The diagnostic accuracy of the Ascertain Dementia 8 questionnaire for detecting cognitive impairment in primary care in the community, clinics and hospitals: a systematic review and meta-analysis

Cognitive Impairment and Social Determinants of Health Among Indigenous Women

BACKGROUND AND OBJECTIVES

Cognitive impairment and Alzheimer's disease and related dementias (ADRD) pose significant challenges for Indigenous populations, necessitating urgent research. Limited evidence suggests that high rates of ADRD among Indigenous peoples are associated with social determinants of health (SDOH), such as education, income, health literacy, religion, and social engagement.

RESEARCH DESIGN AND METHODS

Collaborating with a Northern Plains tribe, participants were recruited 123 self-identified Indigenous women aged 40-70 through a comprehensive recruitment strategy. Employing the SDOH framework, the research assessed cognitive impairment and Alzheimer's disease knowledge (ADK), utilizing the Ascertain Dementia 8 and Alzheimer's disease knowledge scales (ADK-30). The investigation examined the relationships between selected SDOH variables and cognitive impairment status.

RESULTS

More than half of the participants showed signs of cognitive impairment, which correlated with lower income and education levels. Increased knowledge about Alzheimer's disease, particularly in terms of treatment management and its life impact subscales, was associated with lower odds of cognitive impairment. Conversely, higher levels of depressive symptoms and participation in religious activities were linked to increased odds of cognitive impairment.

DISCUSSION AND IMPLICATIONS

The findings underscore the importance of culturally grounded tools and SDOH frameworks tailored to Indigenous contexts in addressing ADRD disparities. Future research should integrate historical and cultural factors to advance health equity within Indigenous communities, ultimately mitigating the impact of ADRD and promoting overall well-being.

Exploring the interplay of psychiatric symptoms, antipsychotic medications, side effects, employment status, and quality of life in Chronic Schizophrenia

BACKGROUND

Many factors contribute to quality of life (QoL) in patients with schizophrenia, yet limited research examined these factors in patients in China. This cross-sectional study explores subjective QoL and its associated factors in patients.

METHODS

The QoL was assessed using the Schizophrenia Quality of Life Scale (SQLS). Clinical symptoms were evaluated using the Brief Psychiatric Rating Scale (BPRS) and seven factors were extracted. Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder Scale (GAD-7) were used to assess depression and anxiety. Cognitive impairment was assessed using the Ascertain Dementia 8 (AD8). The Treatment Emergent Symptom Scale (TESS) and Rating Scale for Extrapyramidal Side Effects (RSESE) were used to evaluate the side effects of medications.

RESULTS

We recruited 270 patients (male:142,52.6%, mean age:41.9 ± 9.4 years). Positive correlations were observed between SQLS and its subdomains with the total score of BPRS, PHQ-9, GAD-7, AD8, TESS, and RSESE (all P < 0.005). Patients who were taking activating second-generation antipsychotics (SGAs) had lower scores on total SQLS, Motivation/ Energy domain of SQLS (SQLS-ME) as well as Symptoms/ Side effects domain of SQLS (SQLS-SS) compared to those taking non-activating SGAs (all P < 0.005). Multiple regression analysis showed that depressive/ anxiety symptoms and cognitive impairment had significant negative effects on QoL (P ≤ 0.001), while activating SGAs had a positive effect (P < 0.005). Blunted affect and unemployment were inversely associated with the motivation/energy domain (P < 0.001).

CONCLUSION

Our findings emphasize the important role of depression/anxiety symptoms and cognitive impairment in the QoL of patients with chronic schizophrenia. Activating SGAs and employment may improve the QoL of these individuals.

TRIAL REGISTRATION

This protocol was registered at chictr.org.cn (Identifier: ChiCTR2100043537).

Primary care and community partnerships to promote age-friendly care for Hispanic older adults

BACKGROUND

Healthcare and community collaborations have the potential to address health-related social needs. We examined the implementation of an educational initiative and collaborative intervention between a geriatric clinic and Area Agency on Aging (AAA) to enhance age-friendly care for a Hispanic patient population.

METHODS

As part of a Health Resources and Services Administration (HRSA)-funded Geriatric Workforce Enhancement Program, a geriatric clinic partnered with AAA to embed an English- and Spanish-speaking Social Service Coordinator (SSC). The SSC met with patients during new and annual visits or by referral to address What Matters and Mentation in the patient's primary language, provide education, and make social service referrals. Patients aged 60 and older, who received SSC services during a 12-month period, were defined as the intervention group (n = 112). Using a retrospective chart review, we compared them to a non-intervention group (n = 228) that received primary care. We examined available demographic and clinical data within the age-friendly areas of What Matters and Mentation. Measures included cognitive health screenings, advance care planning, patient education, and community referrals.

RESULTS

Most of the intervention groups were eligible for AAA services and had the opportunity for service referrals to address identified needs. A higher proportion of patients within the intervention group completed screenings for cognitive health and advance care planning discussions.

CONCLUSION

Interagency partnerships between ambulatory care settings and community-based organizations have the potential to expand access to linguistically and culturally competent age-friendly primary care for older adults.

Development of a new computer simulated environment to screen cognition: assessing the feasibility and acceptability of Leaf Café in younger and older adults

BACKGROUND

Existing traditional cognitive screening tools for dementia have various limitations, including overreliance on tests assessing verbal memory and, to a lesser extent, on some aspects of executive functioning. Comprehensive neuropsychological assessment is sensitive to impairment but time-intensive and expensive. Virtual reality may provide a dynamic and unique understanding of cognitive performance and increase the ecological validity of cognitive assessment. The use of virtual reality in screening for cognitive function in older persons is promising, but evidence for its use remains sparse.

OBJECTIVE

Our primary aim was to examine the feasibility and acceptability of a newly developed, virtual reality assessment module, 'Leaf Café', a computer-based program that assesses cognition in an engaging, efficient, and ecologically relevant way. The secondary aim was to assess the ability of the module to discriminate between performances of younger and older adults.

METHODS

A cross-sectional study was carried out in Sydney, Australia, targeting adults aged 18 years and above. Participants completed a traditional cognitive screening tool (Telephone Interview for Cognitive Status-Modified, TICS-M) and Leaf Café, a low-immersive virtual reality module designed to evaluate learning and memory, perceptual-motor function, and executive functioning. The total performance score for each participant, ranging from 0 to 180, was correlated with their cognitive performance assessed by TICS-M, using Pearson's correlation coefficient. Following module completion, participants were presented with an open and closed-question survey to capture their perceptions, attitudes, and feedback on the module, encompassing practicality, acceptability, and enjoyment. Both descriptive and content analyses were employed to interpret the obtained data.

