Geographical variation in dementia: systematic review with meta-analysis

Measurement invariance of a neuropsychological battery across urban and rural older adults in Costa Rica

This study evaluated the measurement invariance of a neuropsychological battery across rural and urban older adults from Costa Rica. Rural and urban older adults (N = 295) from the Epidemiology and Development of Alzheimer's Disease (EDAD) study in Costa Rica were assessed. The baseline factor model for the EDAD neuropsychological measures was identified with nine neuropsychological measures and three cognitive constructs: Verbal Memory, Spatial Reasoning, and Cognitive Flexibility. Measurement and structural invariance were established, and, then, group comparisons of the latent cognitive factors were conducted to explore regional disparities. The findings showed that most of the neuropsychological tests in EDAD can be directly compared across the groups, allowing for cognitive constructs comparisons. The rural sample showed a disadvantage in the Spatial Reasoning and Cognitive Flexibility abilities. When age and education were included in the models, differences between the regions disappeared. Having more years of education was associated with higher cognitive abilities, with a larger effect for the rural group. Norms for Costa Rican older adults should consider age and education adjustments. This study contributes to the growing area of measurement invariance in neuropsychological assessment as it highlights the importance of examining the comparability of assessment measures across different cultural groups.

Rural-Urban mild cognitive impairment comparison in West Michigan through EHR

INTRODUCTION

Mild cognitive impairment (MCI) is a significant public health concern and a potential precursor to Alzheimer's disease (AD). This study leverages electronic health record (EHR) data to explore rural-urban differences in MCI incidence, risk factors, and healthcare navigation in West Michigan.

METHODS

Analysis was conducted on 1,528,464 patients from Corewell Health West, using face-to-face encounters between 1/1/2015 and 7/31/2022. MCI cases were identified using International Classification of Diseases (ICD) codes, focusing on patients aged 45+ without prior MCI, dementia, or AD diagnoses. Incidence rates, cumulative incidences, primary care physicians (PCPs), and neuropsychology referral outcomes were examined across rural and urban areas. Risk factors were evaluated through univariate and multivariate Cox regression analyses. The geographic distribution of patient counts, hospital locations, and neurology department referrals were examined.

RESULTS

Among 423,592 patients, a higher MCI incidence rate was observed in urban settings compared to rural settings (3.83 vs. 3.22 per 1,000 person-years). However, sensitivity analysis revealed higher incidence rates in rural areas when including patients who progressed directly to dementia. Urban patients demonstrated higher rates of referrals to and completion of neurological services. While the risk factors for MCI were largely similar across urban and rural populations, urban-specific factors for incident MCI are hearing loss, inflammatory bowel disease, obstructive sleep apnea, insomnia, being African American, and being underweight. Common risk factors include diabetes, intracranial injury, cerebrovascular disease, coronary artery disease, stroke, Parkinson's disease, epilepsy, chronic obstructive pulmonary disease, depression, and increased age. Lower risk was associated with being female, having a higher body mass index, and having a higher diastolic blood pressure.

DISCUSSION

This study highlights rural-urban differences in MCI incidence and access to care, suggesting potential underdiagnosis in rural areas likely due to reduced access to specialists. Future research should explore socioeconomic, environmental, and lifestyle determinants of MCI to refine prevention and management strategies across geographic settings.

Highlights

Leveraged EHRs to explore rural-urban differences in MCI in West Michigan.Revealed a significant underdiagnosis of MCI, especially in rural areas.Observed lower rates of neurological referrals and completions for rural patients.Identified risk factors specific to rural and urban populations.

Exploring the influence of weather variability and climate change on health outcomes in people living with dementia: A scoping review protocol

Environmental factors resulting from climate change and air pollution are risk factors for many chronic conditions including dementia. Although research has shown the impacts of air pollution in terms of cognitive status, less is known about the association between climate change and specific health-related outcomes of older people living with dementia. In response, we outline a scoping review protocol to systematically review the published literature regarding the evidence of climate change, including temperature and weather variability, on health-related quality of life, morbidity, mobility, falls, the utilization of health resources, and mortality among older adults living with dementia. This scoping review will be guided by the framework proposed by Arksey and O'Malley. Electronic search (Medline, Embase, PsycINFO, CINAHL, Scopus, Web of Science) using relevant subject headings and synonyms for two concepts (older people with dementia, weather/ climate change). No publication date or other restrictions will be applied to the search strategy. No language restriction will be applied in order to understand the impact of non-English studies in the literature. Eligible studies must include older adults (65+years) with dementia living in the community and investigate the impacts of climate change and/or weather on their health-related quality of life, morbidity, mobility, falls, use of health resources and mortality. Two independent reviewers will screen abstracts and select those for a full-text review, perform these reviews, select articles for retention, and extract data from them in a standardized manner. This data will then be synthesized and interpreted. OSF registration: DOI: 10.17605/OSF.IO/YRFM8.

Modelling the spatial risk pattern of dementia in Denmark using residential location data: A registry-based national cohort

Dementia is a major global public health concern that is increasingly leading to morbidity and mortality among older adults. While studies have focused on the risk factors and care provision, there is currently limited knowledge about the spatial risk pattern of the disease. In this study, we employ Bayesian spatial modelling with a stochastic partial differential equation (SPDE) approach to model the spatial risk using complete residential history data from the Danish population and health registers. The study cohort consisted of 1.6 million people aged 65 years and above from 2005 to 2018. The results of the spatial risk map indicate high-risk areas in Copenhagen, southern Jutland and Funen. Individual socioeconomic factors and population density reduce the intensity of high-risk patterns across Denmark. The findings of this study call for the critical examination of the contribution of place of residence in the susceptibility of the global ageing population to dementia.

Uncovering the extent of dementia prevalence in Iran: a comprehensive systematic review and meta-analysis

BACKGROUND

Dementia is one of the major causes of disability and dependency among older people worldwide. The formation of an aging population in Iran can be associated with societal problems, including age-related disorders such as dementia. This study aimed to estimate the prevalence of dementia& Alzheimer disease in adults aged 60 years or older and it's its geographical distribution in Iran.

METHODS

A systematic review and meta-analysis study included articles published in both English and Persian languages and utilized various databases including: Google Scholar, PubMed, Web of Science, Magiran, and thesis database of medicine universities up to December 2022. The pooled prevalence was calculated using random effects models. The prevalence was reported separately for different geographical locations and types of area sampling, and age adjustment was performed for the selected studies. All statistical analyses were conducted using metaprop package in STATA version 17. The I2 statistic was applied to assess heterogeneity.

RESULTS

The meta-analysis considered nine relevant studies that were carried out up to 2023 in Iran. The study found that the prevalence of dementia in central and east counties was estimated to be 0.14 (95% CI; 0.04-0.31), while in western counties, the prevalence was estimated to be 0.1 (95%CI; 0.01-0.27). The estimated overall crude prevalence of dementia was estimated at 0.14 (95% CI; 0.03-0.31). Estimated prevalence-based health centers sampling and hospital-based studies were 0.02 (95% CI; 0.02-0.03), 0.05 (95% CI 0.06-0.11), respectively. One study used nursing home sampling as the sampling method, and the estimated prevalence was 0.43 (95%CI 0.38-0.49).

CONCLUSION

This is the first systematic review and meta-analysis of the prevalence of dementia's disease up to 2023 in Iran. The estimated overall prevalence of dementia is lower than the reported prevalence in European countries and similar to other Asian countries.

Rural-urban differences in use of health services before and after dementia diagnosis: a retrospective cohort study

BACKGROUND

Rural-urban differences in health service use among persons with prevalent dementia are known. However, the extent of geographic differences in health service use over a long observation period, and prior to diagnosis, have not been sufficiently examined. The purpose of this study was to examine yearly rural-urban differences in the proportion of patients using health services, and the mean number of services, in the 5-year period before and 5-year period after a first diagnosis of dementia.

METHODS

This population-based retrospective cohort study used linked administrative health data from the Canadian province of Saskatchewan to investigate the use of five health services [family physician (FP), specialist physician, hospital admission, all-type prescription drug dispensations, and short-term institutional care admission] each year from April 2008 to March 2019. Persons with dementia included 2,024 adults aged 65 years and older diagnosed from 1 April 2013 to 31 March 2014 (617 rural; 1,407 urban). Matching was performed 1:1 to persons without dementia on age group, sex, rural versus urban residence, geographic region, and comorbidity. Differences between rural and urban persons within the dementia and control cohorts were separately identified using the Z-score test for proportions (p < 0.05) and independent samples t-test for means (p < 0.05).

RESULTS

Rural compared to urban persons with dementia had a lower average number of FP visits during 1-year and 2-year preindex and between 2-year and 4-year postindex (p < 0.05), a lower likelihood of at least one specialist visit and a lower average number of specialist visits during each year (p < 0.05), and a lower average number of all-type prescription drug dispensations for most of the 10-year study period (p < 0.05). Rural-urban differences were not observed in admission to hospital or short-term institutional care (p > 0.05 each year).

CONCLUSIONS

This study identified important geographic differences in physician services and all-type prescription drugs before and after dementia diagnosis. Health system planners and educators must determine how to use existing resources and technological advances to support care for rural persons living with dementia.

