Cognitive Aging in Black and White Americans: Cognition, Cognitive Decline, and Incidence of Alzheimer Disease Dementia

The Mediating Effects of Education and Occupational Complexity Between Race and Longitudinal Change in Late Life Cognition in ACTIVE

This study examined educational and occupational inequality as two aspects of social determinants of health that might mediate the longitudinal relationship between racialization and late life cognitive level and change. Participants were 2371 individuals racialized as Black and White from the ACTIVE study who provided occupational data. Data were analyzed from baseline and five assessments over 10-years using structural equation modeling. Black/White race served as the predictor, occupational complexity (OC) and years of education as mediators, and cognitive (memory, reasoning, and speed of processing) intercept, linear slope, and quadratic slope as the dependent variables. Black/White race showed significant indirect associations through education and OC on level of performance in cognition, linear change in reasoning and memory, and quadratic change in reasoning. Education and OC accounted for 11-16% of the association between race and cognitive level and represent modifiable social determinants of health that are associated with disparities in cognitive aging.

The characteristics of cognitive and daily living functions of neurocognitive disorders with delusions in elderly Alzheimer's disease

Background

Delusions in neurocognitive disorder due to Alzheimer's disease (AD) worsen patients' cognitive functions and activities of daily living (ADL), increasing caregiver burden and the risk of mortality. AD patients with delusions tend to experience a more rapid decline in cognition and have demonstrated poorer performance on various cognitive function tests. Considering the prognosis of delusion in AD patients, it tends to be more favorable with appropriate treatment. However, there is a lack of neuropsychological research, specifically examining the impact of delusions in AD, characterized by progressive deterioration of cognitive function. This study investigates the impact of delusions on cognitive function and ADL under conditions controlling for disease severity.

Methods

We compared cognitive function and ADL in AD patients aged 65 years or older according to the presence of delusions. To assess longitudinal change, we analyzed data from patients monitored for an average of 15 to 16 months. We assessed cognitive function and ADL using the Seoul Neuropsychological Screening Battery-Second Edition (SNSB-II) and delusions using the Neuropsychiatric Inventory (NPI). We used IBM SPSS Statistics version 25.0 for all statistical analyses. The analysis was not adjusted for multiple comparisons. We investigated how delusions impact cognitive function and ADL, controlling for age, educational level, and disease severity.

Results

The delusions group exhibited poorer immediate recall of verbal memory than the non-delusions group. In the follow-up evaluation, patients who developed delusions had lower baseline cognitive function than those who did not, and their language fluency declined over time. In addition, we found the presence of delusions associated with worse functional impairment in ADL as the disease progressed.

Conclusion

While controlling for the severity of AD, we found no significant negative impacts of delusions on most cognitive functions. Nevertheless, it is noteworthy that the immediate recall of verbal memory and the Controlled Oral Word Association Test (COWAT)_animal sensitively detected the negative impact of delusions. Furthermore, since delusions are associated with worsening ADL, we understand that delusion treatment is important for improving the quality of life for patients and caregivers.

Aging in isolation: Sexual orientation differences in navigating cognitive decline

Introduction

Subjective cognitive decline is a self-reported measure of worsening memory and day-to-day decision making. Cognitive decline may impair an individual's ability to complete instrumental activities of daily living (IADL) such as preparing meals or taking medication, ultimately limiting one's ability to live independently. People with IADL impairments typically rely on informal care from spouses or children. Interpersonal and structural discrimination towards sexual minority (SM, including lesbian, gay, bisexual, and other queer identified) populations may contribute to disparities in cognitive decline and informal care outcomes.

Objective

Estimate differences in prevalence, severity, and receipt of social support for subjective cognitive decline stratified by sex and SM status.

Methods

Cross-sectional study design using a probability sample (n = 172,047) from the Behavioral Risk Factor Surveillance System 2015-2019. Prevalence estimates and multivariable Poisson regression models were used to compare outcomes by sex and sexual identity.

Results

Compared to heterosexual peers, SM men and women were more likely to experience cognitive decline (15% of SM men, 11% of heterosexual men, 17% of SM women, 11% of heterosexual women). In adjusted models, SM women were 22% more likely (95%CI:3%-44%, p < .05) to report IADL impairments due to cognitive decline but were 17% less likely (95%CI:1%-31%, p < .05) to receive any social support with IADL impairments compared to heterosexual women. In adjusted models, SM men were 25% more likely (95%CI: 0%-56%, p < .05) to report IADL impairments due to cognitive decline but reported no significant difference in receiving social support with IADL impairments compared to heterosexual men.

Discussion

We identified significant unmet need for social supports for IADL impairments, with highest unmet need among SM women. Comprehensive strategies such as LGBTQ + affirming assisted living and home and community-based services are needed to ensure equity in receipt of long-term supports and services for SM populations.

Geographic disparities in Alzheimer's disease and related dementia mortality in the US: Comparing impacts of place of birth and place of residence

Objective

This study investigates geographic variations in ADRD mortality in the US. By considering both state of residence and state of birth, we aim to discern the relative importance of these geospatial factors.

Methods

We conducted a secondary data analysis of the National Longitudinal Mortality Study (NLMS), that has 3.5 million records from 1973 to 2011 and over 0.5 million deaths. We focused on individuals born in or before 1930, tracked in NLMS cohorts from 1979 to 2000. Employing multi-level logistic regression, with individuals nested within states of residence and/or states of birth, we assessed the role of geographical factors in ADRD mortality variation.

Results

We found that both state of birth and state of residence account for a modest portion of ADRD mortality variation. Specifically, state of residence explains 1.19% of the total variation in ADRD mortality, whereas state of birth explains only 0.6%. When combined, both state of residence and state of birth account for only 1.05% of the variation, suggesting state of residence could matter more in ADRD mortality outcomes.

Conclusion

Findings of this study suggest that state of residence explains more variation in ADRD mortality than state of birth. These results indicate that factors in later life may present more impactful intervention points for curbing ADRD mortality. While early-life environmental exposures remain relevant, their role as primary determinants of ADRD in later life appears to be less pronounced in this study.

Understanding the impact of slowing disease progression for individuals with biomarker-confirmed early symptomatic Alzheimer's disease

Recent advances in development of amyloid-targeting therapies support the potential to slow the rate of progression of Alzheimer's disease. We conducted a narrative review of published evidence identified through a targeted search of the MEDLINE and EMBASE databases (2020-2023), recent presentations at disease-specific conferences, and data updates from cohort studies in Alzheimer's disease to describe the trajectory of the progression of Alzheimer's disease. Our findings enable the interpretation of clinical trial results and the value associated with slowing disease progression across outcomes of relevance to patients, care partners, clinicians, researchers and policymakers.

Even at the earliest stages, Alzheimer's disease imposes a substantial burden on individuals, care partners, and healthcare systems. The magnitude of the burden increases with the rate of disease progression and symptom severity, as worsening cognitive decline and physical impairment result in loss of functional independence. Data from cohort studies also indicate that slowing disease progression is associated with decreased likelihood of needing extensive clinical care over at least 5 years, decreased care partner burden, and substantial individual and societal cost savings.

Slowed disease progression is of significant benefit to individuals with Alzheimer's disease, their loved ones, and the healthcare system. As clinicians and policymakers devise strategies to improve access to treatment earlier in the disease spectrum, they should carefully weigh the benefits of slowing progression early in the disease (e.g. preservation of cognitive and functional abilities, as well as relative independence) to individuals, their loved ones, and broader society.

Establishment, Prediction, and Validation of a Nomogram for Cognitive Impairment in Elderly Patients With Diabetes

Objective: The purpose of this study is to establish a predictive model of cognitive impairment in elderly people with diabetes. Methods: We analyzed a total of 878 elderly patients with diabetes who were part of the National Health and Nutrition Examination Survey (NHANES) from 2011 to 2014. The data were randomly divided into training and validation cohorts at a ratio of 6:4. The least absolute shrinkage and selection operator (LASSO) logistic regression analysis to identify independent risk factors and construct a prediction nomogram for cognitive impairment. The performance of the nomogram was assessed using receiver operating characteristic (ROC) curve and calibration curve. Decision curve analysis (DCA) was performed to evaluate the clinical utility of the nomogram. Results: LASSO logistic regression was used to screen eight variables, age, race, education, poverty income ratio (PIR), aspartate aminotransferase (AST), blood urea nitrogen (BUN), serum uric acid (SUA), and heart failure (HF). A nomogram model was built based on these predictors. The ROC analysis of our training set yielded an area under the curve (AUC) of 0.786, while the validation set showed an AUC of 0.777. The calibration curve demonstrated a good fit between the two groups. Furthermore, the DCA indicated that the model has a favorable net benefit when the risk threshold exceeds 0.2. Conclusion: The newly developed nomogram has proved to be an important tool for accurately predicting cognitive impairment in elderly patients with diabetes, providing important information for targeted prevention and intervention measures.