RESULTS

A sample of 131 participants (mean age 54.9 years, SD = 20.8, range 20-85) took part. The majority were female (71.8%) and born in an English-speaking country (75.8%). The mean amount of time spent in the module was 32.8 min (SD = 13.3) with a mean module score of 107.6 (SD = 38.7). Most participants completed the highest level (5; 80.5%). There was a significant correlation between Leaf Café total scores with TICS-M cognitive scores overall, and for both younger (aged 18-64 years) and older adult (aged 65 + years) groups. No significant difference was found on performance between age groups on TICS-M performance, however, younger adults had significantly better performance on the Leaf Café module than older adults (M = 124.1 vs 95.9; p < .001). Participants had similar response proportions regarding user experience with most agreeing that the module was easy to use (84%) and to navigate (85%). Compared with younger adults, older adults had lower rates of agreement on the module's design (36.8% vs 64.3%; p = .020) and support experienced (20.5% vs 53.6%; p = .007). Participants highlighted the significance of practicality and the cognitive challenges presented by the module, in terms of memory strain and user interface concerns. Feedback encompassed different opinions on the usefulness of music, with suggestions for improvements centred around clearer instructions, varied game dynamics, and considerations for diverse user needs.

CONCLUSIONS

Leaf Café is a feasible and acceptable tool to be used for screening for cognitive impairment in older adults and has real-world assessment value. Further verification on the game's utility in detecting cognitive impairment is required.

A comparison of the diagnostic accuracy of the Mini-Cog and AD8 in identifying cognitive impairment in a geriatric health screening population in China

The present study aimed to evaluate and compare the discriminative abilities of the Mini-Cog and AD8 tests in detecting cognitive impairment in a Chinese health screening population. 160 geriatric participants were enrolled at an academic medical center . The Mini-Cog, AD8, and Mini-Mental State Examination (MMSE) were used to assess the possibility of cognitive impairment. Logistic regression and receiver operator characteristic curve analyses were performed to evaluate the discriminative abilities of the tests. The prevalence of cognitive impairment was 41.25%. Logistic regression modeling showed that the Mini-Cog (odds ratio (OR) = 0.34, 95% confidence interval (CI): 0.25-0.46) and MMSE (OR = 0.58, 95%CI: 0.49-0.69) predicted cognitive impairment with 79.4% and 80.6% correct classification, respectively. While the AD8 (OR = 1.56, 95% CI: 1.32-1.85) predicted cognitive impairment with 72.5% correct classification. The areas under the receiver operating characteristic curves of the Mini-Cog, AD8 and MMSE for detecting cognitive impairment were 0.79 (95% CI: 0.72-0.85), 0.66 (95% CI: 0.58-0.73) and 0.80 (95% CI: 0.73-0.86). Both sensitivity and specificity of the Mini-Cog were superior to those of the AD8 (sensitivity 78.79% vs. 56.06%; specificity 79.79% vs. 75.53%). Cognitive screening is crucial to maintain the quality of life of older adults. Compared with the AD8, the Mini-Cog test is a more effective tool for screening cognitive impairment in older adults.

Presence and Persistence of Perceived Subjective Cognitive Complaints and Incident Mild Cognitive Impairments Among Community-Residing Older Adults

OBJECTIVES

To examine whether Subjective Cognitive Complaints (SCCs) predicted incident mild cognitive impairment (MCI).

DESIGN

Prospective Study.

SETTING

Central Control of Mobility and Aging (CCMA), a cohort study of community-residing older adults.

PARTICIPANTS

Participants were dementia-free community-residing older adults.

MEASUREMENTS

SCCs were assessed at the baseline and via bi-monthly structured phone interviews during the first year using the Ascertain Dementia 8 (AD8). Nonpersistent status required one or two SCCs endorsements and Persistent status required three or more SCCs endorsements. Outcome, presence of mild cognitive impairments (MCI) was determined by established case conference diagnostic procedures. Participants were followed annually. Generalized estimating equations (GEE), logistic model type, were used to determine the odds of developing MCI during follow-up. SCCs served as the three-level predictor (no/nonpersistent/persistent) and cognitive status (MCI versus normal) as the binary outcome. Analyses were adjusted for age, sex, education, race, health status, depressive symptoms, and global cognition.

RESULTS

The sample (n=454; mean age=75.67 ± 6.43; %female=55.3) included 245 participants who reported no SCCs, 156 who reported 1-2 SCCs, and 53 who reported 3 or more SCCs. Sixty-eight participants developed MCI during follow-up. Results showed that compared to no SCCs, persistent SCCs, and nonpersistent SCCs were significantly associated with increased odds of developing MCI during follow-up.

CONCLUSIONS

The presence of SCCs regardless of their persistence was associated with increased odds of developing MCI even when adjusting for objectively-assessed cognitive performance.

The electronic health record Risk of Alzheimer's and Dementia Assessment Rule (eRADAR) Brain Health Trial: Protocol for an embedded, pragmatic clinical trial of a low-cost dementia detection algorithm

BACKGROUND

About half of people living with dementia have not received a diagnosis, delaying access to treatment, education, and support. We previously developed a tool, eRADAR, which uses information in the electronic health record (EHR) to identify patients who may have undiagnosed dementia. This paper provides the protocol for an embedded, pragmatic clinical trial (ePCT) implementing eRADAR in two healthcare systems to determine whether an intervention using eRADAR increases dementia diagnosis rates and to examine the benefits and harms experienced by patients and other stakeholders.

METHODS

We will conduct an ePCT within an integrated healthcare system and replicate it in an urban academic medical center. At primary care clinics serving about 27,000 patients age 65 and above, we will randomize primary care providers (PCPs) to have their patients with high eRADAR scores receive targeted outreach (intervention) or usual care. Intervention patients will be offered a "brain health" assessment visit with a clinical research interventionist mirroring existing roles within the healthcare systems. The interventionist will make follow-up recommendations to PCPs and offer support to newly-diagnosed patients. Patients with high eRADAR scores in both study arms will be followed to identify new diagnoses of dementia in the EHR (primary outcome). Secondary outcomes include healthcare utilization from the EHR and patient, family member and clinician satisfaction assessed through surveys and interviews.

