Cognitive impairment as assessed by a short form of MMSE was predictive of mortality

Association of medicinal plant consumption with all-cause mortality and cognitive impairment in older adult: A large prospective cohort study

BACKGROUND

Panax ginseng and other medicinal plants have long been believed to have beneficial effects on health, and there is substantial evidence supporting their mechanisms of action. However, the extent of the health benefits derived from consuming these medicinal plants lacks substantial evidence from large-scale longitudinal population studies. The purpose of this study was to analyze the effect of consuming these medicinal plants on all-cause mortality and cognitive impairment.

METHODS

A population-based cohort study was conducted using the Chinese Longitudinal Healthy Longevity Survey (CLHLS), which was established in 1998 and has been followed up till now. The main exposure was the frequency of eating medicinal plants, including Panax ginseng, Astragalus membranaceus, Lycium barbarum, Angelica sinensis, etc. According to the consumption patterns of medicinal plants, the participants were divided into three groups: frequent use, occasional use, and rarely or never use group. The participants were individually tracked to determine their mortality and cognitive impairment status during the period from 2008 to 2018. Cox proportional hazards regression and competing risk model were used to calculate the hazard ratio (HR) for the association between the use of medicinal plants and the all-cause mortality and cognitive impairment.

RESULTS

Among 13,918 participants, the average age was 87.2 ± 11.3 years old, and 70.1% (9,754/13,918) of the participants died during follow-up. The proportion of those frequently using, occasionally using, and rarely using medicinal plants was 8.4%, 20.7%, and 70.8%, respectively. Compared with the rarely or never use group, the occasional and frequent use groups demonstrated significantly lower risks for all-cause mortality, with HR of 0.75 (95% CI: 0.71 - 0.79) and 0.53 (95% CI: 0.49 - 0.58), respectively. The protective effect of medicinal plants against all-cause mortality decreased with increasing age in the subgroup analysis. Additionally, frequent use of medicinal plants reduced the risk of cognitive impairment in the competing risk model (HR = 0.73, 95% CI: 0.60 - 0.87). However, there was no protective effect on cognitive function for those who occasional use medicinal plants.

CONCLUSION

In elderly individuals, occasional and frequent use of medicinal plants was associated with reductions in risk of all-cause mortality, and frequent use of medicinal plants could reduce the risk of cognitive impairment.

Cognitive impairment assessed by Mini-Mental State Examination predicts all-cause and CVD mortality in Chinese older adults: A 10-year follow-up study

Objective

Cognitive impairment (CI) has been demonstrated as a useful proxy measure of mortality in Western populations. However, the predictive value of CI in Chinese populations is unknown. We aimed to explore whether CI is independently associated with increased long-term all-cause and cardiovascular disease (CVD) mortality in Chinese older adults and the association of performance in specific MMSE sub-domains to subsequent mortality.

Methods and results

A total of 4,499 older adults [mean (SD) age, 70.3(6.7) years] who received a sample investigation from 2011 to 2014 were followed up till 2021 for mortality. The Mini-Mental State Examination was used to assess cognitive function, and Cox's proportional hazard models were used to evaluate the effects of cognitive function on the risk of all-cause and CVD mortality. Demographic characteristics, lifestyle, and health status were included as covariates. During a 10-year follow-up, a total of 667 (14.8%) died. In the fully adjusted model, compared with cognitively normal participants with CI had a 1.33-fold [HR, 1.33; (95% CI, 1.10-1.61)] greater risk of all-cause mortality and a 1.45-fold [HR, 1.45; (95% CIs, 1.11-1.92)] greater risk of CVD mortality. After a similar multivariable adjustment, a per-SD increase in MMSE scores was associated with a reduced risk of all-cause mortality [HR, 0.85; (95% CI, 0.78-0.93)] and CVD mortality [HR, 0.74; (95% CI, 0.65-0.84)]. In the unadjusted model, MMSE sub-domains (apart from immediate recall) were associated with mortality. But only orientation and calculation and attention were still independently associated with all-cause and CVD mortality in a multivariable model.

Conclusion

These findings confirmed that CI is a marker of all-cause and CVD mortality risk in Chinese older adults, independently of other commonly assessed risk factors, and some sub-domains of the MMSE may have stronger associations with mortality. Further research is needed to identify the mechanisms underlying the observed associations.

Exploring the association between cognitive decline and all-cause mortality with blood pressure as a potential modifier in oldest old individuals

Few studies have systematically explored the association between cognitive decline and all-cause mortality among oldest old individuals (above 80 years old), and there is limited evidence of blood pressure (BP) as a potential effect modifier. Therefore, this study included 14,891 oldest old individuals (mean age: 90.3 ± 7.5 years); 10,904 deaths and 34,486 person-years were observed. Cognitive scores were calculated using the Chinese version of the Mini-Mental State Examination (MMSE). Cognitive decline was stratified into ten categories (C0-C9). Continuous cognitive scores were used to assess the interactions of modifiers of the cognitive decline and all-cause mortality association and potentially modifiable factors. Potential effect modifiers were explored by age, sex, BP status and hypertension. Cox proportional hazards models were used to evaluate the relationship between cognitive decline and all-cause mortality after adjustments for demographic characteristics, socioeconomic status, lifestyle factors, leisure activities and health conditions. Participants who progressed to severe cognitive impairment from high normal cognitive function (C3), low normal cognitive function (C6), or mild cognitive impairment (C8) had 55%, 56%, and 63% higher mortality risks, respectively, than those who maintained high normal cognitive function (C0). The multivariate-adjusted model indicated that oldest old individuals with a decrease of more than one point in the MMSE score per year had an approximately 4% all-cause mortality risk. The relationship between cognitive decline and mortality was statistically influenced by sex (P = 0.013), high BP in nonagenarians (P = 0.003), and hypertension (P = 0.004) but not by age (P = 0.277). Our findings suggest that periodic screening for cognitive decline and strengthening BP management may be necessary for public health.