Temporal trends in Parkinson's disease among older adults in the United States from 1999 to 2020: Retrospective analysis from CDC WONDER database

This retrospective study assessed the mortality trends related to Parkinson's Disease (PD) between 1999 and 2020. We assessed individuals aged 65 years and older and a total of 831,793 deaths were identified. Of these total number of deaths, place of death was accessible for 830,176 cases. Majority of the deaths occurred in nursing homes of long-term care facilities (367,633), followed by at home (212,886), medical facilities (165,450), other locations (44,506), and hospice (39,701). Analysis of age-adjusted mortality rates (AAMR) revealed an overall rise from 1999 to 2020, 88.9 to 119.6 per 100,000 population. AAMR showed an initial decline between 1999 and 2013, followed by a slight increase between 2013 and 2018 and then a significant rise from 2018 to 2020. Gender-based analysis showed a constantly higher AAMR for older men compared to older women. Variations in AAMR based on race and ethnicity revealed that Non-Hispanic White population had the highest AAMRs. Geographic disparities among states showed that Nebraska, Vermont, Minnesota, Utah, and Idaho had a significantly higher AAMR than Hawaii, Florida, Nevada. New York, and District of Columbia. Midwest region had a consistently higher AAMR followed by West, South, and Northeast. Additionally, nonmetropolitan areas had a higher AAMR than metropolitan areas. These findings offer valuable insights into mortality patterns related to PD among the elderly, highlighting the significance of incorporating demographic and geographic variables into public health planning and interventions.

Depressive Symptoms Affect Cognitive Functioning from Middle to Late Adulthood: Ethnoracial Minorities Experience Greater Repercussions

Cognitive deficits, a diagnostic criterion for depressive disorders, may precede or follow the development of depressive symptoms and major depressive disorder. However, an individual can report an increase in depressive symptoms without any change in cognitive functioning. While ethnoracial minority group differences exist, little is known to date about how the relationship between depressive symptoms and cognitive function may differ by ethnoracial minority status. Utilizing data from the Midlife in the United States (MIDUS) study waves II (M2) and III (M3), this study examines the relationship between depressive symptoms and cognitive functioning concurrently and longitudinally in community-dwelling adults, as well as whether the results differed by ethnoracial minority status. Our participants included 910 adults (43.8% male, 80.8% White, 54.4 ± 11.5 years old at M2). Cross-sectionally, depressive symptoms, ethnoracial minority status, and their interaction had significant effects on cognitive function, consistent with previous investigations. Longitudinally, higher M2 depressive symptoms predicted poorer cognitive function at M3 over and above M2 cognitive functioning, but only within the ethnoracial minority sample. Our finding suggests that depressive symptoms predict cognitive functioning both concurrently and across time, and this relationship is moderated by ethnoracial identity, resulting in greater cognitive deficits among ethnoracial minority groups compared to their non-Hispanic White counterparts.

Cognitive Trajectories and Alzheimer Disease Biomarkers: From Successful Cognitive Aging to Clinical Impairment

OBJECTIVE

Cross-sectional definitions of successful cognitive aging have been widely utilized, but longitudinal measurements can identify people who do not decline. We performed this study to contrast maintenance with declining trajectories, including clinical conversion.

METHODS

We included baseline cognitively unimpaired Alzheimer's Disease Neuroimaging Initiative participants with 3 or more cognitive testing sessions (n = 539, follow-up 6.1 ± 3.5 years) and calculated slopes of an episodic memory composite (MEM) to classify them into two groups: maintainers (slope ≥ 0) and decliners (slope < 0). Within decliners, we examined a subgroup of individuals who became clinically impaired during follow-up. These groups were compared on baseline characteristics and cognitive performance, as well as both cross-sectional and longitudinal Alzheimer disease (AD) biomarker measures (beta-amyloid [Aβ], tau, and hippocampal volume).

RESULTS

Forty-one percent (n = 221) of the cohort were MEM maintainers, and 33% (n = 105) of decliners converted to clinical impairment during follow-up. Compared to those with superior baseline scores, maintainers had lower education and were more likely to be male. Maintainers and decliners did not differ on baseline MEM scores, but maintainers did have higher non-MEM cognitive scores. Maintainers had lower baseline global Aβ, lower tau pathology, and larger hippocampal volumes than decliners, even after removing converters. There were no differences in rates of change of any AD biomarkers between any cognitive trajectory groups except for a higher rate of hippocampal atrophy in clinical converters compared to maintainers.

INTERPRETATION

Using longitudinal data to define cognitive trajectory groups reduces education and sex bias and reveals the prognostic importance of early onset of accumulation of AD pathology. ANN NEUROL 2024;96:378-389.

A Protocol for the Inclusion of Minoritized Persons in Alzheimer Disease Research From the ADNI3 Diversity Taskforce

Importance

Black or African American (hereinafter, Black) and Hispanic or Latino/a/x (hereinafter, Latinx) adults are disproportionally affected by Alzheimer disease, but most research studies do not enroll adequate numbers of both of these populations. The Alzheimer's Disease Neuroimaging Initiative-3 (ADNI3) launched a diversity taskforce to pilot a multipronged effort to increase the study inclusion of Black and Latinx older adults.

Objective

To describe and evaluate the culturally informed and community-engaged inclusion efforts to increase the screening and enrollment of Black and Latinx older adults in ADNI3.

Design, Setting, and Participants

This cross-sectional study used baseline data from a longitudinal, multisite, observational study conducted from January 15, 2021, to July 12, 2022, with no follow-up. The study was conducted at 13 ADNI3 sites in the US. Participants included individuals aged 55 to 90 years without cognitive impairment and those with mild cognitive impairment or Alzheimer disease.

Exposures

Efforts included (1) launch of an external advisory board, (2) changes to the study protocol, (3) updates to the digital prescreener, (4) selection and deployment of 13 community-engaged research study sites, (5) development and deployment of local and centralized outreach efforts, and (6) development of a community-science partnership board.

Main Outcomes and Measures

Screening and enrollment numbers from centralized and local outreach efforts, digital advertisement metrics, and digital prescreener completion.

Results

A total of 91 participants enrolled in the trial via centralized and local outreach efforts, of which 22 (24.2%) identified as Latinx and 55 (60.4%) identified as Black (median [IQR] age, 65.6 [IQR, 61.5-72.5] years; 62 women [68.1%]). This represented a 267.6% increase in the monthly rate of enrollment (before: 1.11 per month; during: 4.08 per month) of underrepresented populations. For the centralized effort, social media advertisements were run between June 1, 2021, and July 31, 2022, which resulted in 2079 completed digital prescreeners, of which 1289 met criteria for subsequent site-level screening. Local efforts were run between June 1, 2021, to July 31, 2022. A total of 151 participants underwent site-level screening (100 from local efforts, 41 from centralized efforts, 10 from other sources).

Conclusions and Relevance

In this cross-sectional study of pilot inclusion efforts, a culturally informed, community-engaged approach increased the inclusion of Black and Latinx participants in an Alzheimer disease cohort study.

Early-Life Circumstances and Racial Disparities in Cognition Among Older Adults in the US

Importance

Given the critical role of neurocognitive development in early life, understanding the association between early-life circumstances and racial disparities in cognition has important implications.

Objective

To assess whether racial differences in early-life circumstances are collectively and individually associated with racial disparities in late-life cognition among older adults in the US.

Design, Setting, and Participants

This cross-sectional study used comprehensive life history data from the Health and Retirement Study, a nationally representative survey of US adults 50 years or older. Data analyses were performed from August 9, 2022, to January 20, 2024.

Main Outcomes and Measures

Racial differences in early-life circumstances and racial disparities in late-life cognition were investigated using a Blinder-Oaxaca decomposition regression model. Cognitive outcomes, including cognitive score and cognitive impairment, were evaluated using the Telephone Interview for Cognitive Status. Early-life educational experiences were primary explanatory variables; early-life cohort, regional, financial, health, trauma, family relationship factors, and educational attainment were additional explanatory variables; demographic and genetic factors were covariates.

Results

The study sample comprised 9015 participants; 1634 non-Hispanic Black (hereafter, Black) individuals (18.1%) and 7381 non-Hispanic White (hereafter, White) individuals (81.9%). Among Black participants, the mean (SD) age was 69.2 (9.2) years and 1094 (67.0%) were women. Among White participants, the mean (SD) age was 73.2 (10.1) years and 4410 (59.7%) were women. Cognitive scores (scale, 0-27) were significantly lower among Black participants (13.5 [95% CI, 13.3-13.7] points) than among White participants (15.8 [95% CI, 15.7-15.9] points), while the prevalence of cognitive impairment (cognitive score <12) was significantly higher among Black participants (33.6 [95% CI, 31.3-35.9] percentage points [ppt]) than among White participants (16.4 [95% CI, 15.6-17.2] ppt). Substantial racial differences were observed in early-life circumstances. Overall, differences in early-life circumstances were associated with 61.5% of the racial disparities in cognitive score (1.4 [95% CI, 0.88-2.0] points), and 82.3% of the racial disparities in cognitive impairment (14.2 [95% CI, 8.8-19.5] ppt), respectively. In multivariable analyses, early-life educational experiences were associated with 35.2% of the disparities in cognitive score and 48.6% in cognitive impairment. Notably, school racial segregation (all segregated schooling before college) was associated with 28.8% to 39.7% of the racial disparities in cognition. These findings were consistent in a series of sensitivity analyses.

Conclusions and Relevance

The findings of this cross-sectional study suggest that less favorable early-life circumstances are associated with clinically meaningful racial disparities in late-life cognition. Policies that improve educational equity have the potential to reduce racial disparities in cognition in older ages. Clinicians may leverage early-life circumstances to promote the screening, prevention, and interventions of cognitive impairment more efficiently, thereby promoting health equity.

The association of pre-cancer diagnosis cardiovascular risk factors with memory aging after a cancer diagnosis, overall and by race/ethnicity

PURPOSE

Cardiovascular risk factors (CVRFs) are associated with increased risk for cognitive impairment and decline in the general population, but less is known about how CVRFs might influence cognitive aging among older cancer survivors. We aimed to determine how CVRFs prior to a cancer diagnosis affect post-cancer diagnosis memory aging, compared to cancer-free adults, and by race/ethnicity.

