Dementia in developing countries: Does education play the same role in India as in the West?

Dementia subtypes, cognitive decline and survival among older adults attending a memory clinic in Cape Town, South Africa: a retrospective study

BACKGROUND

There are no published longitudinal studies from Africa of people with dementia seen in memory clinics. The aim of this study was to determine the proportions of the different dementia subtypes, rates of cognitive decline, and predictors of survival in patients diagnosed with dementia and seen in a memory clinic.

METHODS

Data were collected retrospectively from clinic records of patients aged ≥ 60 seen in the memory clinic at Groote Schuur Hospital, Cape Town, South Africa over a 10-year period. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria were used to identify patients with Major Neurocognitive Disorders (dementia). Additional diagnostic criteria were used to determine the specific subtypes of dementia. Linear regression analysis was used to determine crude rates of cognitive decline, expressed as mini-mental state examination (MMSE) points lost per year. Changes in MMSE scores were derived using mixed effects modelling to curvilinear models of cognitive change, with time as the dependent variable. Multivariable cox survival analysis was used to determine factors at baseline that predicted mortality.

RESULTS

Of the 165 patients who met inclusion criteria, 117(70.9%) had Major Neurocognitive Disorder due to Alzheimer's disease (AD), 24(14.6%) Vascular Neurocognitive Disorder (VND), 6(3.6%) Dementia with Lewy Bodies (DLB), 5(3%) Parkinson disease-associated dementia (PDD), 3(1.8%) fronto-temporal dementia, 4(2.4%) mixed dementia and 6(3.6%) other types of dementia. The average annual decline in MMSE points was 2.2(DLB/PDD), 2.1(AD) and 1.3(VND). Cognitive scores at baseline were significantly lower in patients with 8 compared to 13 years of education and in those with VND compared with AD. Factors associated with shorter survival included age at onset greater than 65 (HR = 1.82, 95% C.I. 1.11, 2.99, p = 0.017), lower baseline MMSE (HR = 1.05, 95% C.I. 1.01, 1.10, p = 0.029), Charlson's comorbidity scores of 3 to 4 (HR = 1.88, 95% C.I. 1.14, 3.10, p = 0.014), scores of 5 or more (HR = 1.97, 95% C.I. 1.16, 3.34, p = 0.012) and DLB/PDD (HR = 3.07, 95% C.I. 1.50, 6.29, p = 0.002). Being female (HR = 0.59, 95% C.I.0.36, 0.95, p = 0.029) was associated with longer survival.

CONCLUSIONS

Knowledge of dementia subtypes, the rate and factors affecting cognitive decline and survival outcomes will help inform decisions about patient selection for potential future therapies and for planning dementia services in resource-poor settings.

Association between anemia, physical performance and cognitive function in Iranian elderly people: evidence from Bushehr Elderly Health (BEH) program

Background and objectives

The present study aimed to investigate the relation between anemia and hemoglobin (Hgb) concentration, physical performance, and cognitive function in a large sample of Iranian elderly population.

Methods

Data were collected from Bushehr elderly health (BEH) program. A total of 3000 persons aged ≥60 years were selected through multistage random sampling. Hemoglobin values lower than 12 and 13 g/dL were considered as anemia for women and men, respectively. The cognitive function was measured using the Mini-cog test and Category fluency test (CFT), and the physical function was measured using handgrip strength (muscle strength), Relative handgrip strength (RHGS), and 4.57-m usual gait speed. Univariate and adjusted multivariate logistic regression and linear regression with Stata MP (version 15) were run, and a p-value of < 0.05 was used as statistically significant for all analyses.

Results

Among participants, 7.43% were anemic, and 115 (51.57%) simultaneously had anemia and cognitive disorder. There were significant associations between red blood cell count (RBC), hemoglobin (Hgb), platelet count (PLT), and hematocrit percentage (HCT) with cognitive impairment. Additionally, Hgb concentration was significantly associated with all physical measures (Mean handgrip, Relative handgrip, and usual gait speed) and late recall (mini-cog) among the whole participants. This association remained statistically significant after considering multi-cofounders. In contrast, after stratifying the participants by gender, the association between Hgb concentration and usual gait speed was decreased in both men and women; moreover, Hgb association with cognitive measures (category fluency test and late recall) was no longer significant (all p-values > 0.05).

Conclusion

There was a cross-sectional and significant association between anemia and functional variables (e.g., Relative and mean handgrip) in Iranian elderly population, whereas Semantic memory, Late recall, and walking were more affected by gender.

