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Mobley TM, Hayes-Larson E, Wu Y, Peterson RL, George KM, Gilsanz P, Glymour MM, Thomas MD, Barnes LL, Whitmer RA, Mayeda ER. School racial composition, effect modification by caring teacher/staff presence, and mid/late-life depressive symptoms: findings from the Study of Healthy Aging among African Americans. Am J Epidemiol 2024:kwae050. [PMID: 38634611 DOI: 10.1093/aje/kwae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 02/26/2024] [Indexed: 04/19/2024] Open
Abstract
For Black students in the United States, attending schools with a higher proportion of White students is associated with worse mental and physical health outcomes in adolescence/early adulthood. No prior studies evaluate K-12 school racial composition and later-life mental health. In a cohort of Black adults ages 50+ in Northern California who retrospectively self-reported school racial composition for grades 1, 6, 9, and 12, we assessed the association between attending a school with mostly Black students vs. not and mid/late-life depressive symptoms (8-item PROMIS depression score, standardized to US adult population) using age-, sex/gender-, southern US birth-, and parental education-adjusted generalized estimating equations, and assessed effect modification by caring teacher/staff presence. Later-life depressive symptoms were lower among those who attended schools with mostly Black students in grades 1 and 6 (b=-0.12, 95% CI: -0.23, 0.00 and b=-0.11, 95% CI: -0.22, 0.00, respectively). In grade 6, this difference was larger for students without an adult at school who cared about them (b=-0.29, 95% CI: -0.51, -0.07 vs. b=-0.04, 95% CI: -0.17, 0.09). Among Black Americans, attending early school with mostly Black students may have later life mental health benefits; this protective association appears more important for students without caring teachers/staff.
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Affiliation(s)
- Taylor M Mobley
- Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles, CA
| | - Eleanor Hayes-Larson
- Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles, CA
| | - Yingyan Wu
- Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles, CA
| | - Rachel L Peterson
- School of Public and Community Health Sciences, University of Montana, Missoula, MT
| | - Kristen M George
- Department of Public Health Sciences, University of California, Davis, School of Medicine, Davis, CA
| | - Paola Gilsanz
- Kaiser Permanente Division of Research, Oakland, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - M Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
- Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, MA
| | - Marilyn D Thomas
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
- University of California, San Francisco, Department of Psychiatry and Behavioral Sciences, San Francisco, CA
| | - Lisa L Barnes
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL
| | - Rachel A Whitmer
- Department of Public Health Sciences, University of California, Davis, School of Medicine, Davis, CA
- Kaiser Permanente Division of Research, Oakland, CA
- Alzheimer's Disease Research Center, University of California, Davis, School of Medicine, Sacramento, CA
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles, CA
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Almeida ML, Pederson AM, Zimmerman SC, Chen R, Ackley S, Riley A, Eng CW, Whitmer RA, George KM, Peterson RL, Mayeda ER, Gilsanz P, Mungas DM, Farias ST, Glymour MM. The Association Between Physical Activity and Cognition in a Racially/Ethnically Diverse Cohort of Older Adults: Results From the Kaiser Healthy Aging and Diverse Life Experiences Study. Alzheimer Dis Assoc Disord 2024:00002093-990000000-00102. [PMID: 38533734 DOI: 10.1097/wad.0000000000000612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/01/2024] [Indexed: 03/28/2024]
Abstract
OBJECTIVE Most prior research on physical activity (PA) and cognition is based on predominantly white cohorts and focused on associations of PA with mean (average) cognition versus the distribution of cognition. Quantile regression offers a novel way to quantify how PA affects cognition across the entire distribution. METHODS The Kaiser Healthy Aging and Diverse Life Experiences study includes 30% white, 19% black, 25% Asian, and 26% Latinx adults age 65+ living in Northern California (n = 1600). The frequency of light or heavy PA was summarized as 2 continuous variables. Outcomes were z-scored executive function, semantic memory, and verbal episodic memory. We tested associations of PA with mean cognition using linear regression and used quantile regression to estimate the association of PA with the 10th-90th percentiles of cognitive scores. RESULTS Higher levels of PA were associated with higher mean semantic memory (b = 0.10; 95% CI: 0.06, 0.14) and executive function (b = 0.05; 95% CI: 0.01, 0.09). Associations of PA across all 3 cognitive domains were stronger at low quantiles of cognition. CONCLUSION PA is associated with cognition in this racially/ethnically diverse sample and may have larger benefits for individuals with low cognitive scores, who are most vulnerable to dementia.
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Affiliation(s)
- Mariana L Almeida
- The Nursing School of Ribeirao Preto, University of Sao Paulo, Brazil
| | - Anna M Pederson
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Scott C Zimmerman
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco
| | - Ruijia Chen
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Sarah Ackley
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Alicia Riley
- Department of Sociology, University of California, Santa Cruz
| | - Chloe W Eng
- Department of Epidemiology and Population Health, Stanford University, Stanford
| | - Rachel A Whitmer
- Department of Public Health Sciences, University of California Davis, Davis
| | - Kristen M George
- Department of Public Health Sciences, University of California Davis, Davis
| | - Rachel L Peterson
- School of Public and Community Health Sciences, University of Montana, Missoula, MT
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, University of California Los Angeles, Fielding School of Public Health, Los Angeles
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Dan M Mungas
- Department of Neurology, University of California Davis Health, Sacramento, CA
| | | | - M Maria Glymour
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
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Jimenez MP, Gause EL, Sims KD, Hayes-Larson E, Morris EP, Fletcher E, Manly J, Gilsanz P, Soh Y, Corrada M, Whitmer RA, Glymour MM. Racial and ethnic differences in the association between depressive symptoms and cognitive outcomes in older adults: Findings from KHANDLE and STAR. Alzheimers Dement 2024. [PMID: 38477489 DOI: 10.1002/alz.13768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Depressive symptoms are associated with higher risk of dementia, but how they impact cognition in diverse populations is unclear. METHODS Asian, Black, Latino, or White participants (n = 2227) in the Kaiser Healthy Aging and Diverse Life Experiences (age 65+) and the Study of Healthy Aging in African Americans (age 50+) underwent up to three waves of cognitive assessments over 4 years. Multilevel models stratified by race/ethnicity were used to examine whether depressive symptoms were associated with cognition or cognitive decline and whether associations differed by race/ethnicity. RESULTS Higher depressive symptoms were associated with lower baseline verbal episodic memory scores (-0.06, 95% CI: -0.12, -0.01; -0.15, 95% CI: -0.25, -0.04), and faster decline annually in semantic memory (-0.04, 95% CI: -0.07, -0.01; -0.10, 95% CI: -0.15, -0.05) for Black and Latino participants. Depressive symptoms were associated with lower baseline but not decline in executive function. DISCUSSION Depressive symptoms were associated with worse cognitive outcomes, with some evidence of heterogeneity across racial/ethnic groups. HIGHLIGHTS We examined whether baseline depressive symptoms were differentially associated with domain-specific cognition or cognitive decline by race/ethnicity. Depressive symptoms were associated with worse cognitive scores for all racial/ethnic groups across different domains examined. Higher depressive symptoms were associated with faster cognitive decline for semantic memory for Black and Latino participants. The results suggest a particularly harmful association between depressive symptoms and cognition in certain racial/ethnic groups.
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Affiliation(s)
- Marcia P Jimenez
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Emma L Gause
- Center for Climate and Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Kendra D Sims
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Eleanor Hayes-Larson
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Emily P Morris
- Department of Psychology, University of Michigan, Ann Arbor, Michigan, USA
| | - Evan Fletcher
- Department of Neurology, University of California, Davis, California, USA
| | - Jennifer Manly
- Department of Neurology, Columbia University, New York, New York, USA
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Yenee Soh
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Maria Corrada
- Department of Epidemiology, University of California Irvine School of Medicine, Irvine, California, USA
| | - Rachel A Whitmer
- Department of Public Health Sciences and Neurology, University of California Davis School of Medicine, Davis, California, USA
| | - Medellena Maria Glymour
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
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Lee DR, Lo JC, Chandra M, Lee C, Gilsanz P. Racial and Ethnic Variation in Dementia Prevalence in a Diverse Cohort of Adults with Hip Fracture. J Gen Intern Med 2024; 39:716-719. [PMID: 38142461 PMCID: PMC10973300 DOI: 10.1007/s11606-023-08578-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/08/2023] [Indexed: 12/26/2023]
Affiliation(s)
- David R Lee
- Department of Hospital Medicine, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA
- The Permanente Medical Group, Oakland, CA, USA
- UCLA Multicampus Program in Geriatric Medicine and Gerontology, Los Angeles, CA, USA
| | - Joan C Lo
- The Permanente Medical Group, Oakland, CA, USA.
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
| | - Malini Chandra
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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Peterson RL, Pejak R, George KM, Gilsanz P, Ko M, Meyer OL, Mayeda ER, Kind A, Whitmer RA. Race, community disadvantage, and cognitive decline: Findings from KHANDLE and STAR. Alzheimers Dement 2024; 20:904-913. [PMID: 37817548 PMCID: PMC10917037 DOI: 10.1002/alz.13511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/24/2023] [Accepted: 09/19/2023] [Indexed: 10/12/2023]
Abstract
INTRODUCTION Community disadvantage is associated with late-life cognition. Few studies examine its contribution to racial disparities in cognition/cognitive change. METHODS Inverse probability weighted models estimated expected mean differences in cognition/cognitive change attributed to residing in less advantaged communities, defined as cohort top quintile of Area Deprivation Indices (ADI): childhood 66-100; adulthood ADI 5-99). Interactions by race tested. RESULTS More Black participants resided in less advantaged communities. Semantic memory would be lower if all participants had resided in less advantaged childhood (b = -0.16, 95% confidence interval [CI] = -0.30, -0.03) or adulthood (b = -0.14, 95% CI = -0.22, -0.04) communities. Race interactions indicated that, among Black participants, less advantaged childhood communities were associated with higher verbal episodic memory (interaction p-value = 0.007) and less advantaged adulthood communities were associated with lower semantic memory (interaction p-value = 0.002). DISCUSSION Examining racial differences in levels of community advantage and late-life cognitive decline is a critical step toward unpacking community effects on cognitive disparities.