Metabolomics and Risk of Dementia: A Systematic Review of Prospective Studies

BACKGROUND

The projected increase in the prevalence of dementia has sparked interest in understanding the pathophysiology and underlying causal factors in its development and progression. Identifying novel biomarkers in the preclinical or prodromal phase of dementia may be important for predicting early disease risk. Applying metabolomic techniques to prediagnostic samples in prospective studies provides the opportunity to identify potential disease biomarkers.

OBJECTIVE

The objective of this systematic review was to summarize the evidence on the associations between metabolite markers and risk of dementia and related dementia subtypes in human studies with a prospective design.

DESIGN

We searched PubMed, PsycINFO, and Web of Science databases from inception through December 8, 2023. Thirteen studies (mean/median follow-up years: 2.1-21.0 y) were included in the review.

RESULTS

Several metabolites detected in biological samples, including amino acids, fatty acids, acylcarnitines, lipid and lipoprotein variations, hormones, and other related metabolites, were associated with risk of developing dementia. Our systematic review summarized the adjusted associations between metabolites and dementia risk; however, our findings should be interpreted with caution because of the heterogeneity across the included studies and potential sources of bias. Further studies are warranted with well-designed prospective cohort studies that have defined study populations, longer follow-up durations, the inclusion of additional diverse biological samples, standardization of techniques in metabolomics and ascertainment methods for diagnosing dementia, and inclusion of other related dementia subtypes.

CONCLUSIONS

This study contributes to the limited systematic reviews on metabolomics and dementia by summarizing the prospective associations between metabolites in prediagnostic biological samples with dementia risk. Our review discovered additional metabolite markers associated with the onset of developing dementia and may help aid in the understanding of dementia etiology. The protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (https://www.crd.york.ac.uk/prospero/; registration ID: CRD42022357521).

Features of the Physical and Social Neighborhood Environment and Neighborhood-Level Alzheimer's Disease and Related Dementia in South Carolina

BACKGROUND

Studies are increasingly examining the relationship between the neighborhood environment and cognitive decline; yet, few have investigated associations between multiple neighborhood features and Alzheimer's disease and related dementias (ADRD).

OBJECTIVE

We investigated the relationship between neighborhood features and ADRD cumulative incidence from 2010 to 2014 in the South Carolina Alzheimer's Disease Registry (SCADR).

METHODS

Diagnosed ADRD cases ≥ 50  years of age were ascertained from the SCADR by ZIP code and census tract. Neighborhood features from multiple secondary sources included poverty, air pollution [particulate matter with a diameter of 2.5 micrometers or less (PM 2.5 )], and rurality at the census-tract level and access to healthy food, recreation facilities, and diabetes screening at the county level. In addition to using Poisson generalized linear regression to estimate ADRD incident rate ratios (IRR) with 95% confidence intervals (CIs), we applied integrated nested Laplace approximations and stochastic partial differential equations (INLA-SPDE) to address disparate spatial scales. We estimated associations between neighborhood features and ADRD cumulative incidence.

RESULTS

The average annual ADRD cumulative incidence was 690 per 100,000 people per census tract (95% CI: 660, 710). The analysis was limited to 98% of census tracts with a population ≥ 50  years old (i.e., 1,081 of 1,103). The average percent of families living below the federal poverty line per census tract was 18.8%, and ∼ 20 % of census tracts were considered rural. The average percent of households with limited access to healthy food was 6.4%. In adjusted models, every 5 μ g / m 3 ) increase of PM 2.5 was associated with 65% higher ADRD cumulative incidence (IRR = 1.65 ; 95% CI: 1.30, 2.09), where PM 2.5 at or below 12   μ g / m 3 is considered healthy. Compared to large urban census tracts, rural and small urban tracts had 10% (IRR = 1.10 ; 95% CI: 1.00, 1.23) and 5% (IRR = 1.05 ; 95% CI: 0.96, 1.16) higher ADRD, respectively. For every percent increase of the county population with limited access to healthy food, ADRD was 2% higher (IRR = 1.02 ; 95% CI: 1.01, 1.04).

CONCLUSIONS

Neighborhood environment features, such as higher air pollution levels, were associated with higher neighborhood ADRD incidence. The INLA-SPDE method could have broad applicability to data collected across disparate spatial scales. https://doi.org/10.1289/EHP13183.

Rural-urban disparities in fruit and vegetable consumption and cognitive performance in Brazil

OBJECTIVES

Rural residents are exposed to many risk factors for poor diet quality, such as low socioeconomic status and food insecurity. However, the differences between urban and rural residents regarding the association of fruit and vegetable consumption with cognitive performance have not been explored. The aim of this study was to investigate the association of fruit and vegetable consumption with cognitive performance in urban and rural areas in a nationally representative sample of Brazilian older adults.

METHODS

The sample included 9,412 adults aged 50 years or older from the Brazilian Longitudinal Study of Aging (Estudo Longitudinal da Saúde dos Idosos Brasileiros [ELSI]). The association between consumption of fruits and vegetables and cognitive performance was evaluated using linear regression.

RESULTS

In 8,158 participants (mean age 61.6 ± 9.3 years, 54% women, 44% White, and 15% from rural areas), the mean frequency of fruit and vegetable consumption was 2.0 ± 1.3 times a day. Higher intake of fruits and vegetables was associated with better memory (ß = 0.031, 95%CI 0.014-0.049), verbal fluency (ß = 0.030, 95%CI 0.004-0.056), and global cognition (ß = 0.035, 95%CI 0.015-0.055) performance in urban, but not rural residents (p for interaction = 0.036).

CONCLUSIONS

Higher frequency of fruit and vegetable intake was associated with better cognitive performance in urban, but not in rural areas in Brazil.

Rural-Urban Differences in Cognition: Findings From the Advanced Cognitive Training for Independent and Vital Elderly Trial

ObjectivesWe examined associations between three geographic areas (urban, suburban, rural) and cognition (memory, reasoning, processing speed) over a 10-year period. Methods: Data were obtained from 2539 participants in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial. Multilevel, mixed-effects linear regression was used to estimate cognitive trajectories by geographical areas over 10 years, after adjusting for social determinants of health. Results: Compared to urban and suburban participants, rural participants fared worse on all cognitive measures-memory (B = -1.17 (0.17)), reasoning (B = -1.55 (0.19)), and processing speed (B = 0.76 (0.19)) across the 10-year trajectory. Across geographic areas, greater economic stability, health care access and quality, and neighborhood resources were associated with better cognition over time. Discussion: Findings highlight the importance of geographical location when examining cognition later in life. More research examining place-based life experiences is needed to make the greatest impact on geographically diverse communities.

Digital phenotyping: An equal opportunity approach to reducing disparities in Alzheimer's disease and related dementia research

A rapidly aging world population is fueling a concomitant increase in Alzheimer's disease (AD) and related dementias (ADRD). Scientific inquiry, however, has largely focused on White populations in Australia, the European Union, and North America. As such, there is an incomplete understanding of AD in other populations. In this perspective, we describe research efforts and challenges of cohort studies from three regions of the world: Central America, East Africa, and East Asia. These cohorts are engaging with the Davos Alzheimer's Collaborative (DAC), a global partnership that brings together cohorts from around the world to advance understanding of AD. Each cohort is poised to leverage the widespread use of mobile devices to integrate digital phenotyping into current methodologies and mitigate the lack of representativeness in AD research of racial and ethnic minorities across the globe. In addition to methods that these three cohorts are already using, DAC has developed a digital phenotyping protocol that can collect ADRD-related data remotely via smartphone and/or in clinic via a tablet to generate a common data elements digital dataset that can be harmonized with additional clinical and molecular data being collected at each cohort site and when combined across cohorts and made accessible can provide a global data resource that is more racially/ethnically represented of the world population.

Association between neighborhood availability of physical activity facilities and cognitive performance in older adults

The existing evidence on the contextual influence of the availability of local facilities for physical activity on the cognitive health of elderly residents is sparse. This study examined the association between neighborhood physical activity facilities and cognitive health in older individuals. A cohort study of community-dwelling older adults was performed using baseline data and follow-up data from the Taiwan Biobank. Cognitive health was measured in 32,396 individuals aged 60-70 years using the Mini-Mental State Examination (MMSE) with follow-up information on 8025 participants. The district was used as the proxy for local neighborhood. To determine neighborhood physical activity facilities, school campuses, parks, activity centers, gyms, swimming pools, and stadiums were included. Multilevel linear regression models were applied to examine the associations of neighborhood physical activity facilities with baseline MMSE and MMSE decline during follow-up, with adjustment for individual factors and neighborhood socioeconomic characteristics. Multilevel analyses revealed that there was a neighborhood-level effect on cognitive health among older adults. After adjusting for compositional and neighborhood socioeconomic characteristics, baseline MMSE was higher in individuals living in the middle- (beta = 0.12, p-value = 0.140) and high-density facility (beta = 0.22, p-value = 0.025) groups than in the low-density group (p-value for trend-test = 0.031). MMSE decline during follow-up was slower in the middle- (beta = 0.15, p-value = 0.114) and high-density facility (beta = 0.27, p-value = 0.052) groups than in the low-density group (p-value for trend-test = 0.032). Greater neighborhood availability of physical activity facilities was associated with better cognitive health among older residents. These findings have implications for designing communities and developing strategies to support cognitive health of an aging population.