Does bilingualism protect against dementia? A meta-analysis

Evidence suggests that bilingualism may contribute to neuroplasticity and cognitive reserve, allowing individuals to resist cognitive decline associated with Alzheimer's disease progression, although the idea remains controversial. Here, we argue that the reason for the discrepancy stems from conflating incidence rates of dementia and the age at which the symptoms first appear, as well as statistical and methodological issues in the study designs. To clarify the issues, we conducted a comprehensive meta-analysis on the available literature regarding bilingualism and Alzheimer's disease, including both retrospective and prospective studies, as well as age of onset and incidence rates. Results revealed a moderate effect size for the protective effect of bilingualism on age of onset of symptoms of Alzheimer's disease (Cohen's d = 0.32), and weaker evidence that bilingualism prevents the occurrence of disease incidence itself (Cohen's d = 0.10). Moreover, our results cannot be explained by SES, education, or publication bias. We conclude with a discussion on how bilingualism contributes to cognitive reserve and protects against Alzheimer's disease and recommend that future studies report both age of onset as well as incidence rates when possible.

Assessment of Lifestyle Experiences across Lifespan and Cognitive Ageing in the Indian Context

With rising numbers of elderly and dementia in developing societies, there is a need to understand factors protective against dementia. Evidence suggests that lifetime cognitive activities including education, occupation, and complex leisure activities contribute to cognitive reserve. However, these factors are understudied in India. This paper describes the validation of the Lifetime of Experiences Questionnaire (LEQ), a comprehensive measure of complex lifetime activities, to the Indian cultural context. It also examines the relationship between lifetime experiences and cognition among 52 healthy elderly and 30 dementia patients. High inter-rater (κ=0.923, p < 0.001), test-retest (ρ: 0.905 to 0.986) reliability, and internal consistency were found for LEQ-total (0.992) and sub-scores. Literate dementia patients (25) scored significantly lower mid-life (27.5 vs. 23.3), late-life (28.5 vs. 22.5) and total LEQ (83.5 vs. 20.9) scores than literate healthy group (37). LEQ scores positively correlated with global cognition, and domains of attention and memory on the Addenbrooke’s Cognitive Examination, in healthy and dementia groups. Moreover, LEQ scores correlated positively with age at onset of dementia and negatively with clinical dementia rating (CDR) scores. Our study demonstrates that lifetime activities, especially mid-life experiences, play a protective role in development of late-life dementia, and need to be advocated to preserve late-life cognition.

Preventing dementia by preventing stroke: The Berlin Manifesto

The incidence of stroke and dementia are diverging across the world, rising for those in low- and middle-income countries and falling in those in high-income countries. This suggests that whatever factors cause these trends are potentially modifiable. At the population level, neurological disorders as a group account for the largest proportion of disability-adjusted life years globally (10%). Among neurological disorders, stroke (42%) and dementia (10%) dominate. Stroke and dementia confer risks for each other and share some of the same, largely modifiable, risk and protective factors. In principle, 90% of strokes and 35% of dementias have been estimated to be preventable. Because a stroke doubles the chance of developing dementia and stroke is more common than dementia, more than a third of dementias could be prevented by preventing stroke. Developments at the pathological, pathophysiological, and clinical level also point to new directions. Growing understanding of brain pathophysiology has unveiled the reciprocal interaction of cerebrovascular disease and neurodegeneration identifying new therapeutic targets to include protection of the endothelium, the blood-brain barrier, and other components of the neurovascular unit. In addition, targeting amyloid angiopathy aspects of inflammation and genetic manipulation hold new testable promise. In the meantime, accumulating evidence suggests that whole populations experiencing improved education, and lower vascular risk factor profiles (e.g., reduced prevalence of smoking) and vascular disease, including stroke, have better cognitive function and lower dementia rates. At the individual levels, trials have demonstrated that anticoagulation of atrial fibrillation can reduce the risk of dementia by 48% and that systolic blood pressure lower than 140 mmHg may be better for the brain. Based on these considerations, the World Stroke Organization has issued a proclamation, endorsed by all the major international organizations focused on global brain and cardiovascular health, calling for the joint prevention of stroke and dementia. This article summarizes the evidence for translation into action.

Special topic section: linkages among cerebrovascular, cardiovascular, and cognitive disorders: Preventing dementia by preventing stroke: The Berlin Manifesto