The association between cognitive impairment and 30-day mortality among older Chinese inpatients

Purpose

Although the association between cognitive impairment and mortality has been widely described among community-dwelling older adults, this association in hospitalized patients was limited.

Objectives

This study's purpose was to explore the association between cognitive impairment and 30-day mortality after adjustment of factors among Chinese in-patients.

Methods

This was a large-scale prospective study based on a cohort of patients aged 65 years and older, whose cognitive function was assessed using the Mini-Cog instrument, followed up at 30-days for mortality. Multivariate logistic regression models were used to assess the association between cognitive impairment and 30-day mortality.

Results

There were 9,194 inpatients in our study, with an average age of 72.41 ± 5.72. The prevalence of cognitive impairment using the Mini-Cog instrument was 20.5%. Multivariable analyses showed that patients with cognitive impairment have an increased risk of 30-day mortality, compared to those with normal cognitive function (OR = 2.83,95%CI:1.89–4.24) in an unadjusted model. In the fully adjusted model, Patients with cognitive impairment had an increased risk of 30-day mortality compared to those with normal cognitive function in the completely adjusted model (OR = 1.76,95% CI: 1.14–2.73). Additionally, this association still existed and was robust after performing a stratified analysis of age, gender, frailty and depression, with no significant interaction (P > 0.05).

Conclusions

Our study found that older Chinese in-patients with cognitive impairment have a 1.76-fold risk of 30-day mortality compared to patients with normal cognitive function, suggesting that clinicians and nurses need to early implement cognitive function screening and corresponding interventions to improve clinical outcomes for older in-patients.

Associated mortality risk of atypical antipsychotic medication in individuals with dementia

BACKGROUND

Antipsychotic medications such as risperidone, olanzapine and aripiprazole are used to treat psychological and behavioural symptoms among dementia patients. Current evidence indicate prescription rates for antipsychotics vary and wider consensus to evaluate clinical epidemiological outcomes is limited.

AIM

To investigate the potential impact of atypical antipsychotics on the mortality of patients with dementia.

METHODS

A retrospective clinical cohort study was developed to review United Kingdom Clinical Record Interactive Search system based data between January 1, 2013 to December 31, 2017. A descriptive statistical method was used to analyse the data. Mini Mental State Examination (MMSE) scores were used to assess the severity and stage of disease progression. A cox proportional hazards model was developed to evaluate the relationship between survival following diagnosis and other variables.

RESULTS

A total of 1692 patients were identified using natural language processing of which, 587 were prescribed olanzapine, quetiapine or risperidone (common group) whilst 893 (control group) were not prescribed any antipsychotics. Patients prescribed olanzapine showed an increased risk of death [hazard ratio (HR) = 1.32; 95% confidence interval (CI): 1.08-1.60; P < 0.01], as did those with risperidone (HR = 1.35; 95%CI: 1.18-1.54; P < 0.001). Patients prescribed quetiapine showed no significant association (HR = 1.09; 95%CI: 0.90-1.34; P = 0.38). Factors associated with a lower risk of death were: High MMSE score at diagnosis (HR = 0.72; 95%CI: 0.62-0.83; P < 0.001), identifying as female (HR = 0.73; 95%CI: 0.64-0.82; P < 0.001), and being of a White-British ethnic group (HR = 0.82; 95%CI: 0.72-0.94; P < 0.01).

CONCLUSION

A significant mortality risk was identified among those prescribed olanzapine and risperidone which contradicts previous findings although the study designs used were different. Comprehensive research should be conducted to better assess clinical epidemiological outcomes associated with diagnosis and therapies to improve clinical management of these patients.

Explaining the association between frailty and mortality in older adults: The mediating role of lifestyle, social, psychological, cognitive, and physical factors

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Frailty in older adults is associated with adverse outcomes such as mortality.

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Not much is known about underlying pathways of the frailty-mortality association.

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We assessed the mediating role of a wide range of factors.

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In both men and women, only polypharmacy was identified as explanatory factor.

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Targeting polypharmacy in frail older adults could reduce their risk of mortality.

