Impact of the Presence of Select Cardiovascular Risk Factors on Cognitive Changes among Dementia Subtypes

The association of pre-cancer diagnosis cardiovascular risk factors with memory aging after a cancer diagnosis, overall and by race/ethnicity

PURPOSE

Cardiovascular risk factors (CVRFs) are associated with increased risk for cognitive impairment and decline in the general population, but less is known about how CVRFs might influence cognitive aging among older cancer survivors. We aimed to determine how CVRFs prior to a cancer diagnosis affect post-cancer diagnosis memory aging, compared to cancer-free adults, and by race/ethnicity.

METHODS

Incident cancer diagnoses and memory (immediate and delayed recall) were assessed biennially in the US Health and Retirement Study (N = 5,736, 1998-2018). CVRFs measured at the wave prior to a cancer diagnosis included self-reported cigarette smoking, obesity, diabetes, heart disease, hypertension, and stroke. Multivariable-adjusted linear mixed-effects models evaluated the rate of change in standardized memory score (SD/decade) post-cancer diagnosis for those with no, medium, and high CVRFs, compared to matched cancer-free adults, overall and stratified by sex and race/ethnicity.

RESULTS

Higher number of CVRFs was associated with worse baseline memory for both men and women, regardless of cancer status. Cancer survivors with medium CVRFs had slightly slower rates of memory decline over time relative to cancer-free participants (0.04 SD units/decade [95% CI: 0.001, 0.08]). Non-Hispanic Black (NHB) and Hispanic cancer-free participants and cancer survivors had worse baseline memory than their Non-Hispanic White (NHW) counterparts.

CONCLUSIONS

CVRFs were associated with worse baseline memory function, but not decline, for cancer-free adults and cancer survivors. Racial disparities were largely similar between cancer survivors and cancer-free adults.

IMPLICATIONS FOR CANCER SURVIVORS

These findings may inform hypotheses about pre-diagnosis multimorbidity and cognitive aging of cancer survivors from diverse groups.

Exploring the relationship between patient-relevant outcomes and Alzheimer's disease progression assessed using the clinical dementia rating scale: a systematic literature review

Background

People with Alzheimer's disease (AD) have difficulties in performing activities of daily living (ADLs) as the disease progresses, commonly experience neuropsychiatric symptoms (NPS), and often have comorbidities such as cardiovascular disease. These factors all contribute to a requirement for care and considerable healthcare costs in AD. The Clinical Dementia Rating (CDR) scale is a widely used measure of dementia staging, but the correlations between scores on this scale and patient-/care partner-relevant outcomes have not been characterized fully. We conducted a systematic literature review to address this evidence gap.

Methods

Embase, MEDLINE, and the Cochrane Library were searched September 13, 2022, to identify published studies (no restriction by date or country) in populations with mild cognitive impairment due to AD or AD dementia. Studies of interest reported data on the relationships between CDR Global or CDR-Sum of Boxes (CDR-SB) scores and outcomes including NPS, comorbidities, ADLs, nursing home placement, healthcare costs, and resource use.

Results

Overall, 58 studies met the inclusion criteria (42 focusing on comorbidities, 14 on ADLs or dependence, five on nursing home placement, and six on economic outcomes). CDR/CDR-SB scores were correlated with the frequency of multiple NPS and with total scores on the Neuropsychiatric Inventory. For cardiovascular comorbidities, no single risk factor was consistently linked to AD progression. Increasing CDR/CDR-SB scores were correlated with decline in multiple different measures of ADLs and were also associated with nursing home placement and increasing costs of care.

Conclusion

NPS, ADLs, and costs of care are clearly linked to AD progression, as measured using CDR Global or CDR-SB scores, from the earliest stages of disease. This indicates that scores derived from the CDR are a meaningful way to describe the severity and burden of AD for patients and care partners across disease stages.

Hypergraph Transformers for EHR-based Clinical Predictions

Electronic health records (EHR) data contain rich information about patients' health conditions including diagnosis, procedures, medications and etc., which have been widely used to facilitate digital medicine. Despite its importance, it is often non-trivial to learn useful representations for patients' visits that support downstream clinical predictions, as each visit contains massive and diverse medical codes. As a result, the complex interactions among medical codes are often not captured, which leads to substandard predictions. To better model these complex relations, we leverage hypergraphs, which go beyond pairwise relations to jointly learn the representations for visits and medical codes. We also propose to use the self-attention mechanism to automatically identify the most relevant medical codes for each visit based on the downstream clinical predictions with better generalization power. Experiments on two EHR datasets show that our proposed method not only yields superior performance, but also provides reasonable insights towards the target tasks.

