modifying therapies in early disease phases where pathology is still limited. Lifestyle interventions offer a promising avenue for preventing progression from prodromal to manifest PD. We illustrate this primarily for 1 specific lifestyle intervention, namely aerobic exercise because the case for the other main lifestyle factor (dietary interventions) to modify the course of prodromal PD is currently less persuasive. Various observations have hinted at the disease-modifying potential of exercise. First, studies in rodents with experimental parkinsonism showed that exercise elicits adaptive neuroplasticity in basal ganglia circuitries. Second, exercise is associated with a reduced risk of developing PD, suggesting a disease-modifying potential. Third, 2 large trials in persons with manifest PD indicate that exercise can help to stabilize motor parkinsonism, although this could also reflect a symptomatic effect. In addition, exercise seems to be a feasible intervention, given its minimal risk of side effects. Theoretical risks include an increase in fall incidents and cardiovascular complications, but these concerns seem to be acceptably low. Innovative approaches using gamification elements indicate that adequate long-term compliance with regular exercise programs can be achieved, although more work remains necessary to demonstrate enduring adherence for multiple years. Advances in digital technology can be used to deliver the exercise intervention in the participant's own living environment and also to measure the outcomes remotely, which will help to further boost long-term compliance. When delivering exercise to prodromal participants, outcome measures should focus not just on phenoconversion to manifest PD (which may well take many years to occur) but also on measurable intermediate outcomes, such as physical fitness or prodromal nonmotor symptoms. Taken together, there seems to be sufficient evidence to advocate the first judicious attempt of investigating exercise as a disease-modifying treatment in prodromal PD.

Dementia prevention: The potential long-term cost-effectiveness of the FINGER prevention program

INTRODUCTION

The aim of this study was to estimate the potential cost-effectiveness of the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) program.

METHODS

A life-time Markov model with societal perspective, simulating a cohort of people at risk of dementia reflecting usual care and the FINGER program.

RESULTS

Costs were 1,653,275 and 1,635,346 SEK and quality-adjusted life years (QALYs) were 8.636 and 8.679 for usual care and the FINGER program, respectively, resulting in savings of 16,928 SEK (2023 US$) and 0.043 QALY gains per person, supporting extended dominance for the FINGER program. A total of 1623 dementia cases were avoided with 0.17 fewer person-years living with dementia. The sensitivity analysis confirmed the conclusions in most scenarios.

DISCUSSION

The model provides support that programs like FINGER have the potential to be cost-effective in preventing dementia. Results at the individual level are rather modest, but the societal benefits can be substantial because of the large potential target population.

Multidomain interventions for risk reduction and prevention of cognitive decline and dementia: current developments

PURPOSE OF REVIEW

The potential for dementia prevention is deemed substantial if modifiable risk factors were addressed. First large-scale multidomain lifestyle interventions aiming at reducing risk of cognitive decline and dementia have yielded mixed but promising evidence.

RECENT FINDINGS

Despite the impact of the COVID-19 pandemic on trials conduction, causing interruptions and delays, the research landscape on multidomain interventions is growing rapidly. The successful Finish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) has led to an adaptation of the FINGER model in trials underway or being planned in over 40 countries. Recent studies identified barriers and facilitators of and adherence to multidomain interventions, showed the suitability of dementia risk scores as surrogate outcomes, and suggested mechanisms. Multidomain interventions are increasingly conducted in the Global South, and study protocols are increasingly testing expanded FINGER models, for example, with pharmacological components, in digital/remote settings and co-designed personalized interventions.

SUMMARY

Though results remain mixed, the many ongoing trials will provide more conclusive evidence within the next few years and help to optimize interventions. Continued international collaboration is pivotal to scale and accelerate the development and implementation of effective multidomain interventions as part of larger public health strategies to counteract the global dementia increase.

Predictors of Mortality in 433 Nonagenarians Inside the Mugello Study: A 10 Years Follow-Up Study

OBJECTIVE

to identify the predictors of mortality in a cohort of nonagenarians inside the "Mugello study" after 10 years follow-up.

METHODS

Information on sociodemographic data, cognitive and functional status, lifestyle, medical history, and drug use was collected from 433 non-selected participants aged 90-99 years, living in the Mugello area (Italy). Participants were followed over 10 years and their dates of death were retrieved from the municipal registers. Cox regression analysis was used to determine significant potential prognostic factors.

RESULTS

The mortality rate was 96.5%. Cox proportional hazards analysis showed that a lower cognitive status was significantly associated with higher mortality as well as a poorer functional status, a higher comorbidity, and a higher number of drugs consumption.

DISCUSSION

Impaired cognitive function, loss of functional independence, higher comorbidity, and higher drugs intake were the stronger predictors of mortality.

The medium-term consequences of COVID-19 lockdown on lifestyle among Spanish older people with hypertension, pulmonary, cardiovascular, and musculoskeletal-diseases, depression, and cancer

Objectives

To assess the influence of different chronic diseases on lifestyle and health behaviours changes after COVID-19 lockdown in Spanish older people compared to people without these diseases and compare the differences in these changes between both periods.

Methods

1092 participants (80.3±5.6y;66.5%women) from two Spanish cohorts were included. Telephone-based questionaries were used to evaluate health risk behaviours and lifestyle during lockdown and 7-months later. Self-reported physician-based diagnosis of chronic diseases was also reported. Cox-proportional models adjusted for main confounders were applied.

Results

Improvements concerning lifestyle were found in older people with chronic diseases, although they worsened the physical component (except cancer). When they were compared to those without these diseases, hypertension was associated with a lower frequency of increased alcohol consumption (Hazard ratio:0.73[95% confidence interval:0.55;0.99]). Pulmonary diseases were associated with a lower risk of both decreased sedentary time (0.58[0.39;0.86]) and worsening sleep quality (0.56[0.36;0.87]), while CVD was only associated with a lower frequency of decreased sedentary time (0.58[0.38;0.88]). Depression was linked to a higher risk of increasing diet quality (1.53[1.00;2.36]). Cancer was less likely to worsen sleep quality (0.44[0.22;0.89]), but more likely to worsen their social contact frequency (2.05[1.05;3.99]). No significant association related to musculoskeletal diseases.