METHODS

Incident cancer diagnoses and memory (immediate and delayed recall) were assessed biennially in the US Health and Retirement Study (N = 5,736, 1998-2018). CVRFs measured at the wave prior to a cancer diagnosis included self-reported cigarette smoking, obesity, diabetes, heart disease, hypertension, and stroke. Multivariable-adjusted linear mixed-effects models evaluated the rate of change in standardized memory score (SD/decade) post-cancer diagnosis for those with no, medium, and high CVRFs, compared to matched cancer-free adults, overall and stratified by sex and race/ethnicity.

RESULTS

Higher number of CVRFs was associated with worse baseline memory for both men and women, regardless of cancer status. Cancer survivors with medium CVRFs had slightly slower rates of memory decline over time relative to cancer-free participants (0.04 SD units/decade [95% CI: 0.001, 0.08]). Non-Hispanic Black (NHB) and Hispanic cancer-free participants and cancer survivors had worse baseline memory than their Non-Hispanic White (NHW) counterparts.

CONCLUSIONS

CVRFs were associated with worse baseline memory function, but not decline, for cancer-free adults and cancer survivors. Racial disparities were largely similar between cancer survivors and cancer-free adults.

IMPLICATIONS FOR CANCER SURVIVORS

These findings may inform hypotheses about pre-diagnosis multimorbidity and cognitive aging of cancer survivors from diverse groups.

Racial and ethnic differences in the risk of dementia diagnosis under hypothetical blood pressure-lowering interventions: The Multi-Ethnic Study of Atherosclerosis

INTRODUCTION

Substantial racial and ethnic disparities in hypertension and dementia exist in the United States. We evaluated the effect of maintaining systolic blood pressure (SBP) below clinical thresholds on dementia incidence.

METHODS

We included 6806 Multi-Ethnic Study of Atherosclerosis participants (44 to 84 years old). We implemented the parametric g-formula to simulate the hypothetical interventions to reduce SBP below 120 and 140 mmHg over time, accounting for time-varying confounding. We estimated risk ratios (RRs) and risk differences for dementia incidence at 19 years.

RESULTS

The RRs (95% confidence intervals [CIs]) comparing an intervention reducing SBP below 120 mmHg to no intervention were 0.93 (0.87 to 0.99) for total sample, 0.95 (0.88 to 1.02) for White, 0.90 (0.79 to 1.02) for Black, 0.90 (0.78 to 1.05) for Latino, and 1.16 (0.83 to 1.55) for Chinese American participants. Results for lowering SBP below 140 mmHg and with death as competing event were attenuated.

DISCUSSION

The reduction of SBP below 120 mmHg over time has modest effects on reducing dementia incidence. More work is needed to understand the heterogeneity across racial and ethnic groups.

HIGHLIGHTS

There is a potential beneficial effect in lowering SBP to reduce the risk of dementia, which may vary by race and ethnicity. The percentage of participants who would need intervention on blood pressure to meet clinical thresholds is greater for Black and Latino communities. Results are sensitive to the way that death is specified in the research question and analysis.

Revised criteria for diagnosis and staging of Alzheimer's disease: Alzheimer's Association Workgroup

The National Institute on Aging and the Alzheimer's Association convened three separate work groups in 2011 and single work groups in 2012 and 2018 to create recommendations for the diagnosis and characterization of Alzheimer's disease (AD). The present document updates the 2018 research framework in response to several recent developments. Defining diseases biologically, rather than based on syndromic presentation, has long been standard in many areas of medicine (e.g., oncology), and is becoming a unifying concept common to all neurodegenerative diseases, not just AD. The present document is consistent with this principle. Our intent is to present objective criteria for diagnosis and staging AD, incorporating recent advances in biomarkers, to serve as a bridge between research and clinical care. These criteria are not intended to provide step-by-step clinical practice guidelines for clinical workflow or specific treatment protocols, but rather serve as general principles to inform diagnosis and staging of AD that reflect current science. HIGHLIGHTS: We define Alzheimer's disease (AD) to be a biological process that begins with the appearance of AD neuropathologic change (ADNPC) while people are asymptomatic. Progression of the neuropathologic burden leads to the later appearance and progression of clinical symptoms. Early-changing Core 1 biomarkers (amyloid positron emission tomography [PET], approved cerebrospinal fluid biomarkers, and accurate plasma biomarkers [especially phosphorylated tau 217]) map onto either the amyloid beta or AD tauopathy pathway; however, these reflect the presence of ADNPC more generally (i.e., both neuritic plaques and tangles). An abnormal Core 1 biomarker result is sufficient to establish a diagnosis of AD and to inform clinical decision making throughout the disease continuum. Later-changing Core 2 biomarkers (biofluid and tau PET) can provide prognostic information, and when abnormal, will increase confidence that AD is contributing to symptoms. An integrated biological and clinical staging scheme is described that accommodates the fact that common copathologies, cognitive reserve, and resistance may modify relationships between clinical and biological AD stages.

An exploration of neighborhood characteristics, psychosocial resilience resources, and cognitive functioning among midlife and older black adults

OBJECTIVES

While existing research has shown that Black adults have worse cognitive functioning than their White counterparts, the psychosocial correlates of cognitive functioning for Black older adults are understudied. The objective of this study was to investigate the relationships among perceived neighborhood characteristics, psychosocial resilience resources, and cognitive functioning among midlife and older Black adults.

METHODS

Data were from 3,191 Black adults ages 51+ in the 2008-2016 waves of the Health and Retirement Study to examine associations among neighborhood characteristics, psychosocial resilience (sense of purpose, mastery, and social support), and cognitive functioning among Black adults. Multilevel linear regression models assessed direct effects of neighborhood characteristics and psychosocial resources on cognitive functioning. We then tested whether psychosocial resources moderated the association between neighborhood characteristics and cognitive functioning.

RESULTS

Mean levels of cognitive functioning, sense of purpose, social support, and mastery were significantly related to neighborhood disorder and discohesion. Regression results showed that levels of neighborhood disorder and high discohesion were significantly associated with cognitive functioning. Sense of purpose was positively associated with cognitive functioning, net of neighborhood characteristics. However, only social support moderated the association between neighborhood discohesion and cognition.

CONCLUSIONS

These findings demonstrate the importance of examining psychosocial and contextual risk and resilience resources among midlife and older Black adults. This work may inform the development of cognitive behavioral interventions aimed at increasing sense of purpose to promote and enhance cognitive resiliency among Black adults. Altogether, this work may have implications for policy aimed at advancing cognitive health equity.

Neuropathological Lesions and Cognitive Abilities in Black and White Older Adults in Brazil

Importance

Race differences in dementia prevalence and incidence have previously been reported, with higher dementia burden in Black decedents. However, previous neuropathological studies were conducted mostly in convenience samples with White participants; conducting clinicopathological studies across populations is crucial for understanding the underlying dementia causes in individuals from different racial backgrounds.

Objective

To compare the frequencies of neuropathological lesions and cognitive abilities between Black and White Brazilian adults in an autopsy study.

Design, Setting, and Participants

This cross-sectional study used samples from the Biobank for Aging Studies, a population-based autopsy study conducted in Sao Paulo, Brazil. Participants were older adults whose family members consented to the brain donations; Asian participants and those with missing data were excluded. Samples were collected from 2004 to 2023. Neuropathologists were masked to cognitive outcomes.

Exposure

Race as reported by the deceased's family member.

Main Outcomes and Measures

The frequencies of neurodegenerative and cerebrovascular lesions were evaluated in 13 selected cerebral areas. Cognitive and functional abilities were examined with the Clinical Dementia Rating Scale.

Results

The mean (SD) age of the 1815 participants was 74.0 (12.5) years, 903 (50%) were women, 617 (34%) were Black, and 637 (35%) had cognitive impairment. Small vessel disease (SVD) and siderocalcinosis were more frequent in Black compared with White participants (SVD: odds ratio [OR], 1.74; 95% CI, 1.29-2.35; P < .001; siderocalcinosis: OR, 1.70; 95% CI, 1.23-2.34; P = .001), while neuritic plaques were more frequent in White compared with Black participants (OR, 0.61; 95% CI, 0.44-0.83; P = .002). Likewise, Alzheimer disease neuropathological diagnosis was more frequent in White participants than Black participants (198 [39%] vs 77 [33%]), while vascular dementia was more common among Black participants than White participants (76 [32%] vs 121 [24%]). Race was not associated with cognitive abilities, nor did it modify the association between neuropathology and cognition.

Conclusions and Relevance

In this cross-sectional study of Brazilian older adults, Alzheimer disease pathology was more frequent in White participants while vascular pathology was more frequent in Black participants. Further neuropathological studies in diverse samples are needed to understand race disparities in dementia burden.

Racial/ethnic differences in neuropsychiatric disturbances associated with incident dementia

INTRODUCTION

Neuropsychiatric symptoms (NPS) are nearly universal in dementia; some cross-sectional studies of NPS in dementia have found racial/ethnic differences, though it is unknown if NPS prevalence differs among racial/ethnic groups before and after dementia diagnosis.

METHODS

Participants were followed annually at Alzheimer's Disease Centers and were assessed on the Neuropsychiatric Inventory-Questionnaire (NPI-Q) with at least one follow-up visit at which they were diagnosed with dementia. Descriptive statistics were generated by race/ethnicity. NPS were modeled over time as a function of race/ethnicity and with diagnosis date as the baseline.

RESULTS

NPS were present in 95% in at least one time point. After adjusting for covariates, there were no statistically significant differences in NPI-Q total scores among racial/ethnic groups at the time of and after dementia diagnosis.

DISCUSSION

Findings from our prospective cohort study suggest that when individuals are matched at the time of conversion to dementia, there are no racial/ethnic differences in NPS.

