Fast cognitive decline at the time of dementia diagnosis: a major prognostic factor for survival in the community

Predictors for survival in patients with Alzheimer's disease: a large comprehensive meta-analysis

The prevalence of Alzheimer's disease (AD) is increasing as the population ages, and patients with AD have a poor prognosis. However, knowledge on factors for predicting the survival of AD remains sparse. Here, we aimed to systematically explore predictors of AD survival. We searched the PubMed, Embase and Cochrane databases for relevant literature from inception to December 2022. Cohort and case-control studies were selected, and multivariable adjusted relative risks (RRs) were pooled by random-effects models. A total of 40,784 reports were identified, among which 64 studies involving 297,279 AD patients were included in the meta-analysis after filtering based on predetermined criteria. Four aspects, including demographic features (n = 7), clinical features or comorbidities (n = 13), rating scales (n = 3) and biomarkers (n = 3), were explored and 26 probable prognostic factors were finally investigated for AD survival. We observed that AD patients who had hyperlipidaemia (RR: 0.69) were at a lower risk of death. In contrast, male sex (RR: 1.53), movement disorders (including extrapyramidal signs) (RR: 1.60) and cancer (RR: 2.07) were detrimental to AD patient survival. However, our results did not support the involvement of education, hypertension, APOE genotype, Aβ42 and t-tau in AD survival. Our study comprehensively summarized risk factors affecting survival in patients with AD, provided a better understanding on the role of different factors in the survival of AD from four dimensions, and paved the way for further research.

Serum brain-derived neurotrophic factor levels as a predictor for Alzheimer disease progression

BACKGROUND

Brain-derived neurotrophic factor (BDNF) has been implicated in the pathophysiology of Alzheimer's disease (AD), and decreased peripheral levels of this protein are associated with an increased risk of developing the disease. This study focuses on whether serum BDNF levels could be used as a predictor of AD progression.

METHODS

In this longitudinal observational study, we recruited cognition normal participants (N = 98) and AD (N = 442) from the Clinic at the Taipei Veterans General Hospital. We conducted a mini-mental status exam, a 12-item memory test, a categorical verbal fluency test, and a modified 15-item Boston naming test. A Serum BDNF level and apolipoprotein E ( APOE ) allele status were measured. The AD patients were followed prospectively. Based on the difference of MMSE scores, these patients were divided into fast decliners (decline ≥ 3/y) and slow decliners (MMSE decline < 3/y). Logistic regression was conducted to examine the impact of serum BDNF levels and other factor on the likelihood of AD patients being slow decliners. Pearson's correlation was used to estimate the relationship between serum BDNF levels and the score of neuropsychological tests.

RESULTS

In a logistic regression model containing serum BDNF levels, age, sex, APOE4 carrier status, education levels, and baseline MMSE score, higher serum BDNF levels were associated with a slower rate of cognitive decline in the AD group. Serum BDNF levels positively correlated with the results of multiple neuropsychological tests.

CONCLUSION

BDNF is a protective factor against AD progression and likely plays a role in establishing a link between AD pathology and clinical manifestations.

Disease progression and costs at the 3-year follow-up of the GERAS-US study

Introduction

GERAS-US prospectively characterized clinical and economic outcomes of early symptomatic Alzheimer's disease (AD). Societal cost changes were examined in amyloid-positive patients with mild cognitive impairment due to AD (MCI) and mild dementia due to AD (MILD).

Methods

Cognition, function, and caregiver burden were assessed using Mini-Mental State Examination (MMSE), Cognitive Function Index (CFI), and Zarit Burden Interview, respectively. Costs are presented as least square mean for the overall population and for MCI versus MILD using mixed model repeated measures.

Results

MMSE score and CFI worsened. Total societal costs (dollars/month) for MCI and MILD, respectively, were higher at baseline ($2430 and $4063) but steady from 6 ($1977 and $3032) to 36 months ($2007 and $3392). Direct non-medical costs rose significantly for MILD. Caregiver burden was higher for MILD versus MCI at 12, 18, and 24 months.

Discussion

Function and cognition declined in MILD. Non-medical costs reflect the increasing impact of AD even in its early stages.

HIGHLIGHTS

In the GERAS-US study, total societal costs for patients with mild cognitive impairment due to Alzheimer's disease (MCI) and mild dementia due to Alzheimer's disease (MILD) were higher at baseline but steady from 6 to 36 months.Mini-Mental State Examination (MMSE) and Cognitive Function Index (CFI) worsened; the rate of decline was significant for patients with MILD but not for those with MCI.There was a rise in direct non-medical costs at 36 months for patients with MILD.Caregiver burden was higher for MILD versus MCI at 12, 18, and 24 months.Slowing the rate of disease progression in this early symptomatic population may allow patients to maintain their ability to carry out everyday activities longer.

The Multidimensional Prognostic Index Predicts Mortality in Older Outpatients with Cognitive Decline

Since the heterogeneity of the growing group of older outpatients with cognitive decline, it is challenging to evaluate survival rates in clinical shared decision making. The primary outcome was to determine whether the Multidimensional Prognostic Index (MPI) predicts mortality, whilst assessing the MPI distribution was considered secondary. This retrospective chart review included 311 outpatients aged ≥65 years and diagnosed with dementia or mild cognitive impairment (MCI). The MPI includes several domains of the comprehensive geriatric assessment (CGA). All characteristics and data to calculate the risk score and mortality data were extracted from administrative information in the database of the Alzheimer’s Center and medical records. The study population (mean age 76.8 years, men = 51.4%) was divided as follows: 34.1% belonged to MPI category 1, 52.1% to MPI category 2 and 13.8% to MPI category 3. Patients with dementia have a higher mean MPI risk score than patients with MCI (0.47 vs. 0.32; p < 0.001). The HRs and corresponding 95% CIs for mortality in patients in MPI categories 2 and 3 were 1.67 (0.81−3.45) and 3.80 (1.56−9.24) compared with MPI category 1, respectively. This study shows that the MPI predicts mortality in outpatients with cognitive decline.

Sex differences in risk factors for cognitive decline and dementia, including death as a competing risk, in individuals with diabetes: Results from the ADVANCE trial

AIM

To estimate the associations between risk factors and cognitive decline (CD)/dementia, and the sex differences in these risk factors in individuals with type 2 diabetes, while accounting for the competing risk of death.

MATERIALS AND METHODS

The Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) trial of 11,140 individuals with type 2 diabetes was used to estimate the odds of CD/dementia using multinomial logistic regression.

RESULTS

During a median 5-year follow-up, 1827 participants (43.2% women) had CD/dementia (1718 with CD only; 21 with dementia only; 88 with CD and dementia), and 929 (31.0% women) died without CD/dementia. Women had lower odds of CD/dementia than men (odds ratio [OR] [95% confidence interval], 0.88 [0.77, 1.00]); older age, higher total cholesterol, HbA1c, waist circumference, waist-to-height ratio, moderately increased albumin-creatinine ratio, stroke/transient ischaemic attack and retinal disease were each associated with greater odds of CD/dementia; higher years at education completion, baseline cognitive function, taller stature and current alcohol use were inversely associated. Higher waist circumference (women-to-men ratio of ORs [ROR], 1.05 [1.00, 1.10] per 5 cm) and presence of anxiety/depression (ROR, 1.28 [1.01, 1.63]) were associated with greater ORs for CD/dementia in women than men.