Conclusion

Beneficial changes in health risk behaviours and lifestyle after the COVID-19 lockdown in older people with chronic diseases were found. Particularly, older people with hypertension, pulmonary disease and cancer showed beneficial changes after lockdown compared to their counterparts without diseases. Those with CVD and depression showed lifestyles that could involve a health risk.

Adherence to self-management in patients with multimorbidity and associated factors: A cross-sectional study in primary health care

AIM

The aim of the study was to explore the adherence to self-management of patients with multimorbidity, identify associated factors, and determine explanatory factors of their adherence to self-management in terms of the Theory of Adherence of People with Chronic Disease.

BACKGROUND

Adherence to self-management is essential for successful care of multimorbid patients, but multimorbidity poses challenges for both patients and practitioners due to its care complexity and broad impact on patients' lives.

DESIGN

A cross-sectional, descriptive exploratory design with the STROBE reporting checklist was applied.

METHODS

Adult multimorbid patients who attended primary healthcare consultations in Finland were surveyed using self-administered questionnaires with several instruments including the Adherence of People with Chronic Disease Instrument, Kasari's FIT Index, and Alcohol Use Disorders Identification test. Responses of 124 patients were analysed using descriptive statistics, Spearman correlations, binary logistic regression analysis, and Chi-squared, or corresponding, tests.

RESULTS

Most patients' responses indicated good or adequate adherence to care regimens and medications. However, adherence to self-management for a healthy lifestyle was more frequently inadequate. Adherence was significantly associated with several patient-related factors, including demographic and health-related factors, perceived adequacy of loved ones, and patient activation. Significant explanatory factors for adherence included energy and willpower, motivation, results of care, sense of normality, fear of complications and additional diseases, and support from nurses, from physicians, and from family and friends. Various factors were relevant for specific aspects of self-management.

CONCLUSIONS

Multimorbid patients' adherence to self-management is not an 'all or none phenomenon, but a multifaceted process with numerous associated and explanatory factors.

RELEVANCE TO CLINICAL PRACTICE

The findings highlight needs for an individualised whole-person approach in multimorbid patients' care to provide the required support for good adherence to self-management. Healthcare professionals, especially nurses working in primary health care, are well-positioned to meet this need.

The Association of Periodontitis and Alzheimer's Disease: How to Hit Two Birds with One Stone

Alzheimer's disease (AD) is the leading cause of cognitive impairment in the elderly. Recent evidence suggests that preventive interventional trials could significantly reduce the risk for development of dementia. Periodontitis is the most common dental disease characterized by chronic inflammation and loss of alveolar bone and perialveolar attachment of teeth. Growing number of studies propose a potential link between periodontitis and neurodegeneration. In the first part of the paper, we overview case-control studies analyzing the prevalence of periodontitis among AD patients and healthy controls. Second, we survey observational libraries and cross-sectional studies investigating the risk of cognitive decline in patients with periodontitis. Next, we describe the current view on the mechanism of periodontitis linked neural damage, highlighting bacterial invasion of neural tissue from dental plaques, and periodontitis induced systemic inflammation resulting in a neuroinflammatory process. Later, we summarize reports connecting the four most common periodontal pathogens to AD pathology. Finally, we provide a practical guide for further prevalence and interventional studies on the management of cognitively high-risk patients with and without periodontitis. In this section, we highlight strategies for risk control, patient information, dental evaluation, reporting protocol and dental procedures in the clinical management of patients with a risk for periodontitis and with diagnosed periodontitis. In conclusion, our review summarizes the current view on the association between AD and periodontitis and provides a research and intervention strategy for harmonized interventional trials and for further case-control or cross-sectional studies.

Effect of a Multidomain Lifestyle Intervention on Estimated Dementia Risk

We investigated the effect of a multidomain lifestyle intervention on the risk of dementia estimated using the validated CAIDE risk score (post-hoc analysis). The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) is a 2-year randomized controlled trial among 1,260 at-risk older adults (60-77 years). Difference in the estimated mean change in CAIDE score at 2 years in the intervention compared to the control group was -0.16 (95 %CI -0.31 to 0.00) (p = 0.013), corresponding to a relative dementia risk reduction between 6.04-6.50%. This could be interpreted as a reflection of the prevention potential of the intervention.

How can dementia and disability be prevented in older adults: where are we today and where are we going?

Ageing of the population, together with population growth, has brought along an ample increase in the number of older individuals living with dementia and disabilities. Dementia is the main cause of disability in old age, and promoting healthy brain ageing is considered as a key element in diminishing the burden of age-related disabilities. The World Health Organization recently launched the first risk reduction guidelines for cognitive impairment and dementia. According to recent estimates, approximately 40% of dementia cases worldwide could be attributable to 12 modifiable risk factors: low education; midlife hypertension and obesity; diabetes, smoking, excessive alcohol use, physical inactivity, depression, low social contact, hearing loss, traumatic brain injury and air pollution indicating clear prevention potential. Dementia and physical disability are closely linked with shared risk factors and possible shared underlying mechanisms supporting the possibility of integrated preventive interventions. FINGER trial was the first large randomized controlled trial indicating that multidomain lifestyle-based intervention can prevent cognitive and functional decline amongst at-risk older adults from the general population. Within the World-Wide FINGERS network, the multidomain FINGER concept is now tested and adapted worldwide proving evidence and tools for effective and easily implementable preventive strategies. Close collaboration between researchers, policymakers and healthcare practitioners, involvement of older adults and utilization of new technologies to support self-management is needed to facilitate the implementation of the research findings. In this scoping review, we present the current scientific evidence in the field of dementia and disability prevention and discuss future directions in the field.

