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Rensink M, Bolt I, Schermer M. Predicting age of onset and progression of disease in late-onset genetic neurodegenerative diseases: An ethics review and research agenda. Eur J Hum Genet 2024:10.1038/s41431-024-01688-7. [PMID: 39317749 DOI: 10.1038/s41431-024-01688-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Revised: 08/15/2024] [Accepted: 08/15/2024] [Indexed: 09/26/2024] Open
Abstract
Currently, a prognostic biomarker-based model is being developed to predict the onset and disease progression of Huntington's Disease (HD) and Spinocerebellar Ataxia (SCA) types 1 and 3, both late-onset genetic neurodegenerative diseases lacking a disease-modifying treatment (DMT). The need for more accurate predictions of onset and disease progression arises in the context of clinical trials evaluating the effectiveness of potential DMTs and identifying the optimal time to initiate such a DMT. Moreover, such a prognostic model may provide mutation carriers with personal utility. The aim of this article is to anticipate the ethical issues raised by these new prognostic models and to formulate the ethical issues that need to be addressed to facilitate an ethically responsible development and implementation of such a model. Part one of this article describes the ethical issues raised by presymptomatic genetic testing for HD and evaluates whether and how these issues may also occur by predicting onset and disease progression. Part two presents the results of a critical interpretative review into the ethical issues raised by biomarker testing in other late-onset neurodegenerative diseases lacking a DMT. The review aims to identify new ethical issues related to biomarker testing for predicting the onset and disease progression of HD and SCA. Finally, based on parts one and two, part three proposes a research agenda for the near future regarding the most pressing ethical issues that need to be addressed to ensure an ethically responsible implementation of such a prognostic model in both research settings and clinical practice.
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Affiliation(s)
- Max Rensink
- Dept. of Medical Ethics, Philosophy, and History of Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
| | - Ineke Bolt
- Dept. of Medical Ethics, Philosophy, and History of Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Maartje Schermer
- Dept. of Medical Ethics, Philosophy, and History of Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
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Clark LR, Erickson CM, Chin NA, Basche KE, Ketchum FB, Rosario HL, Peterson AJ, Eveler ML, Johnson SC. Psychosocial implications of learning amyloid PET results in an observational cohort. Alzheimers Dement 2024. [PMID: 39129396 DOI: 10.1002/alz.14153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 06/28/2024] [Accepted: 07/02/2024] [Indexed: 08/13/2024]
Abstract
INTRODUCTION Information on the psychosocial impact of Alzheimer's disease (AD) biomarker testing in adults at risk of AD is needed to inform best practices for communicating biomarker results. METHODS Ninety-nine cognitively unimpaired older adults learned amyloid positron emission tomography (PET) results (mean age = 72.0 ± 4.8, 95% White, 28% elevated amyloid). Linear mixed-effects regression models were used to test the main effects and interaction of PET result × time on psychosocial outcomes up to 6 months after learning results. RESULTS A significant interaction of PET result × time was observed for concern about AD (β = 0.28, p = 0.02) and intrusive thoughts and avoidance (β = -0.82, p < 0.001). A main effect of PET result was observed for AD test-related distress (β = 12.09, p < 0.001). DISCUSSION Cognitively unimpaired adults learning elevated-amyloid PET results reported mildly intrusive thoughts/avoidance initially following disclosure, but these symptoms decreased over time. Concern about AD dementia and AD biomarker test-related distress remained higher in elevated-amyloid compared to non-elevated-amyloid participants. HIGHLIGHTS Longitudinal assessment of psychosocial reactions after amyloid PET disclosure was conducted. Transient highly intrusive thoughts or avoidance after learning elevated amyloid results. Persistent test result-related distress after receiving elevated-amyloid results. There is increased concern about AD dementia after receiving elevated-amyloid results. Happiness and relief are experienced after receiving non-elevated-amyloid results.
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Affiliation(s)
- Lindsay R Clark
- Department of Medicine, Division of Geriatrics & Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin, USA
| | - Claire M Erickson
- Department of Medical Ethics and Health Policy, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nathaniel A Chin
- Department of Medicine, Division of Geriatrics & Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kristin E Basche
- Department of Medicine, Division of Geriatrics & Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Fred B Ketchum
- Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Hannah L Rosario
- Department of Medicine, Division of Geriatrics & Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Amanda J Peterson
- Department of Medicine, Division of Geriatrics & Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Marcella L Eveler
- Department of Medicine, Division of Geriatrics & Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Sterling C Johnson
- Department of Medicine, Division of Geriatrics & Gerontology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Wisconsin Alzheimer's Institute, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Matthews LJ, Zhang Z, Martschenko DO. Schoolhouse risk: Can we mitigate the polygenic Pygmalion effect? Acta Psychol (Amst) 2024; 248:104403. [PMID: 39003994 PMCID: PMC11343671 DOI: 10.1016/j.actpsy.2024.104403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 07/08/2024] [Accepted: 07/09/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Although limited in predictive accuracy, polygenic scores (PGS) for educational outcomes are currently available to the public via direct-to-consumer genetic testing companies. Further, there is a growing movement to apply PGS in educational settings via 'precision education.' Prior scholarship highlights the potentially negative impacts of such applications, as disappointing results may give rise a "polygenic Pygmalion effect." In this paper two studies were conducted to identify factors that may mitigate or exacerbate negative impacts of PGS. METHODS Two studies were conducted. In each, 1188 students were randomized to one of four conditions: Low-percentile polygenic score for educational attainment (EA-PGS), Low EA-PGS + Mitigating information, Low EA-PGS + Exacerbating information, or Control. Regression analyses were used to examine differences between conditions. RESULTS In Study 1, participants randomized to Control reported significantly higher on the Rosenberg Self-Esteem Scale (RSES), Competence Scale (CS), Academic Efficacy Scale (AES) and Educational Potential Scale (EPS). CS was significantly higher in the Low EA-PGS + Mitigating information condition. CS and AES were significantly lower in the Low EA-PGS + Exacerbating information condition compared to the Low EA-PGS + Mitigating information condition. In Study 2, participants randomized to Control reported significantly higher CS and AES. Pairwise comparisons did not show significant differences in CS and AES. Follow-up pairwise comparisons using Tukey P-value correction did not find significant associations between non-control conditions. CONCLUSION These studies replicated the polygenic Pygmalion effect yet were insufficiently powered to detect significant effects of mitigating contextual information. Regardless of contextual information, disappointing EA-PGS results were significantly associated with lower assessments of self-esteem, competence, academic efficacy, and educational potential.
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Affiliation(s)
- Lucas J Matthews
- Columbia University, Department of Medical Humanities & Ethics, New York, NY, United States; The Hastings Center, New York, NY, United States.
| | - Zhijun Zhang
- New York State Psychiatric Institute, Department of Mental Health and Data Science, New York, NY, United States.
| | - Daphne O Martschenko
- Stanford Center for Biomedical Ethics and Department of Pediatrics, Stanford University; Stanford, CA, United States.
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Narasimhan S, Holtzman DM, Apostolova LG, Cruchaga C, Masters CL, Hardy J, Villemagne VL, Bell J, Cho M, Hampel H. Apolipoprotein E in Alzheimer's disease trajectories and the next-generation clinical care pathway. Nat Neurosci 2024; 27:1236-1252. [PMID: 38898183 DOI: 10.1038/s41593-024-01669-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 04/18/2024] [Indexed: 06/21/2024]
Abstract
Alzheimer's disease (AD) is a complex, progressive primary neurodegenerative disease. Since pivotal genetic studies in 1993, the ε4 allele of the apolipoprotein E gene (APOE ε4) has remained the strongest single genome-wide associated risk variant in AD. Scientific advances in APOE biology, AD pathophysiology and ApoE-targeted therapies have brought APOE to the forefront of research, with potential translation into routine AD clinical care. This contemporary Review will merge APOE research with the emerging AD clinical care pathway and discuss APOE genetic risk as a conduit to genomic-based precision medicine in AD, including ApoE's influence in the ATX(N) biomarker framework of AD. We summarize the evidence for APOE as an important modifier of AD clinical-biological trajectories. We then illustrate the utility of APOE testing and the future of ApoE-targeted therapies in the next-generation AD clinical-diagnostic pathway. With the emergence of new AD therapies, understanding how APOE modulates AD pathophysiology will become critical for personalized AD patient care.
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Affiliation(s)
| | - David M Holtzman
- Department of Neurology, Hope Center for Neurological Disorders, Knight ADRC, Washington University in St. Louis, St. Louis, MO, USA
| | - Liana G Apostolova
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Radiology and Imaging Neurosciences, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carlos Cruchaga
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
- NeuroGenomics and Informatics Center, Washington University School of Medicine, St. Louis, MO, USA
| | - Colin L Masters
- Florey Institute and the University of Melbourne, Parkville, Victoria, Australia
| | - John Hardy
- Department of Neurodegenerative Disease and Dementia Research Institute, Reta Lila Weston Research Laboratories, UCL Institute of Neurology, Queen Square, London, UK
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Amariglio RE, Grill JD, Rentz DM, Marshall GA, Donohue MC, Liu A, Aisen PS, Sperling RA. Longitudinal Trajectories of the Cognitive Function Index in the A4 Study. J Prev Alzheimers Dis 2024; 11:838-845. [PMID: 39044492 PMCID: PMC11266220 DOI: 10.14283/jpad.2024.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 06/18/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The Anti-Amyloid in Asymptomatic Alzheimer's Disease (A4) Study failed to show a treatment benefit with solanezumab, but the longitudinal consequences of elevated amyloid were observed in study participants with objective decline on the Preclinical Alzheimer Cognitive Composite (PACC) and subjective decline on the combined Cognitive Function Index (participant + study partner CFI), during the trial period. OBJECTIVES We sought to expand on previous findings by comparing longitudinal patterns of participant and study partner CFI separately and their associations with the PACC stratified by baseline amyloid tertile over the course of the A4 Study. DESIGN Cognitively unimpaired older adult participants and their study partners were independently administered the CFI at screen prior to amyloid PET disclosure and then at 3 subsequent visits (week 48, week 168, week 240) of the study. PACC collected at visits concurrent with CFI administration were also examined longitudinally. SETTING The A4 Study was conducted at 67 sites in Australia, Canada, Japan, and the United States. PARTICIPANTS 1,147 participants with elevated amyloid based on florbetapir PET were enrolled in the A4 Study and included in these analyses. 583 were on placebo and 564 were treated with solanezumab. MEASUREMENTS The PACC was used to assess objective cognitive performance and the CFI was used to assess change in everyday cognitive functioning by the participant and their study partner independently. Amyloid level was characterized by Centiloid tertiles (<46.1 CL, 46.1 to 77.2 CL, >77.2 CL). Participants were aware of their elevated amyloid status, but not their CL tertile, or specific level of amyloid. Longitudinal correlations between participant and study partner CFI and PACC were examined at all visits where assessments were available. The impact of baseline amyloid tertile on CFI and PACC associations was also examined. RESULTS Both participant and study partner CFI increased over the duration of the study indicating worsening cognitive functioning. Results did not differ by treatment group. The association between higher CFI and worse PACC for both for participant and study partner became progressively stronger over the course of the study. PACC had a significantly higher correlation with study partner CFI than with participant CFI by week 168. The stronger correlations between study partner CFI and PACC were driven by those in the highest amyloid tertile. CONCLUSION Both participant and study partner report captured subtle changes in everyday cognitive functioning for participants with biomarker confirmed and disclosed preclinical AD. Moreover, study partner report was most highly aligned with cognitive decline, particularly among those with the highest amyloid load.