TDP-43 Pathology in the Setting of Intermediate and High Alzheimer's Disease Neuropathologic Changes: A Preliminary Evaluation Across Ethnoracial Groups

BACKGROUND

Transactive Response DNA Binding Protein 43 kDa (TDP-43) pathology is frequently found in cases with Alzheimer's disease (AD). TDP-43 pathology is associated with hippocampal atrophy and greater AD severity denoted by cognition and clinical representation. Current TDP-43 pathology studies are predominantly based on non-Hispanic White cohorts.

OBJECTIVE

We sought to evaluate the presence of TDP-43 pathology across ethnoracial groups utilizing the National Alzheimer's Coordinating Center; a database containing data from over 29 institutions across the United States. Cases (N = 1135: Hispanics/Latinos = 29, African Americans/Black Americans = 51, Asians/Asian Americans = 10, American Indians/Alaskan Natives = 2, non-Hispanic White = 1043) with intermediate/high AD having data on TDP-43 pathology in the amygdala, hippocampus, entorhinal cortex, and neocortex were included.

METHODS

TDP-43 pathology frequency in each neuroanatomic region among ethnoracial groups were compared using generalized linear mixed effects models with center as a random effect adjusting for age at death, education, and gender.

RESULTS

Although groups were imbalanced, there was no significant difference across ethnoracial groups based on TDP-43 pathology (p = 0.84). With respect to neuroanatomical regions evaluated, there were no significant differences across ethnoracial groups (p-values > 0.06). There were also no significant differences for age at death and gender ratios across ethnoracial groups based on TDP-43 pathology. Although not statistically significant, TDP-43 pathology was present less often in Hispanic/Latinos (34%) when compared to non-Hispanic Whites (46%).

CONCLUSION

While this is a preliminary evaluation, it highlights the need for diverse cohorts and on TDP-43 pathology research across ethnoracial groups. This is the first study to our knowledge having a focus on the neuroanatomical distribution of TDP-43 deposits in Hispanic/Latino decedents with AD.

Lewy body dementia is associated with an increased risk of atrial fibrillation: A case-control study

BACKGROUND

Lewy bodies are a hallmark of Dementia with Lewy Bodies. They can also be found in the sinoatrial node and may be associated with heart disease.

OBJECTIVES

We aimed to investigate a possible association between Lewy Body dementia and atrial fibrillation.

METHODS

We performed a case-control study based on our centre's cohort of degenerative dementia (Dementia with Lewy Bodies and Alzheimer's disease) patients. The possible association between Lewy Body dementia and atrial fibrillation was studied through a binomial logistic regression, which adjusted for comorbidity data.

RESULTS

We included 461 patients. 45 of the 398 (11.3%) with Alzheimer's disease and 14 of the 63 with Dementia with Lewy Bodies (22.2%) had atrial fibrillation. Heart failure (OR = 3.345, 95%CI = [1.618, 6.916], p = 0.001), hypertension (OR = 2.547, 95%CI = [1,137, 5.703], p = 0.023), stroke (OR = 2.274, 95%CI = [1.013, 5.103], p = 0.046) and Dementia with Lewy Bodies (OR = 2.536, 95%CI = [1.105, 5.822], p = 0.028) were associated with atrial fibrillation.

CONCLUSIONS

We found an association between Dementia with Lewy bodies and Atrial Fibrillation.

The interaction and pathogenesis between cognitive impairment and common cardiovascular diseases in the elderly

Both cognitive impairment and cardiovascular diseases have a high incidence in the elderly population, increasing the burden of care and reducing the quality of life. Studies have suggested that cognitive impairment interacts with cardiovascular diseases such as coronary heart disease, abnormal blood pressure, heart failure, and arrhythmia. On one hand, cognitive impairment in the elderly influences the progression and self-management of cardiovascular diseases and increases the risk of cardiovascular-related adverse events. On the other hand, coronary heart disease, heart failure, higher blood pressure variability, orthostatic hypotension, and atrial fibrillation may aggravate cognitive impairment. The role of blood pressure levels on cognition remains controversial. Several shared biological pathways have been proposed as the underlying mechanism for the association. Cardiovascular diseases may lead to cognitive decline even dementia through cerebral perfusion damage, brain structural changes, inflammation, β-amyloid deposition, and neuroendocrine disorders. It is of great significance to study the interaction and put forward effective interventions in an overall perspective to reduce care burden and improve the quality of life of the elderly patients.