Multidomain Interventions to Prevent Cognitive Impairment, Alzheimer's Disease, and Dementia: From FINGER to World-Wide FINGERS

Alzheimer’s disease (AD) and dementia are a global public health priority, and prevention has been highlighted as a pivotal component in managing the dementia epidemic. Modifiable risk factors of dementia and AD include lifestyle-related factors, vascular and metabolic disorders, and psychosocial factors. Randomized controlled clinical trials (RCTs) are needed to clarify whether modifying such factors can prevent or postpone cognitive impairment and dementia in older adults. Given the complex, multifactorial, and heterogeneous nature of late-onset AD and dementia, interventions targeting several risk factors and mechanisms simultaneously may be required for optimal preventive effects. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) is the first large, long-term RCT to demonstrate that a multidomain lifestyle-based intervention ameliorating vascular and lifestyle-related risk factors can preserve cognitive functioning and reduce the risk of cognitive decline among older adults at increased risk of dementia. To investigate the multidomain intervention in other populations and diverse cultural and geographical settings, the World-Wide FINGERS (WW-FINGERS) network was recently launched (https://alz.org/wwfingers). Within this network, new FINGER-type trials with shared core methodology, but local culture and context-specific adaptations, will be conducted in several countries. The WW-FINGERS initiative facilitates international collaborations, provides a platform for testing multidomain strategies to prevent cognitive impairment and dementia, and aims at generating high-quality scientific evidence to support public health and clinical decision-making. Furthermore, the WW-FINGERS network can support the implementation of preventive strategies and translation of research findings into practice.

Impact of the COVID-19 pandemic on statistical design and analysis plans for multidomain intervention clinical trials: Experience from World-Wide FINGERS

INTRODUCTION

The coronavirus disease-19 (COVID-19) pandemic presents challenges to the conduct of randomized clinical trials of lifestyle interventions.

METHODS

World-Wide FINGERS is an international network of clinical trials to assess the impact of multidomain lifestyle intervention on cognitive decline in at-risk adults. Individual trials are tailoring successful approaches from the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) to local cultures and environments. The network convened a forum for researchers to discuss statistical design and analysis issues they faced during the pandemic. We report on experiences of three trials that, at various stages of conduct, altered designs and analysis plans to navigate these issues. We provide recommendations for future trials to consider as they develop and launch behavioral intervention trials.

RESULTS

The pandemic led researchers to change recruitment plans, interrupt timelines for assessments and intervention delivery, and move to remote intervention and assessment protocols. The necessity of these changes add emphasis to the importance, in study design and analysis, of intention to treat approaches, flexibility, within-site stratification, interim power projections, and sensitivity analyses.

DISCUSSION

Robust approaches to study design and analysis are critical to negotiate issues related to the intervention. The world-wide network of similarly oriented clinical trials will allow us to evaluate the effectiveness of responses to the pandemic across cultures, local environments, and phases of the pandemic.

Association between multimorbidity patterns and disability among older people covered by long-term care insurance in Shanghai, China

BACKGROUND

Functional disability and multimorbidity are common among older people. However, little is known about the relationship between functional disability and different multimorbidity combinations. We aimed to identify multimorbidity patterns and explore the associations between these patterns and functional disability.

METHODS

We investigated a multi-stage random sample of 1871 participants aged ≥60 years and covered by long-term care insurance in Shanghai, China. Multimorbidity was defined as the simultaneous presence of two or more chronic diseases in an individual. Participants completed scales to assess basic and instrumental activities of daily living (BADL and IADL, respectively). Multimorbidity patterns were identified via exploratory factor analysis. Binary logistic regression models were used to determine adjusted associations between functional disability and number and patterns of multimorbidity.

RESULTS

Multimorbidity was present in 74.3% of participants. The prevalence of BADL disability was 50.7% and that of IADL disability was 90.7%. There was a strong association between multimorbidity and disability. We identified three multimorbidity patterns: musculoskeletal, cardio-metabolic, and mental-degenerative diseases. The cardio-metabolic disease pattern was associated with both BADL (OR 1.28, 95%CI 1.16-1.41) and IADL (OR 1.41, 95%CI 1.19-1.68) disability. The mental-degenerative disease pattern was associated with BADL disability (OR 1.55, 95%CI 1.40-1.72).

CONCLUSIONS

Multimorbidity and functional disability are highly prevalent among older people covered by long-term care insurance in Shanghai, and distinct multimorbidity patterns are differentially associated with functional disability. Appropriate long-term healthcare and prevention strategies for older people may help reduce multimorbidity, maintain functional ability, and improve health-related quality of life.

Changes in Lifestyle, Behaviors, and Risk Factors for Cognitive Impairment in Older Persons During the First Wave of the Coronavirus Disease 2019 Pandemic in Finland: Results From the FINGER Study

Aims: This study aimed to describe how the first phase of the coronavirus disease 2019 (COVID-19) pandemic affected older persons from the general Finnish population who are at risk of developing or have cognitive impairment, specifically, to describe whether participants experienced a change in risk factors that are relevant for the prevention of cognitive decline including diet, physical activity, access to medical care, socially and cognitively stimulating activities, and emotional health and well-being. Method: A postal survey was sent in June 2020 to 859 participants from the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER), an ongoing longitudinal study. The survey was developed to assess the effect of the COVID-19 pandemic and related infection-control measures on daily life, specifically commitment to distancing measures, access to health care and social services, daily activities, and changes in cognitive and social activities. Results: By September 2020, 613 (71%) participants responded (mean age = 77.7 years, 32% lived alone, and 80% had at least one chronic condition). Three quarters adopted some distancing practices during the first months of the pandemic. Older participants were more likely to practice total isolation than younger ones (29 vs. 19%; p = 0.003). Non-acute health-care visits were canceled for 5% of the participants who needed appointments, but cancellations in dental health care (43%), home aid (30%), and rehabilitative services (53%) were more common. Pandemic-related changes were reported in social engagements, for example, less contact with friends (55%) and family (31%), or less frequent attendance in cultural events (38%) or associations (25%), although remote contact with others increased for 40%. Feelings of loneliness increased for 21%, particularly those who were older (p = 0.023) or living alone (p < 0.001). Physical activity reduced for 34%, but dietary habits remained stable or improved. Pandemic-related changes in lifestyle and activities were more evident among those living alone. Conclusions: Finnish older persons generally reported less negative changes in lifestyles and behaviors during the pandemic than expected. Older people and those living alone seemed more susceptible to negative changes. It is important to compare how coping strategies may compare with other European countries to identify factors that may help older individuals to maintain healthy lifestyles during future waves of COVID-19.