CONCLUSIONS

Several risk factors were associated with CD/dementia. Higher waist circumference and mental health symptoms were more strongly associated with CD/dementia in women than men. Further studies should examine the mechanisms that underlie these sex differences.

Association of COVID-19 Pandemic and Rate of Cognitive Decline in Patients with Dementia and Mild Cognitive Impairment: A Cross-sectional Study

Introduction: Since the declaration of coronavirus disease 2019 (COVID-19) as a pandemic, patients with dementia, were specifically vulnerable to the negative impact of the outbreak. Objective: To examine the association between lockdown amid COVID-19 pandemic and the rate of cognitive decline among patients with dementia and mild cognitive impairment (MCI). Methods: We conducted a cross-sectional observational study on patients with dementia and MCI who attended the outpatient clinic at Ibn Sina Hospital, the main tertiary neurology center in Kuwait, during the month of September 2020. The rate of cognitive decline, estimated by MMSE scores, was compared between the period prior to, and during lockdown. Results: We evaluated 36 consecutive patients with cognitive impairment (23 females [63.9%], mean age 71 ± 10.8 years, mean disease duration 34.6 ± 29 months). Eleven patients (30.6%) progressed to a more severe stage during the study period; 1 MCI (2.8%) converted to mild dementia, 6 (16.6%) mild to moderate, and 4 (11.1%) moderate to severe dementia. Monthly decline of MMSE scores before lockdown was 0.2 ± 0.1 points, while it was 0.53 ± 0.3 points during lockdown, which was statistically significant (p = .001). The most affected cognitive domain was the memory with a mean decline of 1.5 ± 0.8 points. Conclusions: This study provides “real-world” data suggesting rapid cognitive decline in patients with dementia during the lockdown period. Healthcare systems should pay more attention to this vulnerable group, to help them maintain their mental, physical and social well-being during this crisis.

Factors associated with slow progression of cognitive impairment following first dementia diagnosis

OBJECTIVES

To investigate the extent to which slow progression of dementia after diagnosis might be predicted from routine longitudinal healthcare data, in order to clarify characteristics of people who experience this outcome.

METHODS

A retrospective observational study was conducted using data from the South London and Maudsley NHS Foundation Trust Biomedical Research Centre Case Register. This study included all patients receiving a first dementia diagnosis between 2006 and 2017, restricted to those with a baseline Mini-Mental State Examination (MMSE) score within 6 months of initial diagnosis of dementia and at least one MMSE score after 3 years post-diagnosis. Slow progression was defined as a change in MMSE score of -1, 0 or an increase at the follow-up point. This group was compared to the remainder with an MMSE decline of -2 or more.

RESULTS

Overall, 682 patients with slow progression were compared to 1045 with faster progression. In the confounder-adjusted multivariate logistic regression model, slow progression was more likely in younger patients (age 65-74 years; odds ratio: 1.18; 95% confidence intervals: 1.04-1.37), males (1.24; 1.01-1.53), those with moderate or severe dementia according to MMSE, patients with mixed-type dementia (2.06; 1.11-3.82) compared to Alzheimer's disease and less likely in those receiving acetylcholinesterase inhibitor (AChEI) treatment (0.57; 0.46-0.71).

CONCLUSION

Slow dementia progression after diagnosis was common in patients with mixed Alzheimer's and vascular dementia, younger age, males and non-receipt of AChEIs, possibly suggesting non-Alzheimer pathologies and clarifying such predictors is important, as there is currently very limited information on which to base prognosis estimates in post-diagnosis counselling.

Survival time tool to guide care planning in people with dementia

OBJECTIVE

To develop survival prediction tables to inform physicians and patients about survival probabilities after the diagnosis of dementia and to determine whether survival after dementia diagnosis can be predicted with good accuracy.

METHODS

We conducted a nationwide registry-linkage study including 829 health centers, i.e., all memory clinics and ≈75% of primary care facilities, across Sweden. Data including cognitive function from 50,076 people with incident dementia diagnoses ≥65 years of age and registered with the Swedish Dementia Register in 2007 to 2015 were used, with a maximum follow-up of 9.7 years for survival until 2016. Sociodemographic factors, comorbidity burden, medication use, and dates of death were obtained from nationwide registries. Cox proportional hazards regression models were used to create tables depicting 3-year survival probabilities for different risk factor profiles.

RESULTS

By August 2016, 20,828 (41.6%) patients in our cohort had died. Median survival time from diagnosis of dementia was 5.1 (interquartile range 2.9-8.0) years for women and 4.3 (interquartile range 2.3-7.0) years for men. Predictors of mortality were higher age, male sex, increased comorbidity burden and lower cognitive function at diagnosis, a diagnosis of non-Alzheimer dementia, living alone, and using more medications. The developed prediction tables yielded c indexes of 0.70 (95% confidence interval [CI] 0.69-0.71) to 0.72 (95% CI 0.71-0.73) and showed good calibration.

CONCLUSIONS

Three-year survival after dementia diagnosis can be predicted with good accuracy. The survival prediction tables developed in this study may aid clinicians and patients in shared decision-making and advance care planning.

Mortality of Alzheimer's Disease Patients: A 10-Year Follow-up Pilot Study in Shanghai

BACKGROUND

Identifying risk factors and mortality of individuals with Alzheimer's disease (AD) could have important implications for the clinical management of AD.

OBJECTIVE

This pilot study aimed to examine the overall mortality of AD patients over a 10-year surveillance period in Shanghai, China. This study is an extension of our previous investigation on mortality of neurodegenerative diseases.

METHODS

One hundred and thirty-two AD patients recruited from the memory clinics of two hospitals in Shanghai in 2007 were followed up until December 31, 2017 or death, representing a follow-up period of up to 10 years. Overall standardized mortality ratios (SMRs) were calculated, and predictors for survival at recruitment were estimated.

RESULTS

Sixty-seven patients had died by December 31, 2017, and the SMR at 10 years of follow-up was 1.225 (95% confidence interval 0.944-1.563). Employing Cox's proportional hazard modeling, lower Mini-Mental State Examination score, and comorbid diabetes predicted poor survival in this cohort.

CONCLUSION

This pilot study suggests a similar survival trend of patients with AD compared to the general population in Shanghai urban region. Poor cognitive status and comorbid diabetes had a negative impact on the survival of AD patients.

Effect of Physical Activity on the Progression of Alzheimer's Disease: The Clinical Research Center for Dementia of South Korea Study

BACKGROUND

There is a lack of research on the effects of physical activity (PA) on the progression of Alzheimer's disease (AD).

OBJECTIVES

We investigated whether PA is associated with progression of dementia and mortality in AD.