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Affiliation(s)
- Rachel L. Peterson
- School of Public and Community Health SciencesUniversity of MontanaMissoulaMontanaUSA
| | - Rebecca Pejak
- School of Public and Community Health SciencesUniversity of MontanaMissoulaMontanaUSA
| | - Kristen M. George
- Department of Public Health SciencesUniversity of California DavisDavisCaliforniaUSA
| | - Paola Gilsanz
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Michelle Ko
- Department of Public Health SciencesUniversity of California DavisDavisCaliforniaUSA
| | - Oanh L. Meyer
- Department of NeurologyUniversity of California DavisDavisCaliforniaUSA
| | - Elizabeth Rose Mayeda
- Fielding School of Public HealthUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Amy Kind
- University of Wisconsin Center for Health Disparities ResearchMadisonWisconsinUSA
| | - Rachel A. Whitmer
- Departments of Public Health Sciences and NeurologyUniversity of California DavisDavisCaliforniaUSA
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Chen R, Wang J, Pederson AM, Prather AA, Hirst AK, Ackley S, Hokett E, George KM, Mungas D, Mayeda ER, Gilsanz P, Haneuse S, Whitmer RA, Glymour MM. Evaluation of racial and ethnic heterogeneity in the associations of sleep quality and sleep apnea risk with cognitive function and cognitive decline. Alzheimers Dement (N Y) 2024; 10:e12441. [PMID: 38356481 PMCID: PMC10865460 DOI: 10.1002/trc2.12441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/09/2023] [Accepted: 11/16/2023] [Indexed: 02/16/2024]
Abstract
INTRODUCTION The prevalence of poor sleep quality and sleep apnea differs by race and ethnicity and may contribute to racial disparities in cognitive aging. We investigated whether sleep quality and sleep apnea risk were associated with cognitive function and decline and whether the associations differed by race/ethnicity. METHODS Participants from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE; N = 1690; mean age: 75.7 years) study, a cohort of Asian, Black, Latino, and White participants, completed a modified Pittsburgh Sleep Quality Index assessing subjective sleep quality, latency, duration, disturbances, sleep medication use, and daytime dysfunction. Sleep apnea risk was measured by questions about snoring, tiredness, and whether apnea was observed. Executive function and verbal episodic memory were assessed at three time points over an average of 2.7 years with the Spanish and English Neuropsychological Assessment Scale. We fit linear mixed-effect models and stratified analyses by race/ethnicity. RESULTS Higher sleep apnea risk was associated with faster declines in verbal episodic memory (β ^ sleep apnea = -0.02, 95% confidence interval [CI], -0.04, -0.001) but not in executive function. Poorer sleep quality was associated with lower levels of and faster decline in executive function but not in verbal episodic memory. Race/ethnicity modified these associations: compared to estimated effects among White participants, poorer global sleep quality (β ^ sleep*time = -0.02, 95% CI, -0.02, -0.01) was associated with larger effects on decline in executive function among Black participants. Estimated effects of some individual sleep quality components were also modified by race/ethnicity; for example, sleep medication use was associated with faster declines in executive function (β ^ sleep*time = -0.05, 95% CI, -0.07, -0.03) and verbal episodic memory β ^ sleep*time = -0.04, 95% CI, -0.07, -0.02) among Black participants compared to White participants. DISCUSSION Observational evidence indicates sleep quality is a promising target for addressing racial/ethnic disparities in cognitive aging, especially among Black older adults. Highlights Sleep apnea risk was associated with faster declines in verbal episodic memory but not executive function among all participants.Global sleep quality was associated with lower levels of and faster decline in executive function but not verbal episodic memory among all participants.Black older adults were particularly susceptible to the estimated adverse cognitive impacts of global sleep quality, particularly the use of sleep medication.
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Affiliation(s)
- Ruijia Chen
- Department of EpidemiologySchool of Public HealthBoston UniversityBostonMassachusettsUSA
| | - Jingxuan Wang
- Department of Epidemiology and BiostaisticsUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Annie M. Pederson
- Department of EpidemiologySchool of Public HealthBoston UniversityBostonMassachusettsUSA
| | - Aric A. Prather
- Department of Psychiatry and Behavioral SciencesUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Andrew K. Hirst
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Sarah Ackley
- Department of EpidemiologySchool of Public HealthBoston UniversityBostonMassachusettsUSA
| | - Emily Hokett
- Department of NeurologyColumbia UniversityNew YorkNew YorkUSA
| | - Kristen M. George
- Department of Public Health SciencesUniversity of CaliforniaDavisCaliforniaUSA
| | - Dan Mungas
- Department of NeurologyUniversity of CaliforniaDavisCaliforniaUSA
| | - Elizabeth Rose Mayeda
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Paola Gilsanz
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Sebastien Haneuse
- Department of BiostatisticsHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Rachel A. Whitmer
- Department of Public Health SciencesUniversity of CaliforniaDavisCaliforniaUSA
| | - M. Maria Glymour
- Department of EpidemiologySchool of Public HealthBoston UniversityBostonMassachusettsUSA
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Soh Y, Whitmer RA, Mayeda ER, Glymour MM, Eng CW, Peterson RL, George KM, Chen R, Quesenberry CP, Mungas DM, DeCarli CS, Gilsanz P. Timing and level of educational attainment and late-life cognition in the KHANDLE study. Alzheimers Dement 2024; 20:593-600. [PMID: 37751937 PMCID: PMC10842991 DOI: 10.1002/alz.13475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/07/2023] [Accepted: 08/23/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION The timing of educational attainment may modify its effects on late-life cognition, yet most studies evaluate education only at a single time point. METHODS Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) Study cohort participants (N = 554) reported educational attainment (dichotomized at any college education) at two time points, and we classified them as having low, high, or later-life high educational attainment. Linear mixed-effects models estimated associations between educational attainment change groups and domain-specific cognitive outcomes (z-standardized). RESULTS Compared to low educational attainment, high (β= 0.59 SD units; 95% confidence interval [CI]: 0.39, 0.79) and later-life high educational attainment (β = 0.22; 95% CI: 0.00, 0.44) were associated with higher executive function. Only high educational attainment was associated with higher verbal episodic memory (β = 0.27; 95% CI: 0.06, 0.48). DISCUSSION Level and timing of educational attainment are both associated with domain-specific cognition. A single assessment for educational attainment may inadequately characterize protective associations with late-life cognition. HIGHLIGHTS Few studies have examined both level and timing of educational attainment on cognition. Marginalized populations are more likely to attain higher education in adulthood. Higher educational attainment in late life is also associated with higher cognition.
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Affiliation(s)
- Yenee Soh
- Kaiser Permanente Division of ResearchOaklandCaliforniaUSA
| | - Rachel A. Whitmer
- Kaiser Permanente Division of ResearchOaklandCaliforniaUSA
- Department of NeurologySchool of MedicineUniversity of CaliforniaDavisCaliforniaUSA
- Department of Public Health SciencesUniversity of CaliforniaDavisCaliforniaUSA
| | - Elizabeth Rose Mayeda
- Department of EpidemiologyUniversity of California, Los Angeles Fielding School of Public HealthLos AngelesCaliforniaUSA
| | - M. Maria Glymour
- Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Chloe W. Eng
- Department of Epidemiology and Population HealthStanford UniversityStanfordCaliforniaUSA
| | - Rachel L. Peterson
- School of Public and Community Health SciencesUniversity of MontanaMissoulaMontanaUSA
| | - Kristen M. George
- Department of Public Health SciencesUniversity of CaliforniaDavisCaliforniaUSA
| | - Ruijia Chen
- Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | | | - Dan M. Mungas
- Department of NeurologySchool of MedicineUniversity of CaliforniaDavisCaliforniaUSA
| | - Charles S. DeCarli
- Department of NeurologySchool of MedicineUniversity of CaliforniaDavisCaliforniaUSA
| | - Paola Gilsanz
- Kaiser Permanente Division of ResearchOaklandCaliforniaUSA
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Ferguson EL, Zimmerman SC, Jiang C, Choi M, Swinnerton K, Choudhary V, Meyers TJ, Hoffmann TJ, Gilsanz P, Oni-Orisan A, Whitmer RA, Risch N, Krauss RM, Schaefer CA, Glymour MM. Low- and High-Density Lipoprotein Cholesterol and Dementia Risk Over 17 Years of Follow-up Among Members of a Large Health Care Plan. Neurology 2023; 101:e2172-e2184. [PMID: 37793911 PMCID: PMC10663022 DOI: 10.1212/wnl.0000000000207876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/24/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The associations of high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) with dementia risk in later life may be complex, and few studies have sufficient data to model nonlinearities or adequately adjust for statin use. We evaluated the observational associations of HDL-C and LDL-C with incident dementia in a large and well-characterized cohort with linked survey and electronic health record (EHR) data. METHODS Kaiser Permanente Northern California health plan members aged 55 years and older who completed a health behavior survey between 2002 and 2007, had no history of dementia before the survey, and had laboratory measurements of cholesterol within 2 years after survey completion were followed up through December 2020 for incident dementia (Alzheimer disease-related dementia [ADRD]; Alzheimer disease, vascular dementia, and/or nonspecific dementia) based on ICD-9 or ICD-10 codes in EHRs. We used Cox models for incident dementia with follow-up time beginning 2 years postsurvey (after cholesterol measurement) and censoring at end of membership, death, or end of study period. We evaluated nonlinearities using B-splines, adjusted for demographic, clinical, and survey confounders, and tested for effect modification by baseline age or prior statin use. RESULTS A total of 184,367 participants [mean age at survey = 69.5 years, mean HDL-C = 53.7 mg/dL (SD = 15.0), mean LDL-C = 108 mg/dL (SD = 30.6)] were included. Higher and lower HDL-C values were associated with elevated ADRD risk compared with the middle quantile: HDL-C in the lowest quintile was associated with an HR of 1.07 (95% CI 1.03-1.11), and HDL-C in the highest quintile was associated with an HR of 1.15 (95% CI 1.11-1.20). LDL-C was not associated with dementia risk overall, but statin use qualitatively modified the association. Higher LDL-C was associated with a slightly greater risk of ADRD for statin users (53% of the sample, HR per 10 mg/dL increase = 1.01, 95% CI 1.01-1.02) and a lower risk for nonusers (HR per 10 mg/dL increase = 0.98; 95% CI 0.97-0.99). There was evidence for effect modification by age with linear HDL-C (p = 0.003) but not LDL-C (p = 0.59). DISCUSSION Both low and high levels of HDL-C were associated with elevated dementia risk. The association between LDL-C and dementia risk was modest.