Highlights

Neuropsychiatric symptoms of dementia are frequent and increase caregiver burden.Prior studies reported more neuropsychiatric symptoms (NPS) in Black compared to White individuals with dementia.National Alzheimer's Coordinating Center Black, White, and Hispanic participants did not differ in NPS at the time of dementia diagnosis.

Examining cross-sectional and longitudinal relationships between multidomain physical fitness metrics, education, and cognition in Black older adults

A limited number of studies examine cognitive aging in Black or African American older adults. The purpose of this study was to explore the relationship between health-related fitness metrics, education, and cognition at baseline and over a 4-year follow-up in a sample of 321 Black or African American older adults in the Health and Retirement Study (HRS). Physical fitness was assessed with measures of gait speed, peak expiratory flow, grip strength, and body mass index. Global cognition was assessed with an adapted version of the Telephone Interview for Cognitive Status (TICS). Analyses of relative importance and hierarchical multiple regression were used to examine baseline cross-sectional relationships. Multiple logistic regression was used to examine prospective relationships with longitudinal cognitive status. Education was the strongest predictor of global cognition at baseline and follow-up. More years of education significantly increased the odds of maintaining cognitive status at 4-year follow-up. After accounting for education, gait speed was independently associated with baseline cognitive performance and accounted for additional variance. Grip strength, peak expiratory flow, and body mass index were not significantly associated with cognition. The results indicated that modifiable variables, including years of educational attainment and gait speed, were more strongly associated with global cognition than other modifiable variables including body mass index, grip strength, and peak expiratory flow. The lack of observed associations between other fitness variables and cognition may be attributable to the brief assessment methods implemented, which was necessitated by the large-scale, epidemiological approach of the HRS.

Health literacy, but not memory, is associated with hippocampal connectivity in adults with low levels of formal education

INTRODUCTION

The influence of hippocampal connectivity on memory performance is well established in individuals with high educational attainment. However, the role of hippocampal connectivity in illiterate populations remains poorly understood.

METHODS

Thirty-five illiterate adults were administered a literacy assessment (Test of Functional Health Literacy in Adults [TOFHLA]), structural and resting state functional magnetic resonance imaging, and an episodic memory test (Free and Cued Selective Reminding Test). Illiteracy was defined as a TOFHLA score < 53. We evaluated the correlation between hippocampal connectivity at rest and both free recall and literacy scores.

RESULTS

Participants were mostly female (57.1%) and self-declared as being Black individuals (84.8%), with a median age of 50 years. The median TOFHLA literacy score was 28.0 [21.0; 42.5] out of 100 points and the median free recall score was 30.0 [26.2; 35] out of 48 points. The median gray matter volume of both the left and right hippocampi was 2.3 [2.1; 2.4] cm3. We observed a significant connectivity between both hippocampi and the precuneus and the ventral medial prefrontal cortex. The right hippocampal connectivity positively correlated with the literacy scores (β = 0.58, P = 0.008). There was no significant association between episodic memory and hippocampal connectivity. Neither memory nor literacy scores correlated with hippocampal gray matter volume.

DISCUSSION

Low literacy levels correlated with hippocampal connectivity in illiterate adults. The lack of association with memory scores might be associated with low brain reserve in this sample.

Highlights

A significant link was found between health literacy and hippocampal connectivity.Enhanced hippocampus- ventromedial prefrontal cortex connectivity suggests potential cognitive reserve improvement.Higher cognitive reserve may protect against hippocampal atrophy and neurodegeneration.Health literacy improvements could help prevent cognitive impairment in illiterate populations.Study highlights importance of considering structural racism in brain connectivity research.

Characterization of African-American Super-Agers in the National Alzheimer's Coordinating Center cohort

BACKGROUND

"Super-agers" are adults aged ≥80 with cognitive performance similar to persons two to three decades younger. Characteristics such as larger hippocampal volume, APOE-ε4 allele absence, higher educational attainment, female sex, and lifelong cognitive stimulation are associated with cognitive performance compatible with super-aging. These findings are based on predominantly white research samples. Limited data are available on African-American super-agers. To fill this gap, we explored potential factors associated with super-aging in older African-American adults.

METHODS

Data from African-American participants aged ≥80 in the National Alzheimer's Coordinating Center (NACC) dataset were analyzed. Using global Clinical Dementia Rating (CDR) scores, participants were first categorized as impaired (score ≥0.5) or non-impaired/normal cognition (NC) (score = 0). From the NC group, super-agers were identified using NACC-data-driven cutoffs. Participants were considered super-agers if their memory performance was similar to persons aged 50-60 with NC, and their performance on other domains was within one standard deviation of the mean for persons aged ≥80. We examined group characteristics (NC, super-ager, impaired) using chi-square and ANOVA with pairwise comparisons. Multinomial logistic regression, adjusted for sex and education, evaluated correlates of super-ager group assignment.

RESULTS

Data for 1285 African-American participants aged ≥80 were analyzed. We identified 24.7% (n = 316) NC, 4.8% (n = 61) super-agers, and 70.6% (n = 905) impaired. Super-agers were mostly female and more educated, had similar vascular comorbidities as the other groups, and had less sleep disorders, depression, and alcohol use. After adjusting for sex and education, super-ager group assignment was associated with less sleep disorders, less depression, and moderate alcohol use.

CONCLUSIONS

Participants with controlled vascular risk, mental health, alcohol use, and sleep disorders tended to be in the super-ager group. These factors may be important focus areas in clinical practice to support cognitive resilience with aging in older African-American adults.

Diverging Patterns of Cognitive Decline by Sex and Race-Ethnicity in Seriously Ill Older Americans

Objectives

Differences in Cognitive decline are common in older adults in the last years of life, but differences across sex and race-ethnicity are poorly understood. This study investigated if sex and/or race-ethnicity moderated changes in cognitive function in older adults in the last years of life.

Methods

Data from the Health and Retirement Study (HRS) from 1993 to 2016 were used to analyze imputed cognition summary scores for total word recall and mental status of older adults aged 60-99. Loss of cognitive function was estimated using a multilevel mixed-effects model and accelerated cognitive decline was approximated by incorporating a change-point model using a restricted sample of decedent respondents who died aged 65-99.

Results

Notable disparities were seen in the rates of cognitive decline across sex and race-ethnic groups in the last years of life. Women consistently scored lower than men in word recall but higher in mental status, regardless of race-ethnicity. Non-Hispanic White respondents, men and women, consistently outperformed Hispanic and Black respondents in word recall tasks and mental status.

Conclusions

Our study shows that sex and race-ethnicity moderate cognitive decline in older adults during the last years of life. Older adults from underserved communities are at higher risk of cognitive decline. Our study could inform clinical practice and policy focused on mitigating the adverse impact of cognitive decline experienced by marginalized populations of older adults in the last years of life.

Loneliness and global cognitive functioning in racially and ethnically diverse US midlife and older adults

Introduction

Few studies have examined the association of loneliness and cognitive functioning in the US. We used two common measures of loneliness and examined their association in a large sample of US Black, Latino, and White adults (ages ≥ 50).

Methods

We analyzed Wave 3 of the National Social Life, Health, and Aging Project (N = 2,757). We examined loneliness using one item from the CES-D and the Felt Loneliness Measure (NFLM); cognitive functioning was assessed using the Montreal Cognitive Assessment (MoCA) tool, where higher scores indicated better functioning. We used weighted ordinary least squares regressions to examine the effects of loneliness (CES-D loneliness and NFLM in separate models) on MoCA scores. In exploratory analyses, we examined if these relationships varied by race and ethnicity. We adjusted all models for sociodemographic and other salient factors (e.g., chronic disease, depressive symptoms, living alone).

Results

Mean age was 63.49 years, 52% were female, and 9% were Black and 6% Latino persons. Approximately 54% endorsed feeling lonely on at least one measure; 31% (CES-D) and 46% (NFLM). The relationship between loneliness measures was positive and significant, X 2 (1, N = 2,757) = 435.493 p < 0.001. However, only 40% of lonely individuals were identified as lonely on both assessments. CES-D loneliness was inversely (βˆ = -0.274, p = 0.032) associated with MoCA scores and this association did not vary by race and ethnicity. Greater NFLM loneliness was positively associated (βˆ = 0.445, p < 0.001) with higher MoCA scores for Latino participants only.

Discussion

Loneliness appears to be an important predictor of cognitive functioning. However, the association of loneliness and cognitive functioning varied when using the CES-D loneliness item or the NFLM. Future work is needed to understand how loneliness and its clinically relevant dimensions (social, emotional, existential, chronicity) relate to global and individual cognitive domains. Research is needed with racially and ethnically diverse midlife and older adults, particularly to understand our counterintuitive finding for Latino participants. Finally, findings also support the need for research on interventions to prevent cognitive decline targeting loneliness.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

An overview of the hallmarks of cognitive aging

Although the notion of cognitive aging is commonly associated with decline in popular culture, a wealth of scientific literature shows that cognitive aging is more aptly characterized as multidirectional, such that trajectories of cognitive changes include areas of stability and growth (e.g., general knowledge) in addition to decline (e.g., episodic long-term memory). This article overviews these multidirectional trajectories, the heterogeneous factors that moderate the rate of change across individual trajectories, and the extensive literature that has investigated the most important factors, such as working memory, that constrain cognition across the adult lifespan. In light of the multidirectional nature of cognitive change, increasing research has considered methods to leverage the often-overlooked benefits of getting older to ameliorate cognitive deficits.