METHODS

In the present study, 934 patients with mild-to-moderate AD were included. PA was evaluated using a questionnaire written by the caregiver. The outcome measures were the Clinical Dementia Rating-Sum of Boxes (CDR-SB), Seoul-Instrumental Activities of Daily Living (S-IADL), Caregiver-Administered Neuropsychiatric Inventory (CGA-NPI), a global composite score of neuropsychological subtests, and mortality. They were evaluated annually and received a maximum of three follow-up examinations.

RESULTS

Between-group differences compared with the no PA group in the change of CDR-SB scores were -0.431 (95% CI = -0.824∼-0.039; p = 0.031) for the moderate PA group (150-750 minutes per week of moderate intensity PA), and -1.148 (-1.656∼-0.639; p < 0.001) for the high PA group (>750 minutes per week). As PA increased, there was a significant trend to slow the rate of increase in the CDR-SB, S-IADL, and CGA-NPI scores. The patients with ≥150 minutes per week for each of non-recreational and recreational PAs had a lower risk of mortality compared to those with <150 minutes per week for each of the PAs (hazard ratio 0.22, 95% CI = 0.05∼0.88; p = 0.033).

CONCLUSION

More PA is associated with slower progression of dementia severity, functional decline, and abnormal behavior, and with a lower risk of mortality in AD.

Evaluating trajectories of episodic memory in normal cognition and mild cognitive impairment: Results from ADNI

BACKGROUND

Memory assessment is a key factor for the diagnosis of cognitive impairment. However, memory performance over time may be quite heterogeneous within diagnostic groups.

METHOD

To identify latent trajectories in memory performance and their associated risk factors, we analyzed data from Alzheimer's Disease Neuroimaging Initiative (ADNI) participants who were classified either as cognitively normal or as Mild Cognitive Impairment (MCI) at baseline and were administered the Rey Auditory Verbal Learning test (RAVLT) for up to 9 years. Group-based trajectory modeling on the 30-minute RAVLT delayed recall score was applied separately to the two baseline diagnostic groups.

RESULTS

There were 219 normal subjects with mean age 75.9 (range from 59.9 to 89.6) and 52.5% male participants, and 372 MCI subjects with mean age 74.8 (range from 55.1 to 89.3) and 63.7% male participants included in the analysis. For normal subjects, six trajectories were identified. Trajectories were classified into three types, determined by the shape, each of which may comprise more than one trajectory: stable (~30% of subjects), curvilinear decline (~ 28%), and linear decline (~ 42%). Notably, none of the normal subjects assigned to the stable stratum progressed to dementia during the study period. In contrast, all trajectories identified for the MCI group tended to decline, although some participants were later re-diagnosed with normal cognition. Age, sex, and education were significantly associated with trajectory membership for both diagnostic groups, while APOE ɛ4 was only significantly associated with trajectories among MCI participants.

CONCLUSION

Memory trajectory is a strong indicator of dementia risk. If likely trajectory of memory performance can be identified early, such work may allow clinicians to monitor or predict progression of individual patient cognition. This work also shows the importance of longitudinal cognitive testing and monitoring.

The Pathology of Rapid Cognitive Decline in Clinically Diagnosed Alzheimer's Disease

BACKGROUND

Variable rate of cognitive decline among individuals with Alzheimer's disease (AD) is an important consideration for disease management, but risk factors for rapid cognitive decline (RCD) are without consensus.

OBJECTIVE

To investigate demographic, clinical, and pathological differences between RCD and normal rates of cognitive decline (NCD) in AD.

METHODS

Neuropsychology test and autopsy data was pulled from the National Alzheimer's Coordinating Center database from individuals with a clinical diagnosis of AD. Individuals with average decline of 3 or more points on the Mini-Mental Status Examination (MMSE) per year over 3 years were labeled RCD; all others were NCD.

RESULTS

Sixty individuals identified as RCD; 230 as NCD. These neuropsychology tests differed at baseline (RCD versus NCD): WMS-LM Immediate Recall (4.35[3.39] versus 6.31[3.97], p < 0.001), Animal Naming (12.1[4.83] versus 13.9[4.83], p = 0.007), TMT Part B (187[86.1] versus 159[79.0], p = 0.02), WAIS-Digit Symbol (29.5[11.3] versus 29.5[11.3], p = 0.04), and the BNT (21.5[7.05] versus 23.6[5.09], p = 0.04). RCD had more thyroid disease (30% versus 16%, p = 0.01) and greater usage of AD medication at baseline (80% versus 62%, p = 0.01). RCD had more severe cerebral amyloid angiopathy (1.62[1.0] versus 1.13[1.0], p = 0.002), more neocortical Lewy bodies (20% versus 10%, p = 0.04), and more atrophy (1.54[0.92] versus 1.17[0.83], p = 0.04). A model combining select variables was significant above chance (χ2 = 25.8, p = 0.002), but not to clinical utility (AUC < 0.70; 95% CI).

CONCLUSION

Individuals with RCD have more severe pathology, more comorbidities, and lower baseline neuropsychology test scores of language and executive function.

Predictors of Rapid Cognitive Decline in Patients with Mild-to-Moderate Alzheimer Disease: A Prospective Cohort Study with 12-Month Follow-Up Performed in Memory Clinics

BACKGROUND/AIMS

Alzheimer disease (AD) is particularly devastating, with no cure, no means of prevention, and no proven way to slow progression. AD is associated with the worsening of cognitive function attributable to a variety of factors of which little is known. Our main objective was to determine factors associated with rapid cognitive decline (RCD) in older AD patients.

METHODS

We conducted a 12-month, prospective, multi-centre cohort study. Community-living individuals aged ≥65 years with mild-to-moderate AD were included. RCD was defined as the loss of ≥3 points/year in the Mini-Mental State Examination (MMSE) score. Potential individual-level predictors were collected at baseline.

RESULTS

A total of 521 individuals were included. The mean age was 80.8 ± 9.0 years and 66.0% were females. The average baseline MMSE score was 20.5 ± 4.5. The incidence of RCD was 40.9% (95% confidence interval [CI], 36.7-45.1). RCD was more common in patients with moderate (53.5%) than mild (22.3%) AD. The factors associated with RCD were: a parental history of dementia (odds ratio [OR], 2.32 [95% CI, 1.24-4.21], p = 0.011), psychotic symptoms (OR, 2.06 [95% CI, 1.22-3.48], p = 0.007), malnutrition (OR, 1.61 [95% CI, 1.06-2.63], p = 0.028), and the female gender (OR, 1.48 [95% CI, 1.03-2.15], p = 0.036). An MMSE score < 20 at treatment onset was also associated with RCD (p < 0.001).

CONCLUSION

The factors associated with RCD were an MMSE score < 20 at treatment onset, female gender, psychotic symptoms, malnutrition, and a family history of dementia. These results may be directly relevant to patients, their families, and their physicians, enabling early anticipation of difficult clinical trajectories and poor functional outcomes.