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Affiliation(s)
- Erin L Ferguson
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA.
| | - Scott C Zimmerman
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Chen Jiang
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Minhyuk Choi
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Kaitlin Swinnerton
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Vidhu Choudhary
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Travis J Meyers
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Thomas J Hoffmann
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Paola Gilsanz
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Akinyemi Oni-Orisan
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Rachel A Whitmer
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Neil Risch
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Ronald M Krauss
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - Catherine A Schaefer
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
| | - M Maria Glymour
- From the Department of Epidemiology and Biostatistics (E.L.F., S.C.Z., M.C., K.S., T.J.H., N.R., M.M.G.), University of California, San Francisco; Kaiser Permanente Division of Research (C.J., V.C., T.J.M., P.G., C.A.S.), Oakland; Institute for Human Genetics (A.O.-O., N.R.); Department of Clinical Pharmacy (A.O.-O.), University of California, San Francisco; Department of Public Health Sciences (R.A.W.), University of California, Davis; and Departments of Pediatrics and Medicine (R.M.K.), University of California, San Francisco. K.S. is currently affiliated with the VA Boston Healthcare System, MA. T.J.H. is currently affiliated with the Department of Epidemiology and Biostatistics, University of California, San Francisco, and the Institute for Human Genetics, University of California, San Francisco. P.G. is currently affiliated with the Kaiser Permanente Division of Research, Oakland, CA, and the Department of Epidemiology and Biostatistics, University of California, San Francisco. N.R. is currently affiliated with the Department of Epidemiology and Biostatistics, the Institute for Human Genetics, University of California, San Francisco, and the Kaiser Permanente Division of Research, Oakland, CA. M.M.G. is currently affiliated with the Department of Epidemiology, Boston University School of Public Health, MA
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9
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Lor Y, George KM, Gilsanz P, Meunier CC, Peterson RL, Hayes-Larson E, Barnes LL, Mungas D, Whitmer RA. What is the association between adverse childhood experiences and late-life cognitive decline? Study of Healthy Aging in African Americans (STAR) cohort study. BMJ Open 2023; 13:e072961. [PMID: 37918928 PMCID: PMC10626853 DOI: 10.1136/bmjopen-2023-072961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023] Open
Abstract
OBJECTIVES Adverse childhood experiences (ACEs) are associated with higher risk of chronic disease, but little is known about the association with late life cognitive decline. We examined the longitudinal association between ACEs and late-life cognitive decline in the Study of Healthy Aging in African Americans (STAR). DESIGN Linear mixed models with random intercepts and slope examined the association of individual and composite ACEs with cognitive change adjusting for years from baseline (timescale), baseline age, sex, parental education, childhood socioeconomic status and childhood social support. Participants reported whether they had experienced nine types of ACEs. Executive function and verbal episodic memory were measured up to three times over a 3-year period using the Spanish and English Neuropsychological Assessment Scales. SETTINGS Kaiser Permanente Northern California members living in the Bay Area. PARTICIPANTS STAR is a cohort study of cognitive ageing launched in 2018 that has enrolled 764 black Americans ages ≥50 years (mean age=67.5; SD=8.5). RESULTS Twenty-one per cent of participants reported no ACEs, 24% one ACE, 20% two ACEs, 17% three ACEs and 17% four or more ACEs. Compared with no ACEs, two ACEs (β=0.117; 95% CI 0.052 to 0.182), three ACEs (β=0.075; 95% CI 0.007 to 0.143) and four or more ACEs (β=0.089; 95% CI 0.002 to 0.158) were associated with less decline in executive function. There were no significant associations between number of ACEs and baseline or longitudinal verbal episodic memory or between individual ACEs and executive function or verbal episodic memory. CONCLUSION In this cohort of older black Americans, there was no association between ACEs and baseline cognition or cognitive change in verbal episodic memory; however, experiencing ≥ 2 ACEs was associated with less decline in executive function. These results may indicate that participants who survived to age 50+ and experienced ACEs may have cognitive resilience that warrants further investigation.
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Affiliation(s)
- Yi Lor
- Department of Public Health Sciences, University of California Davis, Davis, California, USA
| | - Kristen M George
- Department of Public Health Sciences, University of California Davis, Davis, California, USA
| | - Paola Gilsanz
- Kaiser Permanente Division of Research, Oakland, California, USA
| | - Claire C Meunier
- Department of Public Health Sciences, University of California Davis, Davis, California, USA
| | - Rachel L Peterson
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | - Eleanor Hayes-Larson
- Department of Epidemiology, UCLA School of Public Health, Los Angeles, California, USA
| | - Lisa L Barnes
- Department of Neurological Sciences, Rush University, Chicago, Illinois, USA
| | - Dan Mungas
- Department of Neurology, University of California Davis, Sacramento, California, USA
| | - Rachel A Whitmer
- Department of Public Health Sciences, University of California Davis, Davis, California, USA
- Department of Neurology, University of California Davis, Sacramento, California, USA
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10
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Zimmerman SC, Ferguson EL, Choudhary V, Ranatunga DK, Oni-Orisan A, Hayes-Larson E, Duarte Folle A, Mayeda ER, Whitmer RA, Gilsanz P, Power MC, Schaefer C, Glymour MM, Ackley SF. Metformin Cessation and Dementia Incidence. JAMA Netw Open 2023; 6:e2339723. [PMID: 37878309 PMCID: PMC10600586 DOI: 10.1001/jamanetworkopen.2023.39723] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/14/2023] [Indexed: 10/26/2023] Open
Abstract
Importance Prior studies suggested that metformin may be associated with reduced dementia incidence, but associations may be confounded by disease severity and prescribing trends. Cessation of metformin therapy in people with diabetes typically occurs due to signs of kidney dysfunction but sometimes is due to less serious adverse effects associated with metformin. Objective To investigate the association of terminating metformin treatment for reasons unrelated to kidney dysfunction with dementia incidence. Design, Setting, and Participants This cohort study was conducted at Kaiser Permanente Northern California, a large integrated health care delivery system, among a cohort of metformin users born prior to 1955 without history of diagnosed kidney disease at metformin initiation. Dementia follow-up began with the implementation of electronic health records in 1996 and continued to 2020. Data were analyzed from November 2021 through September 2023. Exposures A total of 12 220 early terminators, individuals who stopped metformin with normal estimated glomerular filtration rate (eGFR), were compared with routine metformin users, who had not yet terminated metformin treatment or had terminated (with or without restarting) after their first abnormal eGFR measurement. Early terminators were matched with routine users of the same age and gender who had diabetes for the same duration. Main outcomes and measures The outcome of interest was all-cause incident dementia. Follow-up for early terminators and their matched routine users was started at age of termination for the early terminator. Survival models adjusted for sociodemographic characteristics and comorbidities at the time of metformin termination (or matched age). Mediation models with HbA1c level and insulin usage 1 and 5 years after termination tested whether changes in blood glucose or insulin usage explained associations between early termination of metformin and dementia incidence. Results The final analytic sample consisted of 12 220 early terminators (5640 women [46.2%]; mean [SD] age at start of first metformin prescription, 59.4 [9.0] years) and 29 126 routine users (13 582 women [46.6%]; mean [SD] age at start of first metformin prescription, 61.1 [8.9] years). Early terminators had 1.21 times the hazard of dementia diagnosis compared with routine users (hazard ratio, 1.21; 95% CI, 1.12 to 1.30). In mediation analysis, contributions to this association by changes in HbA1c level or insulin use ranged from no contribution (0.00 years; 95% CI, -0.02 to 0.02 years) for insulin use at 5 years after termination to 0.07 years (95% CI, 0.02 to 0.13 years) for HbA1c level at 1 year after termination, suggesting that the association was largely independent of changes in HbA1c level and insulin usage. Conclusions and Relevance In this study, terminating metformin treatment was associated with increased dementia incidence. This finding may have important implications for clinical treatment of adults with diabetes and provides additional evidence that metformin is associated with reduced dementia risk.
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Affiliation(s)
- Scott C. Zimmerman
- Department of Epidemiology and Statistics, University of California, San Francisco
| | - Erin L. Ferguson
- Department of Epidemiology and Statistics, University of California, San Francisco
| | | | - Dilrini K. Ranatunga
- Kaiser Permanente Division of Research, Oakland, California
- Now with Kaiser Permanente Research Bank, Oakland, CA
| | | | - Eleanor Hayes-Larson
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Aline Duarte Folle
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Rachel A. Whitmer
- Kaiser Permanente Division of Research, Oakland, California
- Department of Public Health Sciences, University of California, Davis
| | - Paola Gilsanz
- Department of Epidemiology and Statistics, University of California, San Francisco
- Kaiser Permanente Division of Research, Oakland, California
| | - Melinda C. Power
- Department of Epidemiology, George Washington University Milken Institute School of Public Health, Washington, District of Columbia
| | | | - M. Maria Glymour
- Department of Epidemiology, Boston University, Boston, Massachusetts
| | - Sarah F. Ackley
- Department of Epidemiology, Boston University, Boston, Massachusetts
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11
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Jimenez MP, Gause EL, Hayes-Larson E, Morris EP, Fletcher E, Manly J, Gilsanz P, Soh Y, Corrada M, Whitmer RA, Glymour MM. Racial and Ethnic Differences in the Association between Depressive Symptoms and Cognitive Outcomes in Older Adults: Findings from KHANDLE and STAR. medRxiv 2023:2023.09.07.23295205. [PMID: 37732261 PMCID: PMC10508807 DOI: 10.1101/2023.09.07.23295205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Depressive symptoms are associated with higher risk of dementia but how they impact cognition in diverse populations is unclear. METHODS Asian, Black, LatinX, or White participants (n=2,227) in the Kaiser Healthy Aging and Diverse Life Experiences (age 65+) and the Study of Healthy Aging in African Americans (age 50+) underwent up to three waves of cognitive assessments over four years. Multilevel models stratified by race/ethnicity were used to examine whether depressive symptoms were associated with cognition or cognitive decline and whether associations differed by race/ethnicity. RESULTS Higher depressive symptoms were associated with lower baseline verbal episodic memory scores (-0.06, 95%CI: -0.12, -0.01; -0.15, 95%CI: -0.25, -0.04), and faster decline annually in semantic memory (-0.04, 95%CI: -0.07, -0.01; -0.10, 95%CI: -0.15, -0.05) for Black and LatinX participants. Depressive symptoms were associated with lower baseline but not decline in executive function. DISCUSSION Depressive symptoms were associated with worse cognitive domains, with some evidence of heterogeneity across racial/ethnic groups.