CONCLUSION

If this pragmatic trial is successful, the eRADAR tool and intervention could be adopted by other healthcare systems, potentially improving dementia detection, patient care and quality of life.

Lessons Learned from Age-Friendly, Team-Based Training

According to the Institute of Medicine, immediate steps must be taken across the United States to educate and train the healthcare workforce to work collaboratively to address the needs of the growing older adult population. The Geriatric Practice Leadership Institute (GPLI) was designed to support professional teams working in acute and post-acute care in transforming their organization into a designated Age-Friendly Health System. The program was built around the Institute for Healthcare Improvement's Age-Friendly Health Systems 4Ms framework. This framework focuses on What Matters, Medication, Mentation, and Mobility (the 4Ms) in supporting care for older adults. The GPLI program is an online, seven-month team-based program with four to seven participants from one organization per team. Additionally, each team selected, developed, and completed a quality improvement project based on Age-Friendly Health Systems 4Ms. The curriculum also includes organizational culture, leadership, and interprofessional team-building modules. Using a post-completion survey, the experiences of 41 participants in the GPLI program were assessed. All respondents found the information in the program 'very' or 'extremely' valuable, and their executive sponsor 'very' or 'extremely' valuable in supporting their team's involvement and project. The GPLI program has trained over 200 healthcare professionals and teams that have successfully implemented projects across their organizations.

Cognitive Activities, Lifestyle Factors, and Risk of Cognitive Impairment, with an Analysis of the Apolipoprotein Epsilon 4 Genotype

INTRODUCTION

Cognitive stimulating activities and a healthy lifestyle are associated with less cognitive impairment. However, whether the association is varied by Apolipoprotein epsilon 4 (APOE ε4) allele carrier status remains inconclusive. We aimed to investigate whether the association of cognitively stimulating activities and a healthy lifestyle with the risk of cognitive impairment varied by APOE ε4 allele carrier status.

METHODS

A case-control study was conducted for adults aged 60 years and above. Six province administrative units (Beijing, Shanghai, Hubei, Sichuan, Guangxi, and Yunnan) were included using stratified multistage cluster sampling. A total of 1,300 individuals were identified with cognitive impairment (cases) at enrollment and were matched 1:2 on sex, age (±2 years), and residential district with controls who were cognitively normal at the time of the evaluation. We used a standardized questionnaire to collect information on cognitive stimulating activities, lifestyle factors, demographics, and comorbidity. Cognitive stimulating activities included reading books or newspapers, playing cards or mahjong, using the Internet, socializing with neighbors, and community activities. Lifestyle factors included smoking, alcohol drinking, daily tea drinking, and regular exercise. We used logistic regression to assess the interaction between cognitive stimulating activities, lifestyle factors, and APOE ε4 allele carrier status (yes/no) on the risk of cognitive impairment. We tested for additive interaction by estimating relative excess risk (RERI) due to interaction and multiplicative interaction employing the p value of the interaction term of each lifestyle factor and APOE ε4 into the model.

RESULTS

Four cognitive stimulating activities were associated with less cognitive impairment regardless of APOE ε4 status. Using the Internet (odds ratio [OR]: 0.53, 95% confidence interval [CI]: 0.30-0.95), daily tea drinking (OR: 0.79; 95% CI: 0.63-0.98), and regular exercise (OR: 0.78; 95% CI: 0.65-0.94) were associated with less cognitive impairment only in noncarriers. Multiplicative and additive interactions were found between community activities and APOE ε4 carrier status (multiplicative p value = 0.03; RERI 0.738, 95% CI: 0.201-1.275).

CONCLUSION

The associations between cognitive activities and cognitive impairment were robust regardless of the APOE ε4 carrier status, while the associations between lifestyle factors and cognitive impairment varied by APOE ε4 carrier status.

Revised Chinese resident health literacy scale for the older adults in China: simplified version and initial validity testing

Objective

This study aimed to develop a short version of the Chinese Resident Health Literacy Scale focused on older adults in China, and further assess the reliability and validity of this short version.

Methods

The data was from a cross-sectional community-based older adults health survey conducted in 2020. The total of 5,829 older adults were randomly divided into two parts using for the simplification and assessment of the scale, respectively. Item Response Theory (IRT) and Differential Item Functioning (DIF) were used for item analysis and scale simplification. Cronbach's alpha and McDonald's omega were used to assess the reliability and three factors Confirmatory Factor Analysis (CFA) was used to assess the validity, which were compared to the original version. Moreover, Multi-group Confirmatory Factor Analysis (MCFA) was used to test the model invariance of the short version across groups of gender, age groups, level of education, and cognitive status.

Results

The simplified version consisted of 27 items taken from 50 original items, of them 11 items from the dimension of knowledge and attitudes, 9 items from the dimension of behavior and lifestyle, and 7 items from the dimension of health-related skills. The overall Cronbach's alpha and McDonald's omega were both 0.87 (95%CI: 0.86-0.88). The goodness-of-fits of CFA in simplified version were still acceptable in CFI, TLI, GFI, and RMSEA, even improved in CFI, TLI, and GFI compared to those of original version. Also, the model was stable and invariant in MCFA across gender, cognitive status, and educational level groups.

Conclusion

In this study, we formed a simplified instrument for measuring health literacy focused on older adults in China. This short version might be more suitable for the priority recommendation in extended tracking of the dynamic changes on the levels of health literacy in the whole life cycle in public health settings. Further research might be to identify the cut-off values to distinguish the older adults with different levels of health literacy.

New perspectives on randomized controlled trials with omega-3 fatty acid supplements and cognition: A scoping review

Long chain polyunsaturated omega-3 fatty acids (n-3 FA), such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), are known to be important components in a healthy diet and contribute to healthy functioning of the heart and the brain, among other organs. Although there are epidemiological studies on the strong relationship between fish or n-3 FA consumption and lower risk of cognitive decline, results from randomized controlled trials (RCTs) are less consistent. Here, we performed a scoping review on RCTs with n-3 FA supplementation where cognition was evaluated. Seventy-eight RCTs published before April 2022 were included in this review. Among these RCTs, 43.6% reported a positive cognitive outcome after the consumption of n-3 FA compared to the placebo. However, there was a large diversity of populations studied (age ranges and health status), wide range of doses of EPA + DHA supplemented (79 mg/day - 5200 mg/day) and a multitude of tests evaluating cognition, mainly diagnostic tests, that were used to assess cognitive scores and overall cognitive status. RCTs were thereafter categorized into non-cognitively impaired middle-aged adults (n = 24), non-cognitively impaired older adults (n = 24), adults with subjective memory complaints (n = 14), adults with mild cognitive impairments (MCI, n = 9) and people with diagnosed dementia or other cognitive changes (n = 7). Among these categories, 66.7% of RCTs conducted with MCI adults reported a positive cognitive outcome when supplemented with n-3 FA vs. the placebo. Therefore, this scoping review provides rationale and questions to a) strengthen the design of future RCTs with n-3 FA for cognitive outcomes, and b) generate more informative data to support clinicians in their practice in assessing cognition before and after a nutritional intervention.