The relationship between cardiovascular risk and lifestyle activities on hippocampal volumes in normative aging

Background

Despite the life-course perspective of popular aging models, few studies on healthy aging to date have examined both younger and older adulthood. The current study examined how cumulative vascular risk factors and self-reported levels of physical, social, and cognitive activity are associated with differences in hippocampal volumes in healthy younger and older adults.

Methods

34 neurologically healthy participants were separated into two age cohorts: a younger adult group (age 25-35, n = 17) and an older adult group (age 65-82, n = 17). Participants underwent a 3 T T1 MRI and completed a series of questionnaires. Voxel-based morphometry examined whole-brain grey matter density differences between groups. Hippocampal volumes were computed. Analyses examined the association between hippocampal volumes, cumulative vascular risk, and self-reported levels of physical, social, and cognitive activity, both within and across groups.

Results

Between-group comparisons revealed greater cortical atrophy in older relative to young adults in regions including the left and right hippocampus and temporal fusiform cortex. Across-group analyses revealed a significant negative association between cardiovascular risk scores and bilateral hippocampal volumes across age groups. A significant negative association was identified between frequency of social activities and bilateral hippocampal volumes in older adults only. No significant associations were found between left or right hippocampal volumes and total, cognitive, or physical activities in both within- and across-group analyses.

Conclusion

Greater cumulative vascular risk is associated with smaller hippocampal volumes across age cohorts. Findings suggest that social activities with low cognitive load may not be beneficial to structural brain outcomes in older age.

Metabolic Syndrome: Is It Time to Add the Central Nervous System?

Metabolic syndrome (MS) is a set of cardio-metabolic risk factors that includes central obesity, hyperglycemia, hypertension, and dyslipidemias. The syndrome affects 25% of adults worldwide. The definition of MS has evolved over the last 80 years, with various classification systems and criteria, whose limitations and benefits are currently the subject of some controversy. Likewise, hypotheses regarding the etiology of MS add more confusion from clinical and epidemiological points of view. The leading suggestion for the pathophysiology of MS is insulin resistance (IR). IR can affect multiple tissues and organs, from the classic “triumvirate” (myocyte, adipocyte, and hepatocyte) to possible effects on organs considered more recently, such as the central nervous system (CNS). Mild cognitive impairment (MCI) and Alzheimer’s disease (AD) may be clinical expressions of CNS involvement. However, the association between MCI and MS is not understood. The bidirectional relationship that seems to exist between these factors raises the questions of which phenomenon occurs first and whether MCI can be a precursor of MS. This review explores shared pathophysiological mechanisms between MCI and MS and establishes a hypothesis of a possible MCI role in the development of IR and the appearance of MS.

The Effects of Cardiovascular Risk Factors on Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Performance in Cognitively Healthy Older Adults

OBJECTIVE

The current study investigated the differential impact cardiovascular risk factors (CVRFs) on Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) performance in a large, cognitively healthy, older adult sample across 4 years.

METHOD

Participants were 486 individuals recruited through a longitudinal aging research study in the southeastern United States. Participants were 69.3% female, an average of 69.96 years old (SD = 6.58), 16.32 years of education (SD = 2.27), and Mini-Mental Status Exam score of 29.12 (SD = 1.16). Participants completed the RBANS at baseline and yearly thereafter, as well as the Uniform Data Set demographic and health questionnaires and the Geriatric Depression Scale.

RESULTS

Multilevel modeling was conducted using standardized RBANS index scores. Overall, across indices, performance generally improved across time consistent with practice effects from repeated testing. Some CVRFs were associated with worse performance over time. For example, individuals with hypertension performed more poorly on immediate memory over time (t = -2.06, p < .05). Other CVRFs (e.g., BMI) were not associated with baseline performance or performance over time. (p > .05).

CONCLUSIONS

CVRFs differentially affect RBANS performance over time. These results extend previous cross-sectional findings regarding the impact of different cardiovascular health risks to a large, cognitively healthy, longitudinal sample.

Feasibility and acceptability of a multi-domain intervention to increase Mediterranean diet adherence and physical activity in older UK adults at risk of dementia: protocol for the MedEx-UK randomised controlled trial

INTRODUCTION

Dementia prevalence continues to increase, and effective interventions are needed to prevent, delay or slow its progression. Higher adherence to the Mediterranean diet (MedDiet) and increased physical activity (PA) have been proposed as strategies to facilitate healthy brain ageing and reduce dementia risk. However, to date, there have been no dementia prevention trials in the UK focussed on combined dietary and PA interventions. This study aims to: (1) assess feasibility and acceptability of a theory-underpinned digital and group-based intervention for dementia risk reduction in an 'at risk' UK cohort; (2) evaluate behaviour change responses to the intervention; and, (3) provide information on cognitive, neurological, vascular and physiological outcomes to inform the design of a follow-on, full-scale efficacy trial.