The incidence of multimorbidity and patterns in accumulation of chronic conditions: A systematic review

Multimorbidity, the presence of 1+ chronic condition in an individual, remains one of the greatest challenges to health on a global scale. Although the prevalence of multimorbidity has been well-established, its incidence is not fully understood. This systematic review determined the incidence of multimorbidity across the lifespan; the order in which chronic conditions accumulate to result in multimorbidity; and cataloged methods used to determine and report accumulation of chronic conditions resulting in multimorbidity. Studies were identified by searching MEDLINE, Embase, CINAHL, and Cochrane electronic databases. Two independent reviewers evaluated studies for inclusion and performed quality assessments. Of 36 included studies, there was high heterogeneity in study design and operational definitions of multimorbidity. Studies reporting incidence (n = 32) reported a median incidence rate of 30.7 per 1,000 person-years (IQR 39.5 per 1,000 person-years) and a median cumulative incidence of 2.8% (IQR 28.7%). Incidence was notably higher for persons with older age and 1+ chronic conditions at baseline. Studies reporting patterns in accumulation of chronic conditions (n = 5) reported hypertensive and heart diseases, and diabetes, as among the common starting conditions resulting in later multimorbidity. Methods used to discern patterns were highly heterogenous, ranging from the use of latent growth trajectories to divisive cluster analyses, and presentation using alluvial plots to cluster trajectories. Studies reporting the incidence of multimorbidity and patterns in accumulation of chronic conditions vary greatly in study designs and definitions used. To allow for more accurate estimations and comparison, studies must be transparent and consistent in operational definitions of multimorbidity applied.

Impact of an 8-Year Intensive Lifestyle Intervention on an Index of Multimorbidity

BACKGROUND/OBJECTIVES

Type 2 diabetes mellitus and obesity are sometimes described as conditions that accelerate aging. Multidomain lifestyle interventions have shown promise to slow the accumulation of age-related diseases, a hallmark of aging. However, they have not been assessed among at-risk individuals with these two conditions. We examined the relative impact of 8 years of a multidomain lifestyle intervention on an index of multimorbidity.

DESIGN

Randomized controlled clinical trial comparing an intensive lifestyle intervention (ILI) that targeted weight loss through caloric restriction and increased physical activity with a control condition of diabetes support and education (DSE).

SETTING

Sixteen U.S. academic centers.

PARTICIPANTS

A total of 5,145 volunteers, aged 45 to 76, with established type 2 diabetes mellitus and overweight or obesity who met eligibility criteria for a randomized controlled clinical trial.

MEASUREMENTS

A multimorbidity index that included nine age-related chronic diseases and death was tracked over 8 years of intervention delivery.

RESULTS

Among individuals assigned to DSE, the multimorbidity index scores increased by an average of .98 (95% confidence interval [CI] = .94-1.02) over 8 years, compared with .89 (95% CI = .85-.93) among those in the multidomain ILI, which was a 9% difference (P = .003). Relative intervention effects were similar among individuals grouped by baseline body mass index, age, and sex, and they were greater for those with lower levels of multimorbidity index scores at baseline.

CONCLUSIONS

Increases in multimorbidity over time among adults with overweight or obesity and type 2 diabetes mellitus may be slowed by multidomain ILI. J Am Geriatr Soc 68:2249-2256, 2020.

Physical Activity as a Moderator of Alzheimer Pathology: A Systematic Review of Observational Studies

INTRODUCTION

Observational studies have found that physical activity is associated with a reduced risk of cognitive decline and dementia. Whether physical activity may also reduce the level of AD pathology, remains undetermined.

OBJECTIVE

To examine the relationship between physical activity and AD biomarkers (beta-amyloid1- 42, total tau and phosphorylated tau in CSF, amyloid PET, hippocampal atrophy on MRI and parietotemporal hypometabolism on brain 18F-FDG-PET).

METHODS

We carried out a systematic review of the observational studies of physical activity and AD biomarkers in healthy subjects, subjective cognitive complaints, mild cognitive impairment (MCI) and AD dementia.

RESULTS

We identified a total of 40 papers, which were eligible for inclusion. Thirty-four studies were conducted on healthy subjects, 3 on MCI and healthy subjects, 1 on MCI, and 2 on AD and healthy controls. Six studies reported on CSF biomarkers, 9 on amyloid PET, 29 on MRI and 4 on brain 18FFDG- PET. The majority of studies did not find a significant association between physical activity and AD biomarkers.

CONCLUSION

The quality of included studies with only a few longitudinal studies, limits the conclusions which may be drawn from the present findings especially regarding the biomarkers other than hippocampal volume. However, the majority of the identified studies did not find a significant association.

World-Wide FINGERS Network: A global approach to risk reduction and prevention of dementia

Reducing the risk of dementia can halt the worldwide increase of affected people. The multifactorial and heterogeneous nature of late-onset dementia, including Alzheimer’s disease (AD), indicates a potential impact of multidomain lifestyle interventions on risk reduction. The positive results of the landmark multidomain Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) support such an approach. The World-Wide FINGERS (WW-FINGERS), launched in 2017 and including over 25 countries, is the first global network of multidomain lifestyle intervention trials for dementia risk reduction and prevention. WW-FINGERS aims to adapt, test, and optimize the FINGER model to reduce risk across the spectrum of cognitive decline—from at-risk asymptomatic states to early symptomatic stages—in different geographical, cultural, and economic settings. WW-FINGERS aims to harmonize and adapt multidomain interventions across various countries and settings, to facilitate data sharing and analysis across studies, and to promote international joint initiatives to identify globally implementable and effective preventive strategies.