Slow gait speed as a predictor of 1-year cognitive decline in a veterans' retirement community in southern Taiwan

AIM

Slow gait speed has been associated with mortality, poor physical function and disability in older people. Our aim was to evaluate the association between slow gait speed and rapid cognitive decline among oldest-old men in Taiwan.

METHODS

We carried out a longitudinal cohort study in a veterans' retirement community, and enrolled 249 male residents aged 80 years and older. Slow gait speed was defined as <1 m/s, and rapid cognitive decline was defined as a Mini-Mental State Examination (MMSE) decline of ≥3 points over 1 year. Body mass index, Charlson's Comorbidity Index, handgrip strength, gait speed and Mini-Mental State Examination datasets were collected, and a logistic regression model was built to evaluate the association between fast cognitive decline and slow gait speed.

RESULTS

In all, 249 residents (mean age 86.4 ± 4.01 years) were recruited, including 58 (23.3%) with rapid cognitive decline. Univariate analysis showed that slow gait speed could predict rapid cognitive decline (OR 4.10, 95% CI 1.20-14.00, P = 0.024). After adjusting for age, Charlson's Comorbidity Index, polypharmacy, psychiatric drug usage, cigarette smoking experience, baseline cognitive function, depressive mood, handgrip strength, nutritional status and history of fall, slow gait speed was still independently associated with rapid cognitive decline (adjusted OR 4.58, 95% CI 1.22-17.2, P = 0.024).

CONCLUSIONS

Slow gait speed was thus an independent predictor of rapid cognitive decline in oldest-old men in a veterans' retirement community in Taiwan. Geriatr Gerontol Int 2017: 17 (Suppl. 1): 14-19.

Diagnostic Accuracy of a Combined Analysis of Cerebrospinal Fluid t-PrP, t-tau, p-tau, and Aβ42 in the Differential Diagnosis of Creutzfeldt-Jakob Disease from Alzheimer's Disease with Emphasis on Atypical Disease Variants

According to recent studies, the determination of cerebrospinal fluid (CSF) total tau (t-tau)/phosphorylated tau (p-tau) ratio and total prion protein (t-PrP) levels significantly improves the accuracy of the diagnosis of Alzheimer’s disease (AD) in atypical cases with clinical or laboratory features mimicking Creutzfeldt-Jakob disease (CJD). However, this has neither been validated nor tested in series including atypical CJD variants. Furthermore, the added diagnostic value of amyloid-β (Aβ)₄₂ remains unclear. To address these issues, we measured t-PrP, 14-3-3, t-tau, p-tau, and Aβ₄₂ CSF levels in 45 typical and 44 atypical/rapidly progressive AD patients, 54 typical and 54 atypical CJD patients, and 33 controls. CJD patients showed significantly lower CSF t-PrP levels than controls and AD patients. Furthermore, atypical CJD was associated with lower t-PrP levels in comparison to typical CJD. T-tau, 14-3-3, or t-PrP alone yielded, respectively, 80.6, 63.0, and 73.0% sensitivity and 75.3, 92.1, and 75% specificity in distinguishing AD from CJD. On receiver operating characteristic (ROC) curve analyses of biomarker combinations, the (t-tau×Aβ₄₂)/(p-tau×t-PrP) ratio achieved the best accuracy, with 98.1% sensitivity and 97.7% specificity overall, and 96.2% sensitivity and 95.5% specificity for the “atypical” disease groups. Our results show that the combined analysis of CSF t-PrP, t-tau, p-tau, and Aβ₄₂ is clinically useful in the differential diagnosis between CJD and AD. Furthermore, the finding of reduced CSF t-PrP levels in CJD patients suggest that, likewise Aβ₄₂ in AD, CSF t-PrP levels reflect the extent of PrP^c conversion into abnormal PrP (PrP^Sc) and the burden of PrP^Sc deposition in CJD.

Predictors of Mortality in Dementia: The PRIME Study

BACKGROUND

Dementia is a terminal illness. While various baseline characteristics of patients, such as age, sex, and dementia severity, are known to predict mortality, little research has examined how changes in patients' symptoms over time predict survival. There are also limited data on patients seen in memory clinics, as opposed to other health care settings, and whether antipsychotic medications are associated with mortality in dementia once patients' demographic and clinical features are controlled for.

OBJECTIVE

To identify predictors of mortality in patients with dementia.

METHOD

Of 970 patients recruited from nine memory clinics around Australia, 779 patients had dementia at baseline. Patients completed measures of dementia severity, cognition, functional ability, neuropsychiatric symptoms, caregiver burden, and medication use at baseline and at regular intervals over a three-year period. Mortality data were obtained from state registries eight years after baseline.

RESULTS

Overall, 447 (57.4%) of the patients with dementia died within the eight years. Older age, male sex, more severe dementia and functional impairment at baseline, greater decline in dementia severity and functional impairment over six months, taking a larger number of medications, and use of atypical antipsychotic medication predicted earlier mortality.

CONCLUSIONS

The findings confirm that demographic and diagnostic features predict the survival of patients with dementia. Importantly, the findings indicate that changes in dementia severity and functional impairment over time predict mortality independently of baseline levels, and provide further evidence for the higher mortality risk of patients taking antipsychotic medications.

The Progression of Alzheimer's Disease: Are Fast Decliners Really Fast? A Four-Year Follow-Up

Background: The rate of cognitive and functional decline in Alzheimer’s disease (AD) changes across individuals.

Objectives: Our purpose was to assess whether the concept of “fast decline” really fits its definition and whether cognitive and functional variables at onset can predict the progression of AD.

Methods: 324 AD patients were included. We retrospectively examined their Mini-Mental State Examination (MMSE) total score and sub-items, Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL) at baseline and every six months for a 4-year follow-up. Patients were divided into “fast decliners” (n = 62), defined by a loss ≥5 points on the MMSE score within the first year from the baseline; “intermediate decliners” (n = 37), by a loss ≥5 points after the first year and before the 18th month; or “slow decliners” (n = 225), composed of the remaining patients.

Results: At baseline, the groups did not differ on demographic, clinical, and cognitive variables. The decline at the end of the 4-year follow-up period seems to be similar among the different decline clusters. Predictors of disease progression have not been identified; only the MMSE total score at 12 months <14/30 was indicative of a poor prognosis.

Conclusions: Even with the limitation due to the small sample size, the lack of differences in the disease progression in time in the different clusters suggest the inconsistency of the so-called “fast decliners”. This study was unable to show any significant difference among clusters of AD progression within a 4-year time interval. Further studies should better clarify whether a more consistent distinction exists between slow and fast decliners.

Trajectories of dementia-related cognitive decline in a large mental health records derived patient cohort

BACKGROUND

Modeling trajectories of decline can help describe the variability in progression of cognitive impairment in dementia. Better characterisation of these trajectories has significant implications for understanding disease progression, trial design and care planning.

METHODS

Patients with at least three Mini-mental State Examination (MMSE) scores recorded in the South London and Maudsley NHS Foundation Trust Electronic Health Records, UK were selected (N = 3441) to form a retrospective cohort. Trajectories of cognitive decline were identified through latent class growth analysis of longitudinal MMSE scores. Demographics, Health of Nation Outcome Scales and medications were compared across trajectories identified.