METHODS

One hundred and eight participants aged 55 to 74 years with a QRISK2 score of ≥10% will be recruited to take part in this 24-week multi-site study. Participants will be randomised into three parallel arms: (1) Control; (2) MedDiet; and, (3) MedDiet+PA. The study will evaluate a personalised website, group session and food delivery intervention to increase MedDiet adherence and PA in older adults at risk of dementia. Diet and PA will be monitored prior to, during and following the intervention. Feasibility, acceptability and hypothesised mediators will be assessed in addition to measures of cognitive function, brain structure/perfusion (MRI), vascular function and metabolic markers (blood, urine and faecal) prior to, and following, the intervention.

DISCUSSION

This trial will provide insights into the feasibility, acceptability and mechanism of effect of a multi-domain intervention focussed on the MedDiet alone and PA for dementia risk reduction in an 'at risk' UK cohort.

ETHICS AND DISSEMINATION

The study has received NHS REC and HRA approval (18/NI/0191). Findings will be disseminated via conference presentations, public lectures, and peer-reviewed publications.

TRIAL REGISTRATION DETAILS

ClinicalTrials.gov NCT03673722.

The association of clinical phenotypes to known AD/FTD genetic risk loci and their inter-relationship

To elucidate how variants in genetic risk loci previously implicated in Alzheimer’s Disease (AD) and/or frontotemporal dementia (FTD) contribute to expression of disease phenotypes, a phenome-wide association study was performed in two waves. In the first wave, we explored clinical traits associated with thirteen genetic variants previously reported to be linked to disease risk using both the 23andMe and UKB cohorts. We tested 30 additional AD variants in UKB cohort only in the second wave. APOE variants defining ε2/ε3/ε4 alleles and rs646776 were identified to be significantly associated with metabolic/cardiovascular and longevity traits. APOE variants were also significantly associated with neurological traits. ABI3 variant rs28394864 was significantly associated with cardiovascular (e.g. (hypertension, ischemic heart disease, coronary atherosclerosis, angina) and immune-related trait asthma. Both APOE variants and CLU variant were significantly associated with nearsightedness. HLA- DRB1 variant was associated with diseases with immune-related traits. Additionally, variants from 10+ AD genes (BZRAP1-AS1, ADAMTS4, ADAM10, APH1B, SCIMP, ABI3, SPPL2A, ZNF232, GRN, CD2AP, and CD33) were associated with hematological measurements such as white blood cell (leukocyte) count, monocyte count, neutrophill count, platelet count, and/or mean platelet (thrombocyte) volume (an autoimmune disease biomarker). Many of these genes are expressed specifically in microglia. The associations of ABI3 variant with cardiovascular and immune-related traits are one of the novel findings from this study. Taken together, it is evidenced that at least some AD and FTD variants are associated with multiple clinical phenotypes and not just dementia. These findings were discussed in the context of causal relationship versus pleiotropy via Mendelian randomization analysis.

Associations Between Cardiovascular Risk, Structural Brain Changes, and Cognitive Decline

BACKGROUND

The impact of cardiovascular risk burden on cognitive trajectories and brain structure changes remains unclear.

OBJECTIVES

This study aimed to examine whether cardiovascular risk burden assessed by the Framingham General Cardiovascular Risk Score (FGCRS) is associated with cognitive decline and structural brain differences.

METHODS

Within the Rush Memory and Aging Project, 1,588 dementia-free participants (mean age: 79.5 years) were followed for up to 21 years. FGCRS was assessed at baseline and categorized into tertiles (lowest, middle, and highest). Episodic memory, semantic memory, working memory, visuospatial ability, and perceptual speed were assessed annually with a battery of 19 tests, from which composite scores were derived. A subsample (n = 378) of participants underwent magnetic resonance imaging. Structural total and regional brain volumes were estimated. Data were analyzed using linear mixed-effects models and linear regression models.