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Affiliation(s)
- Marcia P Jimenez
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Emma L Gause
- Center for Climate and Health, Boston University School of Public Health, Boston, MA, USA
| | - Eleanor Hayes-Larson
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Emily P Morris
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
| | - Evan Fletcher
- Department of Neurology, University of California, Davis, CA, USA
| | - Jennifer Manly
- Department of Neurology, Columbia University, New York, NY, USA
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | - Yenee Soh
- Division of Research, Kaiser Permanente, Oakland, CA, USA
| | - Maria Corrada
- Department of Epidemiology, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Rachel A Whitmer
- Department of Public Health Sciences and Neurology, University of California Davis School of Medicine, Davis, CA, USA
| | - M Maria Glymour
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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12
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Chen R, Calmasini C, Swinnerton K, Wang J, Haneuse S, Ackley SF, Hirst AK, Hayes-Larson E, George KM, Peterson R, Soh Y, Barnes LL, Mayeda ER, Gilsanz P, Mungas DM, Whitmer RA, Corrada MM, Glymour MM. Pragmatic approaches to handling practice effects in longitudinal cognitive aging research. Alzheimers Dement 2023; 19:4028-4036. [PMID: 37199336 PMCID: PMC10524983 DOI: 10.1002/alz.13067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 03/02/2023] [Accepted: 03/08/2023] [Indexed: 05/19/2023]
Abstract
INTRODUCTION The challenge of accounting for practice effects (PEs) when modeling cognitive change was amplified by the COVID-19 pandemic, which introduced period and mode effects that may bias the estimation of cognitive trajectory. METHODS In three Kaiser Permanente Northern California prospective cohorts, we compared predicted cognitive trajectories and the association of grip strength with cognitive decline using three approaches: (1) no acknowledgment of PE, (2) inclusion of a wave indicator, and (3) constraining PE based on a preliminary model (APM) fit using a subset of the data. RESULTS APM-based correction for PEs based on balanced, pre-pandemic data, and with current age as the timescale produced the smallest discrepancy between within-person and between-person estimated age effects. Estimated associations between grip strength and cognitive decline were not sensitive to the approach used. DISCUSSION Constraining PEs based on a preliminary model is a flexible, pragmatic approach allowing for meaningful interpretation of cognitive change. HIGHLIGHTS The magnitude of practice effects (PEs) varied widely by study. When PEs were present, the three PE approaches resulted in divergent estimated age-related cognitive trajectories. Estimated age-related cognitive trajectories were sometimes implausible in models that did not account for PEs. The associations between grip strength and cognitive decline did not differ by the PE approach used. Constraining PEs based on estimates from a preliminary model allows for a meaningful interpretation of cognitive change.
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Affiliation(s)
- Ruijia Chen
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Camilla Calmasini
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Kaitlin Swinnerton
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Jingxuan Wang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sarah F Ackley
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Andrew K Hirst
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Eleanor Hayes-Larson
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Kristen M George
- Department of Public Health Sciences, University of California, Davis, California, USA
| | - Rachel Peterson
- School of Public Health and Community Health Sciences, University of Montana, Missoula, Montana, USA
| | - Yenee Soh
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Lisa L Barnes
- Department of Neurological Sciences and Rush Alzheimer's Disease Center, Rush Medical College, Chicago, Illinois, USA
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Dan M Mungas
- Department of Neurology, University of California, Davis, California, USA
| | - Rachel A Whitmer
- Department of Public Health Sciences, University of California, Davis, California, USA
| | - Maria M Corrada
- Department of Neurology, University of California, Irvine, California, USA
| | - M Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
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Soh Y, Eng CW, Mayeda ER, Whitmer RA, Lee C, Peterson RL, Mungas DM, Glymour MM, Gilsanz P. Association of primary lifetime occupational cognitive complexity and cognitive decline in a diverse cohort: Results from the KHANDLE study. Alzheimers Dement 2023; 19:3926-3935. [PMID: 37057753 PMCID: PMC10517075 DOI: 10.1002/alz.13038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/09/2023] [Accepted: 02/20/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Higher occupational complexity has been linked to favorable cognitive outcomes, but rarely examined in racially and ethnically diverse populations. METHODS In a diverse cohort (n = 1536), linear mixed-effects models estimated associations between main lifetime occupational complexity and domain-specific cognitive decline (z-standardized). Occupational complexity with data, people, and things were classified using the Dictionary of Occupational Titles. RESULTS For occupational complexity with data, highest tertile (vs. lowest) was associated with higher baseline executive function (β = 0.11; 95% confidence interval [CI] 0.00-0.22) and slower annual rate of decline (β = 0.03; 95% CI 0.01-0.06), and higher baseline semantic memory (β = 0.14; 95% CI 0.04-0.25). Highest tertile of occupational complexity with people was associated with higher baseline executive function (β = 0.29; 95% CI 0.18-0.40), verbal episodic memory (β = 0.12; 95% CI 0.00-0.24), and semantic memory (β = 0.23; 95% CI 0.12-0.34). DISCUSSION In a diverse cohort, higher occupational complexity is associated with better cognition. Findings should be verified in larger cohorts. HIGHLIGHT Few studies have examined associations of occupational complexity with cognition in diverse populations. Racial and ethnic minorities are disproportionately exposed to lower occupational complexity. Occupational complexity with data and people are associated with better cognition.
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Affiliation(s)
- Yenee Soh
- Kaiser Permanente Division of Research, Oakland, California, USA
| | - Chloe W Eng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, California, USA
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California, USA
| | - Rachel A Whitmer
- Department of Neurology, School of Medicine, University of California, Davis, Davis, California, USA
- Department of Public Health Sciences, University of California, Davis, Davis, California, USA
| | - Catherine Lee
- Kaiser Permanente Division of Research, Oakland, California, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Rachel L Peterson
- University of Montana, School of Public and Community Health Sciences, Missoula, MT, USA
| | - Dan M Mungas
- Department of Neurology, School of Medicine, University of California, Davis, Davis, California, USA
| | - M Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Paola Gilsanz
- Kaiser Permanente Division of Research, Oakland, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
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Thomas MD, Calmasini C, Khela H, Mobley TM, Rose Mayeda E, Mangurian C, Barnes LL, Gilsanz P, Whitmer RA, Glymour MM. The impact of attending historically Black colleges and universities on cognitive decline in Black adults: A longitudinal analysis in the KHANDLE and STAR cohorts. Alzheimers Dement 2023; 19:3426-3434. [PMID: 36800287 PMCID: PMC10432571 DOI: 10.1002/alz.12983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Black students attending predominantly White institutions (PWIs) versus historically Black colleges and universities (HBCUs) report more harmful discrimination and develop worse mental health outcomes, potentially offsetting the established benefits of college for lowering dementia incidence. METHODS Black participants in two cohorts (the Kaiser Healthy Aging and Diverse Life Experiences [KHANDLE] and the Study of Healthy Aging in African Americans [STAR]) who had attended college (N = 716) self-reported the college name (classified as HBCU vs. PWI) and completed three waves of executive function (EF) and verbal episodic memory (VEM) assessments. HBCU effects on cognitive level and decline were estimated using adjusted linear mixed-effects models. RESULTS HBCU (vs. PWI) attendees averaged better EF (β = 0.05 [-0.22, 0.32]) and VEM (β = 0.21 [-0.06, 0.46]) at age 70 though neither association was statistically significant. HBCU attendance was associated with slightly faster VEM decline (β = -0.03 [-0.05, 0.00]). DISCUSSION Harmonized analyses with larger studies are needed to estimate important effects of HBCU attendance. HIGHLIGHTS Higher education is robustly linked to lower dementia risk, yet Black-White inequities persist among college-educated adults. Black students attending predominantly White institutions (PWIs) versus historically Black colleges and universities (HBCUs) report more harmful discrimination and develop worse mental health outcomes, which may offset the established benefits of college for lowering dementia incidence. HBCU (vs. non-HBCU) attendees averaged better executive function and verbal episodic memory (VEM) at average age 70, though confidence intervals were wide and associations were not statistically significant, and averaged slightly faster decline in VEM. Harmonized analyses using larger nationally representative studies are likely needed to avoid underestimating the health effects of HBCU attendance.