Global rural health disparities in Alzheimer's disease and related dementias: State of the science

INTRODUCTION

Individuals living in rural communities are at heightened risk for Alzheimer's disease and related dementias (ADRD), which parallels other persistent place-based health disparities. Identifying multiple potentially modifiable risk factors specific to rural areas that contribute to ADRD is an essential first step in understanding the complex interplay between various barriers and facilitators.

METHODS

An interdisciplinary, international group of ADRD researchers convened to address the overarching question of: "What can be done to begin minimizing the rural health disparities that contribute uniquely to ADRD?" In this state of the science appraisal, we explore what is known about the biological, behavioral, sociocultural, and environmental influences on ADRD disparities in rural settings.

RESULTS

A range of individual, interpersonal, and community factors were identified, including strengths of rural residents in facilitating healthy aging lifestyle interventions.

DISCUSSION

A location dynamics model and ADRD-focused future directions are offered for guiding rural practitioners, researchers, and policymakers in mitigating rural disparities.

HIGHLIGHTS

Rural residents face heightened Alzheimer's disease and related dementia (ADRD) risks and burdens due to health disparities. Defining the unique rural barriers and facilitators to cognitive health yields insight. The strengths and resilience of rural residents can mitigate ADRD-related challenges. A novel "location dynamics" model guides assessment of rural-specific ADRD issues.

Changes in the prevalence of dementia in Australia and its association with geographic remoteness

BACKGROUND

The exact prevalence of dementia in Australia is ambiguous. Australia is a vast continent with a small population, and 80% of the population live in five cities. This study explores recent changes in the prevalence of dementia. It also investigates geographic remoteness as a potential risk factor for developing dementia.

METHODS

Survey of Disability, Ageing and Carers (SDAC), a nationally representative database, was used to conduct this study. A total of 74,862 and 65,487 individuals from 2015 and 2018, respectively, were considered for this study. A multivariable logistic regression model was used to evaluate the association between dementia and geographic remoteness for older adults aged 65 years and over.

RESULTS

The results reveal that from 2015 to 2018, the prevalence of dementia among adults aged 65 years and older was higher in 2018 (5,229 per 100,000) than in 2015 (5,099 per 100,000). Significant geographical differences in the prevalence of dementia are observed among Australian adults, and this trend appears to be increasing. Furthermore, the unadjusted model revealed that, in 2015, older adults living in major cities had 1.29 (AOR: 1.29, 95% CI: 1.17-1.41) times higher odds of having dementia compared with their counterparts from outer regional and remote areas. In 2018, the adjusted model found that older adults living in major cities had 1.12 (AOR: 1.12, 95% CI: 1.01-1.25) times elevated odds of having dementia than their peers living in outer regional and remote areas.

CONCLUSION

There is a rising prevalence of dementia in Australia. Further investigation is required to identify the causes of this increase. Increased public health initiatives should concentrate on behavioural characteristics and contextual environmental factors to ameliorate this trend.

Has COVID-19 affected dementia diagnosis rates in England?

BACKGROUND

The COVID-19 pandemic impacted on the provision of care and routine activity of all National Health Service (NHS) services. While General Practitioner referrals to memory services in England have returned to pre-pandemic levels, the estimated dementia diagnosis rate (DDR) fell by 5.4% between March 2020 and February 2023.

METHODS

In this paper we explore whether this reduction is accurate or is an artefact of the way the NHS collects data.

RESULTS

We explore the processes that may have affected national dementia diagnosis rates during and following the COVID-19 pandemic.

CONCLUSIONS

We discuss what action could be taken to improve the DDR in the future.

Rural versus Urban Residence in Adulthood and Incident Cognitive Impairment

INTRODUCTION

Rural versus urban living is a social determinant of cognitive health. We estimated the association of rural versus urban residence in the USA with incident cognitive impairment (ICI) and assessed effect heterogeneity by sociodemographic, behavioral, and clinical factors.

METHODS

The Reasons for Geographic and Racial Differences in Stroke Study (REGARDS) is a population-based prospective observational cohort of 30,239 adults, 57% female, 36% Black, aged 45+ years, sampled from 48 contiguous states in the USA in 2003-2007. We analyzed 20,878 participants who at baseline were cognitively intact with no history of stroke and had ICI assessed on average 9.4 years later. We classified participants' home addresses at baseline as urban (population ≥50,000), large rural (10,000-49,999), or small rural (≤9,999) by Rural-Urban Commuting Area codes. We defined ICI as ≥1.5 SD below the mean on at least 2 of the following tests: word list learning, word list delayed recall, and animal naming.

RESULTS

Participants' home addresses were 79.8% urban, 11.7% large rural, and 8.5% small rural. ICI occurred in 1,658 participants (7.9%). Small rural residents had higher odds of ICI than urban residents, adjusted for age, sex, race, region, and education (OR = 1.34 [95% CI: 1.10, 1.64]), and after further adjustment for income, health behaviors, and clinical characteristics (OR = 1.24 [95% CI: 1.02, 1.53]). Former smoking versus never, nondrinking versus light alcohol drinking, no exercise versus ≥4 times/week, CES-D depressive symptom score of 2 versus 0, and fair versus excellent self-rated health had stronger associations with ICI in small rural areas than in urban areas. For example, in urban areas, lack of exercise was not associated with ICI (OR = 0.90 [95% CI: 0.77, 1.06]); however, lack of exercise combined with small rural residence was associated with 1.45 times the odds of ICI compared with ≥4 bouts of exercise/week in urban areas (95% CI: 1.03, 2.03). Overall, large rural residence was not associated with ICI; however, black race, hypertension, and depressive symptoms had somewhat weaker associations with ICI, and heavy alcohol drinking a stronger association with ICI, in large rural areas than in urban areas.

CONCLUSION

Small rural residence was associated with ICI among USA adults. Further research to better understand why rural residents are at higher risk for developing ICI and mechanisms to ameliorate that risk will support efforts to advance rural public health.

Temporal Dementia and Cognitive Impairment Trends in the Very Old in the 21st Century

BACKGROUND

Long-increasing dementia incidence and prevalence trends may be shifting. Whether such shifts have reached the very old is unknown.

OBJECTIVE

To investigate temporal trends in the incidence of dementia and cognitive impairment and prevalence of dementia, cognitive impairment, Alzheimer's disease, vascular dementia, and unclassified dementia among 85-, 90-, and ≥ 95-year-olds in Sweden during 2000-2017.

METHODS

This study was conducted with Umeå 85 + /Gerontological Regional Database data from 2182 85-, 90-, and ≥ 95-year-olds in Sweden collected in 2000-2017. Using logistic regression, trends in the cumulative 5-year incidences of dementia and cognitive impairment; prevalences of dementia, cognitive impairment, Alzheimer's disease, and vascular dementia; and Mini-Mental State Examination thresholds for dementia diagnosis were estimated.

RESULTS

Dementia and cognitive impairment incidences decreased in younger groups, which generally showed more-positive temporal trends. The prevalences of overall dementia, cognitive impairment, and Alzheimer's disease were stable or increasing; longer disease durations and increasing dementia subtype classification success may mask positive changes in incidences. Vascular dementia increased while unclassified dementia generally decreased.

CONCLUSION

The cognitive health of the very old may be changing in the 21st century, possibly indicating a trend break.

Rural and urban differences in quality of dementia care of persons with dementia and caregivers across all domains: a systematic review

BACKGROUND

There are challenges in healthcare service delivery in rural areas, and this may be especially true for persons with dementia, who have higher needs to access to the healthcare system, and may have difficulties to commute easily and safely to these services. There is a growing body of literature regarding geographical disparities, but there is no comprehensive systematic review of geographical differences in persons with dementia across all domains of care quality. Therefore, the objective of this study is to conduct a systematic review of the literature on rural and urban differences in quality of dementia care outcomes of persons with dementia across all quality-of-care domains.

METHODS

We performed a digital search in Ovid MEDLINE on July 16, 2019, updated on May 3, 2021, for French or English records. We selected studies that reported outcome from at least one domain of quality of dementia care (Access, Integration, Effective Care, Efficient Care, Population Health, Safety, and Patient-Centered) in both rural and urban persons with dementia or caregivers. We used rigorous, systematic methods for screening, selection, data extraction and we analyzed outcomes reported by at least two studies using vote counting and appraised the certainty of evidence. Finally, we explored sources of heterogeneity.

RESULTS

From the 38 included studies, we found differences in many dementia care domains. Rural persons with dementia had higher mortality rates (Population Health), lower visits to any physicians (Access), more hospitalizations but shorter stays (Integration), higher antipsychotic medications (Safety), lower use of home care services and higher use of nursing home (Patient-Centered Care) compared to urban persons with dementia.

CONCLUSIONS

This comprehensive portrait of rural-urban differences in dementia care highlights possible geographically based inequities and can be used by researchers and decision makers to guide development of more equitable dementia care policies.