RESULTS

In all participants, FGCRS ranged from 4 to 28 (mean score: 15.6 ± 3.7). Compared with the lowest tertile of FGCRS, the highest tertile was associated with faster decline in global cognition (β = -0.019; 95% confidence interval [CI]: -0.035 to -0.003), episodic memory (β = -0.023; 95% CI: -0.041 to -0.004), working memory (β = -0.021; 95% CI: -0.035 to -0.007), and perceptual speed (β = -0.027; 95% CI: -0.042 to -0.011) over the follow-up. In magnetic resonance imaging data analyses, higher FGCRS was related to smaller volumes of the hippocampus (β = -0.021; 95% CI: -0.042 to -0.000), gray matter (β = -1.569; 95% CI: -2.757 to -0.382), and total brain (β = -1.588; 95% CI: -2.832 to -0.344), and greater volume of white matter hyperintensities (β = 0.035; 95% CI: 0.001 to 0.069).

CONCLUSIONS

Higher cardiovascular risk burden may predict decline in episodic memory, working memory, and perceptual speed and is associated with neurodegeneration and vascular lesions in the brain.

Ventricular Repolarization is Associated with Cognitive Function, but Not with Cognitive Decline and Brain Magnetic Resonance Imaging (MRI) Measurements in Older Adults

We aimed to investigate the cross-sectional and longitudinal associations of electrocardiogram (ECG)-based QT, QTc, JT, JTc, and QRS intervals with cognitive function and brain magnetic resonance imaging (MRI) measurements in a cohort of older individuals at increased risk for cardiovascular disease, but free of known arrhythmias. We studied 4627 participants (54% female, mean age 75 years) enrolled in the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER). Ten-second ECGs were conducted at baseline. Cognitive function was tested at baseline and repeated during a mean follow-up time of 3.2 years. Structural MRIs were conducted in a subgroup of 535 participants. Analyses were performed with multivariable (repeated) linear regression models and adjusted for cardiovascular risk-factors, co-morbidities, and cardiovascular drug use. At baseline, longer QT, JT, JTc—but not QTc and QRS intervals—were associated with a worse cognitive performance. Most notably, on the Stroop Test, participants performed 3.02 (95% CI 0.31; 5.73) seconds worse per standard deviation higher QT interval, independent of cardiovascular risk factors and medication use. There was no association between longer ventricular de- or repolarization and structural brain measurements. Therefore, specifically ventricular repolarization was associated with worse cognitive performance in older individuals at baseline but not during follow-up.

A Suboptimal Diet is Associated with Poorer Cognition: The NUDAD Project

Nutrition is one of the modifiable risk factors for cognitive decline and Alzheimer’s disease (AD) dementia, and is therefore highly relevant in the context of prevention. However, knowledge of dietary quality in clinical populations on the spectrum of AD dementia is lacking, therefore we studied the association between dietary quality and cognitive impairment in Alzheimer’s disease (AD) dementia, mild cognitive impairment (MCI) and controls. We included 357 participants from the NUDAD project (134 AD dementia, 90 MCI, 133 controls). We assessed adherence to dietary guidelines (components: vegetables, fruit, fibers, fish, saturated fat, trans-fat, salt, and alcohol), and cognitive performance (domains: memory, language, visuospatial functioning, attention, and executive functioning). In the total population, linear regression analyses showed a lower vegetable intake is associated with poorer global cognition, visuospatial functioning, attention and executive functioning. In AD dementia, lower total adherence to dietary guidelines and higher alcohol intake were associated with poorer memory, a lower vegetable intake with poorer global cognition and executive functioning, and a higher trans-fat intake with poorer executive functioning. In conclusion, a suboptimal diet is associated with more severely impaired cognition—this association is mostly attributable to a lower vegetable intake and is most pronounced in AD dementia.

Lower CSF Amyloid-Beta1-42 Predicts a Higher Mortality Rate in Frontotemporal Dementia

Frontotemporal lobar degeneration, the neuropathological substrate of frontotemporal dementia (FTD), is characterized by the deposition of protein aggregates, including tau. Evidence has shown concomitant amyloid pathology in some of these patients, which seems to contribute to a more aggressive disease. Our aim was to evaluate cerebrospinal fluid (CSF) amyloid-beta as a predictor of the mortality of FTD patients. We included 99 patients diagnosed with FTD—both behavioral and language variants—with no associated motor neuron disease, from whom a CSF sample was collected. These patients were followed prospectively in our center, and demographic and clinical data were obtained. The survival analysis was carried through a Cox regression model. Patients who died during follow up had a significantly lower CSF amyloid-beta_1–42 than those who did not. The survival analysis demonstrated that an increased death rate was associated with a lower CSF amyloid-beta_1–42 (HR = 0.999, 95% CI = [0.997, 1.000], p = 0.049). Neither demographic nor clinical variables, nor CSF total tau or p-tau were significantly associated with this endpoint. These results suggest that amyloid deposition in FTD patients may be associated with a higher mortality.