Frailty is associated with a higher risk of mortality, but not much is known about underlying pathways of the frailty-mortality association. In this study, we explore a wide range of possible mediators of the relation between frailty and mortality. Data were used from the Longitudinal Aging Study Amsterdam (LASA). We included 1477 older adults aged 65 years and over who participated in the study in 2008–2009 and linked their data to register data on mortality up to 2015. We examined a range of lifestyle, social, psychological, cognitive, and physical factors as potential mediators. All analyses were stratified by sex. We used causal mediation analyses to estimate the indirect effects in single-mediator analyses. Statistically significant mediators were then included in multiple-mediator analyses to examine their combined effect. The results showed that older men (OR = 2.79, 95% CI = 1.23;6.34) and women (OR = 2.31, 95% CI = 1.24;4.30) with frailty had higher odds of being deceased 6 years later compared to those without frailty. In men, polypharmacy (indirect effect OR = 1.21, 95% CI = 1.03;1.50) was a statistically significant mediator in this association. In women, polypharmacy, self-rated health, and multimorbidity were statistically significant mediators in the single-mediator models, but only the indirect effect of polypharmacy remained in the multiple-mediator model (OR = 1.16, 95% CI = 1.03;1.38). In conclusion, of many factors that were considered, we identified polypharmacy as explanatory factor of the association between frailty and mortality in older men and women. This finding has important clinical implications, as it suggests that targeting polypharmacy in frail older adults could reduce their risk of mortality.

Associations of Visual Function With Cognitive Performance in Community-Based Older Adults: The Eye Determinants of Cognition Study

BACKGROUND

Given the detrimental impacts of visual and cognitive impairment separately, in older adults, understanding their coexistence could inform strategies against age-related cognitive changes.

METHODS

Participants from Washington County (White) and Jackson (Black) sites of the Atherosclerosis Risk in Communities Study were recruited who differed on racial, regional, urbanicity, and community-based factors. Presenting distance visual acuity (DVA; representing vision loss due to disease or lack of eye-care), corrected DVA (representing optimal correction for refractive loss of vision), and contrast sensitivity were measured. Factor scores for global cognition, memory, executive function, and language domains were calculated for 3 visits. We quantified the associations of vision measures with change in cognitive scores, stratified by community/race, using generalized estimating equations.

RESULTS

In 982 participants, mean (standard deviation [SD]) baseline age was 74 (4) years, with 37% males and 45% Jackson/Black participants. As hypothesized, after accounting for potential confounders, in the better-eye, worse presenting DVA was associated with greater 10-year decline rate in global cognition, memory, and executive function in Washington County/White participants (eg, global cognition: -0.08 SD [95% confidence interval: -0.12, -0.04]). Worse corrected DVA was associated with greater 10-year decline rate in executive function in Washington County/White participants (-0.10 SD [-0.15, -0.04]). Better contrast sensitivity was associated with lower 10-year decline rate in global cognition and executive function in Washington County/White participants (eg, global cognition: 0.10 SD [0.06,0.14]). None of these associations were confirmed in Jackson/Black participants.

CONCLUSIONS

Our study supports a functional link between some vision measures and cognition in older adults, but in only 1 of the 2 communities studied.

Cognitive function assessed by Mini-mental state examination and risk of all-cause mortality: a community-based prospective cohort study

Background

The Mini-Mental State Examination (MMSE) is the most widely used instrument to test cognitive functioning. The present study prospectively investigated the association between MMSE scores, MMSE domains, and all-cause mortality.

Methods

A total of 2134 participants aged 60 years or over, selected from one urban community-dwelling population in China, were enrolled in the study. The cognitive test was performed by use of the MMSE at baseline, and covariates were recorded simultaneously. Cox regression models were used for examining the cognitive function, expressed by different MMSE transformations, and all-cause mortality. After followed up for a median of 10.8 years (ranging from 1.0 to 11.3 years), loss to follow-up was 13.1% and 1854 individuals were finally included in the analyses.

Results

The subjects had the mean (SD) age of 71.01 (7.00) years, and 754 (40.67%) of them were women. Per point increase on MMSE scores was associated a 4% decreased risk of all-cause mortality [hazard ratio (HR): 0.96; 95%confidence interval (CI): 0.93–0.98]; compared to MMSE scores of ≥24, MMSE scores of < 24 was associated with a 43% increased risk of all-cause mortality (HR: 1.43; 95% CI: 1.05–1.95); compared to MMSE scores of 30, MMSE scores of 27–29 (HR: 1.27; 95% CI: 0.89–1.82), 24–26 (HR: 1.30; 95% CI: 0.86–1.99), and < 24 (HR: 1.79; 95% CI: 1.15–2.77) had a graded increase in risk of all-cause mortality (p for trend =0.003). Of MMSE domains, orientation to time (HR: 2.00; 95% CI: 1.29–3.11), attention and calculation (HR: 1.49; 95% CI: 1.16–1.92), recall (HR: 2.59; 95% CI: 1.22–5.47), and language (HR: 1.68; 95% CI: 1.25–2.26) were significantly associated with all-cause mortality in the unadjusted model; for one increase in the number of impaired MMSE domains, the unadjusted HR (95% CI) of mortality is 1.51 (1.38, 1.65), and the HR (95% CI) of mortality is 1.12 (1.01, 1.25) with full adjustment; compared to 0 and 1 impaired MMSE domains, the HRs of all-cause mortality associated with 2, 3, 4, and ≥ 5 impaired MMSE domains were 1.14 (95% CI: 0.84–1.54), 1.50 (95% CI: 0.98–2.28), 2.14 (95% CI: 1.12–4.09) and 2.29 (95% CI: 1.24–5.04), respectively, and a dose-dependent relationship was significant (p for trend =0.003).