Behavioral and Psychological Symptoms of Dementia: Prevalence, Symptom Severity, and Caregiver Distress in South-Western Uganda-A Quantitative Cross-Sectional Study

The purpose of the study was to investigate behavioral and psychological symptoms (BPSD) prevalence, severity, and distress experienced by caregivers of people living with dementia (PLWD). A cross-sectional, population-based study was conducted in a rural area in southwestern Uganda. A Neuropsychiatric Inventory Questionnaire (NPI-Q) was used to determine the presence of BPSD as perceived by caregivers of PLWD. We carried out both descriptive and inferential data analysis. A total of 175 caregivers of PLWD were enrolled in this study. Among PLWD, 99% had presented BPSD in the past month. Hallucinations (75%) and dysphoria/depression (81%) were the two BPSD that occurred most frequently. Most participants (70%) stated that PLWD experienced hallucinations of significant severity. Aberrant motor activity was reported by 60% of the participants as the type of BPSD that caused severe distress. There was a high positive correlation (0.82) between the total severity score and total distress scores. Interventions aimed at addressing dysphoria and hallucinations may be essential for the reduction of caregiver distress. These findings point to the need for promoting early screening for BPSDs and the provision of support to caregivers.

The effect of a multimodal intervention program on cognitive and daily function of older persons residing in rural communities: A pilot study

This pilot study aimed to explore the effects of a 12-week multimodal intervention program, comprising cognitive training and cognitive-stimulation, on cognitive performance and daily function of older adults in rural communities. Fifty-one participants were equally assigned to the multimodal intervention, cognitive-stimulation, and no-intervention control groups. Cognition and daily function were assessed using the Korean version of neuropsychological test battery and instrumental activities of daily living at baseline and at the 12-week follow-up assessment, respectively. Compared with the two other groups, the multimodal intervention group showed significant improvement in global cognitive function, attention, and executive function. A significant group-by-time interaction in instrumental activities of daily living was observed among the groups, with a greater improvement observed in the multimodal intervention group and little changes or decreases over time in the other groups. This study suggested the beneficial effects of a multimodal intervention on cognitive and behavioral improvement in older adults.

Neighbourhood walkability in relation to cognitive functioning in patients with disorders along the heart-brain axis

This study examined associations of neighbourhood walkability with cognitive functioning (i.e., global cognition, memory, language, attention-psychomotor speed, and executive functioning) in participants without or with either heart failure, carotid occlusive disease, or vascular cognitive impairment. Neighbourhood walkability at baseline was positively associated with global cognition and attention-psychomotor speed. These associations were stronger in patients with vascular cognitive impairment. Individuals who live in residential areas with higher walkability levels were less likely to have impairments in language and executive functioning at two-year follow-up. These findings highlight the importance of the built environment for cognitive functioning in healthy and vulnerable groups.

Physical activity and cognitive function: A comparison of rural and urban breast cancer survivors

PURPOSE

Increasing evidence suggests rural breast cancer survivors (BCS) may experience greater burden in symptoms known to be associated with cancer-associated cognitive decline (CACD). Yet, little is known about CACD in rural BCS. This study (1) examined differences in cognitive function, moderate-to-vigorous physical activity (MVPA), and other CACD correlates and (2) tested the effects of MVPA on cognitive function in rural versus urban BCS.

METHODS

Rural and urban BCS (N = 80), matched on age, education, and time since diagnosis from a larger study, completed cognitive tasks assessing processing speed (Trails-B, Mazes, Task-Switch) and working memory (spatial working memory) and questionnaires assessing subjective memory impairment (SMI), MVPA, and CACD correlates (i.e., sleep quality, fatigue, anxiety/depression). Some participants (n = 62) wore an accelerometer to objectively estimate MVPA. Multiple linear regression and multivariate analysis of covariance were used to test study aims.

RESULTS

Rural BCS (n = 40, M = 61.1±8.4 years-old) performed significantly slower on Trails-B (p<0.01) compared with urban BCS (n = 40, M = 61.0±8.2 years-old) and engaged in less objectively-estimated daily MVPA (mean difference = 13.83±4.73 minutes; p = 0.01). No significant differences in SMI, self-reported MVPA, or CACD correlates were observed (all p>0.28). Regression models did not reveal a significant interaction between MVPA and cognitive performance (all p>0.1); however, estimated marginal means models indicated that the effect of MVPA on processing speed was evident only among rural BCS (Trails-B, p = 0.04; Mazes, p = 0.03).

CONCLUSIONS

Findings suggest rural BCS may suffer greater CACD and engage in less MVPA. Additional research is warranted to further examine CACD and more effectively promote MVPA in rural BCS.

Spatial disparity and factors associated with dementia mortality: A cross-sectional study in Zhejiang Province, China

Objective

Evidence of spatial disparity in dementia mortality in China has been found to have higher dementia mortality in eastern and rural China. Regional factors of physical and social features may be influencing this spatial disparity. However, the extent of spatial difference in dementia mortality across small regional localities is unclear. This study aims to investigate the geographic variations in mortality and risk of all dementia subtypes and identify the effect of the associated environmental risk factors.

Methods

We used surveillance data on death reports from Alzheimer's disease and other forms of dementia in Zhejiang province from 2015 to 2019. We estimated the relative risk of dementia mortality using a Bayesian spatial model. We mapped predicted relative risk to visualize the risk of death from different types of dementia and to identify risk factors associated with dementia.

Results

Thirty thousand three hundred and ninety-eight deaths attributable to dementia as the underlying or related cause (multiple causes) were reported during 2015-2019. Counties and districts in the southeast and west of Zhejiang province had significantly higher standardized mortality ratios than others. Counties and districts with a smaller proportion of residents aged 60 years or older, poorer economic status, insufficient health resources, and worse pollution had a higher risk of deaths due to dementia.

Conclusion

Higher risks of dementia mortality were found in counties and districts with poorer economic status, insufficient health resources, and worse pollution in Zhejiang. Our study adds new evidence on the association between socioeconomic and environmental factors and the mortality risk due to dementia.

Social Determinants of Health in Community-Dwelling Dementia Patients Aged 65 and Over: Analysis of the 2019 National Health Interview Survey

Alzheimer's Disease and related dementias affect 3.4 million community-dwelling adults in the United States. Given the burden of disease, a greater understanding of modifiable risk factors is crucial for targeted public health strategies. Social determinants of health (SDOH) are modifiable risk factors categorized in five domains: economic status, education, healthcare access, environment, and community context. Although individual SDOH have been linked to dementia, limited research exists on the interaction of SDOH with dementia across multiple domains. The aim of this study was to evaluate the association between SDOH across all five domains and dementia among community-dwelling adults in the United States. A cross-sectional study was performed on community-dwelling adults aged ≥65 years from the 2019 National Health Interview Survey (NHIS). Respondents (N = 9,277), of whom 303 (4%) self-reported positive dementia diagnosis, were predominantly female (55%), white (76%), and non-Hispanic (91%). Residing in a non-metropolitan area, having a usual place for healthcare, and receiving annual eye or dental exams were negatively associated with dementia. Minority compared to white status was not significantly associated with dementia, suggesting underdiagnosis of dementia within minority groups in the NHIS. We present the first comprehensive national view of SDOH among community-dwelling dementia patients in the United States.

Easing the burden of dementia caregiving: Protocol development for a telephone-delivered mindfulness intervention for rural, African American families

Background

There have been few interventions targeted for rural African American (AA) caregivers of persons with dementia despite their unique cultural, geographic, health-related and socio-economic needs, including relatively less access to-and willingness to engage with-formal supports and resources. One effective intervention, Mindfulness-based stress reduction (MBSR), has been found to be culturally acceptable in AA populations; however, no studies have assessed feasibility, acceptability and impact of an adapted mindfulness intervention targeting rural AA dementia caregivers.

Aims

The purpose of this study is to 1) determine the feasibility and acceptability of a telephone-delivered mindfulness training intervention in decreasing caregiver burden among rural, AA, informal caregiving teams of people with dementia; 2) to explore the effects of the training on caregiver burden and relevant secondary outcomes for both caregiving team members, including emotional regulation, tolerance of uncertainty, emotional and physical health, family conflict within the informal caregiving team, and self-efficacy; and 3) to explore comfort with and willingness to adopt technologies to access mindfulness practices and existing caregiving educational resources.

Methods

Our study utilizes a single-group, uncontrolled design to assess the feasibility and acceptability of telephone-delivered mindfulness training designed to alleviate burden for rural caregivers of AA individuals with moderate to severe dementia. A care partner-the person who provides additional help -is included in the intervention. The primary outcome is feasibility of the telephone-delivered mindfulness intervention as assessed by an 85% retention rate with completion of at least 6 of the intervention sessions. Pre- and post-participation interviews assess acceptability.

How Telemedicine Can Improve the Quality of Care for Patients with Alzheimer's Disease and Related Dementias? A Narrative Review

Background and Objectives: Dementia affects more than 55 million patients worldwide, with a significant societal, economic, and psychological impact. However, many patients with Alzheimer's disease (AD) and other related dementias have limited access to effective and individualized treatment. Care provision for dementia is often unequal, fragmented, and inefficient. The COVID-19 pandemic accelerated telemedicine use, which holds promising potential for addressing this important gap. In this narrative review, we aim to analyze and discuss how telemedicine can improve the quality of healthcare for AD and related dementias in a structured manner, based on the seven dimensions of healthcare quality defined by the World Health Organization (WHO), 2018: effectiveness, safety, people-centeredness, timeliness, equitability, integrated care, and efficiency. Materials and Methods: MEDLINE and Scopus databases were searched for peer-reviewed articles investigating the role of telemedicine in the quality of care for patients with dementia. A narrative synthesis was based on the seven WHO dimensions. Results: Most studies indicate that telemedicine is a valuable tool for AD and related dementias: it can improve effectiveness (better access to specialized care, accurate diagnosis, evidence-based treatment, avoidance of preventable hospitalizations), timeliness (reduction of waiting times and unnecessary transportation), patient-centeredness (personalized care for needs and values), safety (appropriate treatment, reduction of infection risk),integrated care (interdisciplinary approach through several dementia-related services), efficiency (mainly cost-effectiveness) and equitability (overcoming geographical barriers, cultural diversities). However, digital illiteracy, legal and organizational issues, as well as limited awareness, are significant potential barriers. Conclusions: Telemedicine may significantly improve all aspects of the quality of care for patients with dementia. However, future longitudinal studies with control groups including participants of a wide educational level spectrum will aid in our deeper understanding of the real impact of telemedicine in quality care for this population.