The potential long-term impact of the COVID-19 outbreak on patients with non-communicable diseases in Europe: consequences for healthy ageing

The early stages of the COVID-19 pandemic have focused on containing SARS-CoV-2 infection and identifying treatment strategies. While controlling this communicable disease is of utmost importance, the long-term effect on individuals with non-communicable diseases (NCD) is significant. Although certain NCDs appear to increase the severity of COVID-19 and mortality risk, SARS-CoV-2 infection in survivors with NCDs may also affect the progression of their pre-existing clinical conditions. Infection containment measures will have substantial short- and long-term consequences; social distancing and quarantine restrictions will reduce physical activity and increase other unhealthy lifestyles, thus increasing NCD risk factors and worsening clinical symptoms. Vitamin D levels might decrease and there might be a rise in mental health disorders. Many countries have made changes to routine management of NCD patients, e.g., cancelling non-urgent outpatient visits, which will have important implications for NCD management, diagnosis of new-onset NCDs, medication adherence, and NCD progression. We may have opportunities to learn from this unprecedented crisis on how to leverage healthcare technologies and improve procedures to optimize healthcare service provision. This article discusses how the COVID-19 outbreak and related infection control measures could hit the most frail individuals, worsening the condition of NCD patients, while further jeopardizing the sustainability of the healthcare systems. We suggest ways to define an integrated strategy that could involve both public institutional entities and the private sector to safeguard frail individuals and mitigate the impact of the outbreak.

Neurocognition in treatment-resistant hypertension: profile and associations with cardiovascular biomarkers

BACKGROUND

Hypertension in midlife has been associated with increased risk of stroke and neurocognitive decline. Few studies, however, have examined neurocognition among individuals with treatment-resistant hypertension or potential mechanisms by which treatment-resistant hypertension may impair neurocognition.

METHODS

We examined the pattern of neurocognitive impairment and potential mechanisms in a sample of 96 overweight adults with treatment-resistant hypertension, aged 41-81 years. Neurocognitive function was assessed using a 45-min test battery consisting of executive function and memory. Vascular and metabolic mechanisms examined included cerebrovascular risk factors (CVRFs: Framingham Stroke Risk Profile), insulin sensitivity (homeostatic model assessment of insulin resistance), waist-to-hip ratio, microvascular function (hyperemic response), and peak oxygen consumption from an exercise treadmill test. Simple path analyses were used to assess the association between potential vascular and metabolic mechanisms and neurocognition.

RESULTS

Neurocognitive impairments were common, with 70% of the sample exhibiting impaired performance on at least one executive function subtest and 38% on at least one measure of memory. Higher levels of aerobic fitness, greater insulin sensitivity, and better microvascular function, as well as lower CVRFs and waist-to-hip ratio were associated with better neurocognition. In path analyses, aerobic fitness, microvascular function, and CVRFs all were independently associated with neurocognitive performance. Insulin resistance associated with worse executive function but better memory performance among older participants.

CONCLUSION

Neurocognitive impairments are common in adults with treatment-resistant hypertension, particularly on tests of executive function. Better neurocognition is independently associated with aerobic fitness, microvascular function, and CVRFs.

Prevention of dementia presents a potentially critical platform for improvement of long-term public health

With the aging of the population, Alzheimer disease (AD) has become an epidemic and a major public health threat. Hundreds of molecules tested in clinical trials in the last decade to treat AD have failed, moving the field to examine the clinical and neurobiological value of prevention of cognitive decline and AD. This short review describes recently finished or currently ongoing clinical trials for prevention of AD, both their main outcomes and secondary outcomes. In addition, the potential modifying effects of age and of genetics as important factors that may affect the design of future clinical trials is discussed. Finally, we discuss the development of new molecular imaging and of digital technologies as a means to disclosure of dementia-related risk and disease progress, and their potential importance as contributors to adherence to healthy lifestyle for the prevention or delay of AD onset.

Social engagement in late life may attenuate the burden of depressive symptoms due to financial strain in childhood

BACKGROUND

It remains poorly understood if childhood financial strain is associated with old-age depression and if active social life may mitigate this relationship.

AIMS

To investigate the association between childhood financial strain and depressive symptoms during aging; to examine whether late-life social engagement modifies this association.

METHOD

2884 dementia-free individuals (aged 60+) from the Swedish National study of Aging and Care-Kungsholmen were clinically examined over a 15-year follow-up. Presence of childhood financial strain was ascertained at baseline. Depressive symptoms were repeatedly assessed with the Montgomery-Åsberg Depression Rating Scale. Social engagement comprised information on baseline social network and leisure activities. Linear, logistic and mixed-effect models estimated baseline and longitudinal associations accounting for sociodemographic, clinical, and lifestyle factors.

RESULTS

Childhood financial strain was independently associated with a higher baseline level of depressive symptoms (β = 0.37, 95%CI 0.10-0.65), but not with symptom change over time. Relative to those without financial strain and with active social engagement, depressive burden was increased in those without financial strain but with inactive social engagement (β = 0.43, 95%CI: 0.15-0.71), and in those with both financial strain and inactive engagement (β = 0.99, 95%CI: 0.59-1.40). Individuals with financial strain and active social engagement exhibited similar depressive burden as those without financial strain and with active social engagement.

LIMITATIONS

Recall bias and reverse causality may affect study results, although sensitivity analyses suggest their limited effect.

CONCLUSIONS

Early-life financial strain may be of lasting importance for old-age depressive symptoms. Active social engagement in late-life may mitigate this association.

Lifestyle factors and risk of multimorbidity of cancer and cardiometabolic diseases: a multinational cohort study

BACKGROUND

Although lifestyle factors have been studied in relation to individual non-communicable diseases (NCDs), their association with development of a subsequent NCD, defined as multimorbidity, has been scarcely investigated. The aim of this study was to investigate associations between five lifestyle factors and incident multimorbidity of cancer and cardiometabolic diseases.

METHODS

In this prospective cohort study, 291,778 participants (64% women) from seven European countries, mostly aged 43 to 58 years and free of cancer, cardiovascular disease (CVD), and type 2 diabetes (T2D) at recruitment, were included. Incident multimorbidity of cancer and cardiometabolic diseases was defined as developing subsequently two diseases including first cancer at any site, CVD, and T2D in an individual. Multi-state modelling based on Cox regression was used to compute hazard ratios (HR) and 95% confidence intervals (95% CI) of developing cancer, CVD, or T2D, and subsequent transitions to multimorbidity, in relation to body mass index (BMI), smoking status, alcohol intake, physical activity, adherence to the Mediterranean diet, and their combination as a healthy lifestyle index (HLI) score. Cumulative incidence functions (CIFs) were estimated to compute 10-year absolute risks for transitions from healthy to cancer at any site, CVD (both fatal and non-fatal), or T2D, and to subsequent multimorbidity after each of the three NCDs.