The Chinese version of informant AD8 for mild cognitive impairment and dementia screening in community-dwelling older adults

BACKGROUND

Conducting routine mild cognitive impairment (MCI) and dementia screening for older adults in the community is important, which not only can improve our understanding of these diseases but also can increase early detection and treatment.

METHODS

To analyze the reliability and validity of the informant AD8 and explore the cut-off values for screening MCI and dementia in the community-dwelling older adults, this study adopted a multi-stage cluster sampling method to recruit 327 participants aged 60 and over in communities. The informant AD8 and Clinical Dementia Rating (CDR) scales were used to evaluate cognitive function of the subjects, and the receiver operating characteristic curves (ROC) was conducted to test the screening efficacy.

RESULTS

Among the 327 participants, 33.0% of them met the criteria of MCI, and 3.4% of them met the criteria of dementia. The area under the receiver operating characteristic curve (AUC) of the informant AD8 for screening dementia was 0.974, with a screening cut-off of three, sensitivity of 90.9% and specificity of 89.0%. But it has a poor discriminability in MCI screening [AUC = 0.645, 95% confidence interval (CI): 0.578-0.711].

CONCLUSIONS

This study suggests that the informant AD8 is an ideal and useful tool for dementia screening in community-dwelling older adults. However, it is less capable to distinguish older adults with MCI from those with normal cognitive function.

Informant-based screening tools for dementia: an overview of systematic reviews

BACKGROUND

Informant-based questionnaires may have utility for cognitive impairment or dementia screening. Reviews describing the accuracy of respective questionnaires are available, but their focus on individual questionnaires precludes comparisons across tools. We conducted an overview of systematic reviews to assess the comparative accuracy of informant questionnaires and identify areas where evidence is lacking.

METHODS

We searched six databases to identify systematic reviews describing diagnostic test accuracy of informant questionnaires for cognitive impairment or dementia. We pooled sensitivity and specificity data for each questionnaire and used network approaches to compare accuracy estimates across the differing tests. We used grading of recommendations, assessment, development and evaluation (GRADE) to evaluate the overall certainty of evidence. Finally, we created an evidence 'heat-map', describing the availability of accurate data for individual tests in different populations and settings.

RESULTS

We identified 25 reviews, consisting of 93 studies and 13 informant questionnaires. Pooled analysis (37 studies; 11 052 participants) ranked the eight-item interview to ascertain dementia (AD8) highest for sensitivity [90%; 95% credible intervals (CrI) = 82-95; 'best-test' probability = 36]; while the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) was most specific (81%; 95% CrI = 66-90; 'best-test' probability = 29%). GRADE-based evaluation of evidence suggested certainty was 'low' overall. Our heat-map indicated that only AD8 and IQCODE have been extensively evaluated and most studies have been in the secondary care settings.

CONCLUSIONS

AD8 and IQCODE appear to be valid questionnaires for cognitive impairment or dementia assessment. Other available informant-based cognitive screening questionnaires lack evidence to justify their use at present. Evidence on the accuracy of available tools in primary care settings and with specific populations is required.

Frailty Screening in the Emergency Department: Comparing the Variable Indicative of Placement Risk, Clinical Frailty Scale and PRISMA-7

Prompt recognition of frailty in the emergency department (ED) is important to identify patients at higher risk of adverse outcomes. Despite this, few studies examine the diagnostic accuracy of screening instruments for frailty, instead focusing on predictive validity. We compared three commonly used, short frailty screens to an independent comprehensive geriatric assessment (CGA) in an urban University Hospital ED. Consecutive attendees aged ≥70 years were screened by trained raters, blind to the CGA, with the Variable Indicative of Placement risk (VIP), 3 and 4-item versions, Clinical Frailty Scale (CFS) and PRISMA-7. Accuracy was measured from the area under the ROC curve (AUROC). In total, 197 patients were included, median age 79 (±10); 46% were female. Half (49%) were confirmed as frail after CGA. All instruments differentiated frail from non-frail states, although the CFS (AUROC: 0.91) and PRISMA-7 (AUROC: 0.90) had higher accuracy compared to the VIP-4 (AUROC: 0.84) and VIP-3 (AUROC: 0.84). The CFS was significantly more accurate than the VIP-3 (p = 0.026) or VIP-4 (p = 0.047). There was no significant difference between the CFS and PRISMA-7 (p = 0.90). The CFS and PRISMA-7 were more accurate and should be considered in preference to the VIP (3 or 4-item versions) to identify frailty in EDs.

Chinese expert consensus on assessment of cognitive impairment in the elderly

Cognitive impairment is a term that refers to the impairment of one or more cognitive domains to varying degrees caused by a variety of reasons. It is under a high prevalence, many risk factors, complex etiology, and great harm to the elderly population. Early screening, diagnosis, and intervention for cognitive impairment in the elderly are of great importance. However, at present, the recognition rate of cognitive impairment for the elderly in China is low, the rate of missed diagnosis is high, and the evaluation is not standardized. This consensus integrates the commonly used cognitive function assessment scales in China and abroad, and aims to popularize the screening of cognitive impairment, standardize the evaluation methods and procedures of cognitive impairment in the elderly, and establish clinical diagnoses, interventions, and follow-up plans in a timely manner.

Cognitive impairment and frailty screening in older surgical patients: a rural tertiary care centre experience

Introduction

Despite a clear association between cognitive impairment and physical frailty and poor postoperative outcomes in older adults, preoperative rates are rarely assessed. We sought to implement a preoperative cognitive impairment and frailty screening programme to meet the unique needs of our rural academic centre.