Childhood socio-economic circumstances and dementia: prospective register-based cohort study of adulthood socio-economic and cardiovascular health mediators

Background

This study analysed the association between childhood socio-economic circumstances and the risk of dementia, and investigated the mediating role of potentially modifiable risk factors including adulthood socio-economic position and cardiovascular health.

Methods

We used a 10% sample of the 1950 Finnish population census linked with subsequent population and health registers (n = 95 381). Information of socio-economic characteristics, family structure and housing conditions at the age of 0–15 years was obtained from the 1950 census. We identified cohort members who developed dementia in 2000–2018 using national hospital, medication and death registers. Discrete time survival analysis using logistic regression and mediation analysis applying the Karlson–Holm–Breen (KHB) method were employed.

Results

An excess risk of dementia was observed for household crowding [odds ratio (OR) = 1.10; 95% CI 1.02–1.18 for 3 to &lt;4 persons per heated room; OR = 1.19; 95% CI 1.11–1.27 for ≥4 persons], single-father family (OR = 1.27; 95% CI 1.07–1.51) and eastern and northern region of residence (OR = 1.19; 95% CI 1.10–1.28). The effects of single-father family and region of residence were mostly direct with adulthood characteristics mediating 14% and 29% of the total effect, respectively. The largest indirect effect was observed for household crowding mediated through adulthood socio-economic position (47–65%).

Conclusions

The study shows that childhood socio-economic circumstances are associated with dementia, and that the underlying mechanisms only partly relate to adulthood socio-economic position and cardiovascular health. Socio-economic and health interventions targeted at families with children may carry long-term benefits by contributing to a lower dementia risk in later life.

Income, wealth, and Black-White disparities in cognition

We investigated the contributions of income and wealth (beyond education) to Black-White disparities in cognition and evaluated whether the role of socioeconomic status (SES) varies by age. Based on data from a national survey of Americans (aged 23-94), we used regression models to quantify the overall racial disparities in episodic memory, executive function, and overall cognition, adjusted for sex and age. Potential mediators (i.e., measures of childhood environment, educational attainment, marital status, occupation, income, and wealth) were added in subsequent models. The age- and sex-adjusted Black-White differential in overall cognitive function was around one standard deviation (SD) between ages 25 and 50, but declined to 0.6 SD by age 80. Executive function followed a similar pattern, but the racial disparity in episodic memory declined more rapidly between ages 35 (0.7 SD) and 80 (0.2 SD). Childhood environment and the respondent's educational attainment accounted for 20-25% of the racial disparities in overall cognition. The incremental contribution of household income was small (1-5%). Although wealth had only a small effect at younger ages, the contribution grew with age. Wealth was much more important than income in explaining Black-White disparities in cognition at older ages. Childhood environment, marital status, and SES (including wealth) accounted for one-third of the racial disparity in overall cognition at ages 35-65, but an even greater share at age 80. Our study is the first to demonstrate that, with increasing age, wealth explains more of the Black-White disparity in cognition. A widening racial gap in wealth and the disproportionate financial impact of the Great Recession and the COVID-19 pandemic on minorities do not bode well for Black-White differentials in cognition. Working-age Americans suffered the brunt of the economic impact of those events; the impact on cognition may increase as those cohorts grow older.

Neighborhood characteristics and dementia symptomology among community-dwelling older adults with Alzheimer's disease

Background

Neuropsychiatric symptoms (NPSs) lead to myriad poor health outcomes among individuals with Alzheimer's disease (AD). Prior studies have observed associations between the various aspects of the home environment and NPSs, but macro-level environmental stressors (e.g., neighborhood income) may also disrupt the neuronal microenvironment and exacerbate NPSs. Yet, to our knowledge, no studies have investigated the relationship between the neighborhood environment and NPSs.

Methods

Using 2010 data among older adults with AD collected from a sample of the South Carolina Alzheimer's Disease Registry, we estimated cross-sectional associations between neighborhood characteristics and NPSs in the overall population and by race/ethnicity. Neighborhood measures (within a 1/2-mile radius of residence) came from the American Community Survey and Rural Urban Commuting Area Code. We categorized median household income into tertiles: < $30,500, $30,500-40,000, and > $40,000, and rurality as: rural, small urban, and large urban. Residential instability was defined as the percent of residents who moved within the past year. NPSs were defined using the Neuropsychiatric Inventory Questionnaire that included the composite measure of all 12 domains. Adjusting for age, sex/gender, race/ethnicity, and caregiver educational attainment, we used negative binomial regression to estimate prevalence ratios (PR) and 95% confidence intervals (CI) for NPSs by neighborhood characteristics.

Results

Among 212 eligible participants, mean age was 82 ± 8.7 years, 72% were women, and 55% non-Hispanic (NH)-Black. Individuals with AD living in < $30,500 vs. > $40,000 income neighborhoods had a 53% (PR = 1.53; 95% CI = 1.06-2.23) higher prevalence of NPSs while individuals living in rural vs. large urban neighborhoods had a 36% lower prevalence of NPSs (PR = 0.64; 95% CI = 0.45-0.90), after adjustment. We did not observe an association between residential instability and NPSs (PR = 0.92; 95% CI = 0.86-1.00); however, our estimates suggested differences by race/ethnicity where NH-White older adults living in residential instable areas had lower NPSs (PR = 0.89; 95% CI = 0.82-0.96) compared to NH-Black older adults (PR = 0.96; 95% CI = 0.86-1.07).

Discussion

Across racial/ethnic groups, individuals with AD had more symptomology when living in lower income areas. Pending replication, intervention efforts should consider resource allocation to high-need neighborhoods (e.g., lower income), and studies should investigate underlying mechanisms for this relationship.

Regional variation in U.S dementia trends from 2000-2012

Although recent studies report a decline in dementia prevalence among U.S. older adults, national trends may mask subnational variation, particularly given large health and social inequalities linked to geography. To address this gap, we determined if there was subnational variation in reported national dementia trends and if region-specific trends were explained by sociodemographic and health characteristics. Data come from the 2000 (n = 10,447) and 2012 (10,426) waves of the Health and Retirement Study. We used validated methods for dementia classification using proxy and self-respondents. Logistic regression models, adjusted for within-person clustering over time, estimated trends in dementia prevalence by region and census division. We found subnational variation in dementia prevalence in both 2000 and 2012, as well as in change in dementia prevalence during this period. In 2000, dementia prevalence was lowest in the West (8.6%), higher in the Midwest (10.0%) and Northeast (11.1%), and highest in the South (14.6%). Dementia prevalence declined over time across all regions of the U.S. from 2000 to 2012 but remained highest in the South (10.7%) compared to the other regions (7.0-7.8%). Despite downward trends in dementia across the U.S., the prevalence of dementia in the South in 2012 approximated levels found in other regions in 2000. There was relatively less change over time in the West compared to other regions, but dementia prevalence was already quite low in the West in 2000. Within region, trends in dementia prevalence between 2000 and 2012 also varied slightly across census divisions. Subnational variation in changes in dementia prevalence were largely explained by education and health status. Variation in baseline prevalence, as well as differential rates of change, highlight the importance of examining subnational variation in dementia trends.

Facets of Personality and Risk of Cognitive Impairment: Longitudinal Findings in a Rural Community from Sardinia

Background: Few studies have examined the associations between personality facets and dementia risk and rarely included individuals from rural settings or with low education. Objective: To examine the association between personality and the risk of cognitive impairment. Methods: Participants (N = 1,668; age 50 to 94 at baseline; 56.4% women; 86.5% less than high school diploma) were from a rural region of Sardinia (Italy) who completed the Revised NEO Personality Inventory (NEO-PI-R) during the first wave (2001–2004) and the Mini-Mental State Examination (MMSE) at waves two to five (2005–2021). Cox regression was used to test personality and covariates as predictors of cognitive impairment based on MMSE education-adjusted cutoffs. Results: During the up to 18-year follow-up (M = 10.38; SD = 4.76), 187 individuals (11.2%) scored as cognitively impaired. Participants with higher neuroticism (particularly the depression facet [HR = 1.22, 95% CI = 1.06–1.40]), and lower agreeableness (particularly the modesty facet [HR = 0.83, 95% CI = 0.71–0.97]) and lower conscientiousness (particularly the dutifulness facet [HR = 0.78, 95% CI = 0.67–0.92]) were at higher risk of cognitive impairment. Lower warmth ([HR = 0.75, 95% CI = 0.65–0.87], facet of extraversion) and ideas ([HR = 0.76, 95% CI = 0.65–0.89], facet of openness) were also associated with increased risk of impairment. These associations were virtually unchanged in models that accounted for other risk factors, including smoking, depression, obesity, hypertension, diabetes, and apolipoprotein E (APOE) ɛ4 carrier status. Across the five domains, sex and the APOE variant did not moderate the associations. Conclusion: In a sample with demographic characteristics underrepresented in dementia research, this study identifies personality domains and facets most relevant to the risk of cognitive impairment.