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Affiliation(s)
- R E Amariglio
- Rebecca E. Amariglio, Department of Neurology, Mass General Brigham, 60 Fenwood Road, Boston, MA 02115, USA, , Telephone: 617-732-9014, FAX: 617-738-9122
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Rahman-Filipiak A, Lesniak M, Sadaghiyani S, Roberts S, Lichtenberg P, Hampstead BM. Perspectives From Black and White Participants and Care Partners on Return of Amyloid and Tau PET Imaging and Other Research Results. Alzheimer Dis Assoc Disord 2023; 37:274-281. [PMID: 37890053 PMCID: PMC10664783 DOI: 10.1097/wad.0000000000000591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023]
Abstract
PURPOSE Alzheimer disease (AD) biomarker testing is now common in research and approaching clinical translation. Disclosure protocols must be informed by diverse participants' perspectives on if/how the information would be useful. METHODS This study utilized semistructured interviews assessing interest in receiving positron emission tomography (PET) amyloid and tau results, as well as perceived risks and benefits of hypothetical PET disclosure as a function of race and participant diagnosis. PARTICIPANTS Participants [39% Black; 61% White; Mage =74.28 (5.98)] included 57 adults diagnosed as either cognitively healthy (58%) or with mild cognitive impairment (42%) and their respective care partners [33% Black; 67% White; Mage =66.93 (10.92)]. RESULTS Most dyads endorsed strong interest in PET results (82.5% of both participants and partners) regardless of race or diagnosis. Black care partners were less interested in receiving the participant's results than White care partners ( χ2(4) =8.31, P =0.047). Reasons for disclosure were diverse and highly personalized, including access to treatments or clinical trials (23.2% participants; 29.8% partners), advance planning (14.3% participants; 17.5% partners), and improved health knowledge (12.5% participants; 15.8% partners). In contrast, over 80% of respondents denied any risks of disclosure. DISCUSSION Results suggest that predisclosure education, decisional capacity assessment, and a flexible disclosure approach are needed.
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Affiliation(s)
- Annalise Rahman-Filipiak
- Research Program on Cognition and Neuromodulation-Based Interventions
- Michigan Alzheimer’s Disease Research Center, University of Michigan
| | - Mary Lesniak
- Research Program on Cognition and Neuromodulation-Based Interventions
| | - Shima Sadaghiyani
- Research Program on Cognition and Neuromodulation-Based Interventions
| | - Scott Roberts
- Michigan Alzheimer’s Disease Research Center, University of Michigan
- Department of Health Behavior and Health Education, University of Michigan School of Public Health
| | - Peter Lichtenberg
- Michigan Alzheimer’s Disease Research Center, University of Michigan
- Wayne State University Institute of Gerontology, Detroit, MI
| | - Benjamin M. Hampstead
- Research Program on Cognition and Neuromodulation-Based Interventions
- Michigan Alzheimer’s Disease Research Center, University of Michigan
- Mental Health Service, Veterans Affairs Ann Arbor Health System, Ann Arbor
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Rahman-Filipiak A, Bolton C, Grill JD, Rostamzadeh A, Chin N, Heidebrink J, Getz S, Fowler NR, Rosen A, Lingler J, Wijsman E, Clark L. Biomarker disclosure protocols in prodromal Alzheimer's disease clinical trials. Alzheimers Dement 2023; 19:4270-4275. [PMID: 37450489 PMCID: PMC10530125 DOI: 10.1002/alz.13380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION The development of biomarkers for Alzheimer's disease (AD) has allowed researchers to increase sample homogeneity and test candidate treatments earlier in the disease. The integration of biomarker "screening" criteria should be met with a parallel implementation of standardized methods to disclose biomarker testing results to research participants; however, the extent to which protocolized disclosure occurs in trials is unknown. METHODS We reviewed the literature to identify prodromal AD trials published in the past 10 years. From these, we quantified the frequency of biomarker disclosure reporting and the depth of descriptions provided. RESULTS Of 30 published trials using positron emission tomography or cerebrospinal fluid-based amyloid positivity as an eligibility criterion, only one mentioned disclosure, with no details on methods. DISCUSSION Possible reasons for and implications of this information gap are discussed. Recommendations are provided for trialists considering biomarker screening as part of intervention trials focused on prodromal AD. HIGHLIGHTS Few prodromal Alzheimer's disease (AD) trial papers discuss biomarker disclosure. Disclosure has implications for participants, family members, and trial success. Disclosure must be consistently integrated and reported in prodromal AD trials. Best practice guidelines and training resources for disclosure are needed.
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Affiliation(s)
- Annalise Rahman-Filipiak
- Research Program on Cognition & Neuromodulation Based Interventions, University of Michigan, 2101 Commonwealth Blvd, Suite C., Ann Arbor, MI, USA 48105
- Michigan Alzheimer’s Disease Research Center, University of Michigan, 2101 Commonwealth Blvd, Suite C., Ann Arbor, MI, USA 48105
| | - Corey Bolton
- Vanderbilt Memory and Alzheimer’s Center, Vanderbilt University Medical Center, 1207 17th Ave. S, Suite 204, Nashville, TN, USA 37212
- Department of Neurology, Vanderbilt University Medical Center, 1301 Medical Center Dr. #3930, Nashville, TN, USA 37232
| | - Joshua D. Grill
- Departments of Psychiatry and Human Behavior and Neurobiology and Behavior, Institute for Memory Impairments and Neurological Disorders, University of California Irvine, 2642 Biological Sciences III, Irvine, CA, USA 92697-4545
| | - Ayda Rostamzadeh
- Department of Psychiatry and Psychotherapy, Center for Memory Disorders, Faculty of Medicine and University Hospital, University of Cologne, Albertus-Magnus-Platz, 50923 Köln, Germany
| | - Nathaniel Chin
- Wisconsin Alzheimer’s Disease Research Center, 600 Highland Ave J5/1 Mezzanine, Madison, WI, USA 53792
- Department of Medicine, Division of Geriatrics & Gerontology, University of Wisconsin-Madison School of Medicine and Public Health, 750 Highland Ave, Madison, WI, USA 53726
| | - Judith Heidebrink
- Michigan Alzheimer’s Disease Research Center, University of Michigan, 2101 Commonwealth Blvd, Suite C., Ann Arbor, MI, USA 48105
- Department of Neurology, University of Michigan, 1500 E Medical Center Dr # 1914, Ann Arbor, MI, USA 48109
| | - Sarah Getz
- Department of Neurology, University of Miami School of Medicine, 1150 NW 14 St Ste 609, Miami, FL, USA 33136
| | - Nicole R. Fowler
- Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, 340 West 10th Street, Fairbanks Hall, Suite 6200, Indianapolis, IN, USA 46202-3082
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., 1101 W 10th St, Indianapolis, IN, USA 46202
| | - Allyson Rosen
- Palo Alto Veterans Affairs Medical Center, 3801 Miranda Avenue. Palo Alto, CA, USA 94304-1207
- School of Medicine, Stanford University, 291 Campus Drive, Stanford, CA, USA 94305
| | - Jennifer Lingler
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, 3500 Victoria Street, 415 Victoria Building, Pittsburgh, PA, USA 15261
- University of Pittsburgh Alzheimer’s Disease Research Center, UPMC Montefiore, 4th floor, Suite 421, 200 Lothrop Street, Pittsburgh, PA, USA 15213
| | - Ellen Wijsman
- Division of Medical Genetics, Department of Medicine and Department of Biostatistics, University of Washington, Health Sciences Building, K253, Box 357720, Seattle, WA, USA 98195-7720
| | - Lindsay Clark
- Department of Medicine, Division of Geriatrics & Gerontology, University of Wisconsin-Madison School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI, USA 53705-2281
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI, USA 53705
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Turner JR, Hill NL, Brautigam L, Bhargava S, Mogle J. How Does Exposure to Dementia Relate to Subjective Cognition? A Systematic Review. Innov Aging 2023; 7:igad056. [PMID: 37497342 PMCID: PMC10368315 DOI: 10.1093/geroni/igad056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 07/28/2023] Open
Abstract
Background and Objectives Subjective cognitive decline (SCD) may be indicative of future objective cognitive decline. However, factors other than objective cognitive performance may influence SCD. This review addresses whether family history or close, nonfamilial exposure to dementia is associated with self-reported SCD. Research Design and Methods Searches were conducted in PubMed, PsycINFO, Web of Science, and the Dissertations and Theses database. Eligible articles included measures of self-reported cognition for community-dwelling middle-aged or older adults (40+ years) not diagnosed with dementia, and who had either a family history of dementia, a family member, spouse, or close friend with dementia. The quality of evidence was evaluated using the LEGEND Appraisal Tool. Evidence was synthesized narratively. Results A total of 32 articles were included, with 28 rated as good quality. Across studies, the relationship between dementia exposure and SCD was inconsistent. A significant association between exposure and SCD was found in 6 studies; however, 17 reviewed studies found no evidence of a relationship. The remaining 9 studies found mixed associations. Modifying factors that could potentially influence these associations were exploratorily identified among studies to provide context to our results. These factors included dementia worry, emotional closeness, and measurement sensitivity. Discussion and Implications Findings of this review suggest that both first-degree relatives and spouses of persons with dementia may have an increased likelihood of reporting SCD, although the current heterogeneity in definitions of exposure to dementia and SCD may influence these findings. In addition to the relationship between dementia exposure and SCD, future research should examine potential modifiers, including meaning attributed to exposure, as identifying how these perceptions affect cognition may promote early intervention.
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Affiliation(s)
- Jennifer R Turner
- Edna Bennett Pierce Prevention Research Center, College of Health and Human Development, Pennsylvania State University, University Park, Pennsylvania, USA
- Department of Psychology, College of Arts and Sciences, University of Hawaiʻi at Hilo, Hilo, Hawaii, USA
| | - Nikki L Hill
- Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Leslie Brautigam
- Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Sakshi Bhargava
- Department of Patient-Centered Outcomes Assessment, RTI Health Solutions, Research Triangle Park, North Carolina, USA
| | - Jacqueline Mogle
- Edna Bennett Pierce Prevention Research Center, College of Health and Human Development, Pennsylvania State University, University Park, Pennsylvania, USA
- Department of Psychology, College of Behavioral, Social, and Health Sciences, Clemson University, Clemson, South Carolina, USA
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Stites SD, Rubright JD, Harkins K, Karlawish J. Awareness of diagnosis predicts changes in quality of life in individuals with mild cognitive impairment and mild stage dementia. Int J Geriatr Psychiatry 2023; 38:e5939. [PMID: 37300313 PMCID: PMC10638664 DOI: 10.1002/gps.5939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 05/07/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND AND OBJECTIVE This observational study examined how awareness of diagnosis predicted changes in cognition and quality of life (QOL) 1 year later in older adults with normal cognition and dementia diagnoses. RESEARCH DESIGN AND METHODS Older adults (n = 259) with normal cognition, mild cognitive impairment (MCI), or mild stage Alzheimer's disease (AD) completed measures of diagnostic awareness, cognition, and multiple domains of QOL. We compared 1-year change in cognition and QOL by diagnostic group and diagnostic awareness. RESULTS Patients who were unaware of their diagnosis at baseline showed average decreases in both satisfaction with daily life (QOL-AD; paired mean difference (PMD) = -0.9, p < 0.05) and physical functioning (SF-12 PCS; PMD = -2.5, p < 0.05). In contrast, patients aware of their diagnosis at baseline showed no statistically discernable changes in most QOL domains (all p > 0.05). Of patients aware of their diagnosis at baseline (n = 111), those who were still aware (n = 84) showed a decrease in mental functioning at follow up (n = 27; SF-12 MCS). Change in MoCA scores in patients unaware of their diagnosis was similar to that in patients aware of their diagnosis, -1.4 points (95% CI -2.6 to -0.6) and -1.7 points (95% CI -2.4 to -1.1) respectively. DISCUSSION AND IMPLICATIONS Awareness of one's diagnosis of MCI or AD, not the severity of cognitive impairment, may predict changes in patients' mental functioning, expectations of their memory, satisfaction with daily life, and physical functioning. The findings may help clinicians anticipate the types of threats to wellbeing that a patient might encounter and identify key domains for monitoring.
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Affiliation(s)
- Shana D. Stites
- Department of Psychiatry, Perlman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Kristin Harkins
- Penn Memory Center, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Karlawish
- Penn Memory Center, Departments of Medicine, Medical Ethics and Health Policy, and Neurology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Larsen TS, Eugen-Olsen J, Andersen O, Kirk JW. Challenges facing the clinical adoption of a new prognostic biomarker: a case study. BIOSOCIETIES 2023:1-23. [PMID: 36713027 PMCID: PMC9860228 DOI: 10.1057/s41292-022-00296-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/22/2023]
Abstract
In this article, we show how a particular biomarker comes into being in an emergency department in a hospital in Copenhagen, Denmark. We explore the contextual becoming of this biomarker, suPAR, through interviews with nurses and physicians and through relational ontology. We find that as a prognostic biomarker suPAR is challenged in it becoming as an object for clinical practice in the emergency department by the power of diagnostic practices and the desire for experience-based scripts that quickly enable the clinician to reach the right diagnosis. Although suPAR is enacted as a promising triage strategy suggesting a low or high risk of disease, the inability to rule out specific diagnoses and producing the notion of secure clinical actions make its non-specificity and prognostic character problematic in clinical practices. Specific diagnostic criteria versus prognostic interpretation and non-specificity risk profiling challenges the way healthcare workers in an emergency department understand the tasks they are set to solve and how to solve them. We discuss how the becoming of suPAR is strengthened through enactments of specificity and engagement in triage strategies and we reflect on it's becoming through new diagnostic practices with the need to accommodate diagnostic ambiguity.