The incidence of stroke and dementia are diverging across the world, rising for those in low-and middle-income countries and falling in those in high-income countries. This suggests that whatever factors cause these trends are potentially modifiable. At the population level, neurological disorders as a group account for the largest proportion of disability-adjusted life years globally (10%). Among neurological disorders, stroke (42%) and dementia (10%) dominate. Stroke and dementia confer risks for each other and share some of the same, largely modifiable, risk and protective factors. In principle, 90% of strokes and 35% of dementias have been estimated to be preventable. Because a stroke doubles the chance of developing dementia and stroke is more common than dementia, more than a third of dementias could be prevented by preventing stroke. Developments at the pathological, pathophysiological, and clinical level also point to new directions. Growing understanding of brain pathophysiology has unveiled the reciprocal interaction of cerebrovascular disease and neurodegeneration identifying new therapeutic targets to include protection of the endothelium, the blood-brain barrier, and other components of the neurovascular unit. In addition, targeting amyloid angiopathy aspects of inflammation and genetic manipulation hold new testable promise. In the meantime, accumulating evidence suggests that whole populations experiencing improved education, and lower vascular risk factor profiles (e.g., reduced prevalence of smoking) and vascular disease, including stroke, have better cognitive function and lower dementia rates. At the individual levels, trials have demonstrated that anticoagulation of atrial fibrillation can reduce the risk of dementia by 48% and that systolic blood pressure lower than 140 mmHg may be better for the brain. Based on these considerations, the World Stroke Organization has issued a proclamation, endorsed by all the major international organizations focused on global brain and cardiovascular health, calling for the joint prevention of stroke and dementia. This article summarizes the evidence for translation into action. © 2019 the Alzheimer's Association and the World Stroke Organisation. Published by Elsevier Inc. All rights reserved.

Combining modifiable risk factors and risk of dementia: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature relating to the impact of multiple co-occurring modifiable risk factors for cognitive decline and dementia.

DESIGN

A systematic review and meta-analysis of the literature relating to the impact of co-occurring key risk factors for incident cognitive decline and dementia. All abstracts and full text were screened independently by two reviewers and each article assessed for bias using a standard checklist. A fixed effects meta-analysis was undertaken.

DATA SOURCES

Databases Medline, Embase and PsycINFO were searched from 1999 to 2017.

ELIGIBILITY CRITERIA

For inclusion articles were required to report longitudinal data from participants free of cognitive decline at baseline, with formal assessment of cognitive function or dementia during follow-up, and an aim to examine the impact of additive or clustered comorbid risk factor burden in with two or more core modifiable risk factors.

RESULTS

Seventy-nine full-text articles were examined. Twenty-two articles (18 studies) were included reporting data on >40 000 participants. Included studies consistently reported an increased risk associated with greater numbers of intraindividual risk factors or unhealthy behaviours and the opposite for healthy or protective behaviours. A meta-analysis of studies with dementia outcomes resulted in a pooled relative risk for dementia of 1.20 (95% CI 1.04 to 1.39) for one risk factor, 1.65 (95% CI 1.40 to 1.94) for two and 2.21 (95% CI 1.78 to 2.73) for three or more, relative to no risk factors. Limitations include dependence on published results and variations in study outcome, cognitive assessment, length of follow-up and definition of risk factor exposure.

CONCLUSIONS

The strength of the reported associations, the consistency across studies and the suggestion of a dose response supports a need to keep modifiable risk factor exposure to a minimum and to avoid exposure to additional modifiable risks. Further research is needed to establish whether particular combinations of risk factors confer greater risk than others.

PROSPERO REGISTRATION NUMBER

42016052914.

A Persian version of the Affiliate Stigma Scale in caregivers of people with dementia

Background: Dementia is prevalent among older adults and frequently causes dependence on family caregivers. Caregivers may experience a form of stigmatization called affiliate stigma that negatively affects their mental health. The current study sought to establish the psychometric properties of a tool to measure affiliate stigma among Iranian caregivers.

Methods: Overall, 541 caregivers of older people with dementia were included in this cross sectional study. Several measures were used to assess the psychometric properties of the Affiliate Stigma Scale (ASS) including the Zarit Burden Interview (ZBI), Hospital Anxiety and Depression Scale (HADS), Short Form 12 (SF-12), Rosenberg Self-Esteem Scale (RSES), and Multidimensional Scale of Perceived Social Support (MSPSS). Convergent and discriminate validity were examined.Exploratory and confirmatory factor analyses were utilized to assess the factor structure of the Ass and a Rasch model was used to evaluate the measurement functioning of the scale.

Results: Factor loadings ranged from 0.69 to 0.83 and test-retest reliability from 0.72 to 0.89.Item difficulty ranged widely from -0.66 to 0.89. No considerable differential item functioning (DIF) was found across gender. Confirmatory factor analysis confirmed the three cognitive,effective, and behavioral dimensions of the scale (comparative fit index [CFI]=0.931 to 0.995,root mean square error of approximation [RMSEA]=0.046 to 0.068). Internal consistency was acceptable (Cronbach’s α: 0.88 to 0.94). Significant and positive relationships were found between affiliate stigma and depression, anxiety, and care giving burden (β =0.35 to 0.46).

Conclusion: The ASS is a psychometrically valid measure for assessing affiliate stigma in Iranian caregivers of people with dementia. Application of this tool among other caregivers, language sand cultures deserves further study.