Methods

Through stakeholder interviews, we identified five primary drivers underlying screening implementation: staff education, technology infrastructure, workload impact, screening value and patient–provider communication. Based on these findings, we implemented cognitive dysfunction (AD8, Mini-Cog) and frailty (Clinical Frailty Scale) screening in our preoperative care clinic and select surgical clinics.

Results

In the preoperative care clinic, many of our patients scored positive for clinical frailty (428 of 1231, 35%) and for cognitive impairment (264 of 1781, 14.8%). In our surgical clinics, 27% (35 of 131) and 9% (12 of 131) scored positive for clinical frailty and cognitive impairment, respectively. Compliance to screening improved from 48% to 86% 1 year later.

Conclusion

We qualitatively analysed stakeholder feedback to drive the successful implementation of a preoperative cognitive impairment and frailty screening programme in our rural tertiary care centre. Preliminary data suggest that a clinically significant proportion of older adults screen positive for preoperative cognitive impairment and frailty and would benefit from tailored inpatient care.

Association of Health Literacy With Medication Adherence Mediated by Cognitive Function Among the Community-Based Elders With Chronic Disease in Beijing of China

Background

Although health literacy was considered to play a crucial role in non-communicable chronic disease (NCD) prevention and control, the relationship of health literacy and medication adherence has rarely given attention among older adult Chinese population in previous studies, especially considered that they might be with cognitive impairment.

Purpose

This study aimed to investigate the association between health literacy and medication adherence and mediation by cognitive ability among community-based older adults with chronic disease in Beijing of China.

Methods

The older adults aged 60 years old or over were recruited in a cross-sectional survey conducted in Beijing of China by using multistage, stratified sampling method. Of those, the participants with chronic disease and need to take long-term medicine were included in our study. The information about sociodemographic characteristics, health literacy, cognition ability, and medication adherence was collected by the questionnaire. The univariate and multiple logistic regression analysis were used to measure the association of health literacy and adherence medication, and mediate effect by cognitive ability.

Results

The total of 4,166 older adult populations (average age: 70.61 ± 7.38 years) was included in this study, 1,395 participants (33.49%) were non-adherence, 1,983 participants (47.60%) had two chronic conditions or more, and 1,459 participants (35.02%) screened as cognitive impairment. The health literacy was negatively associated with medication adherence. The lower total scores of health literacy were found with a high risk of non-adherence [p < 0.01, adjusted odds ratio (OR) = 0.988 per one point increase, 95% CI: 0.982–0.993] controlling other covariates. However, their association tended to be weakened or even disappeared among the older adults with cognitive impairment compared with the populations with normal cognitive.

Conclusion

Improving health literacy might be a public health strategy to increase the medication adherence of older adults, but need to first identify the potential target population based on their cognitive ability.

Prevalence of Dementia and Associated Factors among Older Adults in Latin America during the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has had a great impact on cognitive health in Latin American older adults, increasing the risk of cognitive impairment and dementia. Our objective was to analyze the prevalence of dementia and the associated factors in Latin American older adults during SARS-CoV-2 pandemic.

METHODS

A multicentric first phase cross-sectional observational study was conducted during the SARS-CoV-2 pandemic. Five thousand two hundred and forty-five Latin American adults over 60 years of age were studied in 10 countries: Argentina, Bolivia, Chile, Colombia, Ecuador, Guatemala, Mexico, Peru, the Dominican Republic, and Venezuela. We used the telephone version of Montreal Cognitive Assessment, the "Alzheimer Disease 8" scale for functional and cognitive changes, and the abbreviated version of the Yesavage depression scale. We also asked for sociodemographic and lockdown data. All the evaluation was made by telephone. Cross-tabulations and χ2 tests were used to determine the variability of the prevalence of impairment by sociodemographic characteristics and binary logistic regression to assess the association between dementia and sociodemographic factors.

RESULTS

We observed that the prevalence of dementia in Latin America is 15.6%, varying depending on the country (Argentine = 7.83 and Bolivia = 28.5%). The variables most associated with dementia were race and age. It does not seem to be associated with the pandemic but with social and socio-health factors.

CONCLUSION

The prevalence of dementia shows a significant increase in Latin America, attributable to a constellation of ethnic, demographic, and socioeconomic factors.

Mobile Phone Use and Cognitive Impairment among Elderly Chinese: A National Cross-Sectional Survey Study

The study aimed to investigate the relationship between mobile phone use and cognitive impairment using the data of the Prevention and Intervention on Neurodegenerative Disease for Elderly in China (PINDEC) survey. A total of 21,732 participants aged 60 years and above in China were recruited using a stratified, multi-stage cluster sampling method, providing information on demographics, lifestyle and health-related characteristics, mobile phone use, and cognitive impairment through face-to-face interviews by trained staff according to a standard protocol. All estimates of rates were weighted by sex, age, and living area (rural or urban) in the elderly Chinese population. The rate of mobile phone usage was 65.5% (14.3% for smartphone use). The prevalence of cognitive impairment in non-users of mobile phone, dumbphone users, and smartphone users were 17.8%, 5.0%, and 1.4%, respectively. The odds of having cognitive impairment in users of dumbphone and smartphone were lower than non-users after adjusting for demographics, lifestyle, and health-related factors (adjusted odds ratio (AOR), 0.39, 95% CI 0.35 to 0.45; p < 0.001; AOR, 0.16, 95% CI 0.11 to 0.25; p < 0.001, respectively). Smartphone use in Chinese elderly people was quite low. A strong correlation was found between mobile phone use and better cognitive function; yet longitudinal studies are warranted to explore the causal relationship. Future design of mobile phone-based interventions should consider the feasibility among those in need.

Modified STEADI Fall Risk Categories Predict Incident Cognitive Impairment

BACKGROUND/OBJECTIVES

It is unknown whether older adults at high risk of falls but without cognitive impairment have higher rates of subsequent cognitive impairment.

DESIGN

This was an analysis of cross-sectional and longitudinal data from National Health and Aging Trends Study (NHATS).

SETTING

NHATS, secondary analysis of data from 2011 to 2019.

PARTICIPANTS

Community dwelling adults aged 65 and older without cognitive impairment.

MEASUREMENTS

Participants were classified at baseline in three categories of fall risk (low, moderate, severe) using a modified algorithm from the Center for Disease Control's STEADI (Stop Elderly Accidents, Deaths, and Injuries) and fall risk from data from the longitudinal NHATS. Impaired global cognition was defined as NHATS-derived impairment in either the Alzheimer's Disease-8 score, immediate/delayed recall, orientation, clock-drawing test, or date/person recall. The primary outcome was the first incident of cognitive impairment in an 8 year follow-up period. Cox-proportional hazard models ascertained time to onset of cognitive impairment (referent = low modified STEADI incidence).