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Affiliation(s)
- Trine Schifter Larsen
- Department of Clinical Research, Copenhagen University Hospital, Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
- The Research Unit of Orthopaedic Nursing, Department of Orthopaedic Surgery, Copenhagen University Hospital, Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
- Department of People and Technology, Roskilde University, Universitetsvej 1, 4000 Roskilde, Denmark
| | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital, Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital, Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
- Emergency Department, Copenhagen University Hospital, Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Jeanette Wassar Kirk
- Department of Clinical Research, Copenhagen University Hospital, Hvidovre, Kettegård Allé 30, 2650 Hvidovre, Denmark
- Department of Public Health, Nursing and Health Care, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
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Galluzzi S, Pievani M, Zanetti O, Benussi L, Frisoni GB, Di Maria E. Disclosure of Genetic Risk Factors for Alzheimer's Disease to Cognitively Healthy Individuals-From Current Practice towards a Personalised Medicine Scenario. Biomedicines 2022; 10:biomedicines10123177. [PMID: 36551936 PMCID: PMC9775740 DOI: 10.3390/biomedicines10123177] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/26/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Alzheimer's disease (AD) is a genetically complex disorder. In addition to the relatively small number of pathogenic variants causing autosomal dominant AD, many others have been associated with the much more common sporadic form. The E4 allele of the Apolipoprotein E (APOE) is the first discovered genetic risk factor for AD. In addition, more than 70 genetic risk loci contributing to AD have been identified. Current guidelines do not recommend AD susceptibility genetic testing in cognitively healthy adults because the implications for clinical care are limited. However, secondary prevention clinical trials of disease-modifying therapies enrol individuals based on genetic criteria, and participants are often informed of APOE testing results. Moreover, the availability of direct-to-consumer genetic testing allows individuals to learn their own AD genetic risk profile without medical supervision. A number of research protocols for AD susceptibility genetic testing have been proposed. In Italy, disclosure processes and protocols beyond those developed for inherited dementia have not been established yet. We reviewed the literature on the current practice and clinical issues related to disclosing AD genetic risk to cognitively healthy individuals and provide suggestions that may help to develop specific guidelines at the national level.
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Affiliation(s)
- Samantha Galluzzi
- Laboratory Alzheimer’s Neuroimaging & Epidemiology, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | - Michela Pievani
- Laboratory Alzheimer’s Neuroimaging & Epidemiology, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | - Orazio Zanetti
- Memory Clinic, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | - Luisa Benussi
- Molecular Markers Laboratory, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, 25125 Brescia, Italy
| | | | - Giovanni B. Frisoni
- Laboratory of Neuroimaging of Aging (LANVIE), University of Geneva, 1205 Geneva, Switzerland
- Geneva Memory Center, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Emilio Di Maria
- Department of Health Sciences, University of Genoa, 16132 Genoa, Italy
- University Unit of Medical Genetics, Galliera Hospital, 16128 Genoa, Italy
- Correspondence:
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Bunnik EM, Smedinga M, Milne R, Georges J, Richard E, Schermer MHN. Ethical Frameworks for Disclosure of Alzheimer Disease Biomarkers to Research Participants: Conflicting Norms and a Nuanced Policy. Ethics Hum Res 2022; 44:2-13. [PMID: 36316970 DOI: 10.1002/eahr.500146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
More and more frequently, clinical trials for Alzheimer disease (AD) are targeting cognitively unimpaired individuals who are at increased risk of developing the disease. It is not always clear whether AD biomarker information should be disclosed to research participants: on the one hand, research participants may be interested in learning this information because of its perceived utility, but on the other hand, learning this information may be harmful, as there are very few effective preventive or therapeutic options available for AD. In this article, we bring together three separate sets of ethical guidance literature: on the return of individual research results, on an individual's right to access personal data, and on transparent enrollment into clinical trials. Based on these literatures, we suggest policies for the disclosure of AD biomarker test results in longitudinal observational cohort studies, clinical trials, and hybrid research projects, such as the European Prevention of Alzheimer's Dementia (EPAD) project, in which we served as an ethics team. We also present and critically discuss recommendations for disclosure of AD biomarkers in practice. We underscore that, as long as the clinical validity of AD biomarkers remains limited, there are good reasons to avoid actively disclosing them to cognitively unimpaired research participants.
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Affiliation(s)
- Eline M Bunnik
- Associate professor at the Erasmus University Medical Center in the Department of Medical Ethics, Philosophy and History of Medicine
| | - Marthe Smedinga
- Scientific secretary for the subcommittee on ethics and societal aspects at the Netherlands Commission on Genetic Modification
| | - Richard Milne
- Sociologist of science, technology, and medicine, the head of research and dialogue at Wellcome Connecting Science, and the deputy director of the Kavli Centre for Ethics, Science, and the Public at the University of Cambridge
| | | | - Edo Richard
- Professor of neurology at Amsterdam University Medical Centre and a neurologist at the Department of Neurology at the Donders Institute for Brain, Cognition and Behaviour at Radboud University Medical Centre
| | - Maartje H N Schermer
- Professor of philosophy of medicine at the Erasmus University Medical Center in the Department of Ethics, Philosophy and History of Medicine
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13
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Ketchum FB, Chin NA, Grill J, Gleason CE, Erickson C, Clark LR, Paulsen JS, Kind AJ. Moving beyond disclosure: Stages of care in preclinical Alzheimer's disease biomarker testing. Alzheimers Dement 2022; 18:1969-1979. [PMID: 35213786 PMCID: PMC9402800 DOI: 10.1002/alz.12620] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 01/28/2023]
Abstract
Alzheimer's disease (AD) begins with an asymptomatic "preclinical" phase, in which abnormal biomarkers indicate risk for developing cognitive impairment. Biomarker information is increasingly being disclosed in research settings, and is moving toward clinical settings with the development of cheaper and non-invasive testing. Limited research has focused on the safety and psychological effects of disclosing biomarker results to cognitively unimpaired adults. However, less is known about how to ensure equitable access and robust counseling for decision-making before testing, and how to effectively provide long-term follow-up and risk management after testing. Using the framework of Huntington's disease, which is based on extensive experience with disclosing and managing risk for a progressive neurodegenerative condition, this article proposes a conceptual model of pre-disclosure, disclosure, and post-disclosure phases for AD biomarker testing. Addressing research questions in each phase will facilitate the transition of biomarker testing into clinical practice.
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Affiliation(s)
- Fred B. Ketchum
- Department of NeurologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Nathaniel A. Chin
- Division of GeriatricsDepartment of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's Disease Research CenterMadisonWisconsinUSA
| | - Joshua Grill
- Institute for Memory Impairments and Neurological DisordersUniversity of California, IrvineIrvineCaliforniaUSA
- Departments of Psychiatry and Human Behavior and Neurobiology and BehaviorUniversity of California, IrvineIrvineCaliforniaUSA
| | - Carey E. Gleason
- Division of GeriatricsDepartment of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's Disease Research CenterMadisonWisconsinUSA
- Geriatric ResearchEducation and Clinical Center (11G)William S. Middleton Memorial Veterans HospitalMadisonWisconsinUSA
| | - Claire Erickson
- Wisconsin Alzheimer's Disease Research CenterMadisonWisconsinUSA
- Neuroscience & Public Policy ProgramUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Lindsay R. Clark
- Division of GeriatricsDepartment of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Jane S. Paulsen
- Department of NeurologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Amy J.H. Kind
- Division of GeriatricsDepartment of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's Disease Research CenterMadisonWisconsinUSA
- Center for Health Disparities ResearchUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
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14
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Wheat R, Vess M, Holte P. Genetic Risk Information Influences Risk-Taking Behavior. SOCIAL COGNITION 2022. [DOI: 10.1521/soco.2022.40.4.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Research indicates that people will behave in ways that are consistent with the genes they believe they possess. We examined this tendency in the context of risk-taking. We predicted that bogus genetic testing results indicating a propensity for risk-taking would cause participants to demonstrate riskier behavior. Participants submitted saliva tests and were randomly assigned to receive bogus genetic feedback indicating high propensity or low propensity for risk-taking. They then completed a standardized measure of risk-taking behavior. Results showed that those who received feedback indicating they were genetically disposed to risky behavior demonstrated higher risk-taking behavior than those who received feedback indicating that they were genetically disposed to risk aversion. These findings extend work on genetic feedback effects to a new domain and further reveal the ways that genetic feedback shapes behavior independent of one's actual genetic propensities.
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Clark LR, Erickson CM, Jonaitis EM, Ma Y, Chin NA, Basche K, Ketchum FB, Gleason CE. Anticipated reactions to learning Alzheimer's disease biomarker results. Alzheimers Res Ther 2022; 14:85. [PMID: 35733219 PMCID: PMC9214979 DOI: 10.1186/s13195-022-01027-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/06/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION We developed the Alzheimer's Biomarker Survey to assess willingness to enroll in biomarker studies that disclose results and anticipated reactions to an elevated biomarker result. METHODS Participants included cognitively unimpaired adults enrolled in longitudinal AD studies (n = 334, mean age = 64.8 ± 7.7, 44% non-Hispanic Black or African American). Exploratory and confirmatory factor analyses determined the latent structure comprising anticipated reactions to learning AD biomarker results. Measurement invariance was tested across racial groups. RESULTS Two models comprising behavior change and psychological impact fit well for the total sample and the two racial groups. The 2-factor behavior change model assessed constructs of planning and dementia risk-reduction. The 3-factor psychological impact model assessed constructs of distress, cognitive symptoms, and stigma. Both models exhibited measurement invariance across racial groups. DISCUSSION The 28-item Anticipated Reactions to AD Biomarker Disclosure scale is a reliable and valid measure of anticipated reactions when communicating AD biomarker results to research participants.
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Affiliation(s)
- Lindsay R. Clark
- grid.14003.360000 0001 2167 3675Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA ,grid.417123.20000 0004 0420 6882Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI USA
| | - Claire M. Erickson
- grid.14003.360000 0001 2167 3675Neuroscience & Public Policy Program, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA
| | - Erin M. Jonaitis
- grid.14003.360000 0001 2167 3675Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA
| | - Yue Ma
- grid.14003.360000 0001 2167 3675Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA
| | - Nathaniel A. Chin
- grid.14003.360000 0001 2167 3675Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA
| | - Kristin Basche
- grid.14003.360000 0001 2167 3675Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA
| | - Frederick B. Ketchum
- grid.14003.360000 0001 2167 3675Department of Neurology, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA
| | - Carey E. Gleason
- grid.14003.360000 0001 2167 3675Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 600 Highland Avenue, Madison, WI USA ,grid.417123.20000 0004 0420 6882Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI USA
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16
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van der Schaar J, Visser LNC, Bouwman FH, Ket JCF, Scheltens P, Bredenoord AL, van der Flier WM. Considerations regarding a diagnosis of Alzheimer's disease before dementia: a systematic review. Alzheimers Res Ther 2022; 14:31. [PMID: 35144684 PMCID: PMC8829985 DOI: 10.1186/s13195-022-00971-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/31/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND The NIA-AA research framework proposes a purely biological definition of Alzheimer's disease (AD). This implies that AD can be diagnosed based on biomarker abnormalities, irrespective of clinical manifestation. While this brings opportunities, it also raises challenges. We aimed to provide an overview of considerations regarding the disclosure of AD pathology before the onset of dementia. METHODS A systematic literature review was conducted and reported according to PRISMA guidelines. We searched PubMed, Embase, APA PsycINFO, and Web of Science Core Collection (on 10 December 2020) for references on conveying AD biomarker results to individuals without dementia. Our query combined variations on the terms Alzheimer's disease, disclosure, or diagnosis, preclinical or prodromal, and biomarkers. Two reviewers independently screened the resulting 6860 titles and abstracts for eligibility and examined 162 full-text records for relevance. We included theoretical articles in English, on communicating amyloid and/or tau results to individuals with mild cognitive impairment, subjective cognitive decline, or normal cognition. MAXQDA-software was used for inductive data analysis. RESULTS We included 27 publications. From these, we extracted 26 unique considerations, which we grouped according to their primary relevance to a clinical, personal, or societal context. Clinical considerations included (lack of) validity, utility, and disclosure protocols. Personal considerations covered psychological and behavioral implications, as well as the right to (not) know. Finally, societal considerations comprised the risk of misconception, stigmatization, and discrimination. Overall, views were heterogeneous and often contradictory, with emphasis on harmful effects. CONCLUSIONS We found 26 diverse and opposing considerations, related to a clinical, personal, or societal context, which are relevant to diagnosing AD before dementia. The theoretical literature tended to focus on adverse impact and rely on common morality, while the motivation for and implications of biomarker testing are deeply personal. Our findings provide a starting point for clinicians to discuss biomarker-based diagnosis with their patients, which will become even more relevant in light of the conditional approval of a first disease-modifying drug for AD.
