Factors associated with cognitive impairment among older Italian inpatients. Gruppo Italiano di Farmacovigilanza nell'Anziano (G.I.F.A.)

Hepatic and cardiac implications of increased toxic amyloid-beta serum level in lipopolysaccharide-induced neuroinflammation in rats: new insights into alleviating therapeutic interventions

Neuroinflammation is a devastating predisposing factor for Alzheimer's disease (AD). A number of clinical findings have reported peripheral disorders among AD patients. Amyloid beta (Aβ) is a toxic physiological aggregate that serves as a triggering factor for hepatic and cardiac disorders related to neurotoxicity. As a drawback of Aβ excessive accumulation in the brain, part of Aβ is believed to readily cross the blood-brain barrier (BBB) into the peripheral circulation resulting in serious inflammatory and toxic cascades acting as a direct bridge to cardiac and hepatic pathophysiology. The main aim is to find out whether neuroinflammation-related AD may result in cardiac and liver dysfunctions. Potential therapeutic interventions are also suggested to alleviate AD's cardiac and hepatic defects. Male rats were divided into: control group I, lipopolysaccharide (LPS)-neuroinflammatory-induced group II, LPS-neuroinflammatory-induced group treated with sodium hydrogen sulphide donor (NaHS) (group III), and LPS-neuroinflammatory-induced group treated with mesenchymal stem cells (MSCs) (group IV). Behavior and histopathological studies were conducted in addition to the estimation of different biological biomarkers. It was revealed that the increased toxic Aβ level in blood resulted in cardiac and hepatic malfunctions as a drawback of exaggerated inflammatory cascades. The administration of NaHS and MSCs proved their efficiency in combating neuroinflammatory drawbacks by hindering cardiac and hepatic dysfunctions. The consistent direct association of decreased heart and liver functions with increased Aβ levels highlights the direct involvement of AD in other organ complications. Thereby, these findings will open new avenues for combating neuroinflammatory-related AD and long-term asymptomatic toxicity.

Altered peripheral factors affecting the absorption, distribution, metabolism, and excretion of oral medicines in Alzheimer's disease

Alzheimer's disease (AD) has traditionally been considered solely a neurological condition. Therefore, numerous studies have been conducted to identify the existence of pathophysiological changes affecting the brain and the blood-brain barrier in individuals with AD. Such studies have provided invaluable insight into possible changes to the central nervous system exposure of drugs prescribed to individuals with AD. However, there is now increasing recognition that extra-neurological systems may also be affected in AD, such as the small intestine, liver, and kidneys. Examination of these peripheral pathophysiological changes is now a burgeoning area of scientific research, owing to the potential impact of these changes on the absorption, distribution, metabolism, and excretion (ADME) of drugs used for both AD and other concomitant conditions in this population. The purpose of this review is to identify and summarise available literature reporting alterations to key organs influencing the pharmacokinetics of drugs, with any changes to the small intestine, liver, kidney, and circulatory system on the ADME of drugs described. By assessing studies in both rodent models of AD and samples from humans with AD, this review highlights possible dosage adjustment requirements for both AD and non-AD drugs so as to ensure the achievement of optimum pharmacotherapy in individuals with AD.

Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study

Background

Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.

Objective

This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.

Design

For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.

Data sources

Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.

Results

In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.

Limitations

A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.

Conclusions

Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.

Future work

Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.

Study registration

This study is registered as PROSPERO CRD42015024492.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Serum albumin and beta-amyloid deposition in the human brain

Objectives

To investigate the relationships of serum albumin with in vivo Alzheimer disease (AD) pathologies, including cerebral β-amyloid (Aβ) protein deposition, neurodegeneration of AD-signature regions, and cerebral white matter hyperintensities (WMH), in the human brain.

Methods

A total of 396 older adults without dementia underwent comprehensive clinical assessments, measurement of serum albumin level, and multimodal brain imaging, including [¹¹C] Pittsburgh compound B-PET, ¹⁸F-fluorodeoxyglucose-PET, and MRI. Serum albumin was categorized as follows: <4.4 g/dL (low albumin), 4.4 to 4.5 g/dL (middle albumin), and >4.5 g/dL (high albumin; used as a reference category). Aβ positivity, AD-signature region cerebral glucose metabolism (AD-CM), AD-signature region cortical thickness (AD-CT), and WMH volume were used as outcome measures.

Results

Serum albumin level (as a continuous variable) was inversely associated with Aβ deposition and Aβ positivity. The low albumin group showed a significantly higher Aβ positivity rate compared to the high albumin group (odds ratio 3.40, 95% confidence interval 1.67–6.92, p = 0.001), while the middle albumin group showed no difference (odds ratio 1.74, 95% confidence interval 0.80–3.77, p = 0.162). Neither serum albumin level (as a continuous variable) nor albumin categories were related to AD-CM, AD-CT, or WMH volume.

Conclusions

Low serum albumin may increase the risk of AD dementia by elevating amyloid accumulation. In terms of AD prevention, more attention needs to be paid to avoid a low serum albumin level, even within the clinical normal range, by clinicians.

Effect of Obesity on Cognitive Functions in Elderly People

Aim: We aimed to evaluate effect of obesity on cognitive functions in 65 years and older patients. Methods: This study was conducted in the Recep Tayyip Erdogan University Family Medicine outpatient clinic between November 2018 and January 2019. 65 years and older 83 voluntary patients were included in our study. All participants evaluated by a survey for their socio-demographic characteristics, Standardized Mini Mental Examination Test and Rey Auditory and Verbal Learning Test. Statistical comparison was made between patients’ body mass indexes and their test scores. Results: Mini Mental Test total score was statistically higher in men. Besides that, working patients had higher Mini Mental Test total score compared to retired patients and housewives. As participants’ waist circumference and body mass index increase, their Mini Mental Test language scores were decreasing. Conclusions: We found that as body mass index increases, Mini Mental Test language scores were significantly decreasing. In literature there are studies that suggesting obesity is related to decline in cognitive functions, but there are also studies that suggesting obesity has protective effect for cognitive decline. More comprehensive prospective studies are required for clearer results. Keywords: geriatrics, obesity, cognitive dysfunction

Does Body Mass Index Modify Memory, Reasoning, and Speed of Processing Training Effects in Older Adults

OBJECTIVE

To describe 10-year trajectories of cognitive performance by body mass index (BMI) class and to investigate BMI differences in response to memory, reasoning, and speed of processing training in older adults.

METHODS

This is a secondary analysis of the multisite, randomized trial Advanced Cognitive Training for Independent and Vital Elderly. There were 701 older adults with normal weight, 1,081 with overweight, and 902 with obesity (mean age 73.6) randomized to memory training, reasoning training, speed of processing training, or no-training control group. Participants completed memory, reasoning, and speed of processing tests. Baseline sociodemographic, health, and chronic disease measures were included as covariates in analyses.

RESULTS

The 10-year trajectories of memory, reasoning, or speed of processing performance did not differ by BMI status among the participants randomized to the untrained control arm. The training effect on the reasoning and speed of processing outcomes did not differ by BMI status. The training effect on the memory outcome in participants with a BMI indicating obesity, however, was just 38% of that observed in participants with normal-weight BMI.

CONCLUSIONS

These analyses of data from the largest trial of cognitive training ever conducted suggest that older adults with obesity may be less responsive to memory training.

Abdominal obesity is a risk factor for dysexecutive function in chronic kidney disease

The aim of this study was to assess the influence of the metabolic syndrome and its components on dysexecutive function (DF) in individuals with and without CKD. Among 588 participants aged over 70 from the Einstein Aging Study (EAS), we defined DF as performance of 2SDs below the mean on any one test or 1.5SDs below the mean on any two of the following: Block Design, Digit Symbol Coding and the Trail-making Tests A and B. We defined CKD as an eGFR below 60 mL/min/m². MetS was defined according to recent guidelines from the National Cholesterol Education Program. 149 participants had CKD at cross-section, 16.1% of which also showed DF. Of the 439 participants without CKD, 12.3% displayed DF. Abdominal obesity as measured by waist circumference, was an independent risk factor for dysexecutive function in CKD (OR = 14.3, 95%CI = 2.21–91.93, p = 0.005) but not in non-CKD. None of the other MetS components were associated with DF. Results suggested that abdominal obesity, recognized as an integral part of the MetS, is a strong risk factor for DF in individuals with CKD.

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The most prevalent components of the MetS were hypertension and abdominal obesity.

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Abdominal obesity was the only component significantly associated with DF in CKD.

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In non-CKD participants, MetS components were not associated with DF.

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Absence of CKD and MetS are significantly associated with lowered odds of DF.

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Abdominal obesity was a stronger risk factor for DF than the MetS composite in CKD.

Obesity and neuroinflammation: a pathway to cognitive impairment

Obesity is a growing problem worldwide and is associated with a range of comorbidities, including cognitive dysfunction. In this review we will address the evidence that obesity and high fat feeding can lead to cognitive dysfunction. We will also examine the idea that obesity-associated systemic inflammation leads to inflammation within the brain, particularly the hypothalamus, and that this is partially responsible for these negative cognitive outcomes. Thus, obesity, and high fat feeding, lead to systemic inflammation and excess circulating free fatty acids. Circulating cytokines, free fatty acids and immune cells reach the brain at the level of the hypothalamus and initiate local inflammation, including microglial proliferation. This local inflammation likely causes synaptic remodeling and neurodegeneration within the hypothalamus, altering internal hypothalamic circuitry and hypothalamic outputs to other brain regions. The result is disruption to cognitive function mediated by regions such as hippocampus, amygdala, and reward-processing centers. Central inflammation is also likely to affect these regions directly. Thus, central inflammation in obesity leads not just to disruption of hypothalamic satiety signals and perpetuation of overeating, but also to negative outcomes on cognition.

Models for estimating the biological age of five organs using clinical biomarkers that are commonly measured in clinical practice settings

OBJECTIVES

To date, no worldwide studies have been conducted to estimate the biological age of five organs using clinical biomarkers that are associated with the aging status. Therefore, we conducted this study to develop the models for estimating the biological age of five organs (heart, lung, liver, pancreas, and kidney) using clinical biomarkers which are commonly measured in clinical practice.

DESIGN

A cross sectional study.

METHODS

Subjects were recruited from the routine health check-up centers in Korea from 2004 through 2010. Data obtained from 121,189 subjects (66,168 men and 55,021 women) were used for clinical evaluation and statistical analysis. We examined the relations between clinical biomarkers associated with five organs and the chronological age and proposed a model for estimating the biological age of five organs.

RESULTS

In the models for predicting the biological ages of the heart, lung, liver, pancreas and kidney in men, 12, 2, 8, 3, and 5 parameters were respectively included (R(2)=0.652, 0.427, 0.107, 0.245, and 0.651). In contrast to men, 10, 2, 8, 3, and 5 parameters in women were respectively included (R(2)=0.780, 0.435, 0.140, 0.384, and 0.501).

CONCLUSION

We first proposed the models for predicting the biological age of five organs in the current study. We developed those using clinical parameters that can be easily obtained in clinical practice settings. Our biological age prediction models may be used as supplementary tools to assess the aging status of five organs in clinical practice settings.

Biodemography: new approaches to understanding trends and differences in population health and mortality

The incorporation of biological information in large population surveys has expanded demographic analysis to clarify the meaning of observed trends and differences in population health and mortality. Levels of measured biological risk in the population were reduced in recent years largely because of the expanded use of prescription drugs. The increased use of antihypertensives and, to a lesser extent, lipid-lowering drugs was a likely cause of significant mortality reduction. Blacks and persons with lower educational attainment experience higher levels of biological risk factors, more diseases, and more frailty; these differences are the sources of higher mortality for these groups. Hispanics are less likely to have a higher prevalence of risk factors and diseases than the non-Hispanic population, providing further understanding of the "Hispanic paradox." Almost every examined indicator of biological risk, disease, and frailty is related to higher mortality, indicating how incorporation of this information provides a fuller understanding of the morbidity process.

Predictors of clock drawing test (CDT) performance in elderly patients attending an internal medicine outpatient clinic: a pilot study on sun exposure and physical activity

Influence of sun exposure and physical activity on cognition has not been evaluated simultaneously. We aimed to evaluate predictors of clock drawing test (CDT) performance on n=125 patients attending an internal medicine outpatient clinic. Interview data was gathered on sociodemographic, health-related and lifestyle factors referring to the last year. Factors associated with obtaining a score >0 and a full score (10/10) were analyzed by univariate (UVA) and multivariate (MVA) logistic regression analyses. Mean age of the participants was 72 ± 5, 58% were women and 17% were illiterate. Mean CDT score was 4.70 ± 2.27, 61.6% scored >0 and 21.6% scored 10/10. Both duration of walking and summer sun exposure predicted a CDT score >0 in UVA. However only summer sun exposure was an independent predictor (odds ratio=OR=1.73, 95% confidence interval=CI=1.16-2.57). Other factors independently associated with obtaining a score >0 were education level (OR=2.70, 95%CI=1.77-4.12) and cerebrovascular disease (CVD) history (OR=0.08, 95%CI=0.008-0.78). Factors independently associated with obtaining a full score were weight (OR=1.05, 95%CI=1.00-1.10), education level (OR=2.04, 95%CI=1.38-3.00) and visiting the clinic alone (OR=3.92, 95%CI=1.354-11.39). Our study shows that CDT can be utilized to unravel the lifestyle factors associated with cognitive function. To our knowledge, this is the first study to suggest an association between sun exposure and cognition.

Albumin, apolipoprotein E-epsilon4 and cognitive decline in community-dwelling Chinese older adults

OBJECTIVES

To examine the association between serum albumin and cognitive impairment and decline in community-living older adults.

DESIGNS

Population-based cohort study, followed up to 2 years; serum albumin, apolipoprotein E (APOE)-epsilon4, and cognitive impairment measured at baseline and cognitive decline (> or =2-point drop in Mini-Mental State Examination (MMSE) score). Odds ratios were controlled for age, sex, education, medical comorbidity, hypertension, diabetes mellitus, cardiac disease, stroke, smoking, alcohol drinking, depression, APOE-epsilon4, nutritional status, body mass index, anemia, glomerular filtration rate, and baseline MMSE.

SETTINGS

Local area whole population.

PARTICIPANTS

One thousand six hundred sixty-four Chinese older adults aged 55 and older.

RESULTS

The mean age of the cohort was 66.0+/-7.3, 65% were women, mean serum albumin was 42.3+/-3.1 g/L, and mean MMSE score was 27.2+/-3.2. Lower albumin tertile was associated with greater risk of cognitive impairment in cross-sectional analysis (low, odds ratio (OR)=2.30, 95% confidence interval (CI)=1.31-4.03); medium, OR=1.59, 95% CI=0.88-2.88) versus high (P for trend=.002); and with cognitive decline in longitudinal analyses: low, OR=1.73, 95% CI=1.18-2.55; medium, OR=1.32, 95% CI=0.89-1.95, vs high (P for trend=.004). In cognitively unimpaired respondents at baseline (MMSE> or =24), similar associations with cognitive decline were observed (P for trends <.002). APOE-epsilon4 appeared to modify the association, due mainly to low rates of cognitive decline in subjects with the APOE-epsilon4 allele and high albumin.

CONCLUSION

Low albumin was an independent risk marker for cognitive decline in community-living older adults.

Albumin, haemoglobin, BMI and cognitive performance in older adults

OBJECTIVES

to examine the relationships between serum albumin, haemoglobin and body mass index (BMI) with cognitive performance among community-living older adults.

METHOD

design--population-based cross-sectional study; setting--local community in Southeast Region of Singapore; subjects--Chinese older adults aged 55 and above (N = 2, 550); measurements--serum albumin, haemoglobin, BMI and Mini-Mental State Examination (MMSE).

RESULTS

in multivariable analyses controlling for gender, age, education and vascular risk factors, low albumin in the bottom quintile (OR 2.04; 95% CI 1.22-3.41) and low haemoglobin in the bottom quintile (OR 1.56; 95% CI 1.00-2.47) and low BMI with chronic comorbidity (OR 1.73; 95%CI 1.02-2.95) were independently associated with poor cognitive performance (MMSE < or = 23). Among cognitively intact respondents (MMSE > or = 24), albumin concentration showed a significant inverse linear relationship with MMSE scores (P for trend =0.002).

CONCLUSION

low albumin, low haemoglobin and low BMI (in the presence of chronic comorbidity) are independently associated with poor cognitive performance in community-living older adults.

Biomarkers related to aging in human populations

Biomarkers are increasingly employed in empirical studies of human populations to understand physiological processes that change with age, diseases whose onset appears linked to age, and the aging process itself. In this chapter, we describe some of the most commonly used biomarkers in population aging research, including their collection, associations with other markers, and relationships to health outcomes. We discuss biomarkers of the cardiovascular system, metabolic processes, inflammation, activity in the hypothalamic-pituitary axis (HPA) and sympathetic nervous system (SNS), and organ functioning (including kidney, lung, and heart). In addition, we note that markers of functioning of the central nervous system and genetic markers are now becoming part of population measurement. Where possible, we detail interrelationships between these markers by providing correlations between high risk levels of each marker from three population-based surveys: the National Health and Nutrition Examination Survey (NHANES) III, NHANES 1999-2002, and the MacArthur Study of Successful Aging. NHANES III is used instead of NHANES 1999-2002 when specific markers of interest are available only in NHANES III and when we examine the relationship of biomarkers to mortality which is only known for NHANES III. We also describe summary measures combining biomarkers across systems. Finally, we examine associations between individual markers and mortality and provide information about biomarkers of growing interest for future research in population aging and health.

Cognitive performance in elderly women: significance of the 19bp insertion/deletion polymorphism in the 5' flank of the dopamine beta-hydroxylase gene, educational level, body fat measures, serum triglyceride, alcohol consumption and age

BACKGROUND

Genetic and environmental factors influence cognitive aging. The gene encoding dopamine beta-hydroxylase (DBH) could be one such factor since this hydroxylase converts dopamine to norepinephrine both of which are involved in cognition regulation.

OBJECTIVE

To assess the effect of the 19bp insertion/deletion polymorphism in the 5' flank of the DBH gene on cognitive performance in elderly women relative to other factors of cognitive aging.

METHODS

We examined a cross-sectional sample of 1371 postmenopausal women. Cognitive abilities were assessed by the 6-item orientation-memory-concentration test. The 19bp insertion/deletion polymorphism of the DBH gene was genotyped and apolipoprotein E (APOE) epsilon4 allele status was determined. In addition blood pressure, body fat mass and blood lipids were measured. Information was also obtained by personal interviews. Data were analyzed by regression analysis.

RESULTS

Cognition was univariately associated with DBH genotype (p = 0.04). A univariate association of borderline significance was observed for APOE epsilon4 allele status (p = 0.07). Exclusion of women with severe cognition impairment did not alter the strength of the association with the DBH gene polymorphism markedly (p = 0.06) but obliterated the weak association between APOE epsilon4 allele status and cognition. The association of the DBH gene polymorphism with cognition persisted after adjustment for other variables (p = 0.03).

CONCLUSIONS

The 19bp insertion/deletion polymorphism of the DBH gene influences cognition in elderly women and might have a stronger effect than APOE epsilon4 allele status on mild cognitive impairment. Both genetic polymorphisms had a significantly smaller impact on cognition than age, education, alcohol consumption and body fat measures.

Cognitive function in normal-weight, overweight, and obese older adults: an analysis of the Advanced Cognitive Training for Independent and Vital Elderly cohort

OBJECTIVES

To assess how elevated body mass index (BMI) affects cognitive function in elderly people.

DESIGN

Cross-sectional study.

SETTING

Data for this cross-sectional study were taken from a multicenter randomized controlled trial, the Advanced Cognitive Training for Independent and Vital Elderly trial.

PARTICIPANTS

The analytic sample included 2,684 normal-weight, overweight, or obese subjects aged 65 to 94.

MEASUREMENTS

Evaluation of cognitive abilities was performed in several domains: global cognition, memory, reasoning, and speed of processing. Cross-sectional association between body weight status and cognitive functions was analyzed using multiple linear regression.

RESULTS

Overweight subjects had better performance on a reasoning task (beta=0.23, standard error (SE)=0.11, P=.04) and the Useful Field of View (UFOV) measure (beta=-39.46, SE=12.95, P=.002), a test of visuospatial speed of processing, after controlling for age, sex, race, years of education, intervention group, study site, and cardiovascular risk factors. Subjects with class I (BMI 30.0-34.9 kg/m2) and class II (BMI>35.0 kg/m2) obesity had better UFOV measure scores (beta=-38.98, SE=14.77, P=.008; beta=-35.75, SE=17.65, and P=.04, respectively) in the multivariate model than normal-weight subjects. The relationships between BMI and individual cognitive domains were nonlinear.

CONCLUSION

Overweight participants had better cognitive performance in terms of reasoning and visuospatial speed of processing than normal-weight participants. Obesity was associated with better performance in visuospatial speed of processing than normal weight. The relationship between BMI and cognitive function should be studied prospectively.

Elderly patients with cognitive impairment have a high risk for functional decline during hospitalization: The GIFA Study

BACKGROUND

We tested the hypothesis that cognitive impairment upon admission (CIA) and cognitive decline (CD) during hospitalization are associated with an increased risk for functional decline (FD) in older inpatients.

METHODS

The Italian Group of Pharmacoepidemiology in the Elderly (Gruppo Italiano di Farmacoepidemiologia nell'Anziano, GIFA) project was a multicenter survey of 9061 older patients admitted to Italian hospitals between 1991 and 1997. CIA was defined as a Hodkinson Abbreviated Mental Test score <7 on admission. The percentage of participants who developed FD, defined as loss of the ability to perform without help one or more activities of daily living between admission and discharge, was compared in patients who did and did not have CIA, and between those who lost at least one point in Hodkinson Abbreviated Mental Test score (CD) and those who did not.

RESULTS

Mean age was 77.4 years, and women represented 52.3% of the sample. CIA was present in 21.0% of the patients. During hospitalization, 176 patients (1.9%) experienced FD (4% of those with CIA vs 1.3% of those without CIA). In multivariate analysis, CIA was an important risk factor for FD (odds ratio 2.4; 95% confidence interval, 1.7-3.5; p <.001), independent of age, gender, comorbidity, polypharmacy, and disability on admission. CD occurred in 3.7% of the sample and was strongly associated with an increased risk for FD (odds ratio 16.0; 95% confidence interval, 10.8-23.6; p <.001).

CONCLUSIONS

Elderly patients with CIA have a higher risk for FD. New strategies should be implemented to prevent FD in patients with cognitive impairment, who account for a high percentage of older persons who are admitted to hospitals.

Nutritional factors, cognitive decline, and dementia

Nutritional factors and nutritional deficiencies have been repeatedly associated with cognitive impairment. Most of the evidence is based on cross-sectional studies, which cannot prove whether a nutritional deficit is the cause or the consequence of an impaired cognitive status. In fact, cognitive impairment, in turn, can determine changes in dietary habits and consequent nutritional deficiencies. We reviewed clinical and epidemiological studies from January 1983 to June 2004. Several cross-sectional and fewer prospective studies reported an association between dietary or supplemental intake of antioxidants and protection from cognitive decline and dementia. There are negative reports as well and some methodological biases might have affected the consistencies across studies. Deficiencies of several B vitamins have been associated with cognitive dysfunction in many observational studies. More recently, deficiencies of folate (B9) and cobalamine (B12) have been studied in relation to hyperhomocysteinemia as potential determinants of cognitive impairment, dementia, and Alzheimer's disease (AD). A small number of studies assessed the association between intake of macronutrients and cognitive function or dementia. Among the others, the intake of fatty acids and cholesterol has received particular attention. Although the results are not always consistent, most studies have reported a protective role of dietary intakes of poly- and mono-unsaturated fatty acids against cognitive decline and AD. We point out that well designed intervention studies are warranted in order to establish specific levels of micro- and macronutrient deficiencies and to set general recommendations for the population.

Effects of atorvastatin on higher functions

OBJECTIVE

This study was undertaken to assess the effects of atorvastatin on cognition and higher mental functions.

METHODS

In this before and after comparison study with controls, group one included 55 subjects aged > or =40 years requiring statins for cardiovascular indications who were started on atorvastatin (10 mg/day). Group two assigned to receive placebo were men and women chosen from the same geographical area and matched for age, sex, education and presence of hypertension and diabetes mellitus. Assessment was done with the Mini-Mental State Examination, Digit Span, Picture Test (average and delayed), Trail Making Test, Controlled Oral Word Association Test, Digit Symbol Substitution Test and Auditory Vigilance and Digit Vigilance Test at baseline and after 6 months. Changes between baseline and 6 months in the above parameters of mental function were compared using suitable statistical tests in the atorvastatin and placebo groups. To limit experiment-wise error, performance scores were grouped into five cognitive domains, which were labeled as attention, psychomotor speed, mental flexibility, working memory and memory retrieval. Summary effect sizes were estimated as z-scores.

RESULTS

Both subjects on atorvastatin and placebo showed improvement in the majority of scales consistent with a learning effect on test performance. However, subjects treated with atorvastatin scored significantly over the placebo group in all domains, i.e. tests of attention [z-score=0.54, 95% confidence interval (CI): 0.38-0.64, p=0.001], psychomotor speed (z-score=0.28, 95% CI: O.09-0.47, p<0.001), mental flexibility (z-score=0.27, 95% CI: 0.22-0.32, p=0.01), working memory (z-score=1.22, 95% CI: 0.93-1.50, p<0.001) and memory retrieval (z-score=0.59, 95% CI: 0.36-0.82, p<0.05).

CONCLUSION

The present study concludes that there are significant beneficial effects of atorvastatin in a dose of 10 mg/day for a period of 6 months on higher functions as measured by the above standard neurocognitive tests.

Serum cholesterol and cognitive performance in the Framingham Heart Study

OBJECTIVE

The objective of this study was to examine the relationship between total cholesterol (TC) and cognitive performance within the context of the Framingham Heart Study, a large, community-based, prospective investigation of cardiovascular risk factors.

METHODS

Participants were 789 men and 1105 women from the Framingham Heart Study original cohort who were free of dementia and stroke and who received biennial TC determinations over a 16- to 18-year surveillance period. Cognitive tests were administered 4 to 6 years subsequent to the surveillance period and consisted of measures of learning, memory, attention/concentration, abstract reasoning, concept formation, and organizational abilities. Statistical models were adjusted for multiple demographic and biological covariates.

RESULTS

There was a significant positive linear association between TC and measures of verbal fluency, attention/concentration, abstract reasoning, and a composite score measuring multiple cognitive domains. Performance levels for three clinically defined groups were examined. Participants with "desirable" TC levels (<200 mg/dL) performed less well than participants with borderline-high TC levels (200-239 mg/dL) and participants with high TC levels (there exists 240 mg/dL).

CONCLUSIONS

Lower naturally occurring TC levels are associated with poorer performance on cognitive measures, which place high demands on abstract reasoning, attention/concentration, word fluency, and executive functioning.

The UCSD Statin Study: a randomized controlled trial assessing the impact of statins on selected noncardiac outcomes

There has been persistent controversy regarding possible favorable or adverse effects of statins or of cholesterol reduction on cognition, mood and behavior (including aggressive or violent behavior), muscle function, and quality of life. The UCSD Statin Study seeks to ascertain the beneficial or adverse effects of statin cholesterol-lowering drugs on a set of noncardiac endpoints, including cognition, behavior, and serotonin biochemistry. The study will enroll 1000 subjects (minimum 20% female) of mixed ethnicity from San Diego. Subjects must be age 20 and older, postmenopausal if female, without known cardiovascular disease or diabetes, and with LDL-cholesterol between 115 and 190 mg/dl. Subjects will be randomized to a double-blind, placebo-controlled trial with assignment 1/3, 1/3, 1/3 to placebo, simvastatin 20 mg, or pravastatin 40 mg (equipotent LDL-cholesterol-lowering doses for drug arms with simvastatin and pravastatin chosen to represent the extremes of the lipophilicity spectrum) for 6 months of treatment followed by 2 months postcessation follow-up. Primary outcomes are cognition (cognitive battery), irritability/aggression (behavior measure), and serotonin (gauged by whole blood serotonin), assessed as the difference between baseline and 6 months, judging combined statin groups vs. placebo. Secondary outcomes include mood (CES-D and Wakefield depression inventory), quality of life (SF-12V), sleep (Leeds sleep scale, modified), and secondary aggression measures (Conflict Tactics Scale; Overt Aggression Scale, Modified). Cardiovascular reactivity will be examined in a 10% subset. As additional secondary endpoints, primary and selected secondary outcomes will be assessed by statin assignment (lipophilic simvastatin vs. hydrophilic pravastatin). "Reversibility" of changes, if any, at 2 months postcessation will be determined. If effects (favorable or unfavorable) are identified, we will seek to ascertain whether there are baseline variables that predict who will be most susceptible to these favorable or adverse noncardiac effects (i.e., effect modification).

Health-related quality of life and long-term therapy with pravastatin and tocopherol (vitamin E) in older adults

INTRODUCTION

Concerns about the effects of HMG-CoA reductase inhibitors ('statins') on health-related quality of life may contribute to their underuse in older adults with and at risk for cardiovascular disease. These concerns also may prevent clinicians from enrolling older patients in clinical trials assessing the efficacy of statins as a preventive therapy for Alzheimer's disease.

OBJECTIVE

To determine the effects of pravastatin and tocopherol (vitamin E), alone and in combination, on health-related quality of life in older adults.

STUDY DESIGN

Double-blind, randomised, placebo-controlled, crossover study.

PARTICIPANTS

Forty-one community-dwelling men and women aged > or = 70 years with low-density lipoprotein-cholesterol (LDL-C) > or = 3.62 mmol/L (140 mg/dl) participated.

METHODS

Subjects received pravastatin for 6 months then pravastatin plus tocopherol for an additional 6 months (group 1), or tocopherol for 6 months then pravastatin plus tocopherol for an additional 6 months (group 2). Dosages were pravastatin 20 mg daily and tocopherol 400 IU daily.

MAIN OUTCOME MEASURES

The following health-related quality-of-life measures were assessed at baseline, after 6 months and after 1 year: health perception, depression, physical function, cognitive function and sleep behaviour. In addition, data on adverse effects and laboratory abnormalities were obtained.

RESULTS

Pravastatin reduced levels of total cholesterol (-21%, p < 0.001) and LDL-C (-29%, p < 0.001). Health-related quality-of-life scores, physical adverse effects, muscle enzyme levels and liver function tests did not change after 12 months of therapy with pravastatin, tocopherol or their combination.

CONCLUSION

Both pravastatin and tocopherol have a good safety profile, are well tolerated and do not adversely affect health-related quality of life in older patients with hypercholesterolaemia. Given the significant beneficial cardiovascular effects of statin therapy in older adults and the potential role of statins in prevention of Alzheimer's disease, concerns about adverse effects on quality of life should not deter use of these medications in this population.

Estrogen and Alzheimer's disease: the story so far

The ovarian hormone estrogen has long been used to treat the physical symptoms of menopause and to aid in the prevention of osteoporosis in postmenopausal women. Cumulative evidence from basic science and clinical research suggests that estrogen also plays a significant neuromodulatory and neuroprotective role. The numerous estrogenic effects in the brain include the modulation of synaptogenesis, increased cerebral blood flow, mediation of important neurotransmitters and hormones, protection against apoptosis, anti-inflammatory actions, and antioxidant properties. These multiple actions in the central nervous system support estrogen as a potential treatment for the cognitive decline associated with Alzheimer's disease (AD), the most common form of dementia. Evidence from epidemiological studies supports enhanced cognitive function in women with AD taking estrogen replacement therapy (ERT) as well as a reduced risk for developing AD in healthy women receiving ERT. Additional clinical evidence suggests that estrogen may modulate specific cognitive functions such as working memory and verbal learning and memory. However, results from more recent controlled trials have not consistently shown a beneficial effect of estrogen on the cognitive function of women with AD. Future research should focus on examining the influence of multiple potential mediators of ERT including the route of estrogen administration, form of estrogen (conjugated estrogens vs estradiol), duration of treatment, opposed versus unopposed estrogen and the use of estrogen analogues. Further, sensitive neuropsychological measures may provide more detailed information concerning the specific effects of estrogen on cognitive function. These important issues must be addressed in order to establish the role of estrogen for the prevention and treatment of AD in women.

The health-related effects of alcohol use in older persons: a systematic review

Increased alcohol consumption is associated with substantial morbidity and mortality in young and middle-aged adult populations, but its effects on the health of older adults have received less attention. The objective of the study was to review published studies that assessed the effects of alcohol on falls or fall injuries, functional impairment, cognitive impairment, and all-cause mortality among older adults. MEDLINE database and bibliographies of selected citations were searched for English language studies published between 1966 and 1998 that examined the relationship between alcohol and one or more of the above outcomes. Also a study was analyzed if it included participants 60 years of age or older, or a broader age range of participants and reported results for older subgroups, or predominantly older participants as evidenced by a mean age of 65 years of age or above. Information on studies' sample sizes, exposure and outcome measures, and risk estimates were extracted, and articles were evaluated for methodologic quality using predetermined criteria. Eighty-four studies were identified that examined 91 potential exposure-outcome associations including falls or fall injuries (n = 26); functional impairment (n = 13); cognitive impairment (n = 32); and all-cause mortality (n = 20). The percentage of studies demonstrating harm, no association, or benefit by outcome included falls (15% vs. 81% vs. 4%); functional disability (38% vs. 46% vs. 16%); cognitive impairment (31% vs. 66% vs. 3%); and all-cause mortality (15% vs. 65% vs. 20%). Studies (n = 84) inconsistently adhered to methodologic standards. Although 90% provided eligibility criteria; 61% cited participation rates; and 73% described the methods used to measure alcohol exposure; only 44% adjusted for potentially important confounding factors; and 26% distinguished former drinkers from nondrinkers. Of the cohort studies (n = 47), 30% assessed for change in participants' exposure status over time, and 17% determined whether losses to follow-up varied by exposure status. The magnitude of risk posed by alcohol use for falls or fall injuries, functional disability, cognitive impairment, and all-cause mortality among older adults remains uncertain. Prospective studies are needed to better define the health-related effects of alcohol use in older populations.

Nutrition and cognitive deficit in the elderly: a population study

OBJECTIVE

To investigate the association between a healthy diet indicator and the prevalence of cognitive impairment in the elderly.

DESIGN

Cross-sectional study.

SETTING

Population based.

SUBJECTS

A total of 1651 subjects (560 men and 1091 women) including everybody aged 70 y or more, and a random sample of people (about 40%) aged 65-69 y resident in four rural towns in the province of Pavia, Italy in 1992-1993.

INTERVENTIONS

The healthy diet indicator based on the WHO guidelines for the prevention of chronic diseases was calculated as reported by Huijbregts et al (1998; Eur. J. Clin. Nutr. 52, 826-831). Food intake was estimated by means of a 180-item food-frequency questionnaire and nutrient intake was calculated using the food composition database compiled for epidemiologic studies in Italy. The cognitive function was categorized into four levels-normal cognition, mild, moderate and severe cognitive deficit-according to the neuropsychological test score. The relationship between the dietary and the ordinal cognitive function variables was studied using the proportional-odds model.

RESULTS

After adjustment for age, sex, education, total energy intake, cigarette smoking, alcohol consumption and physical activity, a better healthy diet score was associated with a lower prevalence of cognitive deficit. The cumulative odds ratio was 0.85 (95% CI 0.77-0.93).

CONCLUSIONS

Our results suggest an association between a globally satisfactory diet and better cognitive performance in the elderly. However, the specific aspects of a 'healthy diet' for the elderly should be clarified.

SPONSORSHIP

National Research Council (Italy), 'Invecchiamento' Project no. 95.01048.PF40.

Nutrition and cognitive impairment in the elderly

As the number of older people is growing rapidly worldwide and the fact that elderly people are also apparently living longer, dementia, the most common cause of cognitive impairment is getting to be a greater public health problem. Nutrition plays a role in the ageing process, but there is still a lack of knowledge about nutrition-related risk factors in cognitive impairment. Research in this area has been intensive during the last decade, and results indicate that subclinical deficiency in essential nutrients (antioxidants such as vitamins C, E and beta-carotene, vitamin B(12), vitamin B(6), folate) and nutrition-related disorders, as hypercholesterolaemia, hypertriacylglycerolaemia, hypertension, and diabetes could be some of the nutrition-related risk factors, which can be present for a long time before cognitive impairment becomes evident. Large-scale clinical trials in high-risk populations are needed to determine whether lowering blood homocysteine levels reduces the risk of cognitive impairment and may delay the clinical onset of dementia and perhaps of Alzheimer's disease. A curative treatment of cognitive impairment, especially Alzheimer's disease, is currently impossible. Actual drug therapy, if started early enough, may slow down the progression of the disease. Longitudinal studies are required in order to establish the possible link of nutrient intake--nutritional status with cognitive impairment, and if it is possible, in fact, to inhibit or delay the onset of dementia.

Effects of lovastatin on cognitive function and psychological well-being

PURPOSE

Animal research and cross-sectional studies suggest that serum lipid concentrations may influence cognitive function, mood, and behavior, but few clinical trials have studied these effects.

SUBJECTS AND METHODS

In this double-blind investigation, 209 generally healthy adults with a serum low-density-lipoprotein (LDL) cholesterol level of 160 mg/dL or higher were randomly assigned to 6-month treatment with lovastatin (20 mg) or placebo. Assessments of neuropsychological performance, depression, hostility, and quality of life were conducted at baseline and at the end of the treatment period. Summary effect sizes were estimated as z scores on a standard deviation (SD) scale.

RESULTS

Placebo-treated subjects improved between baseline and posttreatment periods on neuropsychological tests in all five performance domains, consistent with the effects of practice on test performance (all P <0.04), whereas those treated with lovastatin improved only on tests of memory recall (P = 0.03). Comparisons of the changes in performance between placebo- and lovastatin-treated subjects revealed small, but statistically significant, differences for tests of attention (z score = 0.18; 95% confidence interval (CI), 0.06 to 0.31; P = 0.005) and psychomotor speed (z score = 0.17; 95% CI, 0.05 to 0.28; P = 0. 004) that were consistent with greater improvement in the placebo group. Psychological well-being, as measured several ways, was not affected by lovastatin.

CONCLUSION

Treatment of hypercholesterolemia with lovastatin did not cause psychological distress or substantially alter cognitive function. Treatment did result in small performance decrements on neuropsychological tests of attention and psychomotor speed, the clinical importance of which is uncertain.