Using Video Telehealth to Deliver Patient-Centered Collaborative Care: The G-IMPACT Pilot

Objectives: This pilot project aimed to explore a new model of healthcare delivery to older adult medically complex Veterans by combining telehealth technology with an interdisciplinary medical team operating in real time.Methods: The Geriatric-Interdisciplinary Mobile Patient Access Team (G-IMPACT) was comprised of a field team including a nurse practitioner and technology assistant who visited enrolled patients in their homes using synchronous video to link to a suite of geriatric specialists in a video-enabled room at a Veterans Affairs hospital. Clinicians interacted with patients, caregivers, and each other to develop mutually agreed upon treatment plans that were then immediately implemented in the field.Results: 11 total visits were conducted with 9 Veteran patients aged 55-91 (mean = 75.3 years). Both patients and clinicians reported a high level of satisfaction across multiple metrics, including visit quality, and positive indirect indicators of effectiveness were apparent from qualitative data.Conclusions: Nurse practitioner facilitated video visits allowed geriatric patients to meet with multiple specialists simultaneously with both high patient satisfaction and increased real-time care coordination.Clinical Implications: This project identified challenges and opportunities afforded by this type of real-time telehealth care delivery and can inform the development of future interdisciplinary mobile medical teams.

Spatial–Temporal Variations of Water Ecosystem Services Value and Its Influencing Factors: A Case in Typical Regions of the Central Loess Plateau

Water resources provide indispensable ecosystem services, which are related to human well-being and sustainable social development. Accurately measuring the water ecosystem services value (WESV), and then grasping its changing characteristics, is particularly important for solving water problems. In this study, the typical area of the central Loess Plateau location is taken as the research area. Based on remote sensing images and statistical data, the direct market method combined with the equivalent factor method was used to calculate the WESV including groundwater and surface water, which is of greatest originality. The temporal and spatial variation characteristics in 2010, 2015 and 2020 were analyzed. Then, four WESV driving factors including per capita GDP, population density, proportion of water areas, and water consumption were selected, and the geographically weighted regression (GWR) model was used to analyze the spatial distribution pattern and temporal variation of WESV’s response to the influencing factors. The results showed that WESV experienced a process of first decreasing and then increasing, which was mainly caused by Yulin. For the composition of WESV, the proportion of provisioning services value has increased, which caused the proportion of regulating services value to decrease. The correlations between four factors and WESV were different. The distribution pattern of the influences was spatially heterogeneous, which showed regular variations over time. These results indicate the necessity of WESV’s independent research and provide a realistic basis for ecological compensation in the Yellow River Basin.

The Insignificant Correlation between Androgen Deprivation Therapy and Incidence of Dementia Using an Extension Survival Cox Hazard Model and Propensity-Score Matching Analysis in a Retrospective, Population-Based Prostate Cancer Registry

This study aims to evaluate the effect of androgen-deprivation therapy (ADT) on the incidence of dementia, after considering the time-dependent survival in patients with prostate cancer (PC) using a Korean population-based cancer registry database. After excluding patients with cerebrovascular disease and dementia before or within the 3-month-ADT and those with surgical castration, 9880 (19.3%) patients were matched into ADT and non-ADT groups using propensity-score matching (PSM) among 51,206 patients registered between 2006 and 2013. To define the significant relationship between ADT duration and the incidence of dementia, the extension Cox proportional hazard model was used with p-values < 0.05 regarded as statistically significant. The mean age and survival time were 67.3 years and 4.33 (standard deviation [SD] 2.16) years, respectively. A total of 2945 (9.3%) patients developed dementia during the study period, including Parkinson’s (11.0%), Alzheimer’s (42.6%), vascular (18.2%), and other types of dementia (28.2%). Despite PSM, the PC-treatment subtypes, survival rate, and incidence of dementia significantly differed between the ADT and non-ADT groups (p < 0.05), whereas the rate of each dementia subtype did not significantly differ (p = 0.069). A multivariate analysis for dementia incidence showed no significance of ADT type or use duration among patients with PC (p > 0.05), whereas old age, obesity, regional SEER stage, a history of cerebrovascular disease, and a high Charlson Comorbidity Index were significant factors for dementia (p < 0.05). Insignificant correlation was observed between ADT and the incidence of dementia based on the extension survival model with PSM among patients with PC.

The Relationship Between Adverse Childhood Experiences and Alzheimer's Disease: A Systematic Review

Background

Alzheimer's disease is a global health concern, and with no present cure, prevention is critical. Exposure to adverse childhood experiences may increase the risk of developing Alzheimer's disease. This systematic review was conducted to synthesize the evidence on the associations between adverse childhood experiences (<18 years) and the risk of Alzheimer's disease in adulthood.

Methods

A search strategy was developed and conducted to identify articles investigating the associations between exposure to adverse childhood experiences and the onset of Alzheimer's disease by searching key databases (CINAHL, MEDLINE and PsycInfo). Two reviewers independently determined the eligibility of studies according to pre-determined criteria, and assessed the methodological quality using the US National Heart, Lung and Blood Institute 14-item checklist for observational cohort and cross-sectional studies, respectively. Due to limited studies, a descriptive synthesis was performed. The protocol for this review is published in BMJ Open and registered with PROSPERO (CRD42020191439).

Results

Our search yielded 781 articles, of which three (two separate analyses from the same cohort study and one cross-sectional study) met the predetermined eligibility criteria. The methodological quality assessment yielded an overall mean score of 78.9% (range 66.6 – 84.6%). All studies found adverse childhood experiences were associated with an increased risk of Alzheimer's disease. However, there was a limited number of available studies to inform the synthesis.

Conclusions

Adverse childhood experiences appear to be associated with an increased risk of Alzheimer's disease, although, further research is needed.

Registration and Protocol

The protocol for this review is registered with PROSPERO (CRD42020191439) and published with BMJ Open (Corney et al., 2021).

Sex and Gender Differences in Environmental Influences on Dementia Incidence in Germany, 2014-2019: An Observational Cohort Study Based on Health Claims Data

BACKGROUND

There is an ongoing debate about whether environmental characteristics influence dementia risk like individual traits do, and whether these differ by sex and gender.

OBJECTIVE

This study examines the influence of regional characteristics on the incidence of dementia and explores sex and gender differences using individual-level health information and regional characteristics.

METHODS

Using a random sample of 250,000 people aged 70 + insured through Germany's largest German public health agency, we analyzed quarterly data about diagnoses and place of residence from 2014 to 2019. Using five-digit postal codes, we added data on various dimensions of regional characteristics offered by the INKAR database and the 2011 Census database. We used multilevel survival regressions to tease out regional incidence differences while accounting for spatial clustering.

RESULTS

After adjusting for multi-morbidity and relocation-related selection bias, we saw that people living in regions with the highest tertile of income (HR = 0.87, p <  0.001), and who had the highest tertile of remaining life expectancy at age 60 (HR = 0.93, p = 0.012) had lower dementia risks. There was no gender difference in the regional income effect, but the effect of education (HR = 0.91, p = 0.015) was significant only for men and remaining life-expectancy was significant only for women (HR = 0.93, p = 0.026).

CONCLUSION

Environmental characteristics related to wealth and health resources of a region influence the risk of dementia among the elderly in Germany. This effect is independent of the health profiles of the individuals and differs between the two genders. Health policies need to acknowledge these modifiable risk factors and consider how they affect men and women differently.

Association of Neighborhood-Level Socioeconomic Measures With Cognition and Dementia Risk in Australian Adults

IMPORTANCE

Up to 40% of dementia cases are potentially preventable; therefore, it is important to identify high-risk groups to whom resources could be targeted for maximal impact in preventing late-life dementia. The association of neighborhood-level socioeconomic status (SES) with cognition and dementia risk is not well known, particularly in midlife when late-life dementia may still be preventable through established interventions, such as blood pressure management.

OBJECTIVE

To examine whether neighborhood-level SES is associated with differences in cognitive performance and dementia risk scores.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data collected between November 17, 2016, and April 14, 2020, from 4656 participants in the longitudinal population-based Healthy Brain Project cohort. This large online cohort comprised community-dwelling individuals geographically dispersed across Australia. Participants were aged 40 to 70 years without dementia or other major neurological conditions.

EXPOSURES

Neighborhood-level SES was computed by matching participants' residential addresses to the Australian Bureau of Statistics Index of Relative Socio-economic Advantage and Disadvantage (IRSAD). Postcodes provided by each participant were used to derive an IRSAD score that ranked participants according to deciles of neighborhood-level SES (range, 1-10, with higher deciles indicating greater socioeconomic advantage); neighborhoods in deciles 1 to 7 were considered to have low or intermediate SES, and neighborhoods in deciles 8 to 10 were considered to have high SES.