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Affiliation(s)
- Jetske van der Schaar
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands.
| | - Leonie N C Visser
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
- Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Femke H Bouwman
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
| | | | - Philip Scheltens
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
| | - Annelien L Bredenoord
- Erasmus School of Philosophy, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Wiesje M van der Flier
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, De Boelelaan 1118, 1081, HZ, Amsterdam, The Netherlands
- Department of Epidemiology & Data Sciences, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
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Responsible use of polygenic risk scores in the clinic: potential benefits, risks and gaps. Nat Med 2021; 27:1876-1884. [PMID: 34782789 DOI: 10.1038/s41591-021-01549-6] [Citation(s) in RCA: 198] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/22/2021] [Indexed: 01/24/2023]
Abstract
Polygenic risk scores (PRSs) aggregate the many small effects of alleles across the human genome to estimate the risk of a disease or disease-related trait for an individual. The potential benefits of PRSs include cost-effective enhancement of primary disease prevention, more refined diagnoses and improved precision when prescribing medicines. However, these must be weighed against the potential risks, such as uncertainties and biases in PRS performance, as well as potential misunderstanding and misuse of these within medical practice and in wider society. By addressing key issues including gaps in best practices, risk communication and regulatory frameworks, PRSs can be used responsibly to improve human health. Here, the International Common Disease Alliance's PRS Task Force, a multidisciplinary group comprising expertise in genetics, law, ethics, behavioral science and more, highlights recent research to provide a comprehensive summary of the state of polygenic score research, as well as the needs and challenges as PRSs move closer to widespread use in the clinic.
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18
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Roberts JS, Ferber R, Blacker D, Rumbaugh M, Grill JD. Disclosure of individual research results at federally funded Alzheimer's Disease Research Centers. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2021; 7:e12213. [PMID: 34692986 PMCID: PMC8515553 DOI: 10.1002/trc2.12213] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION This study describes practices for disclosing individual research results to participants in Alzheimer's disease research. METHODS An online survey of clinical core leaders at National Institutes of Health-funded Alzheimer's Disease Research Centers in the United States (response rate: 30/31, 97%) examined return of results practices across nine different types of research results. RESULTS Most centers had returned consensus research diagnoses (83%) and neuropsychological test results (73%), with fewer having shared amyloid positron emission tomography (43%), tau imaging (10%), or apolipoprotein E (APOE) genotype (7%) results. Centers reported having disclosed a mean of 3.1 types of results (standard deviation = 2.1; range 0-8). The most commonly cited reason for disclosure was to inform participants' medical decision-making (88%). Disclosure involved multiple professionals and modalities, with neurologists (87%) and in-person visits (85%) most commonplace. DISCUSSION Centers varied widely as to whether and how they disclosed research results. Diagnostic and cognitive test results were more commonly returned than genetic or biomarker results.
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Affiliation(s)
- J. Scott Roberts
- Department of Health Behavior & Health EducationUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Rebecca Ferber
- Department of Health Behavior & Health EducationUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Deborah Blacker
- Massachusetts General HospitalHarvard Medical SchoolBostonMAUSA
- Department of EpidemiologyHarvard T. H. Chan School of Public HealthBostonMassachusettsUSA
| | - Malia Rumbaugh
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIndianaUSA
| | - Joshua D. Grill
- Institute for Memory Impairments and Neurological DisordersUniversity of California IrvineIrvineCaliforniaUSA
- Department of Psychiatry & Human BehaviorUniversity of California Irvine School of MedicineIrvineCaliforniaUSA
- Department of Neurobiology & BehaviorUniversity of California Irvine School of Biological SciencesIrvineCaliforniaUSA
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Zwicker A, LeBlanc MA, Pavlova B, Alda M, Denovan-Wright EM, Uher R, Austin JC. Genetic counselling for the prevention of mental health consequences of cannabis use: A randomized controlled trial-within-cohort. Early Interv Psychiatry 2021; 15:1306-1314. [PMID: 33242924 DOI: 10.1111/eip.13082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 08/10/2020] [Accepted: 11/15/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cannabis use is a risk factor for severe mental illness. However, cannabis does not affect everyone equally. Genetic information may help identify individuals who are more vulnerable to the harmful effects of cannabis on mental health. A common genetic variant within the AKT1 gene selectively increases risk of psychosis, only among those who use cannabis. Therapeutically oriented genetic counselling may enable us to reduce cannabis exposure among genetically sensitive individuals. METHODS Using a trial-within-cohort design, we aim to test if genetic counselling, including the option to receive AKT1 rs2494732 genotype, reduces cannabis use. To this end, we have designed a genetic counselling intervention: Interdisciplinary approach to Maximize Adolescent potential: Genetic counselling Intervention to reduce Negative Environmental effects (IMAGINE). RESULTS IMAGINE will be implemented in a cohort of children and youth enriched for familial risk for major mood and psychotic disorders. Approximately 110 eligible individuals aged 12-21 years will be randomized in a 1:1 ratio to be offered a single genetic counselling session with a board-certified genetic counsellor, or not. Allocated youth will also be invited to attend a follow-up session approximately 1 month following the intervention. The primary outcome will be cannabis use (measured by self-report or urine screen) at subsequent annual assessments as part of the larger cohort study. Secondary outcomes include intervention acceptability and psychopathology. CONCLUSION This study represents the first translational application of a gene-environment interaction to improve mental health and test an intervention with potential public health benefits. This study is registered with clinicaltrials.gov (NCT03601026).
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Affiliation(s)
- Alyson Zwicker
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Psychiatry, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Marissa A LeBlanc
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Barbara Pavlova
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Psychiatry, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Martin Alda
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Psychiatry, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | | | - Rudolf Uher
- Department of Psychiatry, Dalhousie University, Halifax, Nova Scotia, Canada.,Department of Psychiatry, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Jehannine C Austin
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
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21
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Pygmalion in the genes? On the potentially negative impacts of polygenic scores for educational attainment. SOCIAL PSYCHOLOGY OF EDUCATION 2021. [DOI: 10.1007/s11218-021-09632-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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22
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Erickson CM, Chin NA, Johnson SC, Gleason CE, Clark LR. Disclosure of preclinical Alzheimer's disease biomarker results in research and clinical settings: Why, how, and what we still need to know. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2021; 13:e12150. [PMID: 33665341 PMCID: PMC7896633 DOI: 10.1002/dad2.12150] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/02/2020] [Indexed: 12/18/2022]
Abstract
Disclosure of personal disease-related information to asymptomatic adults has been debated over the last century in medicine and research. Recently, Alzheimer's disease (AD) has been conceptualized as a continuum that begins with a "preclinical" stage in which biomarkers are present in the absence of cognitive impairment. Studies have begun assessing the safety, psychological, and behavioral effects of disclosing both AD-related genetic and biomarker information to cognitively unimpaired older adults. Yet, debate continues over the appropriate circumstances and methods for returning such information. This article outlines concerns with and rationale for AD biomarker disclosure and summarizes findings from prior studies. Overall, this article aims to describe and respond to key questions concerning disclosure of amyloid positron emission tomography scan results to asymptomatic adults in a research setting. Moving forward, such conditions are important to consider as interventions target the preclinical phase of AD and normalize disclosing biomarker information to cognitively unimpaired persons.
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Affiliation(s)
- Claire M. Erickson
- Neuroscience & Public Policy ProgramUniversity of Wisconsin‐Madison School of Medicine and Public HealthMadisonWisconsinUSA
- Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Nathaniel A. Chin
- Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Sterling C. Johnson
- Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's InstituteUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Geriatric Research Education and Clinical CenterWilliam S. Middleton Memorial Veterans HospitalMadisonWisconsinUSA
| | - Carey E. Gleason
- Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Geriatric Research Education and Clinical CenterWilliam S. Middleton Memorial Veterans HospitalMadisonWisconsinUSA
| | - Lindsay R. Clark
- Alzheimer's Disease Research CenterUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Wisconsin Alzheimer's InstituteUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
- Geriatric Research Education and Clinical CenterWilliam S. Middleton Memorial Veterans HospitalMadisonWisconsinUSA
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23
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Largent EA, Bhardwaj T, Abera M, Stites SD, Harkins K, Lerner AJ, Bradbury AR, Karlawish J. Disclosing Genetic Risk of Alzheimer's Disease to Cognitively Unimpaired Older Adults: Findings from the Study of Knowledge and Reactions to APOE Testing (SOKRATES II). J Alzheimers Dis 2021; 84:1015-1028. [PMID: 34602479 PMCID: PMC8629880 DOI: 10.3233/jad-210675] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Current practice guidelines recommend against Apolipoprotein E (APOE) testing. However, advances in Alzheimer's disease (AD) research and care may soon change this. OBJECTIVE To examine longitudinally the experience of learning an APOE result and, if an ɛ4 carrier, taking a disease-specific treatment to reduce one's risk of AD. METHODS Fifty ɛ4 carriers and 20 non-carriers completed semi-structured interviews 3 months and 15 months after APOE disclosure. RESULTS Individuals generally understand their APOE results. While non-carriers felt relief, ɛ4 carriers often described themselves as disappointed by their result but nevertheless glad to know. Carriers expressed concerns about stigma and discrimination, including in the workplace. Carriers adopted new health behaviors at higher rates than non-carriers and revised their future plans to account for their increased risk of AD. Individuals participating in research were hopeful that their participation would help them or others; individuals who learned they were at increased risk for AD but who could not participate in research were disappointed. CONCLUSION Providers disclosing APOE results should be sensitive to how APOE results shape emotions, self-perceptions, and attitudes about memory; raise concerns about stigma and discrimination in personal and professional relationships; influence health behaviors and decision-making; and can have follow-on effects on family members.
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Affiliation(s)
- Emily A Largent
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Maramawit Abera
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shana D Stites
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristin Harkins
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alan J Lerner
- Brain Health and Memory Center, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Angela R Bradbury
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Perceptions of best practices for return of results in an international survey of psychiatric genetics researchers. Eur J Hum Genet 2020; 29:231-240. [PMID: 33011736 PMCID: PMC7532738 DOI: 10.1038/s41431-020-00738-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/02/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022] Open
Abstract
Many research sponsors and genetic researchers agree that some medically relevant genetic findings should be offered to participants. The scarcity of research specific to returning genetic results related to psychiatric disorders hinders the ability to develop ethically justified and empirically informed guidelines for responsible return of results for these conditions. We surveyed 407 psychiatric genetics researchers from 39 countries to examine their perceptions of challenges to returning individual results and views about best practices for the process of offering and returning results. Most researchers believed that disclosure of results should be delayed if a patient-participant is experiencing significant psychiatric symptoms. Respondents felt that there is little research on the impact of returning results to participants with psychiatric disorders and agreed that return of psychiatric genetics results to patient-participants may lead to discrimination by insurance companies or other third parties. Almost half of researchers believed results should be returned through a participant's treating psychiatrist, but many felt that clinicians lack knowledge about how to manage genetic research results. Most researchers thought results should be disclosed by genetic counselors or medical geneticists and in person; however, almost half also supported disclosure via telemedicine. This is the first global survey to examine the perspectives of researchers with experience working with this patient population and with these conditions. Their perspectives can help inform the development of much-needed guidelines to promote responsible return of results related to psychiatric conditions to patients with psychiatric disorders.