Conclusion

Cognitive impairment is associated with the increased risk of all-cause mortality in the Chinese elderly. Similarly, reduced MMSE scores, as well as impaired MMSE domains, are also associated with the increasing risk of all-cause mortality.

Cognitive decline and mortality in a community-based sample of homeless and precariously housed adults: 9-year prospective study

BACKGROUND

Homeless and precariously housed individuals experience a high burden of comorbid illnesses, and excess mortality. Cross-sectional studies report a high rate of cognitive impairment. Long-term trajectories have not been well investigated in this group.

AIMS

To longitudinally assess risks for premature and/or accelerated cognitive ageing, and the relationship with early mortality in homeless and precariously housed people.

METHOD

This is a 9-year community-based study of 375 homeless and precariously housed individuals from Vancouver, Canada. Annual cognitive testing assessed verbal learning and memory, and inhibitory control. Linear mixed-effects models examined associations between clinical risk factors (traumatic brain injury, psychotic disorders, viral exposure, alcohol dependence) and cognitive change over 9 years. Cox regression models examined the association between cognition and mortality.

RESULTS

Traumatic brain injury and alcohol dependence were associated with decline in verbal memory. Inhibitory control declined, independent of risk factors and to a greater extent in those who died during the study. Better inhibitory control was associated with a 6.6% lower risk of mortality at study entry, with a 0.3% greater effect for each year of life. For each one-point increase in the Charlson Comorbidity Index score at study entry, the risk of mortality was 9.9% higher, and was consistent across age. Adjusting for comorbidities, inhibitory control remained a significant predictor of mortality.

CONCLUSIONS

Findings raise the possibility of a premature onset, and accelerated trajectory, of cognitive ageing in this group of homeless and precariously housed people. Traumatic brain injury, alcohol dependence and cognition could be treatment priorities.

Association of cognitive impairment and elderly mortality: differences between two cohorts ascertained 6-years apart in China

BACKGROUND

Cognitive impairment is a major contributor to mortality among the elderly. However, the relationship between cognitive impairment evaluated by educational levels and mortality and the trend between cognitive impairment and mortality with time are unclear. We aim to evaluate the differences in associations of cognitive impairment, taking the stratification by educational levels into account, with all-cause mortality and further explore the relationship of cognitive impairment with mortality in different age and sex groups in two cohorts ascertained 6 years apart in China.

METHODS

A total of 13,906 and 13,873 Chinese elderly aged 65 years and older were included in the 2002-2008 and 2008-2014 cohorts from the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Mortality data was ascertained from interviews with family members or relatives of participants. Cognitive function, evaluated by the Mini-Mental State Examination (MMSE), were defined by different cut-offs taking educational background into account. Cox models were used to explore the relationship of cognitive impairment with mortality.

RESULTS

For the 2002-2008 and 2008-2014 cohorts, 55,277 and 53,267 person-years were followed up, and the mean (SD) age were 86.5 (11.6) and 87.2 (11.3) years, respectively. Compared to normal cognition, cognitive impairment was independently associated with higher mortality risk after controlling for potential confounders, with hazard ratios (HRs) of 1.32 (95% confidence interval [CI], 1.25-1.39) in 2002-2008 cohort and 1.26 (95% CI, 1.19-1.32) in 2008-2014 cohort, stratified by educational levels. The trend of cognitive impairment with all-cause mortality risk decreased from 2002 to 2008 to 2008-2014 cohort, while no significant interaction of cognitive impairment with cohort for all-cause mortality was observed. The associations of cognitive impairment and mortality were decreased with age in the two cohorts.

CONCLUSIONS

Cognitive impairment evaluated by different cut-offs were associated with increased risk of mortality, especially among those aged 65-79 years in the two cohorts; this advocates that periodic screening for cognitive impairment among the elderly is warranted.

Cognitive Function in Dementia-Free Subjects and Survival in Old Age: The PROSPER Study

BACKGROUND

Impairment in domain-specific cognitive function is associated with the increased risk of mortality. We prospectively evaluated the association of executive function and memory with the risk of long-term mortality in dementia-free older subjects. Moreover, we investigated the role of structural brain abnormalities in this association.

METHODS

We included 547 dementia-free participants (mean age 78 years, 56.5% male) from the nested magnetic resonance imaging sub-study of the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER). Cox proportional hazard models were used to model 10-year risk of all-cause, cardiovascular, and noncardiovascular mortality in relation to performance in executive function and memory. Moreover, we evaluated the role of total brain parenchymal volume, cerebral blood flow, white matter hyperintensity, and the presence of microbleeds and infarcts in the link between cognitive function and mortality.