RESULTS

Four of the six trajectories showed increased rate of decline with lower baseline MMSE. Two trajectories had similar initial MMSE scores but different rates of decline. In the faster declining trajectory of the two, a higher incidence of both behavioral problems and sertraline prescription were present.

CONCLUSIONS

We find suggestive evidence for association of behavioral problems and sertraline prescription with rate of decline. Further work is needed to determine whether trajectories replicate in other datasets.

Predictive Factors of Rapid Cognitive Decline in Patients with Alzheimer Disease

Aim

To determine predictive factors associated with rapid cognitive decline (RCD) in elderly patients suffering from Alzheimer disease (AD).

Methods

Patients suffering from mild to moderate AD were included. RCD was defined as the loss of at least 3 points on the Mini-Mental State Examination (MMSE) over 12 months. Factors associated with RCD were identified by logistic regression.

Results

Among 123 patients included, 61 were followed up until 12 months. RCD occurred in 46% of patients (n = 28). Polymedication (p < 0.0001), the fact that the caregiver was the child or spouse of the patient (p < 0.0001) and autonomy for washing (p < 0.0001) were protective factors against RCD, while the presence of caregiver burden (p < 0.0001) was shown to be a risk factor for RCD.

Conclusion

Early detection of the RCD risk in AD patients could make it possible to anticipate the patient's medical needs and adjust the care plan for caregiver burden.

Predictors of Cognitive Decline in a Rural and Remote Saskatchewan Population With Alzheimer's Disease

To determine the predictors of cognitive decline in a rural and remote population with Alzheimer's disease (AD), we examined the association between cognitive change and sociodemographic, clinical, and functional data at the initial day of diagnosis. Simple linear regression analysis and multiple regression analysis were used to determine the predictors of cognitive decline as measured by the difference in the Mini-Mental State Examination over 1 year. Our sample included 72 patients with AD. Age at the clinic day appointment was 75.3 (standard deviation [SD] = 7.44). History of hypertension and decreased ability to carry out activities of daily living were statistically significant and predicted greater cognitive decline at 1 year. Many previously suggested predictors of cognitive decline were not evidenced in this study. This research helps identify clinically useful predictors of decline in a rural and remote population with AD.

Demographic and clinical characteristics related to cognitive decline in Alzheimer disease in China: A multicenter survey from 2011 to 2014

Alzheimer disease (AD) is the most frequent cause of dementia. AD diagnosis, progression, and treatment have not been analyzed nationwide in China. The primary aim of this study was to analyze demographic and clinical characteristics related to cognitive decline in AD patients treated at outpatient clinics in China.We performed a retrospective study of 1993 AD patients at 10 cognitive centers across 8 cities in China from March 2011 to October 2014. Of these, 891 patients were followed for more than 1 year.The mean age at diagnosis was 72.0 ± 10.0 years (range 38-96 years), and the mean age at onset of AD was 69.8 ± 9.5 years. Most patients (65.1%) had moderate to severe symptoms at the time of diagnosis, and mean Mini-Mental State Examination at diagnosis was 15.7 ± 7.7. AD patients showed significant cognitive decline at 12 months after diagnosis. Having more than 9 years of formal education was an independent risk factor related to rapid cognitive decline [odds ratio (OR) = 1.80; 95% confidence interval (95% CI): 1.11-2.91]. Early-onset AD patients experienced more rapid cognitive decline than late-onset patients (OR = 1.83; 95% CI: 1.09-3.06).Most AD patients in China had moderate to severe symptoms at the time of diagnosis and experienced significant cognitive decline within 1 year. Rapid cognitive decline in AD was related to having a higher educational level and younger age of onset.

Neuropsychological predictors of rapidly progressive Alzheimer's disease

OBJECTIVE

Alzheimer's disease (AD), the most common cause of dementia, typically shows a slow clinical progression over time. 'Rapidly progressive' AD, a variant of the disease characterized by an aggressive course, exhibits distinct clinical, biological, and neuropathological features. Here, we investigate neuropsychological predictors of rapid decline in a group of mild patients with AD.

METHODS

One hundred fifty-three mild patients with AD admitted to a memory disorder clinic and followed for up to 3 years were included in this study. A comprehensive neuropsychological (NP) battery was performed at the time of enrollment. Patients were defined as 'rapidly progressive' if they exhibited a drop of 6 or more points on the Mini Mental State Examination (MMSE) between two consecutive annual visits. This event defined the main outcome in multiple analyses of variance and Cox proportional hazards models that investigated the impact of NP predictors. Categorical principal component analysis (CATPCA) was also employed in order to delineate clusters of NP tests and to test their effect on the outcome.

RESULTS

Of 153 subjects, thirty-seven (24%) were classified as 'rapidly progressive'; those subjects showed younger age of symptoms onset compared to slow decliners (68 vs 71.5 years old). Baseline lower performance on a neuropsychological test of naming predicted a rapid decline over the follow-up (P = 0.001). Three clusters of NP were defined by CATPCA: (i) executive/language, (ii) visuospatial memory, and (iii) verbal memory. The executive/language component predicted a rapid decline over the follow-up (P = 0.016).

CONCLUSION

Early executive/language impairment is highly predictive of a rapid progression of AD.

Cognitive function and 10 year mortality in an 85 year-old community-dwelling population

The relationship between mortality and impaired cognitive function has not been thoroughly investigated in a very elderly community-dwelling population, and little is known about the association of disease-specific mortality with Mini-Mental State Examination (MMSE) subscale scores. Here we evaluated these data in Japanese community-dwelling elderly. In 2003, 85 year-olds (n=207) were enrolled; 205 completed the MMSE for cognitive function and were followed-up for 10 years, during which time 120 participants died, 70 survived, and 17 were lost to follow-up. Thirty-eight deaths were due to cardiovascular disease, 22 to senility, 21 to respiratory disease, and 16 to cancer. All-cause mortality decreased by 4.3% with a 1-point increase in the global MMSE score without adjustment, and it decreased by 6.3% with adjustment for both sex and length of education. Cardiovascular mortality decreased by 7.6% and senility mortality decreased by 9.2% with a 1-point increase in the global MMSE score with adjustment for sex and education. No association was found between respiratory diseases or cancer mortality and global MMSE score. All-cause mortality also decreased with increases in MMSE subscale scores for time orientation, place orientation, delayed recall, naming objects, and listening and obeying. Cardiovascular mortality was also associated with the MMSE subscale of naming objects, and senility mortality was associated with the subscales of time orientation and place orientation. Thus, we found that impaired cognitive function determined by global MMSE score and some MMSE subscale scores were independent predictors of all-cause mortality or mortality due to cardiovascular disease or senility in 85 year-olds.

Survival and early recourse to care for dementia: A population based study

BACKGROUND

A large proportion of dementia cases are still undiagnosed. Although early dementia care has been hypothesized to benefit both patients and families, evidence-based benefits are lacking. Thus, investigating the benefits for newly demented persons according to their recourse to care in the "real life" appears critical.