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25
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Barber SJ. The Applied Implications of Age-Based Stereotype Threat for Older Adults. JOURNAL OF APPLIED RESEARCH IN MEMORY AND COGNITION 2020; 9:274-285. [PMID: 36032188 PMCID: PMC9415413 DOI: 10.1016/j.jarmac.2020.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Stereotype threat occurs when people feel concerned about the possibility of confirming, or being negatively judged by, a negative stereotype. This review highlights the applied implications of this phenomenon for older adults In clinical settings, older adults often feel that their physicians have negative expectations about their abilities because of their age. These feelings of age-based stereotype threat can increase older adults' subjective cognitive complaints and impair their performance on mental status examinations. Other research has shown that stereotype threat also adversely affects older adults' physical performance, motor learning, and driving performance. In workplace settings, older adults who experience stereotype threat also report lower job satisfaction, poorer work-related mental health, and greater intentions to resign or retire. Overall, this review provides evidence that the situational phenomenon of stereotype threat can affect older adults' performance in a variety of applied settings, and this can contribute to age differences in performance.
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Roberts JS, Patterson AK, Uhlmann WR. Genetic testing for neurodegenerative diseases: Ethical and health communication challenges. Neurobiol Dis 2020; 141:104871. [PMID: 32302673 PMCID: PMC7311284 DOI: 10.1016/j.nbd.2020.104871] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/01/2020] [Accepted: 04/13/2020] [Indexed: 12/31/2022] Open
Abstract
Advances in genomic science are informing an expansion of genetic testing for neurodegenerative diseases, which can be used for diagnostic and predictive purposes and performed in both medical and consumer genomics settings. Such testing-which is often for severe and incurable conditions like Huntington's, Alzheimer's, and Parkinson's diseases-raises important ethical and health communication challenges. This review addresses such challenges in the contexts of clinical, research, and direct-to-consumer genetic testing; these include informed consent, risk estimation and communication, potential benefits and psychosocial harms of genetic information (e.g., genetic discrimination), access to services, education and workforce needs, and health policies. The review also highlights future areas of likely growth in the field, including polygenic risk scores, use of genetic testing in clinical trials, and return of individual research results.
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Affiliation(s)
- J Scott Roberts
- Department of Health Behavior & Health Education, University of Michigan School of Public Health, United States of America.
| | - Anne K Patterson
- University of Michigan School of Public Health, United States of America
| | - Wendy R Uhlmann
- Department of Internal Medicine, Division of Genetic Medicine, Department of Human Genetics, University of Michigan School of Medicine, United States of America
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Goldman JS. Predictive Genetic Counseling for Neurodegenerative Diseases: Past, Present, and Future. Cold Spring Harb Perspect Med 2020; 10:cshperspect.a036525. [PMID: 31548223 DOI: 10.1101/cshperspect.a036525] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Predictive genetic counseling for neurodegenerative diseases commenced with Huntington's disease (HD). Because the psychological issues and outcomes have been best studied in HD, the HD genetic counseling and testing protocol is still accepted as the gold standard for genetic counseling for these diseases. Yet, advances in genomic technology have produced an abundance of new information about the genetics of diseases such as Alzheimer's disease, frontotemporal dementia, amyotrophic lateral sclerosis, and Parkinson's disease. The resulting expansion of genetic tests together with the availability of direct-to-consumer testing and clinical trials for treatment of these diseases present new ethical and practical issues requiring modifications to the protocol for HD counseling and new demands on both physicians and genetic counselors. This work reviews the history of genetic counseling for neurodegenerative diseases, its current practice, and the future direction of genetic counseling for these conditions.
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Affiliation(s)
- Jill S Goldman
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Department of Neurology, Columbia University Vagelos College of Medicine, New York, New York 10032, USA
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28
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Folkersen L, Pain O, Ingason A, Werge T, Lewis CM, Austin J. Impute.me: An Open-Source, Non-profit Tool for Using Data From Direct-to-Consumer Genetic Testing to Calculate and Interpret Polygenic Risk Scores. Front Genet 2020; 11:578. [PMID: 32714365 PMCID: PMC7340159 DOI: 10.3389/fgene.2020.00578] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 05/11/2020] [Indexed: 01/07/2023] Open
Abstract
To date, interpretation of genomic information has focused on single variants conferring disease risk, but most disorders of major public concern have a polygenic architecture. Polygenic risk scores (PRSs) give a single measure of disease liability by summarizing disease risk across hundreds of thousands of genetic variants. They can be calculated in any genome-wide genotype data-source, using a prediction model based on genome-wide summary statistics from external studies. As genome-wide association studies increase in power, the predictive ability for disease risk will also increase. Although PRSs are unlikely ever to be fully diagnostic, they may give valuable medical information for risk stratification, prognosis, or treatment response prediction. Public engagement is therefore becoming important on the potential use and acceptability of PRSs. However, the current public perception of genetics is that it provides "yes/no" answers about the presence/absence of a condition, or the potential for developing a condition, which in not the case for common, complex disorders with polygenic architecture. Meanwhile, unregulated third-party applications are being developed to satisfy consumer demand for information on the impact of lower-risk variants on common diseases that are highly polygenic. Often, applications report results from single-nucleotide polymorphisms (SNPs) and disregard effect size, which is highly inappropriate for common, complex disorders where everybody carries risk variants. Tools are therefore needed to communicate our understanding of genetic vulnerability as a continuous trait, where a genetic liability confers risk for disease. Impute.me is one such tool, whose focus is on education and information on common, complex disorders with polygenetic architecture. Its research-focused open-source website allows users to upload consumer genetics data to obtain PRSs, with results reported on a population-level normal distribution. Diseases can only be browsed by International Classification of Diseases, 10th Revision (ICD-10) chapter-location or alphabetically, thus prompting the user to consider genetic risk scores in a medical context of relevance to the individual. Here, we present an overview of the implementation of the impute.me site, along with analysis of typical usage patterns, which may advance public perception of genomic risk and precision medicine.
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Affiliation(s)
- Lasse Folkersen
- Institute of Biological Psychiatry, Mental Health Centre Sankt Hans, Copenhagen, Denmark
| | - Oliver Pain
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Andrés Ingason
- Institute of Biological Psychiatry, Mental Health Centre Sankt Hans, Copenhagen, Denmark
| | - Thomas Werge
- Institute of Biological Psychiatry, Mental Health Centre Sankt Hans, Copenhagen, Denmark
| | - Cathryn M. Lewis
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
- Department of Medical & Molecular Genetics, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Jehannine Austin
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
- Department of Medical Genetics, University of British Columbia, Vancouver, BC, Canada
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Haddad R, Lenze EJ, Nicol G, Miller JP, Yingling M, Wetherell JL. Does patient expectancy account for the cognitive and clinical benefits of mindfulness training in older adults? Int J Geriatr Psychiatry 2020; 35:626-632. [PMID: 32017250 DOI: 10.1002/gps.5279] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/20/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Patient expectations of treatment effects could influence neuropsychological and clinical outcomes in clinical trials of behavioral and lifestyle interventions, which could potentially confound the interpretation of findings. Our aim was to examine whether patient expectancy mediated effectiveness of Mindfulness-Based Stress Reduction (MBSR) for improving cognitive function and clinical outcome. METHODS The present study uses data from a single-blind, multi-site, randomized controlled trial comparing MBSR to a health education attention control in older adults with anxiety and/or depressive disorders and subjective cognitive concerns. Using the Credibility and Expectations Questionnaire, we measured expectancy and perceived credibility of the interventions assigned to patients. Using mediational analysis, we examined the influence of expectancy and credibility on two key outcomes: memory performance and clinical global improvement. RESULTS Neither expectancy nor perceived credibility of intervention accounted significantly for MBSR's effectiveness for memory test performance or clinical global improvement. CONCLUSION In this clinical trial, expectancy for improvement did not account for the effectiveness of MBSR on memory performance or clinical outcomes in depressed and anxious older adults. We advise that clinical trials of behavioral and lifestyle interventions for brain health in older adults should measure and test the role of expectancy.
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Affiliation(s)
- Rita Haddad
- Department of Psychiatry, Healthy Mind Lab, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric J Lenze
- Department of Psychiatry, Healthy Mind Lab, Washington University School of Medicine, St. Louis, MO, USA
| | - Ginger Nicol
- Department of Psychiatry, Healthy Mind Lab, Washington University School of Medicine, St. Louis, MO, USA
| | - J Philip Miller
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael Yingling
- Department of Psychiatry, Healthy Mind Lab, Washington University School of Medicine, St. Louis, MO, USA
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30
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Rios-Romenets S, Lopera F, Sink KM, Hu N, Lian Q, Guthrie H, Smith J, Cho W, Mackey H, Langbaum JB, Thomas RG, Giraldo-Chica M, Tobon C, Acosta-Baena N, Muñoz C, Ospina P, Tirado V, Henao E, Bocanegra Y, Chen K, Su Y, Goradia D, Thiyyagura P, VanGilder PS, Luo J, Ghisays V, Lee W, Malek-Ahmadi MH, Protas HD, Chen Y, Quiroz YT, Reiman EM, Tariot PN. Baseline demographic, clinical, and cognitive characteristics of the Alzheimer's Prevention Initiative (API) Autosomal-Dominant Alzheimer's Disease Colombia Trial. Alzheimers Dement 2020; 16:1023-1030. [PMID: 32418361 PMCID: PMC7819133 DOI: 10.1002/alz.12109] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 01/26/2020] [Accepted: 02/21/2020] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The API AutosomalDominant AD (ADAD) Colombia Trial is a placebo-controlled clinical trial of crenezumab in 252 cognitively unimpaired 30 to 60-year-old Presenilin 1 (PSEN1) E280A kindred members, including mutation carriers randomized to active treatment or placebo and non-carriers who receive placebo. METHODS Of the 252 enrolled, we present data on a total of 242 mutation carriers and non-carriers matched by age range, excluding data on 10 participants to protect participant confidentiality, genetic status, and trial integrity. RESULTS We summarize demographic, clinical, cognitive, and behavioral data from 167 mutation carriers and 75 non-carriers, 30 to 53 years of age. Carriers were significantly younger than non-carriers ((mean age ± SD) 37 ± 5 vs 42 ± 6), had significantly lower Mini Mental Status Exam (MMSE) scores (28.8 ± 1.4 vs 29.2 ± 1.0), and had consistently lower memory scores. DISCUSSION Although PSEN1 E280A mutation carriers in the Trial are cognitively unimpaired, they have slightly lower MMSE and memory scores than non-carriers. Their demographic characteristics are representative of the local population.
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Affiliation(s)
| | - Francisco Lopera
- Neurosciences Group of Antioquia/University of Antioquia, Medellin, Colombia
| | - Kaycee M Sink
- Genentech Inc., South San Francisco, California, USA
| | - Nan Hu
- Genentech Inc., South San Francisco, California, USA
| | - Qinshu Lian
- Genentech Inc., South San Francisco, California, USA
| | | | | | - William Cho
- Genentech Inc., South San Francisco, California, USA
| | - Howard Mackey
- Genentech Inc., South San Francisco, California, USA
| | | | | | | | - Carlos Tobon
- Neurosciences Group of Antioquia/University of Antioquia, Medellin, Colombia
| | | | - Claudia Muñoz
- Neurosciences Group of Antioquia/University of Antioquia, Medellin, Colombia
| | - Paula Ospina
- Neurosciences Group of Antioquia/University of Antioquia, Medellin, Colombia
| | - Victoria Tirado
- Neurosciences Group of Antioquia/University of Antioquia, Medellin, Colombia
| | - Eliana Henao
- Neurosciences Group of Antioquia/University of Antioquia, Medellin, Colombia
| | - Yamile Bocanegra
- Neurosciences Group of Antioquia/University of Antioquia, Medellin, Colombia
| | - Kewei Chen
- Banner Alzheimer's Institute, Phoenix, Arizona, USA
| | - Yi Su
- Banner Alzheimer's Institute, Phoenix, Arizona, USA
| | | | | | | | - Ji Luo
- Banner Alzheimer's Institute, Phoenix, Arizona, USA
| | | | - Wendy Lee
- Banner Alzheimer's Institute, Phoenix, Arizona, USA
| | | | | | - Yinghua Chen
- Banner Alzheimer's Institute, Phoenix, Arizona, USA
| | - Yakeel T Quiroz
- Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
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- Neurosciences Group of Antioquia/University of Antioquia, Medellin, Colombia
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31
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Hercher L. Discouraging Elective Genetic Testing of Minors: A Norm under Siege in a New Era of Genomic Medicine. Cold Spring Harb Perspect Med 2020; 10:a036657. [PMID: 31548217 PMCID: PMC7197418 DOI: 10.1101/cshperspect.a036657] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Consistently, the field of genetic counseling has advocated that parents be advised to defer elective genetic testing of minors until adulthood to prevent a range of potential harms, including stigma, discrimination, and the loss of the child's ability to decide for him- or herself as an adult. However, consensus around the policy of "defer-when-possible" obscures the extent to which this norm is currently under siege. Increasingly, routine use of full or partial genome sequencing challenges our ability to control what is discovered in childhood or, when applied in a prenatal context, even before birth. The expansion of consumer-initiated genetic testing services challenges our ability to restrict what is available to minors. As the barriers to access crumble, medical professionals should proceed with caution, bearing in mind potential risks and continuing to assess the impact of genetic testing on this vulnerable population.