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Affiliation(s)
- Marilyn D. Thomas
- University of California, San Francisco, School of Medicine, Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, San Francisco, CA, USA
- University of California, San Francisco, School of Medicine, Department of Epidemiology and Biostatistics, San Francisco, CA, USA
| | - Camilla Calmasini
- University of California, San Francisco, School of Medicine, Department of Epidemiology and Biostatistics, San Francisco, CA, USA
| | - Harmon Khela
- Johns Hopkins University, Departments of Biology and of Public Health Studies, Baltimore, MD, USA
| | - Taylor M. Mobley
- Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, UCLA Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Christina Mangurian
- University of California, San Francisco, School of Medicine, Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, San Francisco, CA, USA
- University of California, San Francisco, School of Medicine, Department of Epidemiology and Biostatistics, San Francisco, CA, USA
| | - Lisa L. Barnes
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - Paola Gilsanz
- University of California, San Francisco, School of Medicine, Department of Epidemiology and Biostatistics, San Francisco, CA, USA
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | - Rachel A. Whitmer
- Kaiser Permanente Division of Research, Oakland, CA, USA
- Department of Public Health Sciences, University of California Davis School of Medicine, Davis, CA, USA
- Alzheimer’s Disease Research Center, University of California Davis Health, Sacramento, CA, USA
| | - M. Maria Glymour
- University of California, San Francisco, School of Medicine, Department of Epidemiology and Biostatistics, San Francisco, CA, USA
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Cintron DW, Calmasini C, Barnes LL, Mungas DM, Whitmer RA, Eng CW, Gilsanz P, George KM, Peterson R, Glymour MM. Evaluating interpersonal discrimination and depressive symptoms as partial mediators of the effects of education on cognition: Evidence from the Study of Healthy Aging in African Americans (STAR). Alzheimers Dement 2023; 19:3138-3147. [PMID: 36724372 PMCID: PMC10390650 DOI: 10.1002/alz.12957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/18/2022] [Accepted: 12/20/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Education is correlated with positive health outcomes, but associations are sometimes weaker among African Americans. The extent to which exposure to discrimination and depressive symptoms attenuates the education-cognition link has not been investigated. METHODS Study of Healthy Aging in African Americans (STAR) participants (n = 764; average age 69 years) completed the Spanish and English Neuropsychological Assessment Scales. We assessed everyday and major lifetime discrimination and depressive symptoms as mediators of education effects on cognition using G-estimation with measurement error corrections. RESULTS Education was correlated with greater major lifetime and everyday discrimination but lower depressive symptoms. Accounting for discrimination and depressive symptoms slightly reduced the estimated effect of education on cognition. The estimated total effect of graduate education (vs DISCUSSION Education has robust effects on later-life cognition after controlling multiple mediating pathways and offsetting mechanisms.
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Affiliation(s)
- Dakota W. Cintron
- Center for Health and Community, University of California, San Francisco, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Camilla Calmasini
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Lisa L. Barnes
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, USA
- Department of Neurology, Rush University Medical Center, Chicago, IL, USA
| | - Dan M. Mungas
- Department of Neurology, University of California Davis Health, Sacramento, CA, USA
| | - Rachel A. Whitmer
- Department of Public Health Sciences, University of California Davis, Davis, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Chloe W. Eng
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
| | - Paola Gilsanz
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Kristen M. George
- Department of Neurology, University of California Davis Health, Sacramento, CA, USA
- Department of Public Health Sciences, University of California Davis, Davis, CA, USA
| | - Rachel Peterson
- Department of Neurology, University of California Davis Health, Sacramento, CA, USA
- Department of Public Health Sciences, University of California Davis, Davis, CA, USA
| | - M. Maria Glymour
- Center for Health and Community, University of California, San Francisco, San Francisco, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA
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Moran C, Lacy ME, Whitmer RA, Tsai AL, Quesenberry CP, Karter AJ, Adams AS, Gilsanz P. Glycemic Control Over Multiple Decades and Dementia Risk in People With Type 2 Diabetes. JAMA Neurol 2023; 80:597-604. [PMID: 37067815 PMCID: PMC10111232 DOI: 10.1001/jamaneurol.2023.0697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/20/2023] [Indexed: 04/18/2023]
Abstract
Importance The levels of glycemic control associated with the lowest risk of dementia in people with type 2 diabetes are unknown. This knowledge is critical to inform patient-centered glycemic target setting. Objective To examine the associations between cumulative exposure to various ranges of glycated hemoglobin (HbA1c) concentrations with dementia risk across sex and racial and ethnic groups and the association of current therapeutic glycemic targets with dementia risk. Design, Setting, and Participants This cohort study included members of the Kaiser Permanente Northern California integrated health care system with type 2 diabetes who were aged 50 years or older during the study period from January 1, 1996, to September 30, 2015. Individuals with fewer than 2 HbA1c measurements during the study period, prevalent dementia at baseline, or less than 3 years of follow-up were excluded. Data were analyzed from February 2020 to January 2023. Exposures Time-updated cumulative exposure to HbA1c thresholds. At each HbA1c measurement, participants were categorized based on the percentage of their HbA1c measurements that fell into the following categories: less than 6%, 6% to less than 7%, 7% to less than 8%, 8% to less than 9%, 9% to less than 10%, and 10% or more of total hemoglobin (to convert percentage of total hemoglobin to proportion of total hemoglobin, multiply by 0.01). Main Outcomes and Measures Dementia diagnosis was identified using International Classification of Diseases, Ninth Revision codes from inpatient and outpatient encounters. Cox proportional hazards regression models estimated the association of time-varying cumulative glycemic exposure with dementia, adjusting for age, race and ethnicity, baseline health conditions, and number of HbA1c measurements. Results A total of 253 211 participants were included. The mean (SD) age of participants was 61.5 (9.4) years, and 53.1% were men. The mean (SD) duration of follow-up was 5.9 (4.5) years. Participants with more than 50% of HbA1c measurements at 9% to less than 10% or 10% or more had greater risk of dementia compared with those who had 50% or less of measurements in those categories (HbA1c 9% to <10%: adjusted hazard ratio [aHR], 1.31 [95% CI, 1.15-1.51]; HbA1c≥10%: aHR, 1.74 [95% CI, 1.62-1.86]). By contrast, participants with more than 50% of HbA1c concentrations less than 6%, 6% to less than 7%, or 7% to less than 8% had lower risk of dementia (HbA1c<6%: aHR, 0.92 [95% CI, 0.88-0.97]; HbA1c 6% to <7%: aHR, 0.79 [95% CI, 0.77-0.81]; HbA1c 7% to <8%: aHR, 0.93 [95% CI, 0.89-0.97]). Conclusions and Relevance In this study dementia risk was greatest among adults with cumulative HbA1c concentrations of 9% or more. These results support currently recommended relaxed glycemic targets for older people with type 2 diabetes.
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Affiliation(s)
- Chris Moran
- National Centre for Healthy Ageing, Melbourne, Australia
- Peninsula Clinical School, Monash University, Melbourne, Australia
- Department of Geriatric Medicine, Peninsula Health, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mary E. Lacy
- Kaiser Permanente Division of Research, Oakland, California
- College of Public Health, Department of Epidemiology, University of Kentucky, Lexington
| | - Rachel A. Whitmer
- Kaiser Permanente Division of Research, Oakland, California
- Division of Epidemiology, School of Medicine, University of California, Davis
| | - Ai-Lin Tsai
- Kaiser Permanente Division of Research, Oakland, California
| | | | | | - Alyce S. Adams
- Kaiser Permanente Division of Research, Oakland, California
- Department of Epidemiology and Population Health and Health Policy, School of Medicine, Stanford University, Stanford, California
| | - Paola Gilsanz
- Kaiser Permanente Division of Research, Oakland, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco
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Lam JO, Hou CE, Gilsanz P, Lee C, Lea AN, Satre DD, Silverberg MJ. Undiagnosed Cognitive Impairment and Impact on Instrumental Activities of Daily Living Among People With HIV Infection in Primary Care. Open Forum Infect Dis 2023; 10:ofad284. [PMID: 37342311 PMCID: PMC10279416 DOI: 10.1093/ofid/ofad284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/18/2023] [Indexed: 06/22/2023] Open
Abstract
Background Little is known about the prevalence of undiagnosed cognitive impairment and its impact on instrumental activities of daily living (IADL) among people with HIV (PWH) in primary care. Methods PWH were recruited from an integrated health care setting in the United States. PWH were eligible for recruitment if they were ≥50 years old, taking antiretroviral therapy (ie, ≥1 antiretroviral therapy [ART] prescription fill in the past year), and had no clinical diagnosis of dementia. Participants completed a cognitive screen (St. Louis University Mental Status exam) and a questionnaire on IADL (modified Lawton-Brody). Results Study participants (n = 47) were mostly male (85.1%), 51.1% White, 25.5% Black, 17.0% Hispanic, and the average age (SD) was 59.7 (7.0) years. Overall, 27 (57.5%) participants were categorized as cognitively normal, 17 (36.2%) as having mild cognitive impairment, and 3 (6.4%) as having possible dementia. Of the 20 participants with mild cognitive impairment or possible dementia, 85.0% were men, the average age (SD) was 60.4 (7.1) years; 45.0% were White, 40.0% were Black, 10.0% were Hispanic, and 30.0% reported difficulty with at least 1 IADL. Most (66.7%) attributed difficulty with IADL primarily (33.3%) or in part (33.3%) to cognitive problems. Conclusions Undiagnosed cognitive impairment is frequent among ART-treated PWH, with possible elevated risk among Black PWH, and may be accompanied by difficulty with IADL. Efforts are needed to optimize identification of factors contributing to cognitive and IADL difficulties among ART-treated PWH in primary care.