RESULTS

In the multivariable model, lower performance in executive function was associated with greater risk of all-cause (hazard ratio [HR] 1.49; 95% confidence interval [CI], 1.31-1.70), cardiovascular (HR 1.69; 95% CI, 1.36-2.11), and noncardiovascular (HR 1.36; 95% CI, 1.15-1.62) mortality. Similarly, poorer performance in memory tests associated with higher risk of all-cause (HR 1.47; 95% CI, 1.29-1.68), cardiovascular (HR 1.45; 95% CI, 1.15-1.83), and noncardiovascular (HR 1.49; 95% CI, 1.27-1.76) mortality. The associations were similar in subjects with various levels of brain structural abnormalities and cerebral blood flow (all P for interaction ≫ .05).

CONCLUSIONS

Poorer performance in both executive function and memory tests associates with all-cause, cardiovascular, and noncardiovascular mortality in elderly individuals. This association is independent of cardiovascular risk factors and diseases, brain structural abnormalities, and cerebral blood flow.

Longitudinal Associations Between Visual Impairment and Cognitive Functioning: The Salisbury Eye Evaluation Study

Importance

Worsening vision and declining cognitive functioning are common conditions among elderly individuals. Understanding the association between them could be beneficial in mitigating age-related cognitive changes.

Objective

To evaluate the longitudinal associations between visual impairment and cognitive function over time in a population-based study of older US adults.

Design, Setting, and Participants

Prospective longitudinal population-based study of older adults in the greater Salisbury area in Maryland. Overall, 2520 community-residing adults aged 65 to 84 years were assessed at baseline between September 1993 and August 1995 (round 1) and 2 (round 2), 6 (round 3), and 8 (round 4) years later.

Main Outcomes and Measures

Visual acuity (VA) was measured using Early Treatment Diabetic Retinopathy Study charts, and cognitive status was assessed using the Mini-Mental State Examination (MMSE).

Results

Of 2520 individuals, the mean (SD) age was 73.5 (5.1) years, 1458 (58%) were women, and 666 (26%) were black. There were 2240 (89%), 1504 (61%), and 1250 (50%) participants in the second, third, and fourth round of study, respectively, with more than half of the loss being due to death. Both VA and MMSE score worsened over time. The mean biannual decline of VA was 0.022 logMAR (approximately 1 line during 8 years; 95% CI, 0.018-0.026), and the mean biannual worsening of MMSE score was -0.59 (95% CI, -0.64 to -0.54; both P < .001). Worse baseline VA was associated with worse baseline MMSE score (r = -0.226; 95% CI, -0.291 to -0.16; P < .001). The rate of worsening VA was associated with the rate of declining MMSE score (r = -0.139; 95% CI, -0.261 to -0.017; P = .03). Cross-lagged models indicated VA in the previous round was associated with MMSE score in the subsequent round (β = -0.995, P < .001), and MMSE score in the previous round was associated with VA in the following round (β = -0.003, P < .001). However, the standardized effect size of VA on MMSE score (β = -0.074; SE, 0.015; P < .001) is larger relative to the reverse effect (β = -0.038; SE, 0.013; P < .001), demonstrating VA is likely the driving force in these dynamic associations.

Conclusions and Relevance

In a population-based sample of older US adults, visual impairment measured at distance is associated with declining cognitive function both cross-sectionally and longitudinally over time with worsening vision having a stronger association with declining cognition than the reverse. Worsening vision in older adults may be adversely associated with future cognitive functioning. Maintaining good vision may be an important interventional strategy for mitigating age-related cognitive declines.

Cognitive Impairment and Risk of All-Cause and Cardiovascular Disease Mortality Over 20-Year Follow-up: Results From the BLSA

Background Cognitive impairment may increase the risk of all-cause and cardiovascular disease ( CVD ) mortality. This study examined the association between cognitive function and risk of all-cause and CVD mortality among the elderly in Beijing, China. Methods and Results A total of 1996 participants aged ≥55 years at baseline were enrolled from the BLSA (Beijing Longitudinal Study of Aging). Cognitive function was assessed using the Mini-Mental State Examination ( MMSE ), and participants were categorized as: <18, 18 to 23, 24 to 27, and 28 to 30. Cox proportional hazard models were used to estimate the association. Hazard ratio ( HR ) and 95% confidence interval ( CI ) were reported. During a 20-year follow-up, 1122 (56.21%) participants died, 478 (42.60%) of whom died of CVD . Compared with MMSE scores of 28 to 30, participants with MMSE scores of <18 were independently associated with all-cause mortality ( hazard ratio, 2.14; 95% confidence interval, 1.59-2.87; P<0.001) and CVD mortality (hazard ratio , 4.52; 95% confidence interval , 2.80-7.30, P<0.001). Each 5-point decrease in MMSE score was associated with a 34% increased risk of all-cause mortality and a 56% increased risk of CVD mortality. This relationship remained statistically significant after using the competing risk model to consider non- CVD death as a competing risk event. Conclusion Cognitive impairment measured by MMSE score was associated with elevated risk of all-cause and CVD mortality among the elderly in Beijing, China.

Staging cognitive impairment and incidence of dementia

AIMS

In a background of interest in staging models in psychiatry, we tested the validity of a simple staging model of cognitive impairment to predict incident dementia.