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Affiliation(s)
- Laura Hercher
- Sarah Lawrence College, Joan H. Marks Graduate Program in Human Genetics, Bronxville, New York 10708, USA
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32
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Nestor JG, Marasa M, Milo-Rasouly H, Groopman EE, Husain SA, Mohan S, Fernandez H, Aggarwal VS, Ahram DF, Vena N, Bogyo K, Bomback AS, Radhakrishnan J, Appel GB, Ahn W, Cohen DJ, Canetta PA, Dube GK, Rao MK, Morris HK, Crew RJ, Sanna-Cherchi S, Kiryluk K, Gharavi AG. Pilot Study of Return of Genetic Results to Patients in Adult Nephrology. Clin J Am Soc Nephrol 2020; 15:651-664. [PMID: 32299846 PMCID: PMC7269209 DOI: 10.2215/cjn.12481019] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/12/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Actionable genetic findings have implications for care of patients with kidney disease, and genetic testing is an emerging tool in nephrology practice. However, there are scarce data regarding best practices for return of results and clinical application of actionable genetic findings for kidney patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We developed a return of results workflow in collaborations with clinicians for the retrospective recontact of adult nephrology patients who had been recruited into a biobank research study for exome sequencing and were identified to have medically actionable genetic findings. RESULTS Using this workflow, we attempted to recontact a diverse pilot cohort of 104 nephrology research participants with actionable genetic findings, encompassing 34 different monogenic etiologies of nephropathy and five single-gene disorders recommended by the American College of Medical Genetics and Genomics for return as medically actionable secondary findings. We successfully recontacted 64 (62%) participants and returned results to 41 (39%) individuals. In each case, the genetic diagnosis had meaningful implications for the patients' nephrology care. Through implementation efforts and qualitative interviews with providers, we identified over 20 key challenges associated with returning results to study participants, and found that physician knowledge gaps in genomics was a recurrent theme. We iteratively addressed these challenges to yield an optimized workflow, which included standardized consultation notes with tailored management recommendations, monthly educational conferences on core topics in genomics, and a curated list of expert clinicians for patients requiring extranephrologic referrals. CONCLUSIONS Developing the infrastructure to support return of genetic results in nephrology was resource-intensive, but presented potential opportunities for improving patient care. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_04_16_12481019.mp3.
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Affiliation(s)
- Jordan G Nestor
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Maddalena Marasa
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Hila Milo-Rasouly
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Emily E Groopman
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - S Ali Husain
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Hilda Fernandez
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Vimla S Aggarwal
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | - Dina F Ahram
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Natalie Vena
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York.,Institute for Genomic Medicine, Columbia University, New York, New York
| | - Kelsie Bogyo
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York.,Department of Pathology and Cell Biology, Columbia University, New York, New York
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Jai Radhakrishnan
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Gerald B Appel
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Wooin Ahn
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Pietro A Canetta
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Geoffrey K Dube
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Maya K Rao
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Heather K Morris
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Russell J Crew
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Simone Sanna-Cherchi
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York
| | - Ali G Gharavi
- Division of Nephrology, Department of Medicine, Columbia University, New York, New York .,Institute for Genomic Medicine, Columbia University, New York, New York
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Chi CH, Chiu YS, Chang YL. Apolipoprotein E ε4 Allele Is Associated with Reduced Retention of the "Where" Memory Component in Cognitively Intact Older Adults. Arch Clin Neuropsychol 2020; 35:143-154. [PMID: 31701118 DOI: 10.1093/arclin/acz047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 05/03/2019] [Accepted: 08/19/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The present study investigated the effect of the apolipoprotein E (ApoE) ε4 allele on the four memory components (i.e., who, when, where, and what) among cognitively intact older adults. METHODS Participants comprised 47 cognitively intact older adults, who were classified into 2 groups based on the presence or absence of at least 1 ApoE ε4 allele. All participants completed standardized neuropsychological tests, including the Logical Memory subtest of the Wechsler Memory Scale-III with a revised scoring method. RESULTS The results revealed that recollection for each component followed a pattern of who > what > when = where. Furthermore, a significant group-by-component-by-condition interaction indicated that the presence of the ApoE ε4 allele resulted in a disproportionately detrimental effect on the where component retention in the verbal episodic memory task; this finding was significantly correlated with hippocampal volumes. CONCLUSION These results highlighted the importance of evaluating the subcomponents of verbal episodic memory to detect subtle cognitive differences related to ApoE ε4 status, which could help elucidate the mechanism behind the cascades caused by ApoE ε4 in the trajectories of cognitive aging.
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Affiliation(s)
- Chia-Hsing Chi
- Department of Psychology, College of Science, National Taiwan University, Taipei 10617, Taiwan
| | - Yen-Shiang Chiu
- Department of Psychology, College of Science, National Taiwan University, Taipei 10617, Taiwan
| | - Yu-Ling Chang
- Department of Psychology, College of Science, National Taiwan University, Taipei 10617, Taiwan.,Neurobiology and Cognitive Science Center, National Taiwan University, Taipei 10617, Taiwan.,Center for Artificial Intelligence and Advanced Robotics, National Taiwan University, Taipei 10617, Taiwan.,Department of Neurology, National Taiwan University Hospital, Taipei 10048, Taiwan
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McWhirter L, Ritchie C, Stone J, Carson A. Functional cognitive disorders: a systematic review. Lancet Psychiatry 2020; 7:191-207. [PMID: 31732482 DOI: 10.1016/s2215-0366(19)30405-5] [Citation(s) in RCA: 111] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 12/18/2022]
Abstract
Cognitive symptoms are common, and yet many who seek help for cognitive symptoms neither have, nor go on to develop, dementia. A proportion of these people are likely to have functional cognitive disorders, a subtype of functional neurological disorders, in which cognitive symptoms are present, associated with distress or disability, but caused by functional alterations rather than degenerative brain disease or another structural lesion. In this Review, we have systematically examined the prevalence and clinical associations of functional cognitive disorders, and related phenotypes, within the wider cognitive disorder literature. Around a quarter of patients presenting to memory clinics received diagnoses that might indicate the presence of functional cognitive disorders, which were associated with affective symptoms, negative self-evaluation, negative illness perceptions, non-progressive symptom trajectories, and linguistic and behavioural differences during clinical interactions. Those with functional cognitive disorder phenotypes are at risk of iatrogenic harm because of misdiagnosis or inaccurate prediction of future decline. Further research is imperative to improve diagnosis and identify effective treatments for functional cognitive disorders, and better understanding these phenotypes will also improve the specificity of diagnoses of prodromal degenerative brain disease.
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Affiliation(s)
- Laura McWhirter
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - Craig Ritchie
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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35
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Microglia, Lifestyle Stress, and Neurodegeneration. Immunity 2020; 52:222-240. [PMID: 31924476 DOI: 10.1016/j.immuni.2019.12.003] [Citation(s) in RCA: 184] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/26/2019] [Accepted: 12/09/2019] [Indexed: 02/06/2023]
Abstract
Recent years have witnessed a revolution in our understanding of microglia biology, including their major role in the etiology and pathogenesis of neurodegenerative diseases. Technological advances have enabled the identification of microglial signatures in health and disease, including the development of new models to investigate and manipulate human microglia in vivo in the context of disease. In parallel, genetic association studies have identified several gene risk factors associated with Alzheimer's disease that are specifically or highly expressed by microglia in the central nervous system (CNS). Here, we discuss evidence for the effect of stress, diet, sleep patterns, physical activity, and microbiota composition on microglia biology and consider how lifestyle might influence an individual's predisposition to neurodegenerative diseases. We discuss how different lifestyles and environmental factors might regulate microglia, potentially leading to increased susceptibility to neurodegenerative disease, and we highlight the need to investigate the contribution of modern environmental factors on microglia modulation in neurodegeneration.
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36
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Aschenbrenner AJ, James BD, McDade E, Wang G, Lim YY, Benzinger TLS, Cruchaga C, Goate A, Xiong C, Perrin R, Buckles V, Allegri R, Berman SB, Chhatwal JP, Fagan A, Farlow M, O’Connor A, Ghetti B, Graff-Radford N, Goldman J, Gräber S, Karch CM, Lee JH, Levin J, Martins RN, Masters C, Mori H, Noble J, Salloway S, Schofield P, Morris JC, Bateman R, Hassenstab J. Awareness of genetic risk in the Dominantly Inherited Alzheimer Network (DIAN). Alzheimers Dement 2020; 16:219-228. [PMID: 31914221 PMCID: PMC7206736 DOI: 10.1002/alz.12010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 10/14/2019] [Accepted: 10/31/2019] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Although some members of families with autosomal dominant Alzheimer's disease mutations learn their mutation status, most do not. How knowledge of mutation status affects clinical disease progression is unknown. This study quantifies the influence of mutation awareness on clinical symptoms, cognition, and biomarkers. METHODS Mutation carriers and non-carriers from the Dominantly Inherited Alzheimer Network (DIAN) were stratified based on knowledge of mutation status. Rates of change on standard clinical, cognitive, and neuroimaging outcomes were examined. RESULTS Mutation knowledge had no associations with cognitive decline, clinical progression, amyloid deposition, hippocampal volume, or depression in either carriers or non-carriers. Carriers who learned their status mid-study had slightly higher levels of depression and lower cognitive scores. DISCUSSION Knowledge of mutation status does not affect rates of change on any measured outcome. Learning of status mid-study may confer short-term changes in cognitive functioning, or changes in cognition may influence the determination of mutation status.
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Affiliation(s)
- Andrew J. Aschenbrenner
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Bryan D. James
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Department of Internal Medicine, Chicago, IL, USA
| | - Eric McDade
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Guoqiao Wang
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Yen Ying Lim
- The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Tammie LS Benzinger
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Carlos Cruchaga
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Alison Goate
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Chengjie Xiong
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard Perrin
- Division of Neuropathology, Department of Pathology & Immunology Washington University School of Medicine, St. Louis, MO, USA
| | - Virginia Buckles
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Sarah B. Berman
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jasmeer P. Chhatwal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne Fagan
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Martin Farlow
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Antoinette O’Connor
- Dementia Research Centre, Queen Square Institute of Neurology, University College London, London, UK
| | - Bernardino Ghetti
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Jill Goldman
- Department of Neurology, Columbia University, New York, NY, USA
| | - Susanne Gräber
- German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Celeste M. Karch
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Jae-Hong Lee
- Department of Neurology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Johannes Levin
- German Center for Neurodegenerative Diseases (DZNE), Munich, Germany; Department of Neurology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Ralph N. Martins
- Centre of Excellence for Alzheimer’s Disease Research and Care, School of Medical and Health Sciences, Edith Cowan University, Perth, Australia; Department of Biomedical Sciences, Macquarie University, Sydney, NSW, Australia
| | - Colin Masters
- The Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Hiroshi Mori
- Osaka City University Medical School, Asahi Machi, Abenoku, Osaka, Japan
| | - James Noble
- Department of Neurology, Columbia University, New York, NY, USA
| | - Stephen Salloway
- Department of Neurology, Warren Alpert Medical School of Brown University, Providence, RI
| | - Peter Schofield
- Neuroscience Research Australia, Sydney, NSW, Australia; School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - John C. Morris
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Randall Bateman
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - Jason Hassenstab
- Charles F. and Joanne Knight Alzheimer’s Disease Research Center, Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
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Smedinga M, Tromp K, Schermer MHN, Richard E. Ethical Arguments Concerning the Use of Alzheimer's Disease Biomarkers in Individuals with No or Mild Cognitive Impairment: A Systematic Review and Framework for Discussion. J Alzheimers Dis 2019; 66:1309-1322. [PMID: 30507575 DOI: 10.3233/jad-180638] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The shift to defining Alzheimer's disease (AD) as a biological continuum, which is characterized by the presence of biomarkers instead of clinical symptoms, has sparked a widespread debate. Insight into the given arguments and their underlying moral values is crucial to ensure well-considered and appropriate AD biomarker testing in the future. OBJECTIVE To critically review the arguments in favor of or against AD biomarker testing in people with no or mild cognitive impairment and to explicate their underlying moral values. METHODS Seven databases were systematically searched for publications mentioning arguments of interest. Arguments are identified using qualitative data-analysis and evaluated within an ethical framework. RESULTS Our search yielded 3,657 articles of which 34 met the inclusion criteria. We discuss the clusters of arguments separate from their evaluation and the assessment of the debate as a whole. The right to know, which derives from the moral value of respect for autonomy, is a central argument in favor of biomarker testing. On the other hand, fear of the disease and lack of a disease-modifying treatment may result in a negative balance of good over inflicted harms, which argues against its use. CONCLUSION Critical evaluation and weighing of the given arguments in a specific context, within an ethical framework, demonstrates the necessity to differentiate between what we hope or expect from research and where we currently stand. While AD biomarkers may have an indispensable value for research, the current advantage for clinical practice appears limited.