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Affiliation(s)
- Jennifer O Lam
- Correspondence: Jennifer Lam, PhD, MPH, Division of Research, Kaiser Permanente Northern California; 2000 Broadway, Oakland, CA 94612 (); or Michael Silverberg, PhD, MPH, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612 ()
| | - Craig E Hou
- South San Francisco Medical Center, Kaiser Permanente Northern California, South San Francisco, California, USA
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Alexandra N Lea
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, California, USA
| | - Michael J Silverberg
- Correspondence: Jennifer Lam, PhD, MPH, Division of Research, Kaiser Permanente Northern California; 2000 Broadway, Oakland, CA 94612 (); or Michael Silverberg, PhD, MPH, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612 ()
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George KM, Maillard P, Gilsanz P, Fletcher E, Peterson RL, Fong J, Mayeda ER, Mungas DM, Barnes LL, Glymour MM, DeCarli C, Whitmer RA. Association of Early Adulthood Hypertension and Blood Pressure Change With Late-Life Neuroimaging Biomarkers. JAMA Netw Open 2023; 6:e236431. [PMID: 37010868 PMCID: PMC10071343 DOI: 10.1001/jamanetworkopen.2023.6431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/19/2023] [Indexed: 04/04/2023] Open
Abstract
Importance The association between hypertension developed before midlife and late-life brain health is understudied and, because of the cardioprotective benefits of estrogen before menopause, may differ by sex. Objective To assess the association of early adulthood hypertension and blood pressure (BP) change with late-life neuroimaging biomarkers and examine potential sex differences. Design, Setting, and Participants This cohort study used data from the Study of Healthy Aging in African Americans (STAR) and Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study, which were harmonized longitudinal cohorts of racially and ethnically diverse adults aged 50 years and older from the San Francisco Bay area and Sacramento Valley in California. The STAR was conducted from November 6, 2017, to November 5, 2021, and the KHANDLE study was conducted from April 27, 2017, to June 15, 2021. The current study included 427 participants from the KHANDLE and STAR studies who received health assessments between June 1, 1964, and March 31, 1985. Regional brain volumes and white matter (WM) integrity were measured via magnetic resonance imaging between June 1, 2017, and March 1, 2022. Exposures Hypertension status (normotension, transition to hypertension, and hypertension) and BP change (last measure minus first measure) were assessed at 2 multiphasic health checkups (MHCs; 1964-1985) in early adulthood (ages 30-40 years). Main Outcomes and Measures Regional brain volumes and WM integrity were measured using 3T magnetic resonance imaging and z standardized. General linear models adjusted for potential confounders (demographic characteristics and study [KHANDLE or STAR]) were used to assess the association of hypertension and BP change with neuroimaging biomarkers. Sex interactions were tested. Results Among 427 participants, median (SD) ages were 28.9 (7.3) years at the first MHC, 40.3 (9.4) years at the last MHC, and 74.8 (8.0) years at neuroimaging. A total of 263 participants (61.6%) were female and 231 (54.1%) were Black. Overall, 191 participants (44.7%) had normotension, 68 (15.9%) transitioned to hypertension, and 168 (39.3%) had hypertension. Compared with participants who had normotension, those who had hypertension and those who transitioned to hypertension had smaller cerebral volumes (hypertension: β = -0.26 [95% CI, -0.41 to -0.10]; transition to hypertension: β = -0.23 [95% CI, -0.44 to -0.23]), with similar differences in cerebral gray matter volume (hypertension: β = -0.32 [95% CI, -0.52 to -0.13]; transition to hypertension: β = -0.30 [95% CI, -0.56 to -0.05]), frontal cortex volume (hypertension: β = -0.43 [95% CI, -0.63 to -0.23]; transition to hypertension: β = -0.27 [95% CI, -0.53 to 0]), and parietal cortex volume (hypertension: β = -0.22 [95% CI, -0.42 to -0.02]; transition to hypertension: β = -0.29 [95% CI, -0.56 to -0.02]). Participants with hypertension also had smaller hippocampal volume (β = -0.22; 95% CI, -0.42 to -0.02), greater ventricular volumes (lateral ventricle: β = 0.44 [95% CI, 0.25-0.63]; third ventricle: β = 0.20 [95% CI, 0.01-0.39]), larger free water volume (β = 0.35; 95% CI, 0.18-0.52), and lower fractional anisotropy (β = -0.26; 95% CI, -0.45 to -0.08) than those who had normotension. Holding hypertension status constant, a 5-mm Hg increase in systolic BP was associated with smaller temporal cortex volume (β = -0.03; 95% CI, -0.06 to -0.01), while a 5-mm Hg increase in diastolic BP was associated with smaller parietal cortex volume (β = -0.06; 95% CI, -0.10 to -0.02). The negative association of hypertension and BP change with regional brain volumes appeared stronger in men than women for some regions. Conclusions and Relevance In this cohort study, early adulthood hypertension and BP change were associated with late-life volumetric and WM differences implicated in neurodegeneration and dementia. Sex differences were observed for some brain regions whereby hypertension and increasing BP appeared more detrimental for men. These findings suggest that prevention and treatment of hypertension in early adulthood is important for late-life brain health, particularly among men.
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Affiliation(s)
- Kristen M. George
- Department of Public Health Sciences, University of California Davis School of Medicine, Davis
| | - Pauline Maillard
- Department of Neurology, University of California Davis School of Medicine, Sacramento
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente, Oakland, California
| | - Evan Fletcher
- Department of Neurology, University of California Davis School of Medicine, Sacramento
| | - Rachel L. Peterson
- School of Public and Community Health Sciences, University of Montana, Missoula
| | - Joseph Fong
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles
| | - Dan M. Mungas
- Department of Neurology, University of California Davis School of Medicine, Sacramento
| | - Lisa L. Barnes
- Rush Alzheimer’s Disease Center, Rush Medical College, Chicago, Illinois
| | - M. Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco
| | - Charles DeCarli
- Department of Neurology, University of California Davis School of Medicine, Sacramento
| | - Rachel A. Whitmer
- Department of Public Health Sciences, University of California Davis School of Medicine, Davis
- Department of Neurology, University of California Davis School of Medicine, Sacramento
- Division of Research, Kaiser Permanente, Oakland, California
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Soh Y, Whitmer RA, Mayeda ER, Glymour MM, Peterson RL, Eng CW, Quesenberry CP, Manly JJ, Gilsanz P. State-Level Indicators of Childhood Educational Quality and Incident Dementia in Older Black and White Adults. JAMA Neurol 2023; 80:352-359. [PMID: 36780143 PMCID: PMC9926357 DOI: 10.1001/jamaneurol.2022.5337] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/11/2022] [Indexed: 02/14/2023]
Abstract
Importance Higher educational attainment is associated with reduced dementia risk, but the role of educational quality is understudied, presenting a major evidence gap, especially as it may contribute to racial inequities. Objective To evaluate the association between state-level educational quality during childhood and dementia risk. Design, Setting, and Participants This cohort study analyzed longitudinal data collected from January 1, 1997, through December 31, 2019 (23-year follow-up period). The sample comprised members of Kaiser Permanente Northern California (KPNC), a large integrated health care delivery system, who completed an optional survey during 1964-1972. Eligible individuals were US born; non-Hispanic Black or non-Hispanic White; aged 65 years or older as of January 1, 1996; were still alive; and did not have a dementia diagnosis or lapse in KPNC membership greater than 90 days between January 1 and December 31, 1996. Exposures Historical state-level administrative indicators of school quality (school term length, student-teacher ratio, and attendance rates) linked to participants using birth state and birth year (with a 6-year lag) and divided into tertiles using the pooled sample. Main Outcomes and Measures Dementia diagnoses from electronic health records between 1997 and 2019 were analyzed between March 1 and August 31, 2022. The associations of educational quality with incident dementia were estimated using Cox proportional hazards regression models. Results Among 21 450 KPNC members who participated in the optional survey, individuals born before availability of educational quality records (n = 87) and missing educational attainment (n = 585) were excluded. The final analytic sample was 20 778 individuals (56.5% women, 43.5% men; mean [SD] age, 74.7 [6.5] years; 18.8% Black; 81.2% White; 41.0% with less than high school education). Among Black individuals, 76.2% to 86.1% (vs 20.8%-23.3% of White individuals) attended schools in states in the lowest educational quality tertiles. Highest (vs lowest) educational quality tertiles were associated with lower dementia risk (student-teacher ratio: hazard ratio [HR], 0.88 [95% CI, 0.83-0.94]; attendance rates: HR, 0.80 [95% CI, 0.73-0.88]; term length: HR, 0.79 [95% CI, 0.73-0.86]). Effect estimates did not differ by race and were not attenuated by adjustment for educational attainment. Conclusions and Relevance In this cohort study, lower state-average educational quality was more common among Black individuals and associated with higher dementia risk. Differential investment in high-quality education due to structural racism may contribute to dementia disparities.
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Affiliation(s)
- Yenee Soh
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Rachel A. Whitmer
- Department of Public Health Sciences, University of California, Davis
- Department of Neurology, School of Medicine, University of California, Davis
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - M. Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Rachel L. Peterson
- School of Public and Community Health Sciences, University of Montana, Missoula, Montana
| | - Chloe W. Eng
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Epidemiology and Population Health, Stanford University, Stanford, California
| | | | - Jennifer J. Manly
- Department of Neurology, Taub Institute for Research on Alzheimer’s Disease and the Aging Brain, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco
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20
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Hayes-Larson E, Ikesu R, Fong J, Mobley TM, Gee GC, Brookmeyer R, Whitmer RA, Gilsanz P, Mayeda ER. Association of Education With Dementia Incidence Stratified by Ethnicity and Nativity in a Cohort of Older Asian American Individuals. JAMA Netw Open 2023; 6:e231661. [PMID: 36877520 PMCID: PMC9989900 DOI: 10.1001/jamanetworkopen.2023.1661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
IMPORTANCE High education protects against dementia, but returns on educational attainment may be different across sociodemographic groups owing to various social factors. Asian American individuals are a growing and diverse group, but little research has assessed dementia determinants in this population. OBJECTIVE To examine the association of education with dementia in a large cohort of Asian American individuals, stratifying by ethnicity and nativity. DESIGN, SETTING, AND PARTICIPANTS This cohort study used electronic health record (EHR) and survey data from the Research Program on Genes, Environment, and Health and the California Men's Health Study surveys (2002-2020). Data are from Kaiser Permanente Northern California, an integrated health care delivery system. This study used a volunteer sample who completed the surveys. Participants included Chinese, Filipino, and Japanese individuals who were aged 60 to less than 90 years without a dementia diagnosis in the EHR at the time of the survey (baseline) and who had 2 years of health plan coverage before baseline. Data analysis was performed from December 2021 to December 2022. EXPOSURES The main exposure was educational attainment (college degree or higher vs less than a college degree), and the main stratification variables were Asian ethnicity and nativity (born in the US or born outside the US). MAIN OUTCOMES AND MEASURES The primary outcome was incident dementia diagnosis in the EHR. Dementia incidence rates were estimated by ethnicity and nativity, and Cox proportional hazards and Aalen additive hazards models were fitted for the association of college degree or higher vs less than a college degree with time to dementia, adjusting for age (timescale), sex, nativity, and an interaction between nativity and college degree. RESULTS Among 14 749 individuals, the mean (SD) age at baseline was 70.6 (7.3) years, 8174 (55.4%) were female, and 6931 (47.0%) had attained a college degree. Overall, among individuals born in the US, those with a college degree had 12% lower dementia incidence (HR, 0.88; 95% CI, 0.75-1.03) compared with those without at least a college degree, although the confidence interval included the null. The HR for individuals born outside the US was 0.82 (95% CI, 0.72-0.92; P = .46 for the college degree by nativity interaction). The findings were similar across ethnicity and nativity groups except for Japanese individuals born outside the US. CONCLUSIONS AND RELEVANCE These findings suggest that college degree attainment was associated with lower dementia incidence, with similar associations across nativity. More work is needed to understand determinants of dementia in Asian American individuals and to elucidate mechanisms linking educational attainment and dementia.