A review of dairy food intake for improving health among black geriatrics in the US

The transition to older adulthood is generally marked by progressive declines in body composition, metabolism, cognitive function, and immunity. For socially disadvantaged geriatric populations such as Black Americans, this life stage may also include additional stressors, including dealing with discrimination, poor access to healthcare, and food insecurity. These types of chronic stressors are linked to a higher allostatic load, which is associated with accelerated biological aging, higher rates of adverse health outcomes, and an overall lower quality of life. Of the numerous factors involved in healthy aging, a growing body of research indicates that consuming a higher quality diet that is rich in fruits, vegetables, whole grains, protein foods, and dairy foods, is one of the most potent factors for helping to protect against age-related disease progression. Among the food groups listed above that are recommended by the 2020-2025 Dietary Guidelines for Americans dairy foods are unique in their ability to provide several of the essential nutrients (e.g., high-quality protein, calcium, potassium, vitamin B12, and vitamin D in fortified products) that are most often inadequately consumed by older Black Americans. However, dairy is the most inadequately consumed food group in the US, with older Black adults consuming fewer than half of the 3 daily recommended servings. Therefore, this review examines the current body of evidence exploring the links between dairy intake and age-related disease risk, with a special focus on health and disparities among older Black Americans. Overall, the evidence from most systematic reviews and/or meta-analyses focused on dairy intake and musculoskeletal health suggest that higher dairy intake across the life span, and especially from fermented and fortified products, is associated with better bone and muscle health outcomes in older adults. The evidence on dairy intake and neurocognitive and immune outcomes among older adults holds significant promise for potential benefits, but most of these results are sourced from individual studies or narrative reviews and are not currently corroborated in systematic reviews or meta-analyses. Additionally, most of the research on dairy intake and age-related disease risk has been performed in White populations and can only be extrapolated to Black populations. Nonetheless, older Black populations who do not meet the DGA recommended 3 servings of dairy per day due to lactose intolerance, restrictive dietary patterns, or for other reasons, are likely falling short of several of the nutritional requirements necessary to support healthy aging.

Early life adversity, race, and childhood socioeconomic status: intersecting drivers of later life cognition

OBJECTIVES

Research on associations between early life adversity (ELA) and later life cognition has yielded mixed results and generally have not considered how broader societal systems of stratification potentially influence associations. The current study addresses this gap by exploring if racialized identity and childhood socioeconomic status (cSES) moderate associations between ELA exposure and later life cognition.

METHODS

Using data from the Health and Retirement Study (Waves 2010-2018), we used growth curve modeling to examine if the confluence of ELA, cSES, and racialized identity is associated with cognition.

RESULTS

Among White participants, greater exposure to ELA was associated with poorer baseline cognitive functioning, and higher cSES buffered against this association. Among Black participants, exposure to ELA was not associated with baseline cognitive functioning, regardless of cSES. We did not find evidence of any associations between main predictors nor their interactions with change in cognition over time.

CONCLUSIONS

This study provides evidence that associations between ELA and later life cognition is contingent upon multiple social positions in the United States. These findings support the importance of integrating insights on intersecting social positions within life-course-oriented efforts to reduce racialized cognitive disparities.

An Early and Unequal Decline: Life Course Trajectories of Cognitive Aging in the United States

Objectives: Cognitive aging is a lifelong process with implications for Alzheimer's disease and dementia. This study aims to fill major gaps in research on the natural history of and social disparities in aging-related cognitive decline over the life span. Methods: We conducted integrative data analysis of four large U.S. population-based longitudinal studies of individuals aged 12 to 105 followed over two decades and modeled age trajectories of cognitive function in multiple domains. Results: We found evidence for the onset of cognitive decline in the 4th decade of life, varying gender differences with age, and persistent disadvantage among non-Hispanic Blacks, Hispanics, and those without college education. We further found improvement in cognitive function across 20th century birth cohorts but widening social inequalities in more recent cohorts. Discussion: These findings advance an understanding of early life origins of dementia risk and invite future research on strategies for promoting cognitive health for all Americans.

Apolipoprotein E and Its Association With Cognitive Change and Modification of Treatment Effects of Vitamin D3 and Omega-3s on Cognitive Change: Results From the In-Clinic Subset of a Randomized Clinical Trial

BACKGROUND

Apolipoprotein E (APOE)-ε4 allele is associated with cognitive decline; however, its potential to modify effects of vitamin D3 and omega-3s supplementation on later-life cognition is unclear. Our objectives were to estimate among the in-clinic subset of a randomized trial: (1) associations between APOE-ε4 and global and domain-specific cognitive change, with exploration of potential sex and race differences; and (2) modification by APOE-ε4 of effects of vitamin D3 and omega-3s supplementation on cognitive change.

METHODS

From an ancillary study of depression prevention within a completed 2 × 2 factorial trial testing vitamin D3 (2 000 IU per day), omega-3s (1 g per day), and/or placebos, we included 743 older adults with baseline in-person neuropsychiatric assessments and APOE genotyping data. The primary outcome was change in global cognition (averaging z-scores of 9 tests) over 2 years. Secondarily, episodic memory and executive function/attention z-scores were examined. General linear models of response profiles with multiplicative interaction terms were constructed; stratified results were reported.

RESULTS

Mean age (standard deviation) was 67.1 (5.3) years; 50.6% were females; 24.9% were APOE-ε4 carriers. Compared to noncarriers, APOE-ε4 carriers had worse 2-year change in global cognition and episodic memory; differences were more apparent among females than males. There was no variation by race in APOE-ε4 associations with cognition. APOE-ε4 did not significantly modify effects of vitamin D3 or omega-3s, compared to placebo, on change in global cognition, episodic memory, or executive function/attention.

CONCLUSIONS

APOE-ε4 was associated with worse cognition but did not modify overall effects of vitamin D3 or omega-3 supplementation on cognition over 2 years.

Unhealthy white matter connectivity, cognition, and racialization in older adults

INTRODUCTION

White matter hyperintensities (WMH) may promote clinical Alzheimer's disease (AD) disparities between Black American (BA) and non-Hispanic White (nHW) populations. Using a novel measurement, unhealthy white matter connectivity (UWMC), we interrogated racialized group differences in associations between WMH in AD pathology-affected regions and cognition.

METHODS

UWMC is the proportion of white matter fibers that pass through WMH for every pair of brain regions. Individual regression models tested associations of UWMC in beta-amyloid (Aβ) or tau pathology-affected regions with cognition overall, stratified by racialized group, and with a racialized group interaction.

RESULTS

In 201 older adults ranging from cognitively unimpaired to AD, BA participants exhibited greater UWMC and worse cognition than nHW participants. UWMC was negatively associated with cognition in 17 and 5 Aβ- and tau-affected regions, respectively. Racialization did not modify these relationships.

DISCUSSION

Differential UWMC burden, not differential UWMC-and-cognition associations, may drive clinical AD disparities between racialized groups.

HIGHLIGHTS

Unhealthy white matter connectivity (UWMC) in Alzheimer's disease (AD) pathology-affected brain regions is associated with cognition. Relationships between UWMC and cognition are similar between Black American (BA) and non-Hispanic White (nHW) individuals. More UWMC may partially drive higher clinical AD burden in BA versus nHW populations. UWMC risk factors, particularly social and environmental, should be identified.

Mid-life adherence to the Dietary Approaches to Stop Hypertension (DASH) diet and late-life subjective cognitive complaints in women

INTRODUCTION

Evidence is limited on the role of mid-life Dietary Approaches to Stop Hypertension (DASH) diet in late-life subjective cognitive complaints (SCCs).

METHODS

We included 5116 women (mean age in 1985-1991: 46 years) from the New York University Women's Health Study. SCCs were assessed from 2018 to 2020 (mean age: 79 years) by a 6-item questionnaire.

RESULTS

Compared to women in the bottom quartile of the DASH scores, the odds ratio (OR) for having two or more SCCs was 0.83 (95% confidence interval: 0.70-0.99) for women in the top quartile of DASH scores at baseline (P for trend = 0.019). The association was similar with multiple imputation and inverse probability weighting to account for potential selection bias. The inverse association was stronger in women without a history of cancer (P for interaction = 0.003).

DISCUSSION

Greater adherence to the DASH diet in mid-life was associated with lower prevalence of late-life SCCs in women.

Examining racial differences in the network structure and properties of specific cognitive domains among older adults

Older adults oftentimes experience cognitive aging which leads to varying degrees of cognitive impairment. Previous studies have found that racial and ethnic disparities exist in the prevalence and severity of cognitive impairment among older adults. Yet, little is known on the relationship among specific cognitive domains and how this relationship differs between African American and White older adults. This is a secondary data analysis of Wave II (2010-2011) data from the National Social Life, Health, and Aging Project (NSHAP). A total of 2,471 older adults aged between 65 and 85 years old (African American n = 452, White n = 2019) were included. Network analysis was used to visualize and characterize the network structure and to examine network stability. Then, network comparison test was conducted to compare the network properties of the cognitive network structure between African American and White older adults. African American older adults had a lower cognitive function in all cognitive domains than White older adults. While there was no significant difference in global strength, there was a significant difference in the network structure and strength centrality measure between the two groups (p < 0.05). The invariance edge strength test found the language-visuospatial edge to be significantly stronger in African American older adults. Clinicians need to understand the different cognitive function across multiple cognitive domains between African American and White older adults and routinely offer targeted and timely cognitive assessment and management in this population.