METHODS

We examined the relation between initial care recourse care and demented individuals' survival in a large cohort of incident dementia cases screened in a prospective population-based cohort, the Three-City Study. We assessed recourse to care for cognitive complaint at the early beginning of dementia when incident cases were screened. We classified patients in three categories: no care recourse, general practitioner consultation or specialist consultation. We used proportional hazard regression models to test the association between recourse to care and mortality, adjusting on socio-demographical and clinical characteristics.

RESULTS

Two hundred and fifty-three incident dementia participants were screened at the 2 year or 4 year follow-up. One third of the incident demented individuals had not consulted a physician for cognitive problems. Eighty-six (34.0%) individuals had reported a cognitive problem only to their general practitioner (GP) and 80 (31.6%) had consulted a specialist. Mean duration of follow-up after incident dementia was 5.1 years, during which 146 participants died. After adjustment on potential confounders, participants who had consulted a specialist early in the disease course presented a poorer survival than those who did not consult any physician (hazard ratio = 1.64, 95% confidence interval 1.03-2.62). There was a trend but no significant differential survival profile between participants who complained to their GP and those without any care recourse.

CONCLUSION

Neither recourse to a specialist nor recourse to GP improve survival of new dementia cases. Those who had consulted a specialist early in the disease course even reported a worse life expectancy than those who did not.

Predicting aggressive decline in mild cognitive impairment: the importance of white matter hyperintensities

IMPORTANCE

Although white matter hyperintensities (WMHs) are associated with the risk for Alzheimer disease, it is unknown whether they represent an independent source of impairment or interact with known markers of disease.

OBJECTIVE

To examine the degree to which WMHs predict aggressive cognitive decline among individuals with mild cognitive impairment, either independently or by modifying the effects of entorhinal cortex volume (ECV), a marker of Alzheimer disease-related neurodegeneration.

DESIGN, SETTING, AND PARTICIPANTS

The Alzheimer's Disease Neuroimaging Initiative is a longitudinal study with 6-month follow-up visits. Three hundred thirty-two participants (mean [SD] age, 74.6 [7.4] years; 118 women) of a total of 374 participants diagnosed as having mild cognitive impairment were included. Participants were excluded if they did not have longitudinal data, apolipoprotein E genotype data, or had evidence of supratentorial infarct.

MAIN OUTCOMES AND MEASURES

A decline in Mini-Mental State Examination score of 3 points over 6 months or 6 points over 1 year between consecutive visits was defined as aggressive decline. White matter hyperintensity volume and ECV were entered as predictors in Cox proportional hazards models and Wilcoxon-Breslow tests to examine their impact on this outcome, adjusting for sex, age, education, and apolipoprotein E status.

RESULTS

Greater WMH volume at baseline, apolipoprotein E ε4 status, and smaller ECV at baseline were associated with an increased risk for aggressive decline (hazard ratio [HR], 1.23; 95% CI, 1.05-1.43; P = .01 for WMH volume; HR, 1.49; 95% CI, 1.09-2.05; P = .04 for apolipoprotein E ε4 status; HR, 0.66; 95% CI, 0.55-0.79; P < .001 for ECV). White matter hyperintensity volume modified the effect of ECV on aggressive decline risk: individuals with high ECV and low WMH were at particularly low likelihood of decline (χ2 = 15, P = .001). Participants with Mini-Mental State Examination scores that declined by 3 or more points over 6 months or 6 or more points over 12 months were more likely to have converted to Alzheimer disease by the end of the follow-up period (χ2 = 82, P < .001).

CONCLUSIONS AND RELEVANCE

White matter hyperintensity burden and ECV predict rapid cognitive decline among individuals with mild cognitive impairment both additively and multiplicatively.

A simple score to predict survival with dementia in the general population

BACKGROUND/AIMS

This study was designed to develop a practical risk score for predicting 5-year survival after the diagnosis of dementia.

METHODS

Using the Paquid Study (prospective, population-based, long-term cohort study), we created a prognosis score with incident cases of dementia and validated it in another prospective, population-based, long-term cohort study, the Three City Study. -

RESULTS

Among the 3,777 subjects enrolled in the Paquid Study, 454 incident cases of dementia were included in this study. After a 5-year follow-up period, 319 (70.3%) were deceased. The score was constructed from three independent prognostic variables (gender, age at diagnosis and number of ADL restricted). The discriminant ability of the score was good with a c index of 0.754. Sensitivity was 64.7% and specificity 76.3%. In the validation cohort, the discriminant ability of the prognostic score with c statistics was 0.700. Sensitivity was 26.3% and specificity 95.4%.

CONCLUSIONS

The prognostic factors selected in the predictive model are easily assessable, so this simple score could provide helpful information for the management of dementia, particularly to identify patients with duration of the disease greater than 5 years.

Alzheimer's disease: genetic polymorphisms and rate of decline

BACKGROUND/AIM

To investigate the influence of established genetic risk factors for Alzheimer's disease on the speed of disease progression.

METHODS

Polymorphisms (in ACE, ApoE, BIN1, CLU, CR1, CST3, EXOC3L2, GWA14q32.13, IL8, LDLR, PICALM, TNK1) of 40 Alzheimer's disease patients from a longitudinal study were analyzed. A standardized loss of Mini-Mental State Examination points was used as the progression parameter.

RESULTS

Polymorphisms in CST3 and EXOC3L2 as well as the absence of APOE4 were associated with more aggressive disease courses. A trend was observed for BIN1.

CONCLUSION

In addition to being a risk factor for disease development, some of the polymorphisms investigated here are associated with higher rates of decline and disease progression and thus might act as prognostic disease markers. This effect needs to be considered in future treatment strategies.

Using the Guttman scale to define and estimate measurement error in items over time: the case of cognitive decline and the meaning of "points lost"

We used a Guttman model to represent responses to test items over time as an approximation of what is often referred to as "points lost" in studies of cognitive decline or interventions. To capture this meaning of "point loss", over four successive assessments, we assumed that once an item is incorrect, it cannot be correct at a later visit. If the loss of a point represents actual decline, then failure of an item to fit the Guttman model over time can be considered measurement error. This representation and definition of measurement error also permits testing the hypotheses that measurement error is constant for items in a test, and that error is independent of "true score", which are two key consequences of the definition of "measurement error"--and thereby, reliability--under Classical Test Theory. We tested the hypotheses by fitting our model to, and comparing our results from, four consecutive annual evaluations in three groups of elderly persons: a) cognitively normal (NC, N = 149); b) diagnosed with possible or probable AD (N = 78); and c) cognitively normal initially and a later diagnosis of AD (converters, N = 133). Of 16 items that converged, error-free measurement of "cognitive loss" was observed for 10 items in NC, eight in converters, and two in AD. We found that measurement error, as we defined it, was inconsistent over time and across cognitive functioning levels, violating the theory underlying reliability and other psychometric characteristics, and key regression assumptions.