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Affiliation(s)
- Eleanor Hayes-Larson
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Ryo Ikesu
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Joseph Fong
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Taylor M. Mobley
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
| | - Gilbert C. Gee
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles
| | - Ron Brookmeyer
- Department of Biostatistics, Fielding School of Public Health, University of California, Los Angeles
| | - Rachel A. Whitmer
- Department of Public Health Sciences, University of California, Davis School of Medicine, Sacramento
- Alzheimer’s Disease Center, University of California, Davis Health, Sacramento
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles
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21
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Mobley TM, Shaw C, Hayes-Larson E, Fong J, Gilsanz P, Gee GC, Brookmeyer R, Whitmer RA, Casey JA, Rose Mayeda E. Neighborhood disadvantage and dementia incidence in a cohort of Asian American and non-Latino White older adults in Northern California. Alzheimers Dement 2023; 19:296-306. [PMID: 35388625 PMCID: PMC9535033 DOI: 10.1002/alz.12660] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/09/2022] [Accepted: 02/22/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Some evidence suggests that neighborhood socioeconomic disadvantage is associated with dementia-related outcomes. However, prior research is predominantly among non-Latino Whites. METHODS We evaluated the association between neighborhood disadvantage (Area Deprivation Index [ADI]) and dementia incidence in Asian American (n = 18,103) and non-Latino White (n = 149,385) members of a Northern California integrated health care delivery system aged 60 to 89 at baseline. Race/ethnicity-specific Cox proportional hazards models adjusted for individual-level age, sex, socioeconomic measures, and block group population density estimated hazard ratios (HRs) for dementia. RESULTS Among non-Latino Whites, ADI was associated with dementia incidence (most vs. least disadvantaged ADI quintile HR = 1.09, 95% confidence interval [CI] = 1.02-1.15). Among Asian Americans, associations were close to null (e.g., most vs. least disadvantaged ADI quintile HR = 1.01, 95% CI = 0.85-1.21). DISCUSSION ADI was associated with dementia incidence among non-Latino Whites but not Asian Americans. Understanding the potentially different mechanisms driving dementia incidence in these groups could inform dementia prevention efforts.
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Affiliation(s)
- Taylor M. Mobley
- Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Crystal Shaw
- Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
- Department of Biostatistics, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Eleanor Hayes-Larson
- Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Joseph Fong
- Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Paola Gilsanz
- Kaiser Permanente Division of Research, Oakland, CA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Gilbert C. Gee
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Ron Brookmeyer
- Department of Biostatistics, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Rachel A. Whitmer
- Kaiser Permanente Division of Research, Oakland, CA
- Department of Public Health Sciences, University of California Davis School of Medicine, Davis, CA, USA
- Alzheimer’s Disease Center, University of California Davis Health, Sacramento, CA, USA
| | - Joan A. Casey
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, NY USA
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California
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22
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Peterson RL, Gilsanz P, Lor Y, George KM, Ko M, Wagner J, Soh Y, Meyer OL, Glymour MM, Whitmer RA. Rural residence across the life course and late-life cognitive decline in KHANDLE: A causal inference study. Alzheimers Dement (Amst) 2023; 15:e12399. [PMID: 36762299 PMCID: PMC9896964 DOI: 10.1002/dad2.12399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/01/2022] [Accepted: 01/03/2023] [Indexed: 02/05/2023]
Abstract
Background Modifiable risks for dementia are more prevalent in rural populations, yet there is a dearth of research examining life course rural residence on late-life cognitive decline. Methods The association of rural residence and socioeconomic status (SES) in childhood and adulthood with late-life cognitive domains (verbal episodic memory, executive function, and semantic memory) and cognitive decline in the Kaiser Healthy Aging and Diverse Life Experiences cohort was estimated using marginal structural models with stabilized inverse probability weights. Results After adjusting for time-varying SES, the estimated marginal effect of rural residence in childhood was harmful for both executive function (β = -0.19, 95% confidence interval [CI] = -0.32, -0.06) and verbal episodic memory (β = -0.22, 95% CI = -0.35, -0.08). Effects of adult rural residence were imprecisely estimated with beneficial point estimates for both executive function (β = 0.19; 95% CI = -0.07, 0.44) and verbal episodic memory (β = 0.24, 95% CI = -0.07, 0.55). Conclusions Childhood rurality is associated with poorer late-life cognition independent of SES.
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Affiliation(s)
- Rachel L. Peterson
- School of Public and Community Health SciencesUniversity of MontanaMissoulaMontanaUSA
| | - Paola Gilsanz
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Yi Lor
- Department of Public Health SciencesUniversity of California DavisDavisCaliforniaUSA
| | - Kristen M. George
- Department of Public Health SciencesUniversity of California DavisDavisCaliforniaUSA
| | - Michelle Ko
- Department of Public Health SciencesUniversity of California DavisDavisCaliforniaUSA
| | - Jenny Wagner
- Department of Public Health SciencesUniversity of California DavisDavisCaliforniaUSA
| | - Yenee Soh
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCaliforniaUSA
| | - Oanh L. Meyer
- Department of NeurologyUniversity of California DavisSacramentoCaliforniaUSA
| | - M. Maria Glymour
- Department of Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Rachel A. Whitmer
- Department of Public Health SciencesUniversity of California DavisDavisCaliforniaUSA
- Department of NeurologyUniversity of California DavisSacramentoCaliforniaUSA
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23
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Chan ML, Zhou K, Eng CW, Farias S, Gilsanz P, Whitmer RA. Psychosocial and Physical Functioning Predictors of Everyday Functioning in The Kaiser Healthy Aging and Diverse Life Experience (KHANDLE) Study. Alzheimers Dement 2022. [DOI: 10.1002/alz.066560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Chloe W. Eng
- University of California San Francisco San Francisco CA USA
| | - Sarah Farias
- University of California, Davis Sacramento CA USA
| | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
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24
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Lor Y, George KM, Peterson RL, Gilsanz P, Corrada MM, Meunier CC, Soh Y, Kawas CH, DeCarli CS, Whitmer RA. Military Service and Cognitive Decline after age 90: The LifeAfter90 Study. Alzheimers Dement 2022. [DOI: 10.1002/alz.067478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Yi Lor
- University of California Davis Davis CA USA
| | | | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | | | - Yenee Soh
- Kaiser Permanente Division of Research Oakland CA USA
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25
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Peterson RL, Gilsanz P, George KM, Meunier CC, Soh Y, Corrada MM, Glymour MM, Whitmer RA, Lor Y. Childhood measures of socioeconomic status and cognitive decline in the
LifeAfter90
Study. Alzheimers Dement 2022. [DOI: 10.1002/alz.066196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | | | - Yenee Soh
- Kaiser Permanente Division of Research Oakland CA USA
| | | | | | | | - Yi Lor
- University of California Davis Davis CA USA
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26
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Corrada MM, Gilsanz P, Tran D, Al‐Darsani Z, Mungas DM, Glymour MM, Kawas CH, DeCarli CS, Whitmer RA. Neuroimaging Findings in a Racially and Ethnically Diverse Cohort of Oldest‐Old Individuals: The LifeAfter90 Study. Alzheimers Dement 2022. [DOI: 10.1002/alz.064298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | - Diana Tran
- University of California, Irvine Irvine CA USA
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27
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Soh Y, Mayeda ER, Peterson RL, Eng CW, Quesenberry CP, Whitmer RA, Glymour MM, Gilsanz P. Educational Quality and Incident All‐Cause Dementia: Black‐White Differences. Alzheimers Dement 2022. [DOI: 10.1002/alz.063740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Yenee Soh
- Kaiser Permanente Division of Research Oakland CA USA
| | | | | | - Chloe W. Eng
- University of California San Francisco San Francisco CA USA
| | | | | | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
- University of California San Francisco San Francisco CA USA
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28
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Dugger BN, Jin L, Vargo V, DeCarli CS, Johal S, Gilsanz P, Mungas DM, Kawas CH, Glymour MM, Corrada MM, Whitmer RA. Neuropathology in the LifeAfter90 Study: Update on an Ethnically Diverse Cohort Study of Oldest‐Old. Alzheimers Dement 2022. [DOI: 10.1002/alz.063672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Lee‐Way Jin
- University of California, Davis Sacramento CA USA
| | | | | | - Sharan Johal
- University of California, Davis Sacramento CA USA
| | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
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29
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Chen R, Calmasini C, George KM, Gilsanz P, Whitmer RA, Glymour MM. Is Poor Sleep Quality Associated with Lower Levels of and Faster Declines in Cognitive Function? Results from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) Study. Alzheimers Dement 2022. [DOI: 10.1002/alz.067291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Ruijia Chen
- University of California, San Francisco San Francisco CA USA
| | | | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
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30
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Soh Y, Eng CW, Hodis JD, Mayeda ER, Lee C, Peterson RL, Whitmer RA, Glymour MM, Gilsanz P. Racial and Ethnic Differences in Occupational Complexity and Late‐Life Cognition. Alzheimers Dement 2022. [DOI: 10.1002/alz.063760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Yenee Soh
- Kaiser Permanente Division of Research Oakland CA USA
| | - Chloe W. Eng
- University of California San Francisco San Francisco CA USA
| | | | | | - Catherine Lee
- Kaiser Permanente Division of Research Oakland CA USA
| | | | | | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
- University of California San Francisco San Francisco CA USA
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31
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Meunier CC, Corrada MM, Gilsanz P, Kawas CH, Mungas DM, DeCarli CS, Meyer OL, Whitmer RA. Immigration and Cognitive Change after age 90: findings from the LifeAfter90 Study. Alzheimers Dement 2022. [DOI: 10.1002/alz.059908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | | | | | - Oanh L. Meyer
- University of California, Davis School of Medicine Sacramento CA USA
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32
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Mielke MM, Aggarwal NT, Vila‐Castelar C, Agarwal P, Arenaza‐Urquijo EM, Brett B, Brugulat‐Serrat A, DuBose LE, Eikelboom WS, Flatt J, Foldi NS, Franzen S, Gilsanz P, Li W, McManus AJ, van Lent DM, Milani SA, Shaaban CE, Stites SD, Sundermann E, Suryadevara V, Trani J, Turner AD, Vonk JMJ, Quiroz YT, Babulal GM. Consideration of sex and gender in Alzheimer's disease and related disorders from a global perspective. Alzheimers Dement 2022; 18:2707-2724. [PMID: 35394117 PMCID: PMC9547039 DOI: 10.1002/alz.12662] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/15/2022] [Accepted: 02/20/2022] [Indexed: 01/31/2023]
Abstract
Sex or gender differences in the risk of Alzheimer's disease and related dementias (ADRD) differ by world region, suggesting that there are potentially modifiable risk factors for intervention. However, few epidemiological or clinical ADRD studies examine sex differences; even fewer evaluate gender in the context of ADRD risk. The goals of this perspective are to: (1) provide definitions of gender, biologic sex, and sexual orientation. and the limitations of examining these as binary variables; (2) provide an overview of what is known with regard to sex and gender differences in the risk, prevention, and diagnosis of ADRD; and (3) discuss these sex and gender differences from a global, worldwide perspective. Identifying drivers of sex and gender differences in ADRD throughout the world is a first step in developing interventions unique to each geographical and sociocultural area to reduce these inequities and to ultimately reduce global ADRD risk. HIGHLIGHTS: The burden of dementia is unevenly distributed geographically and by sex and gender. Scientific advances in genetics and biomarkers challenge beliefs that sex is binary. Discrimination against women and sex and gender minority (SGM) populations contributes to cognitive decline. Sociocultural factors lead to gender inequities in Alzheimer's disease and related dementias (ADRD) worldwide.