METHOD

A large community sample of adults aged ≥55 years (N = 4803) was assessed in the baseline of a longitudinal, four-wave epidemiological enquiry. A two-phase assessment was implemented in each wave, and the instruments used included the Mini-Mental Status Examination (MMSE); the History and Aetiology Schedule and the Geriatric Mental State-AGECAT. For the standardised degree of cognitive impairment Perneczky et al's MMSE criteria were applied. A panel of psychiatrists diagnosed cases of dementia according to DSM-IV criteria, and cases and sub-cases of dementia were excluded for the follow-up waves. Competing risk regression models, adjusted by potential confounders, were used to test the hypothesised association between MMSE levels and dementia risk.

RESULTS

Out of the 4057 participants followed up, 607 (14.9%) were classified as 'normal' (no cognitive impairment), 2672 (65.8%) as 'questionable' cognitive impairment, 732 (18.0%) had 'mild' cognitive impairment, 38 (0.9%) had 'moderate' cognitive impairment and eight (0.2%) had 'severe' impairment. Cognitive impairment was associated with risk of dementia, the risk increasing in parallel with the level of impairment (hazard ratio: 2.72, 4.78 and 8.38 in the 'questionable', 'mild' and 'moderate' level of cognitive impairment, respectively).

CONCLUSIONS

The documented gradient of increased risk of dementia associated with the severity level of cognitive impairment supports the validity of the simple staging model based on the MMSE assessment.

Mortality in Mild Cognitive Impairment Diagnosed with DSM-5 Criteria and with Petersen's Criteria: A 17-Year Follow-Up in a Community Study

OBJECTIVE

To explore the possibility that the mortality risk of mild cognitive impairment (MCI) as diagnosed using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria (DSM-5-MCI) will be higher than using Petersen's criteria (P-MCI) and to report the population-attributable fraction (PAF) of mortality due to MCI.

METHODS

A representative community sample of 4,803 individuals aged 55 or more years was interviewed and then followed for 17 years. Standardized instruments were used in the assessment, including the Geriatric Mental State-AGECAT, and research psychiatrists diagnosed P-MCI and DSM-5-MCI cases following operationalized criteria. Mortality information was obtained from the official population registry. Kaplan-Meier age-adjusted survival curves were built for the MCI diagnostic groups, and Cox proportional hazards regression models were used to calculate the hazard ratio of death in participants with MCI relative to those without. We also estimated the PAF of mortality due to specific MCI diagnostic groups.

RESULTS

Compared with noncases, the mortality rate ratio was approximately double in DSM-5-MCI individuals (2.3) than in P-MCI individuals (1.2). In the multivariate statistical analysis, a significant association between each diagnostic category and mortality was observed but was only maintained in the final model in DSM-5-MCI cases (hazard ratio: 1.24). The PAF of mortality due to MCI was approximately 1% in both MCI categories.

CONCLUSION

The mortality risk in comparison with noncases was higher in DSM-5-MCI than in P-MCI. The PAF of mortality in DSM-5-MCI individuals was ~ 1% over a 17-year period.

The Effect of Neurobehavioral Test Performance on the All-Cause Mortality among US Population

Evidence of the association between global cognitive function and mortality is much, but whether specific cognitive function is related to mortality is unclear. To address the paucity of knowledge on younger populations in the US, we analyzed the association between specific cognitive function and mortality in young and middle-aged adults. We analyzed data from 5,144 men and women between 20 and 59 years of age in the Third National Health and Nutrition Examination Survey (1988-94) with mortality follow-up evaluation through 2006. Cognitive function tests, including assessments of executive function/processing speed (symbol digit substitution) and learning recall/short-term memory (serial digit learning), were performed. All-cause mortality was the outcome of interest. After adjusting for multiple variables, total mortality was significantly higher in males with poorer executive function/processing speed (hazard ratio (HR) 2.02; 95% confidence interval 1.36 to 2.99) and poorer recall/short-term memory (HR 1.47; 95% confidence interval 1.02 to 2.12). After adjusting for multiple variables, the mortality risk did not significantly increase among the females in these two cognitive tests groups. In this sample of the US population, poorer executive function/processing speed and poorer learning recall/short-term memory were significantly associated with increased mortality rates, especially in males. This study highlights the notion that poorer specific cognitive function predicts all-cause mortality in young and middle-aged males.

Comorbidity of Cognitive Impairment and Late-Life Depression Increase Mortality: Results From a Cohort of Community-Dwelling Elderly Individuals in Rural Greece

OBJECTIVE

To investigate the association of cognitive impairment (COGI) and depression with all-cause mortality and cardiovascular-specific mortality among community-dwelling elderly individuals in rural Greece.

METHODS

Cognition and depressive symptomatology of 676 Velestino town residents aged ≥60 years were assessed using Mini-Mental State Examination (MMSE) and Geriatric Depression Scale (GDS), respectively. Eight-year all-cause mortality and cardiovascular mortality were explored by multivariate Cox regression models controlling for major confounders.

RESULTS

Two hundred and one patients died during follow-up. Cognitive impairment (MMSE ≤ 23) was independently associated with all-cause mortality (hazard ratio [HR]: 1.57, 95% confidence interval [CI]: 1.13-2.18) and cardiovascular mortality (HR: 1.57, 95%CI: 1.03-2.41). Moderate to severe depression (GDS > 10) was significantly associated only with a 51% increase in all-cause mortality. A male-specific association was noted for moderate to severe depression, whereas the effect of COGI was limited to females. Noteworthy, COGI and depression comorbidity, rather than their sole presence, increased all-cause mortality and cardiovascular mortality by 66% and 72%, respectively. The mortality effect of COGI was augmented among patients with depression and of depression among patients with COGI.