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Affiliation(s)
- Marthe Smedinga
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, The Netherlands.,Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Krista Tromp
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Maartje H N Schermer
- Department of Medical Ethics and Philosophy of Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboudumc, Nijmegen, The Netherlands
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Mozersky J, Sankar P, Harkins K, Hachey S, Karlawish J. Comprehension of an Elevated Amyloid Positron Emission Tomography Biomarker Result by Cognitively Normal Older Adults. JAMA Neurol 2019; 75:44-50. [PMID: 29059270 DOI: 10.1001/jamaneurol.2017.2954] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Importance The goal of Alzheimer disease (AD) prevention together with advances in understanding the pathophysiology of AD have led to clinical trials testing drugs in cognitively unimpaired persons who show evidence of AD biomarkers. Data are needed to inform the processes of describing AD biomarkers to cognitively normal adults and assessing their understanding of this knowledge. Objective To determine the comprehension of an elevated amyloid positron emission tomographic (PET) biomarker result by cognitively unimpaired adults. Design, Setting, and Participants The Study of Knowledge and Reactions to Amyloid Testing, a substudy of an AD prevention trial, involved 2 semistructured telephone interviews with 80 participants recruited from 9 study sites: 50 received elevated and 30 received not elevated amyloid PET scan results. Interviews were conducted 4 to 12 weeks after result disclosure and again 1 year later. Data presented here were collected from November 5, 2014, through December 10, 2015. The 50 participants included in this study were cognitively normal, aged 65 to 85 years, evenly distributed by gender, and had elevated amyloid PET results. Subsequent reports will examine persons with "not elevated" results and compare the influence of the different results. Main Outcomes and Measures Participant comprehension of an elevated amyloid result was assessed by analyzing their responses to the following questions: "What was the result of your amyloid PET scan?" (followed by "Can you tell me in your own words what that means?" or "How would you explain it to a friend?"), "Was it the result you expected?" and "Did the result teach you anything or clarify anything for you?" Results Of the 50 participants aged 65 to 85 years, 49 (98%) were white, 40 (80%) reported a family history of AD, and 30 (60%) had a postgraduate educational level. Most participants (31 [62%]) understood that elevated amyloid conferred an increased but uncertain risk of developing AD. Some desired understanding of the term elevated other than its being a categorical result enabling trial entry eligibility; they wanted information regarding how elevated their amyloid was, how close to the study threshold they were, or percentages, numbers, or a scale to help them make sense of the result. Conclusions and Relevance Including an explanation of how and why a dimensional biomarker is converted to a categorical classification would enhance future AD biomarker clinical trials and educational materials.
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Affiliation(s)
- Jessica Mozersky
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Now with the Division of General Medical Sciences, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Pamela Sankar
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kristin Harkins
- Penn Memory Center at the Penn Neuroscience Center, Philadelphia, Pennsylvania
| | - Sara Hachey
- Penn Memory Center at the Penn Neuroscience Center, Philadelphia, Pennsylvania.,Now with the Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Penn Memory Center at the Penn Neuroscience Center, Philadelphia, Pennsylvania.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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39
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Genetic testing for CYP2D6 and CYP2C19 suggests improved outcome for antidepressant and antipsychotic medication. Psychiatry Res 2019; 279:111-115. [PMID: 29699889 DOI: 10.1016/j.psychres.2018.02.055] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 01/22/2018] [Accepted: 02/27/2018] [Indexed: 11/20/2022]
Abstract
Individuals carrying genetic variants that result in non-extensive CYP2D6 and CYP2C19 enzyme activity seem to be more prone to non-response and side-effects of psychotropic medications. Therefore, tailoring prescriptions using genetic information may improve patient outcomes. This study examined treatment outcome in psychiatric care after CYP2D6 and CYP2C19 genetic information was provided to patients and physicians. CYP2D6 and CYP2C19 genotyping, assessment of side effects and medical histories were obtained from 80 subjects who were prescribed either antidepressant or antipsychotic medications. Our measure of outcome was mainly physicians' opinions however UKU side effects scores were also used. For CYP2D6, we calculated an activity score based on genotype and psychiatric medications. Correlation analysis was performed for CYP2D6 activity scores and UKU scores. Overall, we received supportive responses from physicians who enrolled patients in our study. Notably, while almost every fourth physician reported improvement in patient outcome, not a single physician indicated that their patient's symptoms worsened after they had used a pharmacogenetic report to guide treatment. We did not observe statistically significant differences in side effects. Overall, our results suggest improved patient outcome following pharmacogenetic testing; nonetheless, more research is required to assess the exact benefit of pharmacogenetics in clinical practice.
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40
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Prodromes and Preclinical Detection of Brain Diseases: Surveying the Ethical Landscape of Predicting Brain Health. eNeuro 2019; 6:ENEURO.0439-18.2019. [PMID: 31221862 PMCID: PMC6658915 DOI: 10.1523/eneuro.0439-18.2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/16/2019] [Accepted: 06/02/2019] [Indexed: 02/08/2023] Open
Abstract
The future of medicine lies not primarily in cures but in disease modification and prevention. While the science of preclinical detection is young, it is moving rapidly. Preclinical interventions offer hope to decrease the severity of a disease or delay the development of a disorder. With such promise, the research and practice of detecting brain disorders at a preclinical stage present unique ethical challenges that must be addressed to ensure the benefit of these technologies. Direct brain interventions have the potential to impact not just what a patient has but who they are and who they could become. Further, receiving an assessment for a preclinical or prodromal state has potential to impact perceptions about capacity, autonomy and personhood and could become entangled with stigma and discrimination. Exploring ethical issues alongside and integrated into the experimental design and research of these technologies is critical. This review will highlight ethical issues attendant to the current and near future states of preclinical detection across the life span, specifically as it relates to autism spectrum disorder (ASD), schizophrenia, and Alzheimer’s disease.
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41
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Parens E, Appelbaum PS. On What We Have Learned and Still Need to Learn about the Psychosocial Impacts of Genetic Testing. Hastings Cent Rep 2019; 49 Suppl 1:S2-S9. [PMID: 31268574 PMCID: PMC6640636 DOI: 10.1002/hast.1011] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Since the start of the program to investigate the ethical, legal, and social implications (ELSI) of the Human Genome Project in 1990, many ELSI scholars have maintained that genetic testing should be used with caution because of the potential for negative psychosocial effects associated with receiving genetic information. More recently, though, some ELSI scholars have produced evidence suggesting that the original ELSI concerns were unfounded, exaggerated, or, at a minimum, misdirected. At least in the contexts that have been most studied, large negative impacts have not been found in the vast majority of people studied. What might explain the discrepancy between the original hypothesized outcomes and the growing impression that large negative effects appear to be few and far between? And if the original predictions of large negative psychosocial effects were simply wrong, is it time for ELSI researchers to move on? Should genetic testing be routinized, and would it be appropriate to relax or abandon the practice of engaging patients in a process of detailed informed consent before they receive genetic information? To confront those questions, we convened a conference entitled "Looking for the Psychosocial Impacts of Genomic Information" to review what is known about the negative impacts of genetic information on a variety of populations and in multiple medical and social contexts, to explore the implications of the findings, and to consider whether future research might benefit from different methods than have been used to date.
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42
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Roberts JS. Assessing the Psychological Impact of Genetic Susceptibility Testing. Hastings Cent Rep 2019; 49 Suppl 1:S38-S43. [PMID: 31268575 PMCID: PMC7026861 DOI: 10.1002/hast.1015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The expanded use of genetic testing raises key ethical and policy questions about possible benefits and harms for those receiving disease-risk information. As predictive testing for Huntington's was initiated in a clinical setting, survey research posing hypothetical test scenarios suggested that the vast majority of at-risk relatives wanted to know whether they carried a disease-causing mutation. However, only a small minority ultimately availed themselves of this opportunity. Many at-risk individuals concluded that a positive test result would be too psychologically overwhelming. A substantial literature suggests that individuals are often more resilient than anticipated in coping with many different health-related stresses. Much of my own work in the field has been through the Risk Evaluation & Education for Alzheimer's Disease study (REVEAL), a series of randomized clinical trials assessing the impact of genetic susceptibility testing on asymptomatic individuals at risk for Alzheimer's disease. Our experience in developing and implementing four successive, multisite trials provides some potentially useful lessons for the field. More people will be asking for their personal genetic information. Better understanding will help us decide when access is appropriate and how best to disclose results in a manner that supports adjustment to test findings and promotes use of genetic information to improve human health.
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43
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Thomas KR, Eppig JS, Weigand AJ, Edmonds EC, Wong CG, Jak AJ, Delano-Wood L, Galasko DR, Salmon DP, Edland SD, Bondi MW. Artificially low mild cognitive impairment to normal reversion rate in the Alzheimer's Disease Neuroimaging Initiative. Alzheimers Dement 2019; 15:561-569. [PMID: 30610833 DOI: 10.1016/j.jalz.2018.10.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 10/09/2018] [Accepted: 10/30/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION We examined reasons for low mild cognitive impairment (MCI)-to-cognitively normal (CN) reversion rates in the Alzheimer's Disease Neuroimaging Initiative (ADNI). METHODS CN and MCI participants were identified as remaining stable, progressing, or reverting at 1-year of follow-up (Year 1). Application of ADNI's MCI criteria at Year 1 in addition to Alzheimer's disease biomarkers by group were examined. RESULTS The MCI-to-CN reversion rate was 3.0%. When specific components were examined, 22.5% of stable MCI participants had normal memory performance at Year 1 and their Alzheimer's disease biomarkers were consistent with the stable CN group. At Year 1, when all MCI criteria were not met, the more subjective Clinical Dementia Rating rather than objective memory measure appeared to drive continuation of the MCI diagnosis. DISCUSSION Results demonstrate an artificially low 1-year MCI-to-CN reversion rate in ADNI-diagnosed participants. If the Logical Memory cutoffs had been consistently applied, the reversion rate would have been at least 21.8%.
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Affiliation(s)
- Kelsey R Thomas
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, CA, USA
| | - Joel S Eppig
- San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | - Alexandra J Weigand
- San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
| | - Emily C Edmonds
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, CA, USA
| | - Christina G Wong
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, CA, USA
| | - Amy J Jak
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, CA, USA
| | - Lisa Delano-Wood
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, CA, USA
| | - Douglas R Galasko
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, CA, USA; Department of Neurosciences, University of California, San Diego, School of Medicine, La Jolla, CA, USA
| | - David P Salmon
- Department of Neurosciences, University of California, San Diego, School of Medicine, La Jolla, CA, USA
| | - Steven D Edland
- Department of Biostatistics, University of California, San Diego, La Jolla, CA, USA; Department of Family and Preventative Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Mark W Bondi
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, CA, USA.