MAIN OUTCOMES AND MEASURES

Dementia risk estimated using the dementia risk score from the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) tool (n = 4656) and cognitive composite scores for memory and attention measured by the Cogstate Brief Battery (n = 2181).

RESULTS

Of 4656 participants (mean [SD] age, 56.1 [7.2] years; 3445 women [74.0%]), 2688 individuals (57.7%) lived in areas with high neighborhood-level SES (IRSAD decile ≥8), and 1968 (42.3%) lived in areas with low or intermediate neighborhood-level SES (IRSAD decile <8), with 1263 individuals (27.1%) residing in rural or regional areas. A total of 6 participants (0.1%) identified as African, 121 (2.6%) as Asian, 57 (1.2%) as Indigenous Australian, 24 (0.5%) as Latin American, 9 (0.2%) as Pacific Islander, 3671 (78.8%) as White or European, and 768 (16.5%) indicated other race (not specified). Each decile unit increase in neighborhood-level SES was associated with a lower CAIDE dementia risk score after adjustment for race and rurality (β [SE] = -0.070 [0.019]; P = .004). Each decile unit increase was also associated with better memory (β [SE] = 0.022 [0.006]; P = .006) but not with better attention (β [SE] = 0.009 [0.007]; P = .34), as measured by Cogstate Brief Battery composite z scores after adjustment for age, sex, race, years of education, and rurality. When comparing memory performance between individuals with IRSAD scores higher and lower than decile 8, neighborhood-level SES interacted with age (F1-2171 = 6.33; P = .02) and CAIDE dementia risk scores (F1-2173 = 4.02; P = .08). Differences in memory between neighborhood-level SES categories were larger among participants who were older and had a higher risk of dementia.

CONCLUSIONS AND RELEVANCE

In this study, higher neighborhood-level SES was associated with better memory and lower dementia risk scores. These results suggest that efforts to lower dementia risk factors in disadvantaged areas are needed to curtail the increasing burden of dementia and that inclusion of individuals living in areas with lower SES in research on dementia is warranted to improve understanding and potential interventions.

The Impact of Demographic, Socio-Economic and Geographic Factors on Mortality Risk among People Living with Dementia in England (2002-2016)

Increasing numbers of people living with dementia (PLWD), and a pressured health and social care system, will exacerbate inequalities in mortality for PLWD. There is a dearth of research examining multiple factors in mortality risk among PLWD, including application of large administrative datasets to investigate these issues. This study explored variation mortality risk variation among people diagnosed with dementia between 2002-2016, based on: age, sex, ethnicity, deprivation, geography and general practice (GP) contacts. Data were derived from electronic health records from a cohort of Clinical Practice Research Datalink GP patients in England (n = 142,340). Cox proportional hazards regression modelled mortality risk separately for people with early- and later- onset dementia. Few social inequalities were observed in early-onset dementia; men had greater risk of mortality. For early- and later-onset, higher rates of GP observations-and for later-onset only dementia medications-are associated with increased mortality risk. Social inequalities were evident in later-onset dementia. Accounting for other explanatory factors, Black and Mixed/Other ethnicity groups had lower mortality risk, more deprived areas had greater mortality risk, and higher mortality was observed in North East, South Central and South West GP regions. This study provides novel evidence of the extent of mortality risk inequalities among PLWD. Variance in mortality risk was observed by social, demographic and geographic factors, and frequency of GP contact. Findings illustrate need for greater person-centred care discussions, prioritising tackling inequalities among PLWD. Future research should explore more outcomes for PLWD, and more explanatory factors of health outcomes.

Prevalence of Cognitive Impairment and Dementia in Older Adults Living at High Altitude: A Systematic Review and Meta-Analysis

INTRODUCTION

Dementia is a chronic disease with a variable prevalence throughout the world; however, this could be higher at high-altitude populations. We aimed to summarize the prevalence of cognitive impairment and dementia in older adults living at high altitude.

METHODS

We searched in PubMed, Medline, Scopus, Web of Science, and Embase and included the studies published from inception to July 20, 2020, with no language restriction, which reported the frequency of cognitive impairment or dementia in older adults living at high-altitude populations. Random-effects meta-analyses were performed to calculate the overall prevalence and 95% confidence intervals (95% CI) of cognitive impairment and dementia. The risk of bias was evaluated using the Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies.

RESULTS

Six studies were included (3,724 participants), and 5 of the 6 included studies were carried out in Latin America. The altitude ranged from 1,783 to 3,847 m, the proportion of women included varied from 38.7 to 65.6%, and the proportion of participants with elementary or illiterate educational level ranged from 71.7 to 97.6%. The overall prevalence of cognitive impairment was 22.0% (95% CI: 8-40, I2: 99%), and the overall prevalence of dementia was 11.0% (95% CI: 6-17, I2: 92%). In a subgroup analysis according to the instrument used to evaluate cognitive impairment, the prevalence of cognitive impairment was 21.0% (95% CI: 5-42, I2: 99%) in the MMSE group while the prevalence was 29.0% (95% CI: 0-78) in the non-MMSE group.

CONCLUSIONS

The prevalence of cognitive impairment and dementia in older adults living at high altitude is almost twice the number reported in some world regions.

Environmental factors and risks of cognitive impairment and dementia: A systematic review and meta-analysis

BACKGROUND

Dementia is a challenging neurodegenerative disease. This systematic review aimed to summarize natural, physical, and social environmental factors that are associated with age-related cognitive impairment and dementia.

METHODS

We systematically searched PubMed, EMBASE, Web of Science, and PsychINFO till January 11, 2021 for observational studies. The hazard ratio (HR), relative risk (RR), and odds ratio (OR) with 95% confidence interval (CI) were aggregated using random-effects methods. The quality of evidence for each association was evaluated.

RESULTS

Of the 48,399 publications identified, there were 185 suitable for review across 44 environmental factors. Meta-analyses were performed for 22 factors. With high-to-moderate quality of evidence, risks were suggested in exposure to PM_2.5 (HR=1.24, 95%CI: 1.17-1.31), NO₂ (HR=1.07, 95%CI: 1.02-1.12), aluminum (OR=1.35, 95%CI: 1.14-1.59), solvents (OR=1.14, 95%CI: 1.07-1.22), road proximity (OR=1.08, 95%CI: 1.04-1.12) and other air pollutions, yet more frequent social contact (HR=0.82, 95%CI: 0.76-0.90) and more greenness (OR=0.97, 95%CI: 0.95-0.995) were protective. With low-to-very low quality, electromagnetic fields, pesticides, SO₂, neighborhood socioeconomic status, and rural living were suggested risks, but more community cultural engagement might be protective. No significant associations were observed in exposure to PM₁₀, NO_x, noise, silicon, community group, and temperature. For the remaining 22 factors, only a descriptive analysis was undertaken as too few studies or lack of information.

CONCLUSIONS

This review highlights that air pollutions, especially PM_2.5 and NO₂ play important role in the risk for age-related cognitive impairment and dementia.

Community-level educational attainment and dementia: a 6-year longitudinal multilevel study in Japan

BACKGROUND

As the understanding of the association between community-level education and dementia is insufficient, this study examined the contextual association of community-level prevalence of low educational attainment on the risk of dementia incidence. With this study, we further explored the potential differences in the aforementioned associations for urban and non-urban areas.

METHODS

We analyzed 6 years of prospective cohort data from the Japan Gerontological Evaluation Study, beginning with the baseline data collected between 2010 and 2012, for 51,186 physically and cognitively independent individuals aged ≥65 years (23,785 men and 27,401 women) from 346 communities in 16 municipalities across 7 prefectures. We assessed dementia incidence using available data from the long-term care insurance system in Japan. We dichotomized education years as ≤9 and ≥ 10 years and aggregated individual-level educational attainment as a community-level independent variable. Model 1 covariates were age and sex. Income, residential years, disease, alcohol, smoking, social isolation, and population density were added in Model 2. We conducted multiple imputation to address the missing data. We performed a two-level (community and individual) survival analysis to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

The results indicate that the cumulative incidence of dementia during the follow-up period was 10.6%. The mean proportion with educational attainment of ≤9 years was 40.8% (range: 5.1-87.3%). Low community-level educational attainment was significantly associated with higher dementia incidence (HR: 1.04; 95% CI: 1.01-1.07), estimated by 10 percentage points of low educational attainment after adjusting for individual-level educational years and covariates. While the association was significant in non-urban areas (HR: 1.07; 1.02-1.13), there was no association in urban areas (HR: 1.03; 0.99-1.06).

CONCLUSIONS

Older people living in communities with low educational attainment among their age demographic develop dementia more often compared with those living in areas with high educational attainment after adjusting for individual-level educational attainment and covariates; the association was pronounced in non-urban areas. Securing education for adolescents as a life course and population approach could thus be crucial in preventing dementia later in life among older people living in non-urban areas.