RESULTS

During a median follow-up of 11 years, 1910 men and 1334 women developed multimorbidity of cancer and cardiometabolic diseases. A higher HLI, reflecting healthy lifestyles, was strongly inversely associated with multimorbidity, with hazard ratios per 3-unit increment of 0.75 (95% CI, 0.71 to 0.81), 0.84 (0.79 to 0.90), and 0.82 (0.77 to 0.88) after cancer, CVD, and T2D, respectively. After T2D, the 10-year absolute risks of multimorbidity were 40% and 25% for men and women, respectively, with unhealthy lifestyle, and 30% and 18% for men and women with healthy lifestyles.

CONCLUSION

Pre-diagnostic healthy lifestyle behaviours were strongly inversely associated with the risk of cancer and cardiometabolic diseases, and with the prognosis of these diseases by reducing risk of multimorbidity.

Pathways of Prevention: A Scoping Review of Dietary and Exercise Interventions for Neurocognition

Alzheimer's disease and related dementias (ADRD) represent an increasingly urgent public health concern, with an increasing number of baby boomers now at risk. Due to a lack of efficacious therapies among symptomatic older adults, an increasing emphasis has been placed on preventive measures that can curb or even prevent ADRD development among middle-aged adults. Lifestyle modification using aerobic exercise and dietary modification represents one of the primary treatment modalities used to mitigate ADRD risk, with an increasing number of trials demonstrating that exercise and dietary change, individually and together, improve neurocognitive performance among middle-aged and older adults. Despite several optimistic findings, examination of treatment changes across lifestyle interventions reveals a variable pattern of improvements, with large individual differences across trials. The present review attempts to synthesize available literature linking lifestyle modification to neurocognitive changes, outline putative mechanisms of treatment improvement, and discuss discrepant trial findings. In addition, previous mechanistic assumptions linking lifestyle to neurocognition are discussed, with a focus on potential solutions to improve our understanding of individual neurocognitive differences in response to lifestyle modification. Specific recommendations include integration of contemporary causal inference approaches for analyzing parallel mechanistic pathways and treatment-exposure interactions. Methodological recommendations include trial multiphase optimization strategy (MOST) design approaches that leverage individual differences for improved treatment outcomes.

Frequent Cognitive Impairment in Patients With Disorders Along the Heart-Brain Axis

Background and Purpose—

Patients with cardiovascular disease are at increased risk for cognitive decline. We studied the occurrence and profile of cognitive impairment in 3 patient groups as exemplar conditions of hemodynamic disturbances at different levels of the heart-brain axis, including patients with heart failure (HF), carotid occlusive disease (COD), and patients with cognitive complaints and vascular brain injury on magnetic resonance imaging (possible vascular cognitive impairment [VCI]).

Methods—

In 555 participants (160 HF, 107 COD, 160 possible VCI, 128 reference participants; 68±9 years; 36% F; Mini-Mental State Examination 28±2), we assessed cognitive functioning with a comprehensive test battery. Test scores were transformed into z -scores. Compound z -scores were constructed for: memory, language, attention/psychomotor speed, executive functioning, and global cognitive functioning. We rated cognitive domains as impaired when z -score≤−1.5. Based on the number of impaired domains, patients were classified as cognitively normal, minor, or major cognitive impairment. We used general linear models and χ 2 tests to compare cognitive functioning between patient groups and the reference group.

Results—

Age, sex, and education adjusted global cognitive functioning z-score was lower in patients with COD (β [SE]=−0.46 [0.10], P <0.001) and possible VCI (β [SE]=−0.80 [0.09], P <0.001) compared with reference participants. On all domains, z -scores were lower in patients with COD and possible VCI compared with reference participants. Patients with HF had lower z-scores on attention/speed and language compared with reference participants. Cognitive impairment was observed in 18% of HF, 36% of COD, and 45% possible VCI. There was no difference in profile of impaired cognitive domains between patient groups. Memory and attention-psychomotor speed were most commonly affected, followed by executive functioning and language.

Conclusions—

A substantial part of patients with HF and COD had cognitive impairment, which warrants vigilance for the occurrence of cognitive impairment. These results underline the importance of an integrative approach in medicine in patients presenting with disorders in the heart-brain axis.

Vascular contributions to cognitive impairment and dementia: Research consortia that focus on etiology and treatable targets to lessen the burden of dementia worldwide

The research into vascular contributions to cognitive impairment and dementia (VCID) aims to understand the importance of cerebrovascular biology in cognitive decline. Prevention and treatment of VCID is poised to have major impact on dementia-related disease burden and is thus a critical emerging objective in dementia research. This article presents VCID consortia focused on multidisciplinary approaches to identify key pathologic targets and develop diagnostic tools with the goal of bridging the divide between basic research and clinical trials. Members of these multi-institute, multidisciplinary consortia provide a prospective on the history and emerging science of VCID and how VCID consortia can address some of the more complex questions in VCID and drive the field forward. These consortia, and others like them, are uniquely suited to tackle some of the most difficult obstacles in translating research to the clinic.

Current and emerging avenues for Alzheimer's disease drug targets

Alzheimer's disease (AD), the most frequent cause of dementia, is escalating as a global epidemic, and so far, there is neither cure nor treatment to alter its progression. The most important feature of the disease is neuronal death and loss of cognitive functions, caused probably from several pathological processes in the brain. The main neuropathological features of AD are widely described as amyloid beta (Aβ) plaques and neurofibrillary tangles of the aggregated protein tau, which contribute to the disease. Nevertheless, AD brains suffer from a variety of alterations in function, such as energy metabolism, inflammation and synaptic activity. The latest decades have seen an explosion of genes and molecules that can be employed as targets aiming to improve brain physiology, which can result in preventive strategies for AD. Moreover, therapeutics using these targets can help AD brains to sustain function during the development of AD pathology. Here, we review broadly recent information for potential targets that can modify AD through diverse pharmacological and nonpharmacological approaches including gene therapy. We propose that AD could be tackled not only using combination therapies including Aβ and tau, but also considering insulin and cholesterol metabolism, vascular function, synaptic plasticity, epigenetics, neurovascular junction and blood-brain barrier targets that have been studied recently. We also make a case for the role of gut microbiota in AD. Our hope is to promote the continuing research of diverse targets affecting AD and promote diverse targeting as a near-future strategy.