CONCLUSION

COGI and depression, 2 entities often coexisting among elderly individuals, appear to increase all-cause mortality and cardiovascular mortality. Gender-specific modes may prevail but their comorbidity should be carefully assessed, as it seems to represent an independent index of increased frailty, which eventually shortens life expectancy.

Degree of cognitive impairment and mortality: a 17-year follow-up in a community study

BACKGROUND

To test the hypothesis that cognitive impairment in older adults is associated with all-cause mortality risk and the risk increases when the degree of cognitive impairment augments; and then, if this association is confirmed, to report the population-attributable fraction (PAF) of mortality due to cognitive impairment.

METHOD

A representative random community sample of individuals aged over 55 was interviewed, and 4557 subjects remaining alive at the end of the first year of follow-up were included in the analysis. Instruments used in the assessment included the Mini-Mental Status Examination (MMSE), the History and Aetiology Schedule (HAS) and the Geriatric Mental State (GMS)-AGECAT. For the standardised degree of cognitive impairment Perneczky et al's MMSE criteria were applied. Mortality information was obtained from the official population registry. Multivariate Cox proportional hazard models were used to test the association between MMSE degrees of cognitive impairment and mortality risk. We also estimated the PAF of mortality due to specific MMSE stages.

RESULTS

Cognitive impairment was associated with mortality risk, the risk increasing in parallel with the degree of cognitive impairment (Hazard ratio, HR: 1.18 in the 'mild' degree of impairment; HR: 1.29 in the 'moderate' degree; and HR: 2.08 in the 'severe' degree). The PAF of mortality due to severe cognitive impairment was 3.49%.

CONCLUSIONS

A gradient of increased mortality-risk associated with severity of cognitive impairment was observed. The results support the claim that routine assessment of cognitive function in older adults should be considered in clinical practice.

Cognitive function and 10 year mortality in an 85 year-old community-dwelling population

The relationship between mortality and impaired cognitive function has not been thoroughly investigated in a very elderly community-dwelling population, and little is known about the association of disease-specific mortality with Mini-Mental State Examination (MMSE) subscale scores. Here we evaluated these data in Japanese community-dwelling elderly. In 2003, 85 year-olds (n=207) were enrolled; 205 completed the MMSE for cognitive function and were followed-up for 10 years, during which time 120 participants died, 70 survived, and 17 were lost to follow-up. Thirty-eight deaths were due to cardiovascular disease, 22 to senility, 21 to respiratory disease, and 16 to cancer. All-cause mortality decreased by 4.3% with a 1-point increase in the global MMSE score without adjustment, and it decreased by 6.3% with adjustment for both sex and length of education. Cardiovascular mortality decreased by 7.6% and senility mortality decreased by 9.2% with a 1-point increase in the global MMSE score with adjustment for sex and education. No association was found between respiratory diseases or cancer mortality and global MMSE score. All-cause mortality also decreased with increases in MMSE subscale scores for time orientation, place orientation, delayed recall, naming objects, and listening and obeying. Cardiovascular mortality was also associated with the MMSE subscale of naming objects, and senility mortality was associated with the subscales of time orientation and place orientation. Thus, we found that impaired cognitive function determined by global MMSE score and some MMSE subscale scores were independent predictors of all-cause mortality or mortality due to cardiovascular disease or senility in 85 year-olds.

Executive function and mortality in homebound elderly adults

OBJECTIVES

To determine the association between executive function and mortality in homebound elderly adults.

DESIGN

Longitudinal study.

SETTING

Four home care agencies in the Boston area.

PARTICIPANTS

Homebound adults aged 60 and older with 8-year follow-up for mortality (N=1,172).

MEASUREMENTS

Cognitive domains including executive, memory, and language functions were evaluated at baseline. Executive function was measured using the Trail-Making Test Part B (TMT B), and subjects were divided into four subgroups from lowest to highest TMT B score. The second cross-group analyses were used to compare those who were alive and those who had died. Multivariate logistic regression analysis was used to determine whether there was an association between TMT B scores and mortality.

RESULTS

At baseline, 436 (37.2%) homebound elderly adults had the highest TMT B scores (≥300), which indicated the slowest performance. At 8-year follow-up, 381 (32.5%) participants had died. Participants with the highest TMT B scores were more than twice as likely to have died as those with the lowest scores (0–99) (odds ratio=2.39, 95% confidence interval=1.27–4.52, P=.003) after adjusting for confounders including medical comorbidities related to death. The other cognitive domains, including memory and language, were not associated with mortality in the same model.

CONCLUSION

Many homebound elderly adults have multiple medical conditions, and executive function may be critical in their ability to manage their medical conditions and may affect the outcome of death.