A core avenue for transcultural research on dementia: on the cross-linguistic generalization of language-related effects in Alzheimer's disease and Parkinson's disease

OBJECTIVE

Language is a key source of cross-cultural variability, which may have both subtle and major effects on neurocognition. However, this issue has been largely overlooked in two flourishing lines of research assessing the relationship between language-related neural systems and dementia. This paper assesses the limitations of the evidence on (i) the neuroprotective effects of bilingualism in Alzheimer's disease and (ii) specific language deficits as markers of Parkinson's disease.

DESIGN

First, we outline the rationale behind each line of research. Second, we review available evidence and discuss the potential impact of cross-linguistic factors. Third, we outline ideas to foster progress in both fields and, with it, in cross-cultural neuroscience at large.

RESULTS

On the one hand, studies on bilingualism suggest that sustained use of more than one language may protect against Alzheimer's disease symptoms. On the other hand, insights from the embodied cognition framework point to syntactic and action-verb deficits as early (and even preclinical) markers of Parkinson's disease. However, both fields share a key limitation that lies at the heart of cultural neuroscience: the issue of cross-linguistic generalizability.

CONCLUSION

Relevant evidence for both research trends comes from only a handful of (mostly Indo-European) languages, which are far from capturing the full scope of structural and typological diversity of the linguistic landscape worldwide. This raises questions on the external validity of reported findings. Greater collaboration between linguistic typology and cognitive neuroscience seems crucial as a first step to assess the impact of transcultural differences on language-related effects across neurodegenerative diseases. Copyright © 2017 John Wiley & Sons, Ltd.

Bilingualism delays the onset of behavioral but not aphasic forms of frontotemporal dementia

Bilingualism has been found to delay onset of dementia and this has been attributed to an advantage in executive control in bilinguals. However, the relationship between bilingualism and cognition is complex, with costs as well as benefits to language functions. To further explore the cognitive consequences of bilingualism, the study used Frontotemporal dementia (FTD) syndromes, to examine whether bilingualism modifies the age at onset of behavioral and language variants of Frontotemporal dementia (FTD) differently. Case records of 193 patients presenting with FTD (121 of them bilingual) were examined and the age at onset of the first symptoms were compared between monolinguals and bilinguals. A significant effect of bilingualism delaying the age at onset of dementia was found in behavioral variant FTD (5.7 years) but not in progressive nonfluent aphasia (0.7 years), semantic dementia (0.5 years), corticobasal syndrome (0.4 years), progressive supranuclear palsy (4.3 years) and FTD-motor neuron disease (3 years). On dividing all patients predominantly behavioral and predominantly aphasic groups, age at onset in the bilingual behavioral group (62.6) was over 6 years higher than in the monolingual patients (56.5, p=0.006), while there was no difference in the aphasic FTD group (60.9 vs. 60.6 years, p=0.851). The bilingual effect on age of bvFTD onset was shown independently of other potential confounding factors such as education, gender, occupation, and urban vs rural dwelling of subjects. To conclude, bilingualism delays the age at onset in the behavioral but not in the aphasic variants of FTD. The results are in line with similar findings based on research in stroke and with the current views of the interaction between bilingualism and cognition, pointing to advantages in executive functions and disadvantages in lexical tasks.

The bilingual adaptation: How minds accommodate experience

According to some estimates, more than half of the world's population is multilingual to some extent. Because of the centrality of language use to human experience and the deep connections between linguistic and nonlinguistic processing, it would not be surprising to find that there are interactions between bilingualism and cognitive and brain processes. The present review uses the framework of experience-dependent plasticity to evaluate the evidence for systematic modifications of brain and cognitive systems that can be attributed to bilingualism. The review describes studies investigating the relation between bilingualism and cognition in infants and children, younger and older adults, and patients, using both behavioral and neuroimaging methods. Excluded are studies whose outcomes focus primarily on linguistic abilities because of their more peripheral contribution to the central question regarding experience-dependent changes to cognition. Although most of the research discussed in the review reports some relation between bilingualism and cognitive or brain outcomes, several areas of research, notably behavioral studies with young adults, largely fail to show these effects. These discrepancies are discussed and considered in terms of methodological and conceptual issues. The final section proposes an account based on "executive attention" to explain the range of research findings and to set out an agenda for the next steps in this field. (PsycINFO Database Record

Aging in two languages: Implications for public health

With the population aging and a dramatic increase in the number of senior citizens, public health systems will be increasingly burdened with the need to deal with the care and treatment of individuals with dementia. We review evidence demonstrating how a particular experience, bilingualism, has been shown to protect cognitive function in older age and delay onset of symptoms of dementia. This paper describes behavioral and brain studies that have compared monolingual and bilingual older adults on measures of cognitive function or brain structure and reviews evidence demonstrating a protective effect of bilingualism against symptoms of dementia. We conclude by presenting some data showing the potential savings in both human costs in terms of demented patients and economic considerations in terms of public money if symptoms of dementia could be postponed.