Oral disease in relation to future risk of dementia and cognitive decline: prospective cohort study based on the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) trial

OBJECTIVE

Examine the association of oral disease with future dementia/cognitive decline in a cohort of people with type 2 diabetes.

METHODS

A total of 11,140 men and women aged 55-88 years at study induction with type 2 diabetes participated in a baseline medical examination when they reported the number of natural teeth and days of bleeding gums. Dementia and cognitive decline were ascertained periodically during a 5-year follow-up.

RESULTS

Relative to the group with the greatest number of teeth (more than or equal to 22), having no teeth was associated with the highest risk of both dementia (hazard ratio; 95% confidence interval: 1.48; 1.24, 1.78) and cognitive decline (1.39; 1.21, 1.59). Number of days of bleeding gums was unrelated to these outcomes.

CONCLUSIONS

Tooth loss was associated with an increased risk of both dementia and cognitive decline.

Identifying and characterizing trajectories of cognitive change in older persons with mild cognitive impairment

BACKGROUND

Mild cognitive impairment (MCI) represents a state of high risk for dementia but is heterogeneous in its course. To date, the trajectories reflecting distinct developmental courses of cognition among patients with MCI have not been well defined.

AIM

To identify the developmental trajectory of groups with distinct cognitive change patterns among a cohort of MCI patients.

METHODS

187 MCI patients from 2 geriatric outpatient clinics were evaluated serially with the Mini-Mental State Examination (MMSE) for up to 3.5 years. Group-based trajectory analysis was applied to identify distinct trajectories. Estimates of decline for each group were compared with the mean rate of decline obtained from mixed modeling of the entire sample.

RESULTS

5 trajectories were identified and labeled based on their baseline MMSE score and course: (1) 29/stable (6.5%); (2) 27/stable (53.9%); (3) 25/slow decline (23.8%); (4) 24/slow decline (11.6%); (5) 25/rapid decline (4.2%). Annual rate of change in the MMSE score for these 5 groups was 0.09, -0.43, -1.23, -1.84, and -4.6 points, respectively. None corresponded to the mean rate of -0.82 points estimated for the group as a whole. A majority of MCI patients (60.4%) follow stable cognitive trajectories over time. Within the 3 groups with declining trajectories, cognitive decline occurs slowly in a vast majority of MCI patients (98.5%).

CONCLUSIONS

Results provide direct evidence for the heterogeneous course of cognitive decline that has been suggested by the variable prognosis for patients with MCI.

Diagnosis of Alzheimer's disease patients with rapid cognitive decline in clinical practice: interest of the Deco questionnaire

BACKGROUND

Patients with Alzheimer's disease (AD) who deteriorate rapidly are likely to have a poorer prognosis. There is a clear need for a clinical assessment tool to detect such a decline in newly diagnosed patients.

OBJECTIVE

To identify the predictive factors of rapid cognitive decline (RCD) in a cohort of patients with mild to moderate AD ; and to validate a self-questionnaire for caregivers as a diagnostic tool for rapid decline.

DESIGN AND ANALYSIS

An open-label, observational, 12-month, multicenter, French study. Physicians were asked to record data of three eligible rivastigmine naïve (or on rivastigmine for < 1 year) AD patients. Risk factors of RCD and the detection power of the Détérioration Cognitive Observée scale (Deco), a 19 item self-questionnaire for caregivers, were assessed at endpoint using regression analyses.

RESULTS

Out of the 361 patients enrolled in the study, 91 (25.2%) were excluded due to loss of follow-up. Among subjects using cholinesterase inhibitors or memantine, 161 (59.6%) experienced a stabilization (29.2%) or an improvement (30.4%) in global functioning as measured by the CGI-C. Sixty of the remaining 204 patients retained for analysis (29.6%, CI 95% [23.4; 35.8]) lost three or more points on the MMSE score between the inclusion and one of the follow-up visit. In the multivariate logistic regression analysis, institutionalization, higher level of education and the loss of 3 points or more on the MMSE were found to be significant predictors of a rapid cognitive loss in this population. The threshold which maximizes the predictive values of the Deco score as a diagnostic tool of rapid cognitive decline was significantly different according to the age of the patient (below or over 75 years old). A score below 16 for patients < 75 years old and below 14 for patients ≥ 75 years old consistently predicted a RCD within the next year.

CONCLUSION

The Deco test appears to be a simple tool to alert the physician to the possibility of an aggressive course of the disease which warrants particular management.

Predictive value of platelet activation for the rate of cognitive decline in Alzheimer's disease patients

Vascular risk factors contribute to the progression of dementia in Alzheimer's disease (AD) and influence platelet activation. However, the degree of platelet activation as a possible underlying mechanism of this progression has not been studied till now. Significantly higher baseline expression of both platelet activation biomarkers, activated glycoprotein IIb-IIIa complex and P-selectin, was observed in patients with AD with fast cognitive decline compared with AD patients with slow cognitive decline during a 1-year follow-up period. These results suggest that platelet activation could be a putative prognostic biomarker for the rate of cognitive decline and a potential new treatment target in AD patients.

Trail Making Test predicts physical impairment and mortality in older persons

OBJECTIVES

To examine whether performance in the Trail Making Test (TMT) predicts mobility impairment and mortality in older persons.

DESIGN

Prospective cohort study.

SETTING

Community-dwelling older persons enrolled in the Invecchiare in Chianti (InCHIANTI) Study.

PARTICIPANTS

Five hundred eighty-three participants aged 65 and older and free of major cognitive impairment (Mini-Mental State Examination score >21) with baseline data on TMT performance. Of these, 427 performed the Short Physical Performance Battery (SPPB) for the assessment of lower extremity function at baseline and after 6 years. Of the initial 583 participants, 106 died during a 9-year follow-up.

MEASUREMENTS

The TMT Parts A and B (TMT-A and TMT-B) and SPPB were administered at baseline and 6-year follow-up. Impaired mobility was defined as an SPPB score less than 10. Vital status was ascertained over a 9-year follow-up.

RESULTS

InCHIANTI participants in the fourth quartile of the time to complete TMT-B minus time to complete TMT-A (TMT (B-A)) were significantly more likely to develop an SPPB score less than 10 during the 6-year follow-up than those in the first quartile (relative risk (RR)=2.4, 95% confidence interval (CI)=1.4-3.9, P=.001). After adjusting for potential confounders, these findings were substantially unchanged (RR=2.2, 95% CI=1.4-3.6, P=.001). Worse performance on the TMT was associated with significantly greater decline in SPPB score over the 6-year follow-up, after adjusting for age, sex, and baseline SPPB scores (beta=-0.01, standard error=0.003, P=.004). During the 9-year follow-up, 18.2% of the participants died. After adjustment for age and sex, the proportion of participants who died was higher in participants in the worst than the best performance quartile of TMT (B-A) scores (hazard ratio (HR)=1.7, 95% CI=1.0-2.9, P=.048). Results were similar in a parsimonious adjusted model (HR=1.8, 95% CI=1.0-3.2, P=.04).