Can lifestyle modification improve neurocognition? Rationale and design of the ENLIGHTEN clinical trial

BACKGROUND

Risk factors for cardiovascular disease (CVD) not only increase the risk for clinical CVD events, but also are associated with a cascade of neurophysiologic and neuroanatomic changes that increase the risk of cognitive impairment and dementia. Although epidemiological studies have shown that exercise and diet are associated with lower CVD risk and reduced incidence of dementia, no randomized controlled trial (RCT) has examined the independent effects of exercise and diet on neurocognitive function among individuals at risk for dementia. The ENLIGHTEN trial is a RCT of patients with CVD risk factors who also are characterized by subjective cognitive complaints and objective evidence of neurocognitive impairment without dementia (CIND) STUDY DESIGN: A 2 by 2 design will examine the independent and combined effects of diet and exercise on neurocognition. 160 participants diagnosed with CIND will be randomly assigned to 6 months of aerobic exercise, the DASH diet, or a combination of both exercise and diet; a (control) group will receive health education but otherwise will maintain their usual dietary and activity habits. Participants will complete comprehensive assessments of neurocognitive functioning along with biomarkers of CVD risk including measures of blood pressure, glucose, endothelial function, and arterial stiffness.

CONCLUSION

The ENLIGHTEN trial will (a) evaluate the effectiveness of aerobic exercise and the DASH diet in improving neurocognitive functioning in CIND patients with CVD risk factors; (b) examine possible mechanisms by which exercise and diet improve neurocognition; and (c) consider potential moderators of treatment, including subclinical CVD.

Initial mini-mental state and cerebral perfusion in Alzheimer's disease

PURPOSE

The relationship between the initial mini-mental state examination (MMSE) score and cerebral perfusion was evaluated in patients with Alzheimer's disease (AD).

METHODS

In the study single photon emission computed tomography (SPECT) images of the brains of 40 AD patients were compared with the brain scans of 10 healthy controls. Each patient underwent MMSE analysis at initial evaluation as well as Tc-99 m hexamethylpropyleneamine oxine (HMPAO) brain SPECT. The patients were followed up for at least 42 months.

RESULTS

The regional cerebral blood flow (rCBF) values for patients were found to be significantly decreased for all cerebral lobes compared to the control subjects and p-values were calculated to be less than 0.001 except for occipital lobes. The most statistically significant correlation between the MMSE scores and rCBF values was determined for the left temporal lobe (p < 0.0001). A significant correlation was also found for the right temporal lobe (p < 0.005). A minimal statistically significant correlation was found for the frontal lobes and the left parietal lobe (p < 0.05).

CONCLUSIONS

The overall cerebral perfusion was decreased except in the occipital lobes in AD cases with low initial MMSE scores and there was a significant relationship between the decrease in perfusion of the temporal/frontal lobes and the left parietal lobe with the decrease in the initial MMSE scores. The most significant relationship between the decrease in the initial MMSE scores and the rCBF values was determined for the temporal lobes (especially for the left temporal lobe). It was also found that the left frontal lobe was affected from the beginning of the disease.

Full-scale scores of the Mini Mental State Examination can be generated from an abbreviated version

OBJECTIVE

To determine whether the full Mini Mental State Examination (MMSE) scale range can be derived from an abbreviated 11-item version that was designed for testing general cognitive function in a cohort where only a small proportion were expected to be severely impaired or demented.

STUDY DESIGN AND SETTING

Using simple computation and multiple imputation, the properties of the abbreviated MMSE were compared with the full MMSE score using data from the Medical Research Council Cognitive Function and Ageing Study.

RESULTS

Full MMSE scores can be generated for the abbreviated version by assuming high functioning on excluded items. Of the imputed scores, 88.8% were within 1 point of their true value. When the sample was restricted to individuals with normal cognitive functioning (MMSE total score ≥ 24/30), 96.7% of individuals were classified within 1 point of their true total score. The model worked best at predicting cognitive level when cutoff scores were used to classify individuals into impaired vs. not nonimpaired.

CONCLUSION

Full-scale MMSE scores can be reasonably accurately derived from an 11-item abbreviated version. This reduced version can be applied within other frameworks that require reduced test length but need results that are comparable to studies where the full version has been administered.

Do we really know the cause of death of the very old? Comparison between official mortality statistics and cohort study classification

Causes of death of 625 subjects who died during the 4-year follow-up of a large population-based elderly cohort (Three-City study) were independently classified by the study adjudication committee and the national mortality register. The former used all available data about the cause of death (hospital records, medical data obtained from family physicians or specialists, and proxy interviews) and the latter used internationally standardized recommendations for processing death certificate data. Comparison showed a moderate overall agreement for underlying cause of death between the study adjudication committee and the national register (kappa = 0.51). Differences were found especially for cardiovascular diseases (20.6% of deaths from the study committee vs. 32.5% from the national register) and ill-defined causes of death (22.7 vs. 4%). The proportion of disagreement increased in participants dying at age >85 compared to those dying at age < or =70 (adjusted odds ratio = 2.46, 95% confidence interval = 1.10-5.49). It was also higher when the study committee used hospital record data for defining cause of death, compared to adjudication based on data obtained from proxy (adjusted odds ratio = 1.85, 95% CI = 1.09-3.14). These findings raise questions about the validity of national mortality registers in very old persons. Disease-specific causes of death, especially vascular diseases, could be overestimated in this age group.