Construct validation of NIH Toolbox Cognition Battery premorbid cognitive functioning scores in Black and White older Americans with and without mild cognitive impairment

OBJECTIVE

Valid estimates of premorbid cognitive functioning (PMIQ) are crucial for the assessment of older adults at risk for Alzheimer's disease. We investigated the relationship between the NIH Toolbox-Cognition Battery's (NIHTB-CB) Oral Reading Recognition (ORR) subtest and Wechsler Test of Adult Reading scores (WTAR, convergent validity). We also compared ORR to NIHTB-CB Flanker scores, where null relationships were expected (discriminant validity).

METHODS

The WTAR and NIHTB-CB were administered to 130 cognitively normal (CN) and 113 participants with mild cognitive impairment (MCI). Participants were community-dwelling, older Black and White adults, ages 55-88 years. Data analysis used uncorrected standard scores and Bayesian bivariate correlations. Supplemental materials include intraclass correlations.

RESULTS

ORR and WTAR scores were strongly positively associated, while ORR and Flanker scores were unrelated. This pattern held when restricting analyses to the two cognitive status groups, the two racial groups, and the four race-by-diagnosis subgroups.

CONCLUSION

The findings demonstrate convergent and discriminant validity and support NIHTB-CB ORR scores as valid estimates of scores on a PMIQ measure in older Black and White adults with and without MCI.

Optimizing the Implementation of a Lifestyle Dementia Prevention Intervention for Older Patients in an Academic Healthcare System

Background

Interventions that promote healthy lifestyles are critical for the prevention of Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD). However, knowledge of the best practices for implementing AD/ADRD prevention in healthcare settings remains limited.

Objective

We aimed to qualitatively identify barriers and facilitators to implementing a clinical trial of a novel lifestyle intervention (My Healthy Brain) in our medical center for older patients with subjective cognitive decline who are at-risk for AD/ADRD.

Methods

We conducted focus groups with 26 healthcare professionals (e.g., physicians, psychology, nursing) from 5 clinics that treat older patients (e.g., memory care, psychiatry). Our qualitative analysis integrated two implementation frameworks to systematically capture barriers and facilitators to AD/ADRD prevention (Consolidated Framework for Implementation Science Research) that impact implementation outcomes of acceptability, appropriateness, and feasibility (Proctor's framework).

Results

We found widespread support for an RCT of My Healthy Brain and AD/ADRD prevention. Participants identified barriers related to patients (stigma, technological skills), providers (dismissiveness of "worried well," doubting capacity for behavior change), clinics (limited time and resources), and the larger healthcare system (underemphasis on prevention). Implementation strategies guided by Expert Recommendations for Implementing Change (ERIC) included: developing tailored materials, training staff, obtaining buy-in from leadership, addressing stigmatized language and practices, identifying "champions," and integrating with workflows and resources.

Conclusions

The results will inform our recruitment, enrollment, and retention procedures to implement the first randomized clinical trial of My Healthy Brain. Our study provides a blueprint for addressing multi-level barriers to the implementation of AD/ADRD prevention for older patients in medical settings.

Evaluation of racial and ethnic heterogeneity in the associations of sleep quality and sleep apnea risk with cognitive function and cognitive decline

INTRODUCTION

The prevalence of poor sleep quality and sleep apnea differs by race and ethnicity and may contribute to racial disparities in cognitive aging. We investigated whether sleep quality and sleep apnea risk were associated with cognitive function and decline and whether the associations differed by race/ethnicity.

METHODS

Participants from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE; N = 1690; mean age: 75.7 years) study, a cohort of Asian, Black, Latino, and White participants, completed a modified Pittsburgh Sleep Quality Index assessing subjective sleep quality, latency, duration, disturbances, sleep medication use, and daytime dysfunction. Sleep apnea risk was measured by questions about snoring, tiredness, and whether apnea was observed. Executive function and verbal episodic memory were assessed at three time points over an average of 2.7 years with the Spanish and English Neuropsychological Assessment Scale. We fit linear mixed-effect models and stratified analyses by race/ethnicity.

RESULTS

Higher sleep apnea risk was associated with faster declines in verbal episodic memory (β ^ sleep apnea = -0.02, 95% confidence interval [CI], -0.04, -0.001) but not in executive function. Poorer sleep quality was associated with lower levels of and faster decline in executive function but not in verbal episodic memory. Race/ethnicity modified these associations: compared to estimated effects among White participants, poorer global sleep quality (β ^ sleep*time = -0.02, 95% CI, -0.02, -0.01) was associated with larger effects on decline in executive function among Black participants. Estimated effects of some individual sleep quality components were also modified by race/ethnicity; for example, sleep medication use was associated with faster declines in executive function (β ^ sleep*time = -0.05, 95% CI, -0.07, -0.03) and verbal episodic memory β ^ sleep*time = -0.04, 95% CI, -0.07, -0.02) among Black participants compared to White participants.

DISCUSSION

Observational evidence indicates sleep quality is a promising target for addressing racial/ethnic disparities in cognitive aging, especially among Black older adults.

Highlights

Sleep apnea risk was associated with faster declines in verbal episodic memory but not executive function among all participants.Global sleep quality was associated with lower levels of and faster decline in executive function but not verbal episodic memory among all participants.Black older adults were particularly susceptible to the estimated adverse cognitive impacts of global sleep quality, particularly the use of sleep medication.

The heritability of blood-based biomarkers related to risk of Alzheimer's disease in a population-based sample of early old-age men

INTRODUCTION

Despite their increased application, the heritability of Alzheimer's disease (AD)-related blood-based biomarkers remains unexplored.

METHODS

Plasma amyloid beta 40 (Aβ40), Aβ42, the Aβ42/40 ratio, total tau (t-tau), and neurofilament light (NfL) data came from 1035 men 60 to 73 years of age (μ = 67.0, SD = 2.6). Twin models were used to calculate heritability and the genetic and environmental correlations between them.

RESULTS

Additive genetics explained 44% to 52% of Aβ42, Aβ40, t-tau, and NfL. The Aβ42/40 ratio was not heritable. Aβ40 and Aβ42 were genetically near identical (rg  = 0.94). Both Aβ40 and Aβ42 were genetically correlated with NfL (rg  = 0.35 to 0.38), but genetically unrelated to t-tau.

DISCUSSION

Except for Aβ42/40, plasma biomarkers are heritable. Aβ40 and Aβ42 share mostly the same genetic influences, whereas genetic influences on plasma t-tau and NfL are largely unique in early old-age men. The absence of genetic associations between the Aβs and t-tau is not consistent with the amyloid cascade hypothesis.

Food Insecurity, Race and Ethnicity, and Cognitive Function Among United States Older Adults

BACKGROUND

Cognitive impairment and dementia are severe public health issues in aging populations, which can be exacerbated by insufficient or unhealthy dietary intake. Food (in)security status is linked to cognitive function among older adults, but the relationship is complex and can vary by sociodemographic characteristics.

OBJECTIVE

This article aimed to investigate the association between food insecurity and cognitive function among United States older adults and explore potential variations by race and ethnicity groups.

METHODS

We prospectively examined changes in cognitive function and incidence of cognitive impairment alongside the presence of self-reported food insecurity among older adults of different racial and ethnic groups. Data were from the 2012-2018 Health and Retirement Study (HRS) and the 2013 Health Care and Nutrition Study (HCNS), including N = 6,638 United States adults aged 50 years and older. Food insecurity was measured by a self-reported United States Household Food Security Survey Module, and cognitive function was assessed by the modified version of the Telephone Interview for Cognitive Status.

RESULTS

Results showed that 17% of United States older adults reported food insecurity in the 2013 HCNS. Compared with food secure older adults, those reporting food insecurity experienced worsened cognitive functioning over time (B = -0.63, p < .001), and they were more likely to have onset of cognitive impairment (OR= 1.46, p < .001) in the 6-y observation. Compared with non-Hispanic White older adults, being non-Hispanic Black, non-Hispanic Other, or Hispanic was associated with 2.96, 2.09, or 1.26 odds (p < .001) of cognitive impairment (2012-2018), respectively. Older adults of racial and ethnic minority groups also had higher risks of experiencing the double burden of cognitive impairment alongside food insecurity compared with non-Hispanic White older adults.

CONCLUSION

Findings underscore racial and ethnic structural disparities in food security and cognitive health in the United States aging population.

The Add Health Parent Study: A Biosocial Resource for the Study of Multigenerational Racial/Ethnic Disparities in Alzheimer's Disease and Alzheimer's Disease-Related Dementias

Background

Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD) have increased in prevalence.

Objective

This article describes the Add Health Parent Study (AHPS) Phase 2, a study of social, behavioral, and biological factors influencing healthy aging and risk for AD/ADRD, in a national sample of adults aged 58-90.

Methods

Sample members are parents of the National Longitudinal Study of Adolescent to Adult Health (Add Health) cohort, initially interviewed in Add Health in midlife (1994-95). AHPS Phase 1 (2015-17) collected longitudinal data on a random subsample of parents and their spouse/partners, who were mostly Non-Hispanic (NH) White. AHPS Phase 2 will collect the same longitudinal socio-behavioral, and health survey data on all remaining NH Black and Hispanic parents (Black and Hispanic Supplement, BHS). Additionally, Phase 2 will collect cognitive and DNA data from AHPS Phase 1 and BHS sample parents and their current spouse/partners.

Results

Funded by the National Institute on Aging, recruitment will occur between June 2025 and May 2026, producing an expected total AHPS sample of 5506 parents and their spouse/partners.

Conclusions

The AHPS will be the first longitudinal cohort study powered to address multigenerational racial/ethnic disparities in AD/ADRD risk and protective factors across race/ethnic groups and socioeconomic strata.