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Learning one's genetic risk changes physiology independent of actual genetic risk. Nat Hum Behav 2018; 3:48-56. [PMID: 30932047 DOI: 10.1038/s41562-018-0483-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 10/29/2018] [Indexed: 01/09/2023]
Abstract
Millions of people now access personal genetic risk estimates for diseases such as Alzheimer's, cancer and obesity1. While this information can be informative2-4, research on placebo and nocebo effects5-8 suggests that learning of one's genetic risk may evoke physiological changes consistent with the expected risk profile. Here we tested whether merely learning of one's genetic risk for disease alters one's actual risk by making people more likely to exhibit the expected changes in gene-related physiology, behaviour and subjective experience. Individuals were genotyped for actual genetic risk and then randomly assigned to receive either a 'high-risk' or 'protected' genetic test result for obesity via cardiorespiratory exercise capacity (experiment 1, N = 116) or physiological satiety (experiment 2, N = 107) before engaging in a task in which genetic risk was salient. Merely receiving genetic risk information changed individuals' cardiorespiratory physiology, perceived exertion and running endurance during exercise, and changed satiety physiology and perceived fullness after food consumption in a self-fulfilling manner. Effects of perceived genetic risk on outcomes were sometimes greater than the effects associated with actual genetic risk. If simply conveying genetic risk information can alter actual risk, clinicians and ethicists should wrestle with appropriate thresholds for when revealing genetic risk is warranted.
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Haussmann R, Ganske S, Gruschwitz A, Werner A, Osterrath A, Lange J, Buthut M, Donix KL, Linn J, Donix M. Family History of Alzheimer's Disease and Subjective Memory Performance. Am J Alzheimers Dis Other Demen 2018; 33:458-462. [PMID: 29734820 PMCID: PMC10852425 DOI: 10.1177/1533317518775033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
People with a first-degree family history of Alzheimer's disease are at an increased risk of developing dementia. Subjective memory impairment among individuals with no measurable cognitive deficits may also indicate elevated dementia risk. It remains unclear whether nondemented people with a positive family history of Alzheimer's disease are more likely to experience cognitive deficits and whether such an association reflects underlying neuropathology. We therefore investigated subjective memory impairment and hippocampal cortical thickness in 40 healthy older adults and 35 patients with amnestic mild cognitive impairment. We found greater subjective memory impairment and left hemispheric hippocampal cortical thinning associated with a first-degree family history of Alzheimer's disease in healthy older adults. This suggests that subjective memory impairment could reflect preclinical stage neurodegeneration among individuals with the family history risk factor.
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Affiliation(s)
- Robert Haussmann
- Department of Psychiatry, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Steffi Ganske
- Department of Psychiatry, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Antonia Gruschwitz
- Department of Psychiatry, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Annett Werner
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Antje Osterrath
- Department of Psychiatry, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- DZNE, German Center for Neurodegenerative Diseases, Dresden, Germany
| | - Jan Lange
- Department of Psychiatry, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Maria Buthut
- Department of Neurology (Neustadt/Trachau), Städtisches Klinikum Dresden, Dresden, Germany
| | - Katharina L. Donix
- Department of Psychiatry, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jennifer Linn
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Markus Donix
- Department of Psychiatry, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- DZNE, German Center for Neurodegenerative Diseases, Dresden, Germany
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Marshe VS, Gorbovskaya I, Kanji S, Kish M, Müller DJ. Clinical implications of APOE genotyping for late-onset Alzheimer's disease (LOAD) risk estimation: a review of the literature. J Neural Transm (Vienna) 2018; 126:65-85. [PMID: 30382407 DOI: 10.1007/s00702-018-1934-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/24/2018] [Indexed: 11/29/2022]
Abstract
Alzheimer's disease is a genetically complex neurodegenerative disorder representing the leading cause of dementia. Advances in personal genomics are increasing the public uptake of genetic susceptibility testing for complex diseases such as late-onset Alzheimer's disease (LOAD). For LOAD, the discovery of the major risk ε4 allele of the APOE gene has prompted a debate on the ethics and utility of presymptomatic (i.e., predictive) testing. Although the mechanistic contribution of APOE to disease onset remains uncertain, presymptomatic genetic testing provides a relative risk of developing LOAD. Presymptomatic testing for complex disorders, such as LOAD is much less conclusive than early-onset Alzheimer's disease (EOAD) which follows a Mendelian inheritance pattern. Given the lack of preventive strategies available for EOAD or LOAD, APOE genotyping offers limited clinical utility, thus, raising ethical and practical questions. We conducted a systematic search of five electronic databases or primary studies published during January 2008-January 2018 which investigated practical and ethical issues of presymptomatic APOE genotyping for LOAD risk estimation. We identified 31 articles which suggested that APOE genotyping for LOAD susceptibility provides potential benefits to at-risk patients and can guide changes in positive health-related behaviors. However, other individuals may experience test-related anxiety, depression and psychological distress. Future research should focus on developing an integrated risk assessment tool to enhance the utility of APOE genotyping. Furthermore, empirical research is required to understand actual psychological and social implications associated with testing.
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Affiliation(s)
- Victoria S Marshe
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON, M5T1R8, Canada
| | - Ilona Gorbovskaya
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON, M5T1R8, Canada
| | - Sarah Kanji
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON, M5T1R8, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maxine Kish
- Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON, M5T1R8, Canada.,Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Daniel J Müller
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada. .,Pharmacogenetics Research Clinic, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON, M5T1R8, Canada. .,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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Stites SD, Milne R, Karlawish J. Advances in Alzheimer's imaging are changing the experience of Alzheimer's disease. ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2018; 10:285-300. [PMID: 29780873 PMCID: PMC5956938 DOI: 10.1016/j.dadm.2018.02.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Neuroimaging is advancing a new definition of Alzheimer's disease (AD). Using imaging biomarkers, clinicians may begin to diagnose the disease by identifying pathology and neurodegeneration in either cognitively impaired or unimpaired adults. This "biomarker-based" diagnosis may allow clinicians novel opportunities to use interventions that either delay the onset or slow the progression of cognitive decline, but it will also bring novel challenges. How will changing the definition of AD from a clinical to a biomarker construct change the experience of living with the disease? Knowledge of AD biomarker status can affect how individuals feel about themselves (internalized stigma) and how others judge them (public stigma). Following a review of AD stigma, we appraise how advances in diagnosis may enable or interrupt its transfer from clinical to preclinical stages and then explore conceptual and pragmatic challenges to addressing stigma in routine care.
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Affiliation(s)
- Shana D. Stites
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Richard Milne
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Jason Karlawish
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Political Ideology, Confidence in Science, and Participation in Alzheimer Disease Research Studies. Alzheimer Dis Assoc Disord 2018; 32:179-184. [PMID: 29351092 DOI: 10.1097/wad.0000000000000244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Americans' confidence in science varies based on their political ideology. This ideological divide has potentially important effects on citizens' engagement with and participation in clinical studies of Alzheimer disease (AD). METHODS A probability sample of 1583 Americans was surveyed about their willingness to participate in longitudinal AD research and about their political attitudes. These survey results were compared with a survey of 382 participants in a longitudinal AD study at the Knight Alzheimer Disease Research Center. RESULTS Among Americans, more conservative ideology decreases willingness to participate in a hypothetical longitudinal cohort study of AD both directly and through its negative effect on confidence in science. The Knight Alzheimer Disease Research Center study participants expressed more liberal ideology and greater confidence in science than Americans in general. Of the survey respondents opposed to participation, over a quarter changed to neutral or positive if the study returned their research results to them. CONCLUSIONS AND RELEVANCE Clinical studies of AD are likely biased toward participants who are more liberal and have higher confidence in science than the general population. This recruitment bias may be reduced by lowering the trust demanded of participants through measures such as returning research results to participants.
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Weissberger GH, Strong JV, Stefanidis KB, Summers MJ, Bondi MW, Stricker NH. Diagnostic Accuracy of Memory Measures in Alzheimer's Dementia and Mild Cognitive Impairment: a Systematic Review and Meta-Analysis. Neuropsychol Rev 2017; 27:354-388. [PMID: 28940127 PMCID: PMC5886311 DOI: 10.1007/s11065-017-9360-6] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 08/16/2017] [Indexed: 11/26/2022]
Abstract
With an increasing focus on biomarkers in dementia research, illustrating the role of neuropsychological assessment in detecting mild cognitive impairment (MCI) and Alzheimer's dementia (AD) is important. This systematic review and meta-analysis, conducted in accordance with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) standards, summarizes the sensitivity and specificity of memory measures in individuals with MCI and AD. Both meta-analytic and qualitative examination of AD versus healthy control (HC) studies (n = 47) revealed generally high sensitivity and specificity (≥ 80% for AD comparisons) for measures of immediate (sensitivity = 87%, specificity = 88%) and delayed memory (sensitivity = 89%, specificity = 89%), especially those involving word-list recall. Examination of MCI versus HC studies (n = 38) revealed generally lower diagnostic accuracy for both immediate (sensitivity = 72%, specificity = 81%) and delayed memory (sensitivity = 75%, specificity = 81%). Measures that differentiated AD from other conditions (n = 10 studies) yielded mixed results, with generally high sensitivity in the context of low or variable specificity. Results confirm that memory measures have high diagnostic accuracy for identification of AD, are promising but require further refinement for identification of MCI, and provide support for ongoing investigation of neuropsychological assessment as a cognitive biomarker of preclinical AD. Emphasizing diagnostic test accuracy statistics over null hypothesis testing in future studies will promote the ongoing use of neuropsychological tests as Alzheimer's disease research and clinical criteria increasingly rely upon cerebrospinal fluid (CSF) and neuroimaging biomarkers.
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Affiliation(s)
- Gali H Weissberger
- Brain, Behavior, and Aging Research Center, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Psychology Service, VA Boston Healthcare System, Boston, MA, USA
| | - Jessica V Strong
- Psychology Service, VA Boston Healthcare System, Boston, MA, USA
- New England Geriatric Research, Education and Clinical Center (GRECC), Boston VA Healthcare System, Boston, MA, USA
| | - Kayla B Stefanidis
- Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Mathew J Summers
- Sunshine Coast Mind and Neuroscience - Thompson Institute, University of the Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Mark W Bondi
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Nikki H Stricker
- Psychology Service, VA Boston Healthcare System, Boston, MA, USA.
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Stites SD, Karlawish J, Harkins K, Rubright JD, Wolk D. Awareness of Mild Cognitive Impairment and Mild Alzheimer's Disease Dementia Diagnoses Associated With Lower Self-Ratings of Quality of Life in Older Adults. J Gerontol B Psychol Sci Soc Sci 2017; 72:974-985. [PMID: 28958089 DOI: 10.1093/geronb/gbx100] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/05/2017] [Indexed: 11/12/2022] Open
Abstract
Objective This study examined how awareness of diagnostic label impacted self-reported quality of life (QOL) in persons with varying degrees of cognitive impairment. Method Older adults (n = 259) with normal cognition, Mild Cognitive Impairment (MCI), or mild Alzheimer's disease dementia (AD) completed tests of cognition and self-report questionnaires that assessed diagnosis awareness and multiple domains of QOL: cognitive problems, activities of daily living, physical functioning, mental wellbeing, and perceptions of one's daily life. We compared measures of QOL by cognitive performance, diagnosis awareness, and diagnostic group. Results Persons with MCI or AD who were aware of their diagnosis reported lower average satisfaction with daily life (QOL-AD), basic functioning (BADL Scale), and physical wellbeing (SF-12 PCS), and more difficulties in daily life (DEM-QOL) than those who were unaware (all p ≤ .007). Controlling for gender, those expecting their condition to worsen over time reported greater depression (GDS), higher stress (PSS), lower quality of daily life (QOL-AD, DEM-QOL), and more cognitive difficulties (CDS) compared to others (all p < .05). Discussion Persons aware of their diagnostic label-either MCI or AD-and its prognosis report lower QOL than those unaware of these facts about themselves. These relationships are independent of the severity of cognitive impairment.
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Affiliation(s)
- Shana D Stites
- Department of Medical Ethics and Health Policy, Perlman School of Medicine
| | - Jason Karlawish
- Penn Memory Center, Departments of Medicine, Medical Ethics and Health Policy, and Neurology
| | - Kristin Harkins
- Penn Memory Center, Department of Medicine, University of Pennsylvania, Philadelphia
| | | | - David Wolk
- Penn Memory Center, Department of Neurology, University of Pennsylvania, Philadelphia
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