RESULTS

Of the 7,146 participants (57.8% female), the median age category was 75 to 80 years. Prevalence of baseline fall modified STEADI risk categories in participants was low (51.6%), medium (38.5%), and high (9.9%). In our fully adjusted model, the risk of developing cognitive impairment was hazard ratio (HR) 1.18 [95% CI = 1.08, 1.29] in the moderate risk category, and HR 1.74 [95% CI = 1.53, 1.98] in the high-risk category.

CONCLUSION

Older, cognitively intact adults at high fall risk at baseline had nearly twice the risk of cognitive decline at 8 year follow-up.

Prevalence and association of lifestyle and medical-, psychiatric-, and pain-related comorbidities in patients with migraine: A cross-sectional study

BACKGROUND AND OBJECTIVES

Migraine has been associated with many comorbidities. However, lifestyle factors and the presence of comorbid diseases have not previously been extensively studied in the same sample. This study aimed to compare the prevalence of unhealthy lifestyle factors and comorbid diseases between patients with migraine and migraine-free controls with subgroup analyses to determine the pathophysiology and possible consequences.

METHODS

This cross-sectional study recruited 1257 patients with migraine between the ages of 20 and 65 years from a headache outpatient clinic in Taiwan and 496 non-migraine controls. All participants completed questionnaires regarding demographics, migraine diagnosis, sleep, headache burden, and medical, pain, and psychiatric conditions. Participants also underwent a structured interview. The associations between comorbidities and migraine were investigated and further stratified by sex and aura.

RESULTS

Patients with migraine with aura had an unhealthier lifestyle compared with controls in the form of current smoking status (15.5% [67/431] vs. 11.5% [57/496], p = 0.013). Furthermore, medical- (e.g., thyroid disease; 7.2% [91/1257 vs. 2.8% [14/496]; p = 0.006), psychiatric- (e.g., depression; 6% [76/1257 vs. 2.6% [13/496]; p = 0.031), and pain-related (e.g., fibromyalgia; 8% [101/1257 vs. 3.2% [16/496]; p = 0.006) comorbidities were more prevalent in patients compared with controls. Subgroup analyses revealed that chronic migraine, migraine with aura, and female sex were associated with a greater number of significant comorbidities than episodic migraine, migraine without aura, and male patients with migraine, respectively.

CONCLUSION

Individuals seeking treatment for migraine reported greater levels of smoking and medical, psychiatric, and pain conditions than non-treatment-seeking healthy controls who were recruited from the community. Understanding the relationship between migraine and comorbid diseases may improve medical care as well as the quality of life.

Oral health in patients with dementia: A meta-analysis of comparative and observational studies

OBJECTIVE

Poor oral health is common in dementia, but findings of epidemiological studies have been inconsistent. This meta-analysis examined oral health in patients with dementia diagnosed according to standardized diagnostic criteria.

METHODS

Six international databases (PubMed, EMBASE, PsycINFO, Medline, Cochrane Library, and Web of Science) were searched from their commencement date until 8 November 2018. Oral health was measured by the Remaining Teeth (RT) and Decayed, Missing, and Filled Teeth (DMFT) Index. The mean differences (MD) and 95% confidence intervals (CI) of DMFT Index total and component scores were calculated using a random-effect model.

RESULTS

Twenty-four studies were included for analyses. The pooled DMFT Index was 23.48 (95% CI: 22.34, 24.62), while the pooled score for each component was 2.38 (95% CI: 1.56, 3.20) in decayed teeth (DT), 18.39 (95% CI: 15.92, 20.87) in missing teeth (MT), 2.29 (95% CI: 0.62, 3.95) in filled teeth (FT), and 11.59 (95% CI: 9.14, 14.05) in RT. Compared to controls, people with dementia had significantly a higher DMFT Index total score (MD = 3.80, 95% CI: 2.21, 5.39, p < 0.00,001), and significantly lower number of RT (MD = -3.15, 95% CI: -4.23, -2.06, p < 0.00,001). Subgroup analyses revealed that higher DMFT Index score was significantly associated with year of survey (>2010), study design (case-control study), percentage of females (≤54.3), and the Mini Mental State Examination score (≤18.2). Higher MT score was significantly associated with study design (cross-sectional study), and lower FT score was significantly associated with year of survey (>2010).

CONCLUSIONS

Oral health was significantly poorer in people with dementia compared with controls. Regular screening and effective treatment should be implemented for this population.

Performance of the Eight-item Informant Interview to Differentiate Aging and Dementia within a context similar to the Swedish primary healthcare sector: a systematic review of diagnostic test accuracy studies

OBJECTIVE

Dementia is a common but underdiagnosed health problem. Instruments developed for initial screening exist internationally but are not available within the Swedish primary healthcare sector. This systematic review aimed to evaluate the diagnostic test accuracy of the Eight-item Informant Interview to Differentiate Aging and Dementia in identifying symptomatic dementia within a context similar to the Swedish primary healthcare sector.

DESIGN

A systematic search was conducted in PubMed, CINAHL, PsycInfo, Cochrane Library and manually via reference lists up to November 2019. Eligibility criteria were the reporting of Diagnostic test accuracy outcomes for the Eight-item Informant Interview to Differentiate Aging and Dementia's ability to identify dementia according to internationally approved criteria. The population of interest was selected within the community or primary care. QUADAS-2 was used for quality assessment, and data were analysed with a narrative approach.

RESULTS

Five studies with a total of 13,345 participants were included. With sensitivity (88-100%), specificity (67-91%), positive and negative predictive values (28-63%; 96-100%) respectively, the results show that the Eight-item Informant Interview to Differentiate Aging and Dementia has good ability to identify true positives, false negatives and predict low-risk dementia. That is, the Eight-item Informant Interview to Differentiate Aging and Dementia has a greater ability to predict people who are at risk of not having dementia than to correctly identify those at risk of having dementia within the target population.