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Affiliation(s)
- Michelle M. Mielke
- Division of Epidemiology, Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
| | - Neelum T. Aggarwal
- Department of Neurological SciencesRush University Medical CenterChicagoIllinoisUSA
- Rush Alzheimer's Disease CenterRush University Medical CenterChicagoIllinoisUSA
| | - Clara Vila‐Castelar
- Department of Psychiatry, Harvard Medical SchoolMassachusetts General HospitalMassachusettsBostonUSA
| | - Puja Agarwal
- Rush Alzheimer's Disease CenterRush University Medical CenterChicagoIllinoisUSA
- Department of Internal MedicineRush University Medical CenterChicagoIllinoisUSA
| | - Eider M. Arenaza‐Urquijo
- Barcelonaβeta Brain Research Center (BBRC)Pasqual Maragall FoundationBarcelonaSpain
- IMIM (Hospital del Mar Medical Research Institute)BarcelonaSpain
- CIBER Fragilidad y Envejecimiento Saludable (CIBERFES)MadridSpain
| | - Benjamin Brett
- Department of NeurosurgeryMedical College of WisconsinWisconsinMilwaukeeUSA
| | - Anna Brugulat‐Serrat
- Barcelonaβeta Brain Research Center (BBRC)Pasqual Maragall FoundationBarcelonaSpain
- IMIM (Hospital del Mar Medical Research Institute)BarcelonaSpain
- CIBER Fragilidad y Envejecimiento Saludable (CIBERFES)MadridSpain
- Atlantic Fellow for Equity in Brain HealthThe University of California San FranciscoSan FranciscoCaliforniaUSA
| | - Lyndsey E. DuBose
- Department of Medicine, Division of GeriatricsUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
| | - Willem S. Eikelboom
- Department of NeurologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Jason Flatt
- Social and Behavioral Health Program, School of Public HealthUniversity of Nevada, Las VegasLas VegasNevadaUSA
| | - Nancy S. Foldi
- Department of Psychology, Queens College and The Graduate CenterCity University of New YorkNew YorkUSA
- Department of PsychiatryNew York University Long Island School of MedicineNew YorkUSA
| | - Sanne Franzen
- Department of NeurologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Paola Gilsanz
- Kaiser Permanente Division of ResearchOaklandCaliforniaUSA
| | - Wei Li
- Department of Clinical and Diagnostic SciencesUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Alison J. McManus
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Debora Melo van Lent
- UT Health San AntonioGlenn Biggs Institute for Alzheimer's and Neurodegenerative diseasesSan AntonioTexasUSA
- Framingham Heart StudyFraminghamMassachusettsUSA
- Department of NeurologyBoston University School of MedicineBostonMassachusettsUSA
| | - Sadaf Arefi Milani
- Division of Geriatrics & Palliative Medicine, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTexasUSA
| | - C. Elizabeth Shaaban
- Department of EpidemiologyGraduate School of Public HealthUniversity of PittsburghPittsburghPennsylvaniaUSA
| | - Shana D. Stites
- Department of PsychiatryPerlman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Erin Sundermann
- Department of PsychiatryUniversity of CaliforniaSan DiegoCaliforniaUSA
| | - Vidyani Suryadevara
- Department of Orthopedic SurgeryRush University Medical CenterChicagoIllinoisUSA
| | - Jean‐Francoise Trani
- Department of Public HealthWashington University in St. LouisSt. LouisMissouriUSA
| | - Arlener D. Turner
- Department of Psychiatry & Behavioral SciencesUniversity of Miami Miller School of MedicineMiamiFloridaUSA
| | - Jet M. J. Vonk
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain, College of Physicians and SurgeonsColumbia UniversityNew YorkNew YorkUSA
- Julius Center for Health Sciences and Primary CareDepartment of EpidemiologyUniversity Medical Center Utrecht and Utrecht UniversityUtrechtThe Netherlands
| | - Yakeel T. Quiroz
- Department of Psychiatry, Harvard Medical SchoolMassachusetts General HospitalMassachusettsBostonUSA
- Grupo de Neurociencias de Antioquia of Universidad de AntioquiaMedellinColumbiaUSA
| | - Ganesh M. Babulal
- Department of NeurologyWashington University in St. LouisSt. LouisMississippiUSA
- Department of Clinical Research and LeadershipThe George Washington University School of Medicine and Health SciencesWashingtonDCUSA
- Department of Psychology, Faculty of HumanitiesUniversity of JohannesburgJohannesburgSouth Africa
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33
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George KM, Peterson RL, Gilsanz P, Corrada MM, Lor Y, Meunier CC, Whitmer RA. Experiences of Discrimination on Cognitive Function and Aging among the Oldest Old:
LifeAfter90
(LA90) Study. Alzheimers Dement 2022. [DOI: 10.1002/alz.067244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | - Yi Lor
- University of California Davis Davis CA USA
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34
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Gilsanz P, Soh Y, Malladi P, Barnes LL, Peterson RL, George KM, Mungas DM, Whitmer RA. Childhood perceived financial status, current financial concerns, and late‐life cognition: Study of Healthy Aging in African Americans (STAR). Alzheimers Dement 2022. [DOI: 10.1002/alz.068316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Paola Gilsanz
- University of California San Francisco San Francisco CA USA
- Kaiser Permanente Division of Research Oakland CA USA
| | - Yenee Soh
- Kaiser Permanente Division of Research Oakland CA USA
| | | | | | | | | | | | - Rachel A. Whitmer
- University of California Davis Davis CA USA
- Kaiser Permanente Oakland CA USA
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35
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Hayes‐Larson E, Ikesu R, Gee GC, Brookmeyer R, Whitmer RA, Gilsanz P, Mayeda ER. Differential returns on education by ethnicity and nativity in a cohort of older white and Asian Americans. Alzheimers Dement 2022. [DOI: 10.1002/alz.066595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Ryo Ikesu
- University of California, Los Angeles Los Angeles CA USA
| | - Gilbert C Gee
- University of California, Los Angeles Los Angeles CA USA
| | - Ron Brookmeyer
- University of California, Los Angeles Los Angeles CA USA
| | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
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36
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Hayes-Larson E, Mobley TM, Mungas D, Seamans M, Glymour MM, Gilsanz P, DeCarli C, Whitmer RA, Mayeda ER. Accounting for lack of representation in dementia research: Generalizing KHANDLE study findings on the prevalence of cognitive impairment to the California older population. Alzheimers Dement 2022; 18:2209-2217. [PMID: 35102726 PMCID: PMC9339583 DOI: 10.1002/alz.12522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/13/2021] [Accepted: 10/11/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Most dementia studies are not population-representative; statistical tools can be applied to samples to obtain critically-needed population-representative estimates, but are not yet widely used. METHODS We pooled data from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study and the California Behavioral Risk Factor Surveillance System (CA-BRFSS), a population-representative study. Using weights accounting for sociodemographic/health differences between KHANDLE and CA-BRFSS, we estimated cognitive impairment prevalence and age- and sex-adjusted racial/ethnic inequalities in California adults 65+ without prior dementia diagnosis. RESULTS After weighting KHANDLE, the estimated cognitive impairment prevalence in California was 20.3% (95% confidence interval 17.8-23.0); unweighted prevalence was 24.8% (23.1%-26.6%). Inequalities (larger prevalences) were observed among Black and Asian groups versus whites. DISCUSSION We used a novel statistical approach to estimate population-representative cognitive impairment prevalence and