State-level desegregation in the U.S. South and mid-life cognitive function among Black and White adults

RATIONALE

Black adults experience worse cognitive function than their White peers. Although educational attainment is an important predictor of cognitive function, other aspects of education, including school desegregation, may also shape this relationship. For Black adults who grew up in the U.S. South in the 1950s-1970s, exposure to school desegregation may have altered life course pathways critical for later cognitive function.

OBJECTIVE

We determined if state variation in exposure to school desegregation in the U.S. South was associated with cognitive function at mid-life, if the association varied by race, and if the association remained after adjustment for state-level education quality and respondents' educational attainment.

METHODS

We linked historical data on state-level school desegregation to the Health and Retirement Study, a nationally representative sample of U.S. adults aged 50 and older. We restricted our sample to Black (n = 1443) and White (n = 1507) adults born between 1948 and 1963 who resided in the U.S. South during primary school. We assessed three cognition outcomes: total cognitive function, episodic memory, and mental status. We estimated race-stratified linear regression models with cluster adjustment and a final model using state fixed effects.

RESULTS

Greater exposure to desegregated primary schooling was associated with higher cognitive function and episodic memory among Black but not White adults. Among Black adults, the association between school desegregation and cognitive function and episodic memory remained after adjustment for state-level education quality and educational attainment.

CONCLUSIONS

Our findings suggest that state-level school desegregation efforts played a consequential role in shaping the cognitive function of Black adults who grew up in the U.S. South.

Influence of Gender on Tau Precipitation in Alzheimer's Disease According to ATN Research Framework

Tau proteins accumulation and their spreading pattern were affected by gender in cognitive impairment patients, especially in the progression of Alzheimer's disease (AD). However, it was unclear whether the gender effects for tau deposition influenced by amyloid deposition. The aim of this study was to investigate gender differences for tau depositions in Aβ positive (A+) subjects. In this study, tau and amyloid positron emission tomography images, structural magnetic resonance imaging images, and demographic information were collected from 179 subjects in Alzheimer's Disease Neuroimaging Initiative (ADNI) database and 63 subjects from Huashan Hospital. Subjects were classified as T+ or T- according to the presence or absence of tau (T) biomarkers. We used two-sample t test and one-way analysis of variance test to analyze the effect of gender with adjusting for age, years of education, and Minimum Mental State Examination. In the ADNI cohort, we found differences in Tau deposition in fusiform gyrus, inferior temporal gyrus, middle temporal gyrus and parahippocampal gyrus between the female T+ (FT+) and male T+ (MT+) groups (p < 0.05). Tau deposition did not differ significantly between female T- (FT-) and male T- (MT-) subjects (p > 0.05). In the Huashan Hospital cohort, there was no difference in Tau deposition between FT+ and MT+ (p > 0.05). The results show that tau depositions significantly increased in females in above brain regions. Our findings suggest that tau deposition is influenced by gender in the A+ subjects. This result has important clinical implications for the development of gender-guided early interventions for patients with both Tau and Amyloid depositions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43657-022-00076-9.

What is the association between adverse childhood experiences and late-life cognitive decline? Study of Healthy Aging in African Americans (STAR) cohort study

OBJECTIVES

Adverse childhood experiences (ACEs) are associated with higher risk of chronic disease, but little is known about the association with late life cognitive decline. We examined the longitudinal association between ACEs and late-life cognitive decline in the Study of Healthy Aging in African Americans (STAR).

DESIGN

Linear mixed models with random intercepts and slope examined the association of individual and composite ACEs with cognitive change adjusting for years from baseline (timescale), baseline age, sex, parental education, childhood socioeconomic status and childhood social support. Participants reported whether they had experienced nine types of ACEs. Executive function and verbal episodic memory were measured up to three times over a 3-year period using the Spanish and English Neuropsychological Assessment Scales.

SETTINGS

Kaiser Permanente Northern California members living in the Bay Area.

PARTICIPANTS

STAR is a cohort study of cognitive ageing launched in 2018 that has enrolled 764 black Americans ages ≥50 years (mean age=67.5; SD=8.5).

RESULTS

Twenty-one per cent of participants reported no ACEs, 24% one ACE, 20% two ACEs, 17% three ACEs and 17% four or more ACEs. Compared with no ACEs, two ACEs (β=0.117; 95% CI 0.052 to 0.182), three ACEs (β=0.075; 95% CI 0.007 to 0.143) and four or more ACEs (β=0.089; 95% CI 0.002 to 0.158) were associated with less decline in executive function. There were no significant associations between number of ACEs and baseline or longitudinal verbal episodic memory or between individual ACEs and executive function or verbal episodic memory.

CONCLUSION

In this cohort of older black Americans, there was no association between ACEs and baseline cognition or cognitive change in verbal episodic memory; however, experiencing ≥ 2 ACEs was associated with less decline in executive function. These results may indicate that participants who survived to age 50+ and experienced ACEs may have cognitive resilience that warrants further investigation.

"I Didn't Know I Needed to Be Still": Experiences of Black Dementia Caregivers Attending Tailored Online Worship Services

The current study aimed to determine the feasibility and preliminary efficacy of culturally appropriate online worship services for Black dementia caregivers. Researchers met online with families six times over 8 weeks. Each meeting consisted of families viewing a short, uniquely tailored worship service. Preand post-surveys were conducted, and caregivers participated in in-depth, semi-structured interviews to discuss their experiences with the online worship services. All caregivers (N = 24) identified as Christian and African American. There was no significant mean difference between pre- and post-survey results, but there was a trend toward improving perception of caregiver role, caregiver burden, and dyadic relationship. Observations and interviews revealed two themes, Experiences and Feasibility of Engaging With Culturally Appropriate Online Worship Services. Although the preliminary efficacy of the online worship services remains to be investigated, our results suggest resources developed for caregivers of people living with dementia should be carefully tailored to ensure they are culturally appropriate and responsive. [Research in Gerontological Nursing, 16(6), 273-282.].

The impact of race on olfaction: A systematic review and meta-analysis

BACKGROUND

Many studies have identified a higher degree of Olfactory Dysfunction (OD) in Black patients compared to White patients. This study aims to analyze olfactory outcomes in different races.

METHODS

The PubMed, Scopus, and CINAHL databases were searched from inception to September 5, 2022, for English-language articles documenting self-reported and psychophysical OD stratified by race. A meta-analysis of proportions, comparison of weighted proportions, and comparison of means were performed in MedCalc 20.218. In the quantitative analysis, 79,297 patients were included, comprising 79.3% Whites, 16.1% Blacks, and 4.6% Hispanics.

RESULTS

A total of 14 studies were meta-analyzed. The prevalence of self-reported OD in Hispanic, White, and Black patients was 19.5% (95% CI, 16.6% to 22.6%), 17.2% (95% CI, 10.5% to 25.0%), and 13.9% (95% CI, 9.3% to 19.2%), respectively (p < 0.0007). The prevalence of psychophysical OD in Black, White, and Hispanic patients was 30.3% (95% CI, 24.2% to 36.9%), 24.2% (95% CI, 20.1% to 28.5%), and 18.4% (95% CI, 16.3% to 20.7%), respectively (p < 0.0001). Blacks reported a greater extent of unrecognized OD compared to Whites, with a difference of 16.5% (95% CI, 15.0% to 17.9%) versus 5.8% (95% CI, 3.4% to 8.0%), respectively (p < 0.0001). Hispanic rates of self-reported OD and psychophysical OD were not statistically different.

CONCLUSIONS

Our findings suggest that Blacks have the highest rate of psychophysical OD and are more likely to underreport their awareness compared to Whites.

Racial Differences in Older Adult's Mental Health and Cognitive Symptomatology: Identifying Subgroups Using Multiple-Group Latent Class Analysis

INTRODUCTION

Little is known on the potential racial differences in latent subgroup membership based on mental health and cognitive symptomatology among older adults.

METHODS

This is a secondary data analysis of Wave 2 data from the National Social Life, Health, and Aging Project (N = 1819). Symptoms were depression, anxiety, loneliness, happiness, and cognition. Multiple-group latent class analysis was conducted to identify latent subgroups based on mental health and cognitive symptoms and to compare these differences between race.

RESULTS

Class 1: "Severe Cognition & Mild-Moderate Mood Impaired," Class 2: "Moderate Cognition & Mood Impaired," and Class 3: "Mild Cognition Impaired & Healthy Mood" were identified. Black older adults were more likely to be in Class 1 while White older adults were more likely to be in Class 2 and Class 3.

DISCUSSION

Clinicians need to provide culturally-sensitive care when assessing and treating symptoms across different racial groups.

Epigenetic age and socioeconomic status contribute to racial disparities in cognitive and functional aging between Black and White older Americans

Epigenetic age, a biological aging marker measured by DNA methylation, is a potential mechanism by which social factors drive disparities in age-related health. Epigenetic age gap is the residual between epigenetic age measures and chronological age. Previous studies showed associations between epigenetic age gap and age-related outcomes including cognitive capacity and performance on some functional measures, but whether epigenetic age gap contributes to disparities in these outcomes is unknown. We use data from the Health and Retirement Study to examine the role of epigenetic age gap in racial disparities in cognitive and functional outcomes and consider the role of socioeconomic status (SES). Epigenetic age measures are GrimAge or Dunedin Pace of Aging methylation (DPoAm). Cognitive outcomes are cross-sectional score and two-year change in Telephone Interview for Cognitive Status (TICS). Functional outcomes are prevalence and incidence of limitations performing Instrumental Activities of Daily Living (IADLs). We find, relative to White participants, Black participants have lower scores and greater decline in TICS, higher prevalence and incidence rates of IADL limitations, and higher epigenetic age gap. Age- and gender-adjusted analyses reveal that higher GrimAge and DPoAm gap are both associated with worse cognitive and functional outcomes and mediate 6-11% of racial disparities in cognitive outcomes and 19-39% of disparities in functional outcomes. Adjusting for SES attenuates most DPoAm associations and most mediation effects. These results support that epigenetic age gap contributes to racial disparities in cognition and functioning and may be an important mechanism linking social factors to disparities in health outcomes.