CONCLUSION

Performance on the TMT is a strong, independent predictor of mobility impairment, accelerated decline in lower extremity function, and death in older adults living in the community. The TMT could be a useful addition to geriatric assessment.

Factors affecting survival of patients with neurodegenerative disease

BACKGROUND

Survival varies widely among different neurodegenerative diseases. Data on the role of the Mini Mental State Examination (MMSE) and apolipoprotein E (APOE) in survival are sparse except for Alzheimer's disease (AD).

METHODS

We studied mortality of 3,581 patients in an academic clinic from 1993 to 2004. Average follow-up was 4.1 years. We studied patients with amyotrophic lateral sclerosis (ALS) (n = 174), possible AD (n = 206), probable AD (n = 1,175), Parkinson's disease (PD) (n = 661), mild cognitive impairment (MCI) (n = 357), frontotemporal dementia (FTD) (n = 94), Lewy body disease (LBD) (n = 64), and controls (n = 850). We compared patients' mortality to the US population and to controls.

RESULTS

Mortality ranged from 7% for controls to 58% for ALS patients. The median survival times from initial visit for PD, FTD, probable AD, possible AD, LBD, and ALS were 8.9, 7.0, 5.9, 5.6, 5.3, and 2.7 years, respectively. Mortality rate ratios comparing each disease to controls were 39.43, 7.25, 3.70, 3.51, 2.47, 2.73, and 1.61 for ALS, FTD, LBD, PD, probable AD, possible AD, and MCI, respectively. A lower initial MMSE score was associated with higher mortality for probable AD, PD, and MCI, while APOE4 predicted mortality for PD and LBD. Non-whites had 20% lower mortality rates than whites for all dementias combined, adjusting for education.

CONCLUSIONS

All neurologic diseases, including MCI, had increased mortality versus controls. A lower MMSE score and APOE4 presence predicted higher mortality for some patient groups.

Rapid cognitive decline in Alzheimer's disease. Consensus paper

The rate of cognitive decline in Alzheimer's disease (AD) varies considerably between individuals, with some subjects showing substantial deterioration and others showing little or no change over the course of the disease. These wide variations support the relatively new concept of Rapid Cognitive Decline (RCD). Patients with an accelerated rate of cognitive decline have showed to present a worse evolution in terms of mortality, loss of autonomy and institutionalisation. The conclusions from RCD studies conducted in the past years remain very heterogeneous and sometimes contradictory. This is possibly due to methodological differences, mainly the different "a priori" definitions of RCD used to identify rapid decliners. Consequently of this, there is considerable variation in reported frequency of patients with RCD which may vary from 9.5% to 54%. The lack of both consensus definition and consensual clinical assessment tools is one of the major barriers for establishing an appropriated management of rapid decliners in clinical practice. Presently, management of rapid decliners in AD remains to be a challenge waiting to better know predictive factors of a RCD. To date no specific guidelines exist to follow-up or to treat patients with this condition. This consensus paper proposes the loss of 3 points or greater in Mini-Mental State Examination (MMSE) during six months as an empirical definition of rapid cognitive decline to be used in routine medical practice and to be relevant for clinical-decision making in patients with mild to moderately-severe AD.

Modeling the association between 43 different clinical and pathological variables and the severity of cognitive impairment in a large autopsy cohort of elderly persons

We evaluated the association between mini-mental status examination (MMSE) scores proximal to death and the values of 43 different clinical and pathological parameters. Studies were performed using data from 334 elderly, longitudinally evaluated research subjects who had undergone autopsy and satisfied inclusion criteria from an initial study group of 501. Interindividual variance in MMSE scores was used as a surrogate for the severity of cognitive impairment linked to aging (CILA). A statistical linear regression-based model provided a framework for assessing the parameters with significant, direct impact on CILA severity. Strong association between CILA and Alzheimer's disease (AD) pathology, especially isocortical neurofibrillary tangles, was evident. The pattern of association between AD lesion densities with cognitive impairment severity was biologically informative, with neuritic plaques having more impact in relatively high-functioning individuals. Abundant isocortical Lewy bodies tended to be an additive pathology correlating with final MMSE scores approximately 10 points lower. In a subset of cases we found evidence for association between TDP-43-related pathology and CILA severity, independent of AD or hippocampal sclerosis. There was no support for independent association between CILA severity and most evaluated indices including diffuse plaques, argyrophilic grains, heart disease, education level, apolipoprotein E alleles or diabetes.

Increased homocysteine levels in tear fluid of patients with primary open-angle glaucoma

AIMS

We assessed homocysteine (Hcy) levels in tear fluid and plasma of patients with primary open-angle glaucoma (POAG). We determined the association between Hcy levels, dry eye syndrome and B vitamin status.

METHODS

This prospective case-control study included 36 patients with POAG and 36 controls. Hcy concentrations were measured by high-performance liquid chromatography.

RESULTS

Patients with POAG had significantly higher mean Hcy levels both in tear fluid (205 +/- 84 nmol/l; p < 0.001, t test) and in plasma (13.43 +/- 3.53 micromol/l; p = 0.001, t test) than control subjects (130 +/- 53 nmol/l and 10.50 +/- 3.33 micromol/l, respectively). Hcy in tear fluid was significantly correlated with plasma Hcy in POAG patients (r = 0.459; p = 0.005, Pearson's correlation), but not in controls (r = 0.068; p = 0.695). POAG patients with dry eye disease had significantly higher Hcy levels both in tear fluid and plasma than POAG patients without dry eye disease. There was no association between Hcy levels and B vitamin status in subjects with POAG.

CONCLUSIONS

The study suggests increased Hcy levels in tear fluid and plasma of patients with POAG. Elevated Hcy levels might be a risk factor for POAG and dry eye syndrome in subjects with glaucoma.

Cognitive decline and survival in Alzheimer's disease according to education level

OBJECTIVE

We tested the hypothesis that a higher education level is associated with faster cognitive decline and lower survival in a cohort of 670 Alzheimer's disease patients, followed for 3.5 years at the Lille-Bailleul memory centre.

METHODS

The patients were categorized in 3 groups according to educational levels: low (<or=8 years), intermediate (9-12 years) and high (>12 years). Cognitive function was measured with the Mini Mental State Examination (MMSE) and the Mattis Dementia Rating Scale (DRS). Survival was analyzed with a Cox model. Analyses were adjusted for age, sex, cholinesterase inhibitor treatment, diabetes, hypertension, visible vascular lesions on MRI, baseline DRS and MMSE.

RESULTS

The adjusted mixed random model showed that MMSE declined faster for patients with high and intermediate educational levels compared with those with a low educational level (p < 0.0001). The mean annually adjusted DRS decline was highest for the groups with the most education (p = 0.05). The mortality risk was not higher in the better-educated groups (high vs. low: RR = 0.84; 95% CI = 0.35-1.99, intermediate vs. low: RR = 0.82; 95% CI = 0.41-1.63).

CONCLUSION

In our cohort, highly educated patients had a faster cognitive decline than less educated patients but similar mortality rates. Our findings support the cognitive reserve hypothesis.