Face-to-Face and Digital Multidomain Lifestyle Interventions to Enhance Cognitive Reserve and Reduce Risk of Alzheimer's Disease and Related Dementias: A Review of Completed and Prospective Studies

BACKGROUND

Currently, there is no pharmaceutical intervention to treat or delay pathological cognitive decline or Alzheimer's disease and related dementias (ADRD). Multidomain lifestyle interventions are increasingly being studied as a non-pharmacological solution to enhance cognitive reserve, maintain cognition, and reduce the risk of or delay ADRD. Review of completed and prospective face-to-face (FTF) and digital multidomain interventions provides an opportunity to compare studies and informs future interventions and study design.

METHODS

Electronic databases (PubMed, PsycINFO, clinicaltrials.gov and NIH RePORTER) were searched for multidomain lifestyle programs. Studies were included if the program (1) included a control group, (2) included at least 3 interventions, (3) were at least 6 months in duration, and (4) included measurement of cognitive performance as an outcome.

RESULTS

In total, 17 multidomain lifestyle programs aimed at enhancing cognitive reserve and reducing risk of ADRD were found. Thirteen programs are FTF in intervention delivery, with 3 FTF programs replicating the FINGER protocol as part of the World Wide Fingers Consortium. Four programs are delivered digitally (website, Web application, or mobile app). Program characteristics (e.g., target population, duration, frequency, outcomes, and availability) and results of completed and prospective studies are reviewed and discussed.

CONCLUSION

This review updates and discusses completed and current multidomain lifestyle interventions aimed at enhancing cognitive reserve and reducing risk of ADRD. A growing number of international studies are investigating the efficacy and utility of these programs in both FTF and digital contexts. While a diversity of study designs and interventions exist, FTF and digital programs that build upon the foundational work of the FINGER protocol have significant potential to enhance cognitive reserve and reduce risk of ADRD.

Lifestyle interventions to prevent cognitive impairment, dementia and Alzheimer disease

Research into dementia prevention is of paramount importance if the dementia epidemic is to be halted. Observational studies have identified several potentially modifiable risk factors for dementia, including hypertension, dyslipidaemia and obesity at midlife, diabetes mellitus, smoking, physical inactivity, depression and low levels of education. Randomized clinical trials are needed that investigate whether interventions targeting these risk factors can reduce the risk of cognitive decline and dementia in elderly adults, but such trials are methodologically challenging. To date, most preventive interventions have been tested in small groups, have focused on a single lifestyle factor and have yielded negative or modest results. Given the multifactorial aetiology of dementia and late-onset Alzheimer disease, multidomain interventions that target several risk factors and mechanisms simultaneously might be necessary for an optimal preventive effect. In the past few years, three large multidomain trials (FINGER, MAPT and PreDIVA) have been completed. The FINGER trial showed that a multidomain lifestyle intervention can benefit cognition in elderly people with an elevated risk of dementia. The primary results from the other trials did not show a statistically significant benefit of preventive interventions, but additional analyses among participants at risk of dementia showed beneficial effects of intervention. Overall, results from these three trials suggest that targeting of preventive interventions to at-risk individuals is an effective strategy. This Review discusses the current knowledge of lifestyle-related risk factors and results from novel trials aiming to prevent cognitive decline and dementia. Global initiatives are presented, including the World Wide FINGERS network, which aims to harmonize studies on dementia prevention, generate high-quality scientific evidence and promote its implementation.

Independent Functioning in Nonagenarians Living in a Rural Italian Community: The Mugello Study

Nonagenarians are a fast-growing population deserving specific research. We explored the prevalence and characteristics of functionally independent nonagenarians from a rural community-dwelling Italian population. Data were collected in the Mugello Study; 475 persons aged ≥90 years (median age, 92) underwent a home-based clinical and functional assessment, including psychosocial, clinical, functional, and lifestyle history and status and physical and instrumental examinations. Sixty-eight (15%) persons reported no need for help in basic and instrumental daily living activities. Among variables significantly associated with independent functionality after age- and gender-adjusted cross-sectional analysis, lower body mass index (BMI; p = .034) and depressive symptoms (p = .028), higher current physical activity (p < .001), better cognitive status (p = .033), and lower medication intake (p = .048) were associated with reporting no disability in the logistic regression analysis. Disability was mainly associated with current lifestyle-related potentially modifiable factors. Thus, lifestyle-oriented multidimensional interventions, should be developed and evaluated for their potential effects on functionality, even in the oldest old.

Multimorbidity and functional impairment-bidirectional interplay, synergistic effects and common pathways

This review discusses the interplay between multimorbidity (i.e. co-occurrence of more than one chronic health condition in an individual) and functional impairment (i.e. limitations in mobility, strength or cognition that may eventually hamper a person's ability to perform everyday tasks). On the one hand, diseases belonging to common patterns of multimorbidity may interact, curtailing compensatory mechanisms and resulting in physical and cognitive decline. On the other hand, physical and cognitive impairment impact the severity and burden of multimorbidity, contributing to the establishment of a vicious circle. The circle may be further exacerbated by people's reduced ability to cope with treatment and care burden and physicians' fragmented view of health problems, which cause suboptimal use of health services and reduced quality of life and survival. Thus, the synergistic effects of medical diagnoses and functional status in adults, particularly older adults, emerge as central to assessing their health and care needs. Furthermore, common pathways seem to underlie multimorbidity, functional impairment and their interplay. For example, older age, obesity, involuntary weight loss and sedentarism can accelerate damage accumulation in organs and physiological systems by fostering inflammatory status. Inappropriate use or overuse of specific medications and drug-drug and drug-disease interactions also contribute to the bidirectional association between multimorbidity and functional impairment. Additionally, psychosocial factors such as low socioeconomic status and the direct or indirect effects of negative life events, weak social networks and an external locus of control may underlie the complex interactions between multimorbidity, functional decline and negative outcomes. Identifying modifiable risk factors and pathways common to multimorbidity and functional impairment could aid in the design of interventions to delay, prevent or alleviate age-related health deterioration; this review provides an overview of knowledge gaps and future directions.