A Revisit to Etiopathogenesis and Therapeutic Strategies in Alzheimer's Disease

Dementia is a cluster of brain abnormalities that trigger progressive memory deficits and other cognitive abilities such as skills, language, or executive function. Alzheimer's disease (AD) is the foremost type of age-associated dementia that involves progressive neurodegeneration accompanied by profound cognitive deficits in advanced stages that severely hamper social or occupational abilities with or without the involvement of any other psychiatric condition. The last two decades witnessed a sharp increase (~123%) in mortality due to AD type dementia, typically owing to a very low disclosure rate (~45%) and hence, the prophylactic, as well as the therapeutic cure of AD, has been a huge challenge. Although understanding of AD pathogenesis has witnessed a remarkable growth (e.g., tauopathy, oxidative stress, lipid transport, glucose uptake, apoptosis, synaptic dysfunction, inflammation, and immune system), still a dearth of an effective therapeutic agent in the management of AD prompts the quest for newer pharmacological targets in the purview of its growing epidemiological status. Most of the current therapeutic strategies focus on modulation of a single target, e.g., inhibition of acetylcholinesterase, glutamate excitotoxicity (memantine), or nootropics (piracetam), even though AD is a multifaceted neurological disorder. There is an impedance urgency to find not only symptomatic but effective disease-modifying therapies. The present review focuses on the risk / protective factors and pathogenic mechanisms involved in AD. In addition to the existing symptomatic therapeutic approach, a diverse array of possible targets linked to pathogenic cascades have been re-investigated to envisage the pharmacotherapeutic strategies in AD.

Cognitive impairment burden in older and younger adults across the kidney transplant care continuum

BACKGROUND

Younger kidney transplant (KT) candidates and recipients may have cognitive impairment due to chronic diseases and reliance on dialysis.

METHODS

To quantify cognitive impairment burden by age across the KT care continuum, we leveraged a two-center cohort study of 3854 KT candidates at evaluation, 1114 recipients at admission, and 405 recipients at 1-year post-KT with measured global cognitive performance (3MS) or executive function (Trail Making Test). We also estimated burden of severe cognitive impairment that affects functional dependence (activities of daily living [ADL] < 6 or instrumental activities of daily living [IADL] < 8).

RESULTS

Among KT candidates, global cognitive impairment (18-34 years: 11.1%; 35-49 years: 14.0%; 50-64 years: 19.5%; ≥65 years: 22.0%) and severe cognitive impairment burden (18-34 years: 1.1%; 35-49 years: 3.0%; 50-64 years: 6.2%; ≥65 years: 7.7%) increased linearly with age. Among KT recipients at admission, global cognitive impairment (18-34 years: 9.1%; 35-49 years: 6.1%; 50-64 years: 9.3%; ≥65 years: 15.7%) and severe cognitive impairment burden (18-34 years: 1.4%; 35-49 years: 1.4%; 50-64 years: 2.2%; ≥65 years: 4.6%) was lower. Despite lowest burden of cognitive impairment among KT recipients at 1-year post-KT across all ages (18-34 years: 1.7%; 35-49 years: 3.4%; 50-64 years: 4.3%; ≥65 years: 6.5%), many still exhibited severe cognitive impairment (18-34 years: .0%; 35-49 years: 1.9%; 50-64 years: 2.4%; ≥65 years: 3.5%).

CONCLUSION

Findings were consistent for executive function impairment. While cognitive impairment increases with age, younger KT candidates have a high burden comparable to community-dwelling older adults, with some potentially suffering from severe forms. Transplant centers should consider routinely screening patients during clinical care encounters regardless of age.

On the Common Journey of Neural Cells through Ischemic Brain Injury and Alzheimer's Disease

Ischemic brain injury and Alzheimer's disease (AD) both lead to cell death in the central nervous system (CNS) and thus negatively affect particularly the elderly population. Due to the lack of a definitive cure for brain ischemia and AD, it is advisable to carefully study, compare, and contrast the mechanisms that trigger, and are involved in, both neuropathologies. A deeper understanding of these mechanisms may help ameliorate, or even prevent, the destructive effects of neurodegenerative disorders. In this review, we deal with ischemic damage and AD, with the main emphasis on the common properties of these CNS disorders. Importantly, we discuss the Wnt signaling pathway as a significant factor in the cell fate determination and cell survival in the diseased adult CNS. Finally, we summarize the interesting findings that may improve or complement the current sparse and insufficient treatments for brain ischemia and AD, and we delineate prospective directions in regenerative medicine.

Joint space-time Bayesian disease mapping via quantification of disease risk association

Alzheimer's disease is an increasingly prevalent neurological disorder with no effective therapies. Thus, there is a need to characterize the progression of Alzheimer's disease risk in order to preclude its inception in patients. Characterizing Alzheimer's disease risk can be accomplished at the population-level by the space-time modeling of Alzheimer's disease incidence data. In this paper, we develop flexible Bayesian hierarchical models which can borrow risk information from conditions antecedent to Alzheimer's disease, such as mild cognitive impairment, in an effort to better characterize Alzheimer's disease risk over space and time. From an application of these models to real-world Alzheimer's disease and mild cognitive impairment spatiotemporal incidence data, we found that our novel models provided improved model goodness of fit, and via a simulation study, we demonstrated the importance of diagnosing the label-switching problem for our models as well as the importance of model specification in order to best capture the contribution of time in modeling Alzheimer's disease risk.

Deaths with Dementia in Indigenous and Non-Indigenous Australians: A Nationwide Study

BACKGROUND

The prevalence of dementia is generally reported to be higher among Indigenous peoples.

OBJECTIVE

The rates and coding of dementia mortality were compared between Indigenous and non-Indigenous Australians.

METHODS

De-identified individual records on causes of death for all people aged 40 years or more who died in Australia between 2006 and 2014 (n = 1,233,084) were used. There were 185,237 records with International Classification of Diseases, Tenth Revision, codes for dementia (Alzheimer's Disease, vascular dementia, or unspecified dementia) as the underlying cause of death or mentioned elsewhere on the death certificate. Death rates were compared using Poisson regression. Logistic regression was used to assess whether dementia was more likely to be classified as 'unspecified' type in Indigenous Australians.

RESULTS

The rates of death with dementia were 57% higher in Indigenous Australians, compared to non-Indigenous, relative rate (RR) 1.57, 95% confidence interval (CI) (1.48, 1.66), p < 0.0001. This excess of deaths was highest at ages below 75 (RRs > 2, test for interaction p < 0.0001), and among men (test for interaction p < 0.0001). When the underreporting of Indigenous status on the death certificate was taken into account the relative rate increased to 2.17, 95% CI (2.07, 2.29). Indigenous Australians were also more likely to have their dementia coded as 'unspecified' on their death certificate (Odds Ratio 1.92, 95% CI (1.66, 2.21), p < 0.0001), compared to the non-Indigenous group.

CONCLUSION

This epidemiological analysis based on population level mortality data demonstrates the higher dementia-related mortality rate for Indigenous Australians especially at younger ages.

Air Pollution as Risk Factor for Mental Disorders: In Search for a Possible Link with Alzheimer's Disease and Schizophrenia

As a global problem that has increasingly been causing worldwide concern, air pollution poses a significant and serious environmental risk to health. Risks of cardiovascular and respiratory diseases, as well as various types of cancer, have been consistently associated with the exposure to air pollutants. More recently, various studies have also shown that the central nervous system is also attacked by air pollution. Air pollution appears to be strongly associated with a higher risk of cognitive defects, neurodevelopmental (e.g., schizophrenia) and neurodegenerative (e.g., Alzheimer's disease) disorders. Subjects with schizophrenia, as well as subjects with Alzheimer's disease, experience a variety of neuropsychological deficits and cognitive impairments. This determines an adverse effect on social and professional functioning, and it contributes to the long-term disease burden. However, no final conclusions have been drawn on the matter of the direct relationship between schizophrenia and Alzheimer's disease. In recent years, the topic of urbanicity and mental health has become increasingly important. Urban exposure to environmental toxins and pollution is currently described as a reliable risk factor for schizophrenia and other psychoses, and it has been demonstrated more and more how exposure to air pollutants is associated with increased risk of dementia. Pathways by which air pollution can target and damage the brain, leading to an increased risk for developing schizophrenia and Alzheimer's disease, are multiple and complex. Results from epidemiological studies suggest potential associations, but are still insufficient to confirm causality. Further studies are needed in order to verify this hypothesis. And if confirmed, the clinical implications could be of substantial relevance for both public and mental health.

Season of birth and the risk of dementia in the population-based Rotterdam Study

Early-life environmental factors have been suggested in the pathophysiology of dementia. Season of birth has previously been used as a proxy for these external exposures. We investigated the link between season of birth and the risk of dementia and further explored underlying pathways by studying structural brain changes on MRI. From the Dutch, population-based Rotterdam Study, 12,964 participants born between 1887 and 1960 were followed between 1990 and 2018 for dementia. Cox regression was conducted to assess the association between season of birth and dementia. In addition, we distinguished between mild and cold winters. The association of season of birth with structural brain markers on MRI was examined in 5237 participants. The risk of dementia in participants born in winter and fall was higher than of those born in summer (hazard ratio (HR) 1.15 [95% confidence interval (CI) 1.01–1.31] for winter and HR 1.17 [95% CI 1.01–1.33] for fall), especially for Alzheimer’s disease (HR 1.23 [1.06–1.43] for winter and HR 1.15 [95% CI 0.99–1.35] for fall). The risk was particularly increased for participants born in a cold winter. Except for slightly lower hippocampus in fall born participants (β − 0.03; 95% CI − 0.06 to 0.00), we did not find associations with brain imaging markers. In conclusion, winter and fall births were associated with a higher incidence of dementia, especially of AD. We did not find evidence for structural brain changes as an underlying mechanism.