CONCLUSION

The results show that the Eight-item Informant Interview to Differentiate Aging and Dementia has the ability to identify persons with symptomatic dementia within the target population. Thus, an evaluation of its potential benefits should be considered and evaluated within the Swedish primary healthcare context. KEY POINTS Dementia is a common but underdiagnosed health problem. Instruments developed for initial screening exist but are not available within the Swedish primary healthcare sector. We found that the Eight-item Informant Interview to Differentiate Aging and Dementia (AD8), has the ability to identify individuals with symptomatic dementia within the target population. The Eight-item Informant Interview to Differentiate Aging and Dementia (AD8), has the potential to increase the possibility for timely detection of individuals with symptomatic dementia.

Abnormal preoperative cognitive screening in aged surgical patients: a retrospective cohort analysis

BACKGROUND

Preoperative cognitive dysfunction has been associated with adverse postoperative outcomes. There are limited data characterising the epidemiology of preoperative cognitive dysfunction in older surgical patients.

METHODS

This retrospective cohort included all patients ≥65 yr old seen at the Washington University preoperative clinic between January 2013 and June 2018. Cognitive screening was performed using the Short-Blessed Test (SBT) and Eight-Item Interview to Differentiate Aging and Dementia (AD8) screen. The primary outcome of abnormal cognitive screening was defined as SBT score ≥5 or AD8 score ≥2. Multivariable logistic regression was used to identify associated factors.

RESULTS

Overall, 21 666 patients ≥65 yr old completed screening during the study period; 23.5% (n=5099) of cognitive screens were abnormal. Abnormal cognitive screening was associated with increasing age, decreasing BMI, male sex, non-Caucasian race, decreased functional independence, and decreased metabolic functional capacity. Patients with a history of stroke or transient ischaemic attack, chronic obstructive pulmonary disease, diabetes mellitus, hepatic cirrhosis, and heavy alcohol use were also more likely to have an abnormal cognitive screen. Predictive modelling showed no combination of patient factors was able to reliably identify patients who had a <10% probability of abnormal cognitive screening.

CONCLUSIONS

Routine preoperative cognitive screening of unselected aged surgical patients often revealed deficits consistent with cognitive impairment or dementia. Such deficits were associated with increased age, decreased function, decreased BMI, and several common medical comorbidities. Further research is necessary to characterise the clinical implications of preoperative cognitive dysfunction and identify interventions that may reduce related postoperative complications.

Subjective cognitive complaints and migraine characteristics: A cross-sectional study

OBJECTIVES

Subjective cognitive complaints by patients with migraine have been associated with memory impairment. However, whether the severity of memory impairment relates to migraine characteristics, such as attack frequency and aura, remains undetermined. We investigated the relationship between subjective cognitive complaints and migraine characteristics.

MATERIALS AND METHODS

This cross-sectional study recruited 669 clinic outpatients from Taiwan. We stratified them by migraine frequency and the presence or absence of aura, and we controlled the data for confounding variables. We performed multivariable linear and logistic regressions to investigate whether different migraine frequencies are associated with subjective cognitive complaints, which were evaluated by the subjective memory complaints scale and the Ascertain Dementia 8 (AD8) questionnaire.

RESULTS

Total subjective memory complaints scores tended to increase with the migraine attack frequency (P = .022) in patients with migraine with aura; similar results were obtained for AD8 scores in women with migraine with aura. Poor sleep quality was associated with a higher total subjective memory complaint (B = 0.08, 95% confidence interval [CI] = 0.03-0.14) and AD8 (B = 0.07, 95% CI = 0.02-0.11) scores. In addition, more severe depression was associated with higher total subjective memory complaints and AD8 scores (B = 0.05, 95% CI = 0.02-0.09; B = 0.08, 95% CI = 0.05-0.11, respectively).

CONCLUSIONS

Subjective cognitive complaints tend to increase with the frequency of migraines with aura, and this interrelation is substantially influenced by depression severity and sleep disturbances.

Dementia screening for elderly in-patients and its association with nursing care satisfaction-an observational study

Inappropriate care for patients with cognitive dysfunction in the hospital could worsen quality of care and medical service satisfaction.All elderly participants were recruited from acute wards of 5 departments in an university hospital. They were administered the Chinese version of Ascertain Dementia 8 (AD8) at admission and the Nursing Service Satisfaction Questionnaire before discharge.A total of 345 participants completed the study. There were 91 (26.4%) participants with AD8 ≥ 2, the cut-off value of high risk of dementia. The prevalence was much higher than prior community-based reports. The Nursing Service Satisfaction Score was significantly lower in AD8 ≥ 2 than in AD8 < 2 (56.99 ± 0.94 vs 60.55 ± 0.48, P < .01).Using AD8 in hospital-based screening might be more efficient than in the community in terms of cost-effectiveness due to higher positive rate and easier approach to diagnostic facilities. AD8 ≥ 2 is also an indicator to identify care dissatisfaction among inpatients. By identifying patients with cognitive dysfunction, such as its related communication barriers, care systems could be tailored for more friendly services.

Cognitive assessment tools for mild cognitive impairment screening

Mild cognitive impairment (MCI) is a clinical condition with a high risk of progression to dementia. Due to lack of effective disease-modifying therapies for advanced dementia, diagnosis and disease intervention at an early stage, particularly at MCI stage, has been widely accepted as a critical strategy in disease management that could potentially affect long-term outcome. However, there is currently no consensus on guidelines for routine screening of MCI, resulting in a considerable number of patients with undiagnosed MCI from community. In addition, the use of different screening guidelines leads to difficulties in comparing different studies. A variety of screening tools have been utilized; however, the sensitivity and specificity vary greatly among these tools. By summarizing the sensitivity, specificity and time efficiency for common MCI screening tools, which are key factors to be taken into consideration when making selections and combinations of screening tools, this review suggests the use of a combination of two self-administered highly sensitive tools, p-AD8 + IQCODE (informant questionnaire on cognitive decline in the elderly individuals) in initial screening, as well as a combination of two highly specific widely covered tools, DemTect + MoCA (Montreal cognitive assessment) or memory and executive screening (MES) + MoCA in secondary screening. In addition, this review also proposes a screening flowchart for MCI, aiming to build a sensitive and time efficient way for recruiting subjects for subsequent investigation and disease differentiation.

AD-8 for detection of dementia across a variety of healthcare settings

BACKGROUND

Dementia assessment often involves initial screening, using a brief tool, followed by more detailed assessment where required. The AD-8 is a short questionnaire, completed by a suitable 'informant' who knows the person well. AD-8 is designed to assess change in functional performance secondary to cognitive change.