Association of Osteoarthritis and Functional Limitations With Cognitive Impairment Among Older Adults in the United States

Objective: Given overlapping pathophysiology, this study sought to assess the association between osteoarthritis (OA), functional impairment, and cognitive impairment in the aging population. Methods: The National Health and Nutrition Examination Survey was used to identify participants >60 years of age. We analyzed multivariable associations of grouped participants that underwent cognitive function testing using linear and logistic regression, adjusting for sex, age, race, and ethnicity. Results: Of 2776 identified participants representing a population of 50,242,917, 40% did not report OA or functional limitations; 21% had OA but not functional limitations; 15% did not have OA but had functional limitations; 17% had OA and related functional limitations; and 7% had OA and non-arthritic functional limitations. OA was not independently associated with cognitive impairment. Contrarily, functional limitations were associated with cognitive impairment regardless of OA diagnosis. Discussion: Cognitive impairment is not associated with OA, but rather functional limitations, potentially guiding future intervention.

Sex differences in associations between APOE ε2 and longitudinal cognitive decline

INTRODUCTION

We examined whether sex modifies the association between APOE ε2 and cognitive decline in two independent samples.

METHODS

We used observational data from cognitively unimpaired non-Hispanic White (NHW) and non-Hispanic Black (NHB) adults. Linear mixed models examined interactive associations of APOE genotype (ε2 or ε4 carrier vs. ε3/ε3) and sex on cognitive decline in NHW and NHB participants separately.

RESULTS

In both Sample 1 (N = 9766) and Sample 2 (N = 915), sex modified the association between APOE ε2 and cognitive decline in NHW participants. Specifically, relative to APOE ε3/ε3, APOE ε2 protected against cognitive decline in men but not women. Among APOE ε2 carriers, men had slower decline than women. Among APOE ε3/ε3 carriers, cognitive trajectories did not differ between sexes. There were no sex-specific associations of APOE ε2 with cognition in NHB participants (N = 2010).

DISCUSSION

In NHW adults, APOE ε2 may protect men but not women against cognitive decline.

HIGHLIGHTS

We studied sex-specific apolipoprotein E (APOE) ε2 effects on cognitive decline. In non-Hispanic White (NHW) adults, APOE ε2 selectively protects men against decline. Among men, APOE ε2 was more protective than APOE ε3/ε3. In women, APOE ε2 was no more protective than APOE ε3/ε3. Among APOE ε2 carriers, men had slower decline than women. There were no sex-specific APOE ε2 effects in non-Hispanic Black (NHB) adults.

Do Associations Between Vascular Risk and Mild Cognitive Impairment Vary by Race?

Objectives: Given prevalence differences of mild cognitive impairment (MCI) among Black and white older adults, this study aimed to examine whether overall vascular risk factor (VRF) burden and individual VRF associations with amnestic (aMCI) and nonamnestic (naMCI) MCI status varied by Black/white race. Methods: Participants included 2755 older adults without dementia from the ACTIVE study. Comprehensive neuropsychological criteria were used to classify cognitively normal, aMCI, and naMCI. VRFs were primarily defined using subjective report and medication data. Multinomial logistic regression was run predicting MCI subtype. Results: Greater overall VRF burden, high cholesterol, and obesity evinced greater odds of naMCI in Black participants than whites. Across participants, diabetes and hypertension were associated with increased odds of aMCI and naMCI, respectively. Discussion: Results may reflect known systemic inequities on dimensions of social determinants of health for Black older adults. Continued efforts toward examining underlying mechanisms contributing to these findings are critical.

Subjective cognitive decline across ethnoracial groups in the A4 study

INTRODUCTION

The associations between subjective cognitive decline (SCD), cognition, and amyloid were explored across diverse participants in the A4 study.

METHODS

Five thousand one hundred and fifty-one non-Hispanic White, 262 non-Hispanic Black, 179 Hispanic-White, and 225 Asian participants completed the Preclinical Alzheimer Cognitive Composite (PACC), self- and study partner-reported Cognitive Function Index (CFI). A subsample underwent amyloid positron emission tomography (18 F-florbetapir) (N = 4384). We examined self-reported CFI, PACC, amyloid, and study partner-reported CFI by ethnoracial group.

RESULTS

The associations between PACC-CFI and amyloid-CFI were moderated by race. The relationships were weaker or non-significant in non-Hispanic Black and Hispanic White groups. Depression and anxiety scores were stronger predictors of CFI in these groups. Despite group differences in the types of study partners, self- and study partner-CFI were congruent across groups.

DISCUSSION

SCD may not uniformly relate to cognition or AD biomarkers in different ethnoracial groups. Nonetheless, self- and study partner-SCD were congruent despite differences in study partner type. Highlights Association between SCD and objective cognition was moderated by ethnoracial group. Association between SCD and amyloid was moderated by ethnoracial group. Depression and anxiety were stronger predictors of SCD in Black and Hispanic groups. Study-partner and self-reported SCD are congruent across groups. Study-partner report was consistent despite difference in study partner types.

Associations of Sex, Race, and Apolipoprotein E Alleles With Multiple Domains of Cognition Among Older Adults

Importance

Sex differences are established in associations between apolipoprotein E (APOE) ε4 and cognitive impairment in Alzheimer disease (AD). However, it is unclear whether sex-specific cognitive consequences of APOE are consistent across races and extend to the APOE ε2 allele.

Objective

To investigate whether sex and race modify APOE ε4 and ε2 associations with cognition.

Design, Setting, and Participants

This genetic association study included longitudinal cognitive data from 4 AD and cognitive aging cohorts. Participants were older than 60 years and self-identified as non-Hispanic White or non-Hispanic Black (hereafter, White and Black). Data were previously collected across multiple US locations from 1994 to 2018. Secondary analyses began December 2021 and ended September 2022.

Main Outcomes and Measures

Harmonized composite scores for memory, executive function, and language were generated using psychometric approaches. Linear regression assessed interactions between APOE ε4 or APOE ε2 and sex on baseline cognitive scores, while linear mixed-effect models assessed interactions on cognitive trajectories. The intersectional effect of race was modeled using an APOE × sex × race interaction term, assessing whether APOE × sex interactions differed by race. Models were adjusted for age at baseline and corrected for multiple comparisons.

Results

Of 32 427 participants who met inclusion criteria, there were 19 007 females (59%), 4453 Black individuals (14%), and 27 974 White individuals (86%); the mean (SD) age at baseline was 74 years (7.9). At baseline, 6048 individuals (19%) had AD, 4398 (14%) were APOE ε2 carriers, and 12 538 (38%) were APOE ε4 carriers. Participants missing APOE status were excluded (n = 9266). For APOE ε4, a robust sex interaction was observed on baseline memory (β = -0.071, SE = 0.014; P = 9.6 × 10-7), whereby the APOE ε4 negative effect was stronger in females compared with males and did not significantly differ among races. Contrastingly, despite the large sample size, no APOE ε2 × sex interactions on cognition were observed among all participants. When testing for intersectional effects of sex, APOE ε2, and race, an interaction was revealed on baseline executive function among individuals who were cognitively unimpaired (β = -0.165, SE = 0.066; P = .01), whereby the APOE ε2 protective effect was female-specific among White individuals but male-specific among Black individuals.

Conclusions and Relevance

In this study, while race did not modify sex differences in APOE ε4, the APOE ε2 protective effect could vary by race and sex. Although female sex enhanced ε4-associated risk, there was no comparable sex difference in ε2, suggesting biological pathways underlying ε4-associated risk are distinct from ε2 and likely intersect with age-related changes in sex biology.

Conventional clock drawing tests have low to moderate reliability and validity for detecting subtle cognitive impairments in community-dwelling older adults

Background

Early identification of subtle cognitive decline in community-dwelling older adults is critical, as mild cognitive impairment contributes to disability and can be a precursor to dementia. The clock drawing test (CDT) is a widely adopted cognitive screening measure for dementia, however, the reliability and validity of paper-and-pencil CDT scoring scales for mild cognitive impairment in community samples of older adults is less well established. We examined the reliability, sensitivity and specificity, and construct validity of two free-drawn clock drawing test scales-the Rouleau System and the Clock Drawing Interpretation Scale (CDIS)-for subtle cognitive decline in community-dwelling older adults.

Methods

We analyzed Rouleau and CDIS scores of 310 community-dwelling older adults who had MoCA scores of 20 or above. For each scale we computed Cronbach's alpha, receiver operating characteristic curves (ROC) for sensitivity and specificity using the MoCA as the index measure, and item response theory models for difficulty level.

Results

Our sample was 75% female and 85% Caucasian with a mean education of 16 years. The Rouleau scale had excellent interrater reliability (94%), poor internal consistency [0.37 (0.48)], low sensitivity (0.59) and moderate specificity (0.71) at a score of 9. The CDIS scale had good interrater reliability (88%), moderate internal consistency [0.66 (0.09)], moderate sensitivity (0.78) and low specificity (0.45) at a score of 19. In the item response models, both scales' total scores gave the most information at lower cognitive levels.

Conclusion

In our community-dwelling sample, the CDIS's psychometric properties were better in most respects than the Rouleau for use as a screening instrument. Both scales provide valuable information to clinicians screening older adults for cognitive change, but should be interpreted in the setting of a global cognitive battery and not as stand-alone instruments.