The Effect of Multidomain Lifestyle Intervention on Daily Functioning in Older People

OBJECTIVE

To investigate the effect of a 2-year multidomain lifestyle intervention on daily functioning of older people.

DESIGN

A 2-year randomized controlled trial (ClinicalTrials.gov, NCT01041989).

SETTING

Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability.

PARTICIPANTS

A total of 1260 older adults, with a mean age of 69 years at the baseline, who were at risk of cognitive decline.

INTERVENTION

A multidomain intervention, including simultaneous physical activity intervention, nutritional counseling, vascular risk monitoring and management, and cognitive training and social activity.

MEASUREMENTS

The ability to perform daily activities (activities of daily living [ADLs] and instrumental ADLs) and physical performance (Short Physical Performance Battery).

RESULTS

The mean baseline ADL score was 18.1 (SD = 2.6) points; the scale ranges from 17 (no difficulties) to 85 (total ADL dependence). During the 2-year intervention, the ADL disability score slightly increased in the control group, while in the intervention group, it remained relatively stable. Based on the latent growth curve model, the difference in the change between the intervention and control groups was -0.95 (95% confidence interval [CI] = -1.61 to -0.28) after 1 year and -1.20 (95% CI = -2.02 to -0.38) after 2 years. In terms of physical performance, the intervention group had a slightly higher probability of improvement (from score 3 to score 4; P = .041) and a lower probability of decline (from score 3 to scores 0-2; P = .043) for chair rise compared to the control group.

CONCLUSION

A 2-year lifestyle intervention was able to maintain the daily functioning of the at-risk older population. The clinical significance of these results in this fairly well-functioning population remains uncertain, but the study results hold promise that healthy eating, exercise, and cognitive and social activity may have favorable effects on functional independence in older people.

Shared genetic architecture between metabolic traits and Alzheimer's disease: a large-scale genome-wide cross-trait analysis

A growing number of studies clearly demonstrate a substantial link between metabolic dysfunction and the risk of Alzheimer's disease (AD), especially glucose-related dysfunction; one hypothesis for this comorbidity is the presence of a common genetic etiology. We conducted a large-scale cross-trait GWAS to investigate the genetic overlap between AD and ten metabolic traits. Among all the metabolic traits, fasting glucose, fasting insulin and HDL were found to be genetically associated with AD. Local genetic covariance analysis found that 19q13 region had strong local genetic correlation between AD and T2D (P = 6.78 × 10^- 22), LDL (P = 1.74 × 10^- 253) and HDL (P = 7.94 × 10^- 18). Cross-trait meta-analysis identified 4 loci that were associated with AD and fasting glucose, 3 loci that were associated with AD and fasting insulin, and 20 loci that were associated with AD and HDL (P_meta < 1.6 × 10^- 8, single trait P < 0.05). Functional analysis revealed that the shared genes are enriched in amyloid metabolic process, lipoprotein remodeling and other related biological pathways; also in pancreas, liver, blood and other tissues. Our work identifies common genetic architectures shared between AD and fasting glucose, fasting insulin and HDL, and sheds light on molecular mechanisms underlying the association between metabolic dysregulation and AD.

A Remote Intervention to Prevent or Delay Cognitive Impairment in Older Adults: Design, Recruitment, and Baseline Characteristics of the Virtual Cognitive Health (VC Health) Study

Background

A growing body of evidence supports the use of lifestyle interventions for preventing or delaying the onset of Alzheimer disease and other forms of dementia in at-risk individuals. The development of internet-delivered programs would increase the scalability and reach of these interventions, but requires validation to ensure similar effectiveness to brick-and-mortar options.

Objective

We describe the study design, recruitment process, and baseline participant characteristics of the sample in the Virtual Cognitive Health (VC Health) study. Future analyses will assess the impact of the remotely delivered lifestyle intervention on (1) cognitive function, (2) depression and anxiety, and (3) various lifestyle behaviors, including diet, exercise, and sleep, in a cohort of older adults with subjective memory decline. Additional analyses will explore feasibility outcomes, as well as the participants’ engagement patterns with the program.

Methods

Older adults (aged 60-75 years) with subjective memory decline as measured by the Subjective Cognitive Decline 9-item (SCD-9) questionnaire, and who reported feeling worried about their memory decline, were eligible to participate in this single-arm pre-post study. All participants enrolled in the yearlong digital intervention, which consists of health coach-guided lifestyle change for improving diet, exercise, sleep, stress, and cognition. All components of this study were conducted remotely, including the collection of data and the administration of the intervention. We assessed participants at baseline, 12 weeks, 24 weeks, and 52 weeks with online surveys and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) test. We will conduct intention-to-treat analysis on all outcomes.

Results

A total of 85 participants enrolled in the intervention and 82 are included in the study sample (3 participants withdrew). The study cohort of 82 participants comprises 61 (74%) female, 72 (88%) white, and 64 (78%) overweight or obese participants, and 55 (67%) have at least a college degree. The average baseline RBANS score was 95.9 (SD 11.1), which is within age-adjusted norms. The average SCD-9 score was 6.0 (SD 2.0), indicating minor subjective cognitive impairment at the beginning of the study. The average baseline Generalized Anxiety Disorder 7-item scale score was 6.2 (SD 4.5), and the average Patient Health Questionnaire 9-item score was 8.5 (SD 4.9), indicating mild levels of anxiety and depression at baseline.

Conclusions

Internet-delivered lifestyle interventions are a scalable solution for the prevention or delay of Alzheimer disease. The results of this study will provide the first evidence for the effectiveness of a fully remote intervention and lay the groundwork for future investigations.

Trial Registration

ClinicalTrials.gov NCT02969460; http://clinicaltrials.gov/ct2/show/NCT02969460 (Archived by WebCite at http://www.webcitation.org/71LkYAkSh)

Registered Report Identifier

RR1-10.2196/11368