OBJECTIVES

To determine the diagnostic accuracy of the informant-based AD-8 questionnaire, in detection of all-cause (undifferentiated) dementia in adults. Where data were available, we described the following: the diagnostic accuracy of the AD-8 at various predefined threshold scores; the diagnostic accuracy of the AD-8 for each healthcare setting and the effects of heterogeneity on the reported diagnostic accuracy of the AD-8.

SEARCH METHODS

We searched the following sources on 27 May 2014, with an update to 7 June 2018: ALOIS (Cochrane Dementia and Cognitive Improvement Group), MEDLINE (Ovid SP), Embase (Ovid SP), PsycINFO (Ovid SP), BIOSIS Previews (Thomson Reuters Web of Science), Web of Science Core Collection (includes Conference Proceedings Citation Index) (Thomson Reuters Web of Science), CINAHL (EBSCOhost) and LILACS (BIREME). We checked reference lists of relevant studies and reviews, used searches of known relevant studies in PubMed to track related articles, and contacted research groups conducting work on the AD-8 to try to find additional studies. We developed a sensitive search strategy and used standardised database subject headings as appropriate. Foreign language publications were translated.

SELECTION CRITERIA

We selected those studies which included the AD-8 to assess for the presence of dementia and where dementia diagnosis was confirmed with clinical assessment. We only included those studies where the AD-8 was used as an informant assessment. We made no exclusions in relation to healthcare setting, language of AD-8 or the AD-8 score used to define a 'test positive' case.

DATA COLLECTION AND ANALYSIS

We screened all titles generated by electronic database searches, and reviewed abstracts of potentially relevant studies. Two independent assessors checked full papers for eligibility and extracted data. We extracted data into two-by-two tables to allow calculation of accuracy metrics for individual studies. We then created summary estimates of sensitivity, specificity and likelihood ratios using the bivariate approach and plotting results in receiver operating characteristic (ROC) space. We determined quality assessment (risk of bias and applicability) using the QUADAS-2 tool.

MAIN RESULTS

From 36 papers describing AD-8 test accuracy, we included 10 papers. We utilised data from nine papers with 4045 individuals, 1107 of whom (27%) had a clinical diagnosis of dementia. Pooled analysis of seven studies, using an AD-8 informant cut-off score of two, indicated that sensitivity was 0.92 (95% confidence interval (CI) 0.86 to 0.96); specificity was 0.64 (95% CI 0.39 to 0.82); the positive likelihood ratio was 2.53 (95% CI 1.38 to 4.64); and the negative likelihood ratio was 0.12 (95% CI 0.07 to 0.21). Pooled analysis of five studies, using an AD-8 informant cut-off score of three, indicated that sensitivity was 0.91 (95% CI 0.80 to 0.96); specificity was 0.76 (95% CI 0.57 to 0.89); the positive likelihood ratio was 3.86 (95% CI 2.03 to 7.34); and the negative likelihood ratio was 0.12 (95% CI 0.06 to 0.24).Four studies were conducted in community settings; four were in secondary care (one in the acute hospital); and one study was in primary care. The AD-8 has a higher relative sensitivity (1.11, 95% CI 1.02 to 1.21), but lower relative specificity (0.51, 95% CI 0.23 to 1.09) in secondary care compared to community care settings.There was heterogeneity across the included studies. Dementia prevalence rate varied from 12% to 90% of included participants. The tool was also used in various different languages. Among all the included studies there was evidence of risk of bias. Issues included the selection of participants, conduct of index test, and flow of assessment procedures.

AUTHORS' CONCLUSIONS

The high sensitivity of the AD-8 suggests it can be used to identify adults who may benefit from further specialist assessment and diagnosis, but is not a diagnostic test in itself. This pattern of high sensitivity and lower specificity is often suited to a screening test. Test accuracy varies by setting, however data in primary care and acute hospital settings are limited. This review identified significant heterogeneity and risk of bias, which may affect the validity of its summary findings.

Validity of screening tools for dementia and mild cognitive impairment among the elderly in primary health care: a systematic review

OBJECTIVES

This systematic review aims to provide updated and comprehensive evidence on the validity and feasibility of screening tools for mild cognitive impairment (MCI) and dementia among the elderly at primary healthcare level.

STUDY DESIGN

A review of articles was performed.

METHODS

A search strategy was used by using electronic bibliographic databases including PubMed, Embase and CENTRAL for published studies and reference list of published studies. The articles were exported to a bibliographic database for further screening process. Two reviewers worked independently to screen results and extract data from the included studies. Any discrepancies were resolved and confirmed by the consensus of all authors.

RESULTS

There were three screening approaches for detecting MCI and dementia - screening by a healthcare provider, screening by a self-administered questionnaire and caretaker informant screening. Montreal Cognitive Assessment (MoCA) was the most common and preferable tool for MCI screening (sensitivity [Sn]: 81-97%; specificity [Sp]: 60-86%), whereas Addenbrooke's Cognitive Examination (ACE) was the preferable tool for dementia screening (Sn: 79-100%; Sp: 86%).

CONCLUSION

This systematic review found that there are three screening approaches for detecting early dementia and MCI at primary health care. ACE and MoCA are recommended tools for screening of dementia and MCI, respectively.

Alzheimer's disease

Alzheimer's disease (AD) dementia refers to a particular onset and course of cognitive and functional decline associated with age together with a particular neuropathology. It was first described by Alois Alzheimer in 1906 about a patient whom he first encountered in 1901. Modern clinical diagnostic criteria have been developed, and criteria have also been proposed to recognize preclinical (or presymptomatic) stages of the disease with the use of biomarkers. The primary neuropathology was described by Alzheimer, and in the mid-1980s subsequently evolved into a more specific neuropathologic definition that recognizes the comorbid neuropathologies that frequently contribute to clinical dementia. Alzheimer's disease is now the most common form of neurodegenerative dementia in the United States with a disproportionate disease burden in minority populations. Deficits in the ability to encode and store new memories characterizes the initial stages of the disease. Subsequent progressive changes in cognition and behavior accompany the later stages. Changes in amyloid precursor protein (APP) cleavage and production of the APP fragment beta-amyloid (Aβ) along with hyperphosphorylated tau protein aggregation coalesce to cause reduction in synaptic strength, synaptic loss, and neurodegeneration. Metabolic, vascular, and inflammatory changes, as well as comorbid pathologies are key components of the disease process. Symptomatic treatment offers a modest, clinically measurable effect in cognition, but disease-modifying therapies are desperately needed.