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Hadley G, Zhang J, Harris-Skillman E, Alexopoulou Z, DeLuca GC, Pendlebury ST. Cognitive decline and diabetes: a systematic review of the neuropathological correlates accounting for cognition at death. J Neurol Neurosurg Psychiatry 2022; 93:246-253. [PMID: 35086942 DOI: 10.1136/jnnp-2021-328158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/24/2021] [Indexed: 11/04/2022]
Abstract
Given conflicting findings in epidemiologic studies, we determined the relative contributions of different neuropathologies to the excess risk of cognitive decline in diabetes mellitus (DM) through a systematic review of the literature. Included studies compared subjects with and without DM and reported neuropathological outcomes accounting for cognition at death. Data on Alzheimer's disease (AD) pathology, cerebrovascular disease and non-vascular, non-AD pathology were extracted from each study. Eleven studies (n=6 prospective cohorts, n=5 retrospective post-mortem series, total n=6330) met inclusion criteria. All 11 studies quantified AD changes and 10/11 measured cerebrovascular disease: macroscopic lesions (n=9), microinfarcts (n=8), cerebral amyloid angiopathy (CAA, n=7), lacunes (n=6), white matter disease (n=5), haemorrhages (n=4), microbleeds (n=1), hippocampal microvasculature (n=1). Other pathology was infrequently examined. No study reported increased AD pathology in DM, three studies showed a decrease (n=872) and four (n= 4018) showed no difference, after adjustment for cognition at death. No study reported reduced cerebrovascular pathology in DM. Three studies (n=2345) reported an increase in large infarcts, lacunes and microinfarcts. One study found lower cognitive scores in DM compared to non-DM subjects despite similar cerebrovascular and AD-pathology load suggesting contributions from other neuropathological processes. In conclusion, lack of an association between DM and AD-related neuropathology was consistent across studies, irrespective of methodology. In contrast to AD, DM was associated with increased large and small vessel disease. Data on other pathologies such as non-AD neurodegeneration, and blood-brain-barrier breakdown were lacking. Further studies evaluating relative contributions of different neuropathologies to the excess risk of DM are needed.
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Affiliation(s)
- Gina Hadley
- Departments of General (internal) Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Jiali Zhang
- St Anne's College, University of Oxford, Oxford, UK
| | - Eva Harris-Skillman
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Gabriele C DeLuca
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Sarah T Pendlebury
- Departments of General (internal) Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK.,Wolfson Centre for Prevention of Stroke and Dementia, Wolfson Building, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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A third of community-dwelling elderly with intermediate and high level of Alzheimer's neuropathologic changes are not demented: A meta-analysis. Ageing Res Rev 2020; 58:101002. [PMID: 31899366 DOI: 10.1016/j.arr.2019.101002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 12/18/2019] [Accepted: 12/20/2019] [Indexed: 01/13/2023]
Abstract
This systematic review and meta-analysis assessed the bidirectional association between AD pathology and dementia in community-dwelling elderly populations. We searched PubMed/MEDLINE, Embase, Scopus, Web of Science, and references of the pertinent articles for community/population-based longitudinal cohorts with regular assessment of cognitive status of participants followed by postmortem neuropathology data, with no language and date restrictions, until 20 September 2019. Finally, we retrieved 18 articles with data from 17 cohorts comprising 4677 persons. Dementia was twice as likely in participants with definitive neuropathological indicator for AD compared to those without it: moderate/high Braak and Braak (BB) stages III-VI of neurofibrillary tangles (54 % vs. 26 % in participants with BB stages 0-II), the Consortium to Establish a Registry for AD (CERAD) moderate/frequent neuritic plaques scores (64 % vs. 33 % in participants with CERAD none/infrequent), and National Institute on Aging and the Reagan Institute of the Alzheimer's Association criteria intermediate/high AD probability (52 % vs. 28 % in participants with no/low AD probability). Accordingly, a substantial proportion of community-dwelling elderly people with definitive AD pathology may not develop dementia. Brain reserve or contribution of other factors and pathologies, such as vascular and degenerative pathology to dementia might explain this apparent discrepancy. These findings also suggest caution in equating Alzheimer pathology biomarkers with dementia.
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Dodge HH, Zhu J, Woltjer R, Nelson PT, Bennett DA, Cairns NJ, Fardo DW, Kaye JA, Lyons DE, Mattek N, Schneider JA, Silbert LC, Xiong C, Yu L, Schmitt FA, Kryscio RJ, Abner EL. Risk of incident clinical diagnosis of Alzheimer's disease-type dementia attributable to pathology-confirmed vascular disease. Alzheimers Dement 2017; 13:613-623. [PMID: 28017827 PMCID: PMC5466467 DOI: 10.1016/j.jalz.2016.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 11/10/2016] [Accepted: 11/16/2016] [Indexed: 01/06/2023]
Abstract
INTRODUCTION The presence of cerebrovascular pathology may increase the risk of clinical diagnosis of Alzheimer's disease (AD). METHODS We examined excess risk of incident clinical diagnosis of AD (probable and possible AD) posed by the presence of lacunes and large infarcts beyond AD pathology using data from the Statistical Modeling of Aging and Risk of Transition study, a consortium of longitudinal cohort studies with more than 2000 autopsies. We created six mutually exclusive pathology patterns combining three levels of AD pathology (low, moderate, or high AD pathology) and two levels of vascular pathology (without lacunes and large infarcts or with lacunes and/or large infarcts). RESULTS The coexistence of lacunes and large infarcts results in higher likelihood of clinical diagnosis of AD only when AD pathology burden is low. DISCUSSION Our results reinforce the diagnostic importance of AD pathology in clinical AD. Further harmonization of assessment approaches for vascular pathologies is required.
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Affiliation(s)
- Hiroko H Dodge
- Layton Aging and Alzheimer's Disease Center, Department of Neurology, Oregon Health & Science University, Portland, OR; Michigan Alzheimer's Disease Center, Department of Neurology, University of Michigan, Ann Arbor, MI.
| | - Jian Zhu
- School of Public Health, Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Randy Woltjer
- Layton Aging and Alzheimer's Disease Center, Department of Neurology, Oregon Health & Science University, Portland, OR
| | - Peter T Nelson
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY; Department of Pathology, University of Kentucky, Lexington, KY
| | - David A Bennett
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | - Nigel J Cairns
- Knight Alzheimer's Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO; Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO
| | - David W Fardo
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY; College of Public Health, Department of Biostatistics, University of Kentucky, Lexington, KY
| | - Jeffrey A Kaye
- Layton Aging and Alzheimer's Disease Center, Department of Neurology, Oregon Health & Science University, Portland, OR; Portland VA Medical Center, Portland, OR
| | - Deniz-Erten Lyons
- Layton Aging and Alzheimer's Disease Center, Department of Neurology, Oregon Health & Science University, Portland, OR; Portland VA Medical Center, Portland, OR
| | - Nora Mattek
- Layton Aging and Alzheimer's Disease Center, Department of Neurology, Oregon Health & Science University, Portland, OR
| | - Julie A Schneider
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL; Department of Pathology, Rush University Medical Center, Chicago, IL
| | - Lisa C Silbert
- Layton Aging and Alzheimer's Disease Center, Department of Neurology, Oregon Health & Science University, Portland, OR; Portland VA Medical Center, Portland, OR
| | - Chengjie Xiong
- Knight Alzheimer's Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Lei Yu
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL; Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | - Frederick A Schmitt
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY; College of Medicine, Departments of Neurology and Psychiatry, University of Kentucky, Lexington, KY
| | - Richard J Kryscio
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY; College of Public Health, Department of Biostatistics, University of Kentucky, Lexington, KY
| | - Erin L Abner
- Sanders-Brown Center on Aging, University of Kentucky, Lexington, KY; College of Public Health, Department of Epidemiology, University of Kentucky, Lexington, KY
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The effects of noncoding aquaporin-4 single-nucleotide polymorphisms on cognition and functional progression of Alzheimer's disease. ALZHEIMERS & DEMENTIA-TRANSLATIONAL RESEARCH & CLINICAL INTERVENTIONS 2017; 3:348-359. [PMID: 29067342 PMCID: PMC5651426 DOI: 10.1016/j.trci.2017.05.001] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Introduction The glymphatic system is a brain-wide perivascular network that facilitates clearance of proteins, including amyloid β, from the brain interstitium through the perivascular exchange of cerebrospinal fluid and interstitial fluid. The astrocytic water channel aquaporin-4 (AQP4) is required for glymphatic system function, and impairment of glymphatic function in the aging brain is associated with altered AQP4 expression and localization. In human cortical tissue, alterations in AQP4 expression and localization are associated with Alzheimer's disease (AD) status and pathology. Although this suggests a potential role for AQP4 in the development or progression of AD, the relationship between of naturally occurring variants in the human AQP4 gene and cognitive function has not yet been evaluated. Methods Using data from several longitudinal aging cohorts, we investigated the association between five AQP4 single-nucleotide polymorphisms (SNPs) and the rate of cognitive decline in participants with a diagnosis of AD. Results None of the five SNPs were associated with different rates of AD diagnosis, age of dementia onset in trial subjects. No association between AQP4 SNPs with histological measures of AD pathology, including Braak stage or neuritic plaque density was observed. However, AQP4 SNPs were associated with altered rates of cognitive decline after AD diagnosis, with two SNPS (rs9951307 and rs3875089) associated with slower cognitive decline and two (rs3763040 and rs3763043) associated with more rapid cognitive decline after AD diagnosis. Discussion These results provide the first evidence that variations in the AQP4 gene, whose gene product AQP4 is vital for glymphatic pathway function, may modulate the progression of cognitive decline in AD.
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Lou W, Wan L, Abner EL, Fardo DW, Dodge HH, Kryscio RJ. Multi-state models and missing covariate data: Expectation-Maximization algorithm for likelihood estimation. ACTA ACUST UNITED AC 2017; 1:20-35. [PMID: 29600291 DOI: 10.1080/24709360.2017.1306156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Multi-state models have been widely used to analyze longitudinal event history data obtained in medical and epidemiological studies. The tools and methods developed recently in this area require completely observed data. However, missing data within variables of interest is very common in practice, and it has been an issue in applications. We propose a type of EM algorithm, which handles missingness within multiple binary covariates efficiently, for multi-state model applications. Simulation studies show that the EM algorithm performs well for both missing completely at random (MCAR) and missing at random (MAR) covariate data. We apply the method to a longitudinal aging and cognition study dataset, the Klamath Exceptional Aging Project (KEAP), whose data were collected at Oregon Health & Science University and integrated into the Statistical Models of Aging and Risk of Transition (SMART) database at the University of Kentucky.
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Affiliation(s)
- Wenjie Lou
- Department of Statistics, University of Kentucky.,Sanders-Brown Center on Aging, University of Kentucky
| | - Lijie Wan
- Department of Statistics, University of Kentucky.,Sanders-Brown Center on Aging, University of Kentucky
| | - Erin L Abner
- Department of Biostatistics, University of Kentucky.,Sanders-Brown Center on Aging, University of Kentucky.,Department of Epidemiology, University of Kentucky
| | - David W Fardo
- Department of Biostatistics, University of Kentucky.,Sanders-Brown Center on Aging, University of Kentucky
| | - Hiroko H Dodge
- Department of Neurology, C. Rex and Ruth H. Layton Center for Alzheimer's Research, Oregon Health and Science University.,Department of Neurology, Michigan Alzheimer's Disease Center, University of Michigan
| | - Richard J Kryscio
- Department of Statistics, University of Kentucky.,Department of Biostatistics, University of Kentucky.,Sanders-Brown Center on Aging, University of Kentucky
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6
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Abner EL, Kryscio RJ, Schmitt FA, Fardo DW, Moga DC, Ighodaro ET, Jicha GA, Yu L, Dodge HH, Xiong C, Woltjer RL, Schneider JA, Cairns NJ, Bennett DA, Nelson PT. Outcomes after diagnosis of mild cognitive impairment in a large autopsy series. Ann Neurol 2017; 81:549-559. [PMID: 28224671 DOI: 10.1002/ana.24903] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 02/20/2017] [Accepted: 02/20/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To determine clinical and neuropathological outcomes following a clinical diagnosis of mild cognitive impairment (MCI). METHODS Data were drawn from a large autopsy series (N = 1,337) of individuals followed longitudinally from normal or MCI status to death, derived from 4 Alzheimer Disease (AD) Centers in the United States. RESULTS Mean follow-up was 7.9 years. Of the 874 individuals ever diagnosed with MCI, final clinical diagnoses were varied: 39.2% died with an MCI diagnosis, 46.8% with a dementia diagnosis, and 13.9% with a diagnosis of intact cognition. The latter group had pathological features resembling those with a final clinical diagnosis of MCI. In terms of non-AD pathologies, both primary age-related tauopathy (p < 0.05) and brain arteriolosclerosis pathology (p < 0.001) were more severe in MCI than cognitively intact controls. Among the group that remained MCI until death, mixed AD neuropathologic changes (ADNC; ≥1 comorbid pathology) were more frequent than "pure" ADNC pathology (55% vs 22%); suspected non-Alzheimer pathology comprised the remaining 22% of cases. A majority (74%) of subjects who died with MCI were without "high"-level ADNC, Lewy body disease, or hippocampal sclerosis pathologies; this group was enriched in cerebrovascular pathologies. Subjects who died with dementia and were without severe neurodegenerative pathologies tended to have cerebrovascular pathology and carry the MCI diagnosis for a longer interval. INTERPRETATION MCI diagnosis usually was associated with comorbid neuropathologies; less than one-quarter of MCI cases showed "pure" AD at autopsy. Ann Neurol 2017;81:549-559.
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Affiliation(s)
- Erin L Abner
- Department of Epidemiology, University of Kentucky, Lexington, KY
| | | | | | - David W Fardo
- Department of Biostatistics, University of Kentucky, Lexington, KY
| | - Daniela C Moga
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY
| | - Eseosa T Ighodaro
- Department of Anatomy and Neurobiology, University of Kentucky, Lexington, KY
| | - Gregory A Jicha
- Department of Neurology, University of Kentucky, Lexington, KY
| | - Lei Yu
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | - Hiroko H Dodge
- Department of Neurology, Oregon Health & Science University, Portland, OR
| | - Chengjie Xiong
- Division of Biostatistics, Washington University, St Louis, MO
| | - Randall L Woltjer
- Department of Pathology, Oregon Health & Science University, Portland, OR
| | - Julie A Schneider
- Department of Pathology, Rush University Medical Center, Chicago, IL
| | - Nigel J Cairns
- Department of Neurology, Washington University, St Louis, MO
| | - David A Bennett
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | - Peter T Nelson
- Department of Pathology, University of Kentucky, Lexington, KY
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7
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Brenowitz WD, Keene CD, Hawes SE, Hubbard RA, Longstreth WT, Woltjer RL, Crane PK, Larson EB, Kukull WA. Alzheimer's disease neuropathologic change, Lewy body disease, and vascular brain injury in clinic- and community-based samples. Neurobiol Aging 2017; 53:83-92. [PMID: 28236716 PMCID: PMC5385292 DOI: 10.1016/j.neurobiolaging.2017.01.017] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/02/2017] [Accepted: 01/22/2017] [Indexed: 02/02/2023]
Abstract
We examined the relationships between Alzheimer's disease neuropathologic change (ADNC), Lewy body disease (LBD), and vascular brain injury (VBI) in 2 large autopsy samples. Because findings may differ between study populations, data came from U.S. Alzheimer's Disease Centers contributing to the National Alzheimer's Coordinating Center (n = 2742) and from the population-based Adult Changes in Thought study (n = 499). Regardless of study population, over 50% of participants with ADNC had co-occurring LBD or VBI; the majority of whom had a clinical AD dementia diagnosis prior to death. Overlap of pathologies was similar between studies, especially after standardizing to the distribution of age and dementia status in the Adult Changes in Thought population. LBD, but not VBI, was positively associated with ADNC in both studies. Interestingly, cortical LBD was more common in those with intermediate ADNC compared to low or high ADNC, especially in the National Alzheimer's Coordinating Center (p < 0.001). High prevalence of co-occurring neuropathologies among older adults with dementia has implications for accurate diagnosis of dementia etiologies and development of disease-modifying strategies.
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Affiliation(s)
- Willa D Brenowitz
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - C Dirk Keene
- Department of Pathology, University of Washington, Seattle, WA, USA
| | - Stephen E Hawes
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Rebecca A Hubbard
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - W T Longstreth
- Department of Epidemiology, University of Washington, Seattle, WA, USA; Department of Neurology, University of Washington, Seattle, WA, USA
| | - Randy L Woltjer
- Department of Pathology, Health Sciences University of Oregon, Portland, OR, USA
| | - Paul K Crane
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Eric B Larson
- Department of Medicine, University of Washington, Seattle, WA, USA; Group Health Research Institute, Seattle, WA, USA
| | - Walter A Kukull
- Department of Epidemiology, University of Washington, Seattle, WA, USA
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8
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Brenowitz WD, Hubbard RA, Keene CD, Hawes SE, Longstreth WT, Woltjer RL, Kukull WA. Mixed neuropathologies and estimated rates of clinical progression in a large autopsy sample. Alzheimers Dement 2016; 13:654-662. [PMID: 27870939 DOI: 10.1016/j.jalz.2016.09.015] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 08/27/2016] [Accepted: 09/29/2016] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Whether co-occurring neuropathologies interact or independently affect clinical disease progression is uncertain. We estimated rates of clinical progression and tested whether associations between clinical progression and Alzheimer's disease neuropathology (ADNP) were modified by co-occurring Lewy body disease (LBD) or vascular brain injury (VBI). METHODS Linear mixed effects models evaluated longitudinal trends in the Clinical Dementia Rating Scale Sum of Boxes on 2046 autopsied participants seen at a U.S. Alzheimer's Disease Center. RESULTS Annual clinical progression was slightly faster for ADNP + LBD compared with ADNP only (P = .06) and slightly slower for ADNP + VBI (P = .003). Differences in progression were less than expected if each neuropathology independently contributed to progression; ADNP interacted with LBD (P = .002) and VBI (P = .003). In secondary models, the effect of additional pathologies on clinical progression was greater in those with intermediate compared with high levels of ADNP. DISCUSSION The impact of co-occurring pathologies on progression may depend on severity of ADNP.
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Affiliation(s)
- Willa D Brenowitz
- National Alzheimer's Coordinating Center, University of Washington, Seattle, WA, USA.
| | - Rebecca A Hubbard
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, USA
| | - C Dirk Keene
- Department of Pathology, University of Washington, Seattle, WA, USA
| | - Stephen E Hawes
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - W T Longstreth
- National Alzheimer's Coordinating Center, University of Washington, Seattle, WA, USA; Department of Neurology, University of Washington, Seattle, WA, USA
| | - Randy L Woltjer
- Department of Pathology, Oregon Health and Science University, Portland, OR, USA
| | - Walter A Kukull
- National Alzheimer's Coordinating Center, University of Washington, Seattle, WA, USA
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Brodaty H, Woolf C, Andersen S, Barzilai N, Brayne C, Cheung KSL, Corrada MM, Crawford JD, Daly C, Gondo Y, Hagberg B, Hirose N, Holstege H, Kawas C, Kaye J, Kochan NA, Lau BHP, Lucca U, Marcon G, Martin P, Poon LW, Richmond R, Robine JM, Skoog I, Slavin MJ, Szewieczek J, Tettamanti M, Viña J, Perls T, Sachdev PS. ICC-dementia (International Centenarian Consortium - dementia): an international consortium to determine the prevalence and incidence of dementia in centenarians across diverse ethnoracial and sociocultural groups. BMC Neurol 2016; 16:52. [PMID: 27098177 PMCID: PMC4839126 DOI: 10.1186/s12883-016-0569-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 04/07/2016] [Indexed: 12/29/2022] Open
Abstract
Background Considerable variability exists in international prevalence and incidence estimates of dementia. The accuracy of estimates of dementia in the oldest-old and the controversial question of whether dementia incidence and prevalence decline at very old age will be crucial for better understanding the dynamics between survival to extreme old age and the occurrence and risk for various types of dementia and comorbidities. International Centenarian Consortium – Dementia (ICC-Dementia) seeks to harmonise centenarian and near-centenarian studies internationally to describe the cognitive and functional profiles of exceptionally old individuals, and ascertain the trajectories of decline and thereby the age-standardised prevalence and incidence of dementia in this population. The primary goal of the ICC-Dementia is to establish a large and thorough heterogeneous sample that has the power to answer epidemiological questions that small, separate studies cannot. A secondary aim is to examine cohort-specific effects and differential survivorship into very old age. We hope to lay the foundation for further investigation into risk and protective factors for dementia and healthy exceptional brain ageing in centenarians across diverse ethnoracial and sociocultural groups. Methods Studies focusing on individuals aged ≥95 years (approximately the oldest 1 percentile for men, oldest 5th percentile for women), with a minimum sample of 80 individuals, including assessment of cognition and functional status, are invited to participate. There are currently seventeen member or potential member studies from Asia, Europe, the Americas, and Oceania. Initial attempts at harmonising key variables are in progress. Discussion General challenges facing large, international consortia like ICC-Dementia include timely and effective communication among member studies, ethical and practical issues relating to human subject studies and data sharing, and the challenges related to data harmonisation. A specific challenge for ICC-Dementia relates to the concept and definition of’abnormal’ in this exceptional group of individuals who are rarely free of physical, sensory and/or cognitive impairments.
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Affiliation(s)
- Henry Brodaty
- Dementia Collaborative Research Centre - Assessment and Better Care, School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia.,Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia
| | - Claudia Woolf
- Dementia Collaborative Research Centre - Assessment and Better Care, School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia.,Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia.,Psychogeriatric Mental Health and Dementia Service, St Vincent's Hospital Sydney, Darlinghurst, Australia
| | - Stacy Andersen
- New England Centenarian Study, Geriatrics Section, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Nir Barzilai
- Department of Medicine, Albert Einstein College of Medicine, Bronx, USA.,Department of Genetics, Albert Einstein College of Medicine, Bronx, USA
| | - Carol Brayne
- Department of Public Health and Primary Care, Institute of Public Health, Cambridge University, Cambridge, UK
| | - Karen Siu-Lan Cheung
- Sau Po Centre on Ageing, The University of Hong Kong, Hong Kong, SAR, China.,Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, SAR, China
| | - Maria M Corrada
- Department of Neurology, University of California Irvine, Irvine, USA.,Department of Epidemiology, University of California Irvine, Irvine, USA
| | - John D Crawford
- Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia
| | - Catriona Daly
- Dementia Collaborative Research Centre - Assessment and Better Care, School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia.,Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia
| | - Yasuyuki Gondo
- Graduate School of Human Sciences, Clinical Thanatology and Geriatric Behavioral Science, Osaka University, Suita, Japan
| | - Bo Hagberg
- Gerontology Research Centre, Lund, Sweden
| | - Nobuyoshi Hirose
- Centre for Supercentenarian Research, Keio University School of Medicine, Tokyo, Japan
| | - Henne Holstege
- Department of Clinical Genetics, VU University Medical Centre, Amsterdam, The Netherlands.,Alzheimer Centre, Department of Neurology, VU University Medical Centre, Neuroscience Campus Amsterdam, Amsterdam, The Netherlands
| | - Claudia Kawas
- Department of Neurology, University of California Irvine, Irvine, USA.,Department of Neurobiology and Behavior, University of California Irvine, Irvine, USA
| | - Jeffrey Kaye
- Department of Neurology and Biomedical Engineering, Oregon Health and Science University, Portland, USA
| | - Nicole A Kochan
- Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia.,Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, Australia
| | - Bobo Hi-Po Lau
- Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, SAR, China
| | - Ugo Lucca
- Laboratory of Geriatric Neuropsychiatry, Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Gabriella Marcon
- Department of Medical and Biological Sciences, University of Udine, Udine, Italy.,AAS 1 Triestina, Trieste, Italy
| | - Peter Martin
- Department of Human Development and Family Studies, Iowa State University, Ames, USA
| | - Leonard W Poon
- Institute of Gerontology, University of Georgia, Athens, Georgia, USA
| | - Robyn Richmond
- School of Public Health and Community Medicine, UNSW Medicine, The University of New South Wales, Sydney, Australia
| | - Jean-Marie Robine
- National Institute on Health and Medical Research, INSERM, Paris, France
| | - Ingmar Skoog
- Department of Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Melissa J Slavin
- Dementia Collaborative Research Centre - Assessment and Better Care, School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia.,Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia
| | - Jan Szewieczek
- Department of Geriatrics, School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Mauro Tettamanti
- Laboratory of Geriatric Neuropsychiatry, Department of Neuroscience, IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - José Viña
- Department of Physiology, University of Valencia and INCLIVA, Valencia, Spain
| | - Thomas Perls
- New England Centenarian Study, Geriatrics Section, Department of Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Perminder S Sachdev
- Centre for Healthy Brain Ageing (CHeBA), School of Psychiatry, UNSW Medicine, The University of New South Wales, Sydney, Australia. .,Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, Australia.
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Abner EL, Nelson PT, Kryscio RJ, Schmitt FA, Fardo DW, Woltjer RL, Cairns NJ, Yu L, Dodge HH, Xiong C, Masaki K, Tyas SL, Bennett DA, Schneider JA, Arvanitakis Z. Diabetes is associated with cerebrovascular but not Alzheimer's disease neuropathology. Alzheimers Dement 2016; 12:882-9. [PMID: 26812281 DOI: 10.1016/j.jalz.2015.12.006] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/20/2015] [Accepted: 12/07/2015] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The relationship of diabetes to specific neuropathologic causes of dementia is incompletely understood. METHODS We used logistic regression to evaluate the association between diabetes and infarcts, Braak neurofibrillary tangle stage, and neuritic plaque score in 2365 autopsied persons. In a subset of >1300 persons with available cognitive data, we examined the association between diabetes and cognition using Poisson regression. RESULTS Diabetes increased odds of brain infarcts (odds ratio [OR] = 1.57, P < .0001), specifically lacunes (OR = 1.71, P < .0001), but not Alzheimer's disease neuropathology. Diabetes plus infarcts was associated with lower cognitive scores at end of life than infarcts or diabetes alone, and diabetes plus high level of Alzheimer's neuropathologic changes was associated with lower mini-mental state examination scores than the pathology alone. DISCUSSION This study supports the conclusions that diabetes increases the risk of cerebrovascular but not Alzheimer's disease pathology, and at least some of diabetes' relationship to cognitive impairment may be modified by neuropathology.
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Affiliation(s)
- Erin L Abner
- Sanders-Brown Center on Aging and Alzheimer's Disease Center, University of Kentucky, Lexington, KY, USA; College of Public Health, Department of Epidemiology, University of Kentucky, Lexington, KY, USA; College of Public Health, Department of Biostatistics, University of Kentucky, Lexington, KY, USA.
| | - Peter T Nelson
- Sanders-Brown Center on Aging and Alzheimer's Disease Center, University of Kentucky, Lexington, KY, USA; College of Medicine, Department of Pathology, University of Kentucky, Lexington, KY, USA
| | - Richard J Kryscio
- Sanders-Brown Center on Aging and Alzheimer's Disease Center, University of Kentucky, Lexington, KY, USA; College of Public Health, Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Frederick A Schmitt
- Sanders-Brown Center on Aging and Alzheimer's Disease Center, University of Kentucky, Lexington, KY, USA; College of Medicine, Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - David W Fardo
- Sanders-Brown Center on Aging and Alzheimer's Disease Center, University of Kentucky, Lexington, KY, USA; College of Public Health, Department of Biostatistics, University of Kentucky, Lexington, KY, USA
| | - Randall L Woltjer
- Layton Aging and Alzheimer's Disease Center, Oregon Health & Science University, Portland, OR, USA; School of Medicine, Department of Pathology, Oregon Health & Science University, Portland, OR, USA
| | - Nigel J Cairns
- Knight Alzheimer's Disease Research Center, Washington University, St. Louis, MO, USA; School of Medicine, Department of Neurology, Washington University, St. Louis, MO, USA
| | - Lei Yu
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA; Rush University Medical Center, Department of Neurological Sciences, Chicago, IL, USA
| | - Hiroko H Dodge
- Layton Aging and Alzheimer's Disease Center, Oregon Health & Science University, Portland, OR, USA; School of Medicine, Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Chengjie Xiong
- Knight Alzheimer's Disease Research Center, Washington University, St. Louis, MO, USA; School of Medicine, Division of Biostatistics, Washington University, St. Louis, MO, USA
| | - Kamal Masaki
- Kuakini Medical Center and John A. Burns School of Medicine, Department of Geriatric Medicine, University of Hawaii, Honolulu, HI, USA
| | - Suzanne L Tyas
- School of Public Health and Health Systems, Department of Psychology, University of Waterloo, Waterloo, ON, Canada
| | - David A Bennett
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA; Rush University Medical Center, Department of Neurological Sciences, Chicago, IL, USA
| | - Julie A Schneider
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA; Rush University Medical Center, Department of Pathology, Chicago, IL, USA
| | - Zoe Arvanitakis
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA; Rush University Medical Center, Department of Neurological Sciences, Chicago, IL, USA
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11
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Abner EL, Schmitt FA, Nelson PT, Lou W, Wan L, Gauriglia R, Dodge HH, Woltjer RL, Yu L, Bennett DA, Schneider JA, Chen R, Masaki K, Katz MJ, Lipton RB, Dickson DW, Lim KO, Hemmy LS, Cairns NJ, Grant E, Tyas SL, Xiong C, Fardo DW, Kryscio RJ. The Statistical Modeling of Aging and Risk of Transition Project: Data Collection and Harmonization Across 11 Longitudinal Cohort Studies of Aging, Cognition, and Dementia. OBSERVATIONAL STUDIES 2015; 1:56-73. [PMID: 25984574 PMCID: PMC4431579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Longitudinal cognitive trajectories and other factors associated with mixed neuropathologies (such as Alzheimer's disease with co-occurring cerebrovascular disease) remain incompletely understood, despite being the rule and not the exception in older populations. The Statistical Modeling of Aging and Risk of Transition study (SMART) is a consortium of 11 different high-quality longitudinal studies of aging and cognition (N=11,541 participants) established for the purpose of characterizing risk and protective factors associated with subtypes of age-associated mixed neuropathologies (N=3,001 autopsies). While brain donation was not required for participation in all SMART cohorts, most achieved substantial autopsy rates (i.e., > 50%). Moreover, the studies comprising SMART have large numbers of participants who were followed from intact cognition and transitioned to cognitive impairment and dementia, as well as participants who remained cognitively intact until death. These data provide an exciting opportunity to apply sophisticated statistical methods, like Markov processes, that require large, well-characterized samples. Thus, SMART will serve as an important resource for the field of mixed dementia epidemiology and neuropathology.
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Affiliation(s)
- E L Abner
- Snders-Brown Center on Aging, University of Kentucky
| | - F A Schmitt
- Oregon Center for Aging & Technology, Oregon Health & Science University
| | - P T Nelson
- Rush Alzheimer's Disease Center, Rush University Medical Center
| | | | - L Wan
- Department of Neurology, Albert Einstein College of Medicine
| | - R Gauriglia
- Department of Laboratory Medicine & Pathology, Mayo Clinic Jacksonville
| | - H H Dodge
- Department of Psychiatry, University of Minnesota
| | - R L Woltjer
- Alzheimer's Disease Research Center, Washington University
| | - L Yu
- School of Public Health and Health Systems, University of Waterloo
| | - D A Bennett
- College of Public Health, University of Kentucky
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12
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Gardner RC, Valcour V, Yaffe K. Dementia in the oldest old: a multi-factorial and growing public health issue. ALZHEIMERS RESEARCH & THERAPY 2013; 5:27. [PMID: 23809176 PMCID: PMC3706944 DOI: 10.1186/alzrt181] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The population of oldest old, or people aged 85 and older, is growing rapidly. A better understanding of dementia in this population is thus of increasing national and global importance. In this review, we describe the major epidemiological studies, prevalence, clinical presentation, neuropathological and imaging features, risk factors, and treatment of dementia in the oldest old. Prevalence estimates for dementia among those aged 85+ ranges from 18 to 38%. The most common clinical syndromes are Alzheimer's dementia, vascular dementia, and mixed dementia from multiple etiologies. The rate of progression appears to be slower than in the younger old. Single neuropathological entities such as Alzheimer's dementia and Lewy body pathology appear to have declining relevance to cognitive decline, while mixed pathology with Alzheimer's disease, vascular disease (especially cortical microinfarcts), and hippocampal sclerosis appear to have increasing relevance. Neuroimaging data are sparse. Risk factors for dementia in the oldest old include a low level of education, poor mid-life general health, low level of physical activity, depression, and delirium, whereas apolipoprotein E genotype, late-life hypertension, hyperlipidemia, and elevated peripheral inflammatory markers appear to have less relevance. Treatment approaches require further study, but the oldest old may be more prone to negative side effects compared with younger patients and targeted therapies may be less efficacious since single pathologies are less frequent. We also highlight the limitations and challenges of research in this area, including the difficulty of defining functional decline, a necessary component for a dementia diagnosis, the lack of normative neuropsychological data, and other shortcomings inherent in existing diagnostic criteria. In summary, our understanding of dementia in the oldest old has advanced dramatically in recent years, but more research is needed, particularly among varied racial, ethnic, and socioeconomic groups, and with respect to biomarkers such as neuroimaging, modifiable risk factors, and therapy.
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Affiliation(s)
- Raquel C Gardner
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, 675 Nelson Rising Lane - Box 1207, San Francisco, CA 94158, USA
| | - Victor Valcour
- Department of Neurology, Memory and Aging Center, University of California, San Francisco, 675 Nelson Rising Lane - Box 1207, San Francisco, CA 94158, USA ; Division of Geriatric Medicine, Department of Medicine, University of California, San Francisco, 675 Nelson Rising Lane - Box 1207, San Francisco, CA 94158, USA
| | - Kristine Yaffe
- Department of Psychiatry, Neurology, Epidemiology and Biostatistics, School of Medicine, University of California, 4150 Clement Street - Box 181, San Francisco, CA 94121, USA ; Veterans Affairs Medical Center, 4150 Clement Street - Box 181, San Francisco, CA 94121, USA
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13
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Cosentino S, Schupf N, Christensen K, Andersen SL, Newman A, Mayeux R. Reduced prevalence of cognitive impairment in families with exceptional longevity. JAMA Neurol 2013; 70:867-74. [PMID: 23649824 PMCID: PMC4151346 DOI: 10.1001/jamaneurol.2013.1959] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Family studies of centenarians and long-lived persons have found substantial familial aggregation of survival to extreme ages; however, the extent to which such familial longevity is characterized by cognitively intact survival is not established. OBJECTIVE To determine whether families with exceptional longevity are protected against cognitive impairment consistent with Alzheimer disease. DESIGN Cross-sectional analysis. SETTING Multisite study in New York, Massachusetts, Pennsylvania, and Denmark. PARTICIPANTS A total of 1870 individuals (1510 family members and 360 spouse controls) recruited through the Long Life Family Study. MAIN OUTCOME AND MEASURE Prevalence of cognitive impairment based on a diagnostic algorithm validated using the National Alzheimer's Coordinating Center data set. RESULTS The cognitive algorithm classified 546 individuals (38.5%) as having cognitive impairment consistent with Alzheimer disease. Long Life Family Study probands had a slightly but not statistically significant reduced risk of cognitive impairment compared with spouse controls (121 of 232 for probands vs 45 of 103 for spouse controls; odds ratio = 0.7; 95% CI, 0.4-1.4), whereas Long Life Family Study sons and daughters had a clearly reduced risk of cognitive impairment (11 of 213 for sons and daughters vs 28 of 216 for spouse controls; odds ratio = 0.4; 95% CI, 0.2-0.9). Restriction to nieces and nephews in the offspring generation attenuated this effect (37 of 328 for nieces and nephews vs 28 of 216 for spouse controls; odds ratio = 0.8; 95% CI, 0.4-1.4). CONCLUSIONS AND RELEVANCE Rates of cognitive impairment characteristic of Alzheimer disease were relatively high. In the proband generation, rates were comparable across family members and spouse controls, whereas sons and daughters of probands had significantly lower rates than spouse controls. Results suggest a delayed onset of cognitive impairment in families with exceptional longevity, but assessment of age-specific incidence rates is required to confirm this hypothesis.
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Affiliation(s)
- Stephanie Cosentino
- Gertrude H. Sergievsky Center, Columbia University, New York, NY
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University, New York, NY
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Nicole Schupf
- Gertrude H. Sergievsky Center, Columbia University, New York, NY
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Kaare Christensen
- The Danish Aging Research Center, University of Southern Denmark and the Department of Clinical Genetics, and Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense C, Denmark
| | - Stacy L. Andersen
- Geriatrics Section, School of Medicine, Boston University and Boston Medical Center, Boston, MA
| | - Anne Newman
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Richard Mayeux
- Gertrude H. Sergievsky Center, Columbia University, New York, NY
- Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Columbia University, New York, NY
- Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Balldin VH, Hall JR, Barber RC, Hynan L, Diaz-Arrastia R, O'Bryant SE. The Relation between Inflammation and Neuropsychological Test Performance. Int J Alzheimers Dis 2012; 2012:703871. [PMID: 23008797 PMCID: PMC3449133 DOI: 10.1155/2012/703871] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 07/25/2012] [Accepted: 08/03/2012] [Indexed: 11/18/2022] Open
Abstract
Background. Considerable research documents an association between pro- and anti-inflammatory markers and Alzheimer's disease (AD), yet the differential relation between these markers and neuropsychological functioning in AD and nondemented controls has received less attention. The current study sought to evaluate the relationship between peripheral markers of inflammation (both pro- and anti-inflammatory) and neuropsychological functioning through the Texas Alzheimer's Research and Care Consortium (TARCC) cohort. Methods. There were 320 participants (Probable AD n = 124, Controls n = 196) in the TARCC Longitudinal Research Cohort available for analysis. Regression analyses were utilized to examine the relation between proinflammatory and anti-inflammatory markers and neuropsychological functioning. Follow-up analyses were conducted separately by case versus control status. Results. Proinflammatory and anti-inflammatory markers were found to be associated with neuropsychological testing. Third tertile proinflammatory markers were negatively associated with measures of attention and language, and anti-inflammatory markers were positively associated with measures of immediate verbal memory and delayed verbal and visual memory. Conclusions. These findings support the link between peripheral inflammatory markers and neuropsychological functioning and suggest the utility of examining profiles of inflammatory markers in the future.
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Affiliation(s)
- Valerie H. Balldin
- Psychology Service, South Texas Veterans Healthcare System, San Antonio, TX 78229, USA
| | - James R. Hall
- Department of Psychiatry & Behavioral Health, University of North Texas Health Science Center, Fort Worth, TX 76107, USA
| | - Robert C. Barber
- Department of Pharmacology & Neurosicence, University of North Texas Health Science Center, Fort Worth, TX 76107, USA
| | - Linda Hynan
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Sid E. O'Bryant
- Department of Internal Medicine, University of North Texas Health Science Center, Fort Worth, TX 76107, USA
- Institute for Aging and Alzheimer's Disease Research, University of North Texas Health Sciences Center, Fort Worth, TX 76107, USA
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Qu B, Li X, Liu J, Mao J. Analysis of the Current Situation Regarding the Aging Rural Population in China and Proposed Countermeasures. Popul Health Manag 2012; 15:181-5. [DOI: 10.1089/pop.2011.0033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Bo Qu
- Department of Epidemiology and Statistics, School of Public Health, China Medical University, Shenyang, People's Republic of China
| | - Xiyuan Li
- Students' Affairs Division, China Medical University, Shenyang, People's Republic of China
| | - Jie Liu
- Department of Epidemiology and Statistics, School of Public Health, China Medical University, Shenyang, People's Republic of China
| | - Jiawen Mao
- Center of Health Statistics, Ministry of Health, Beijing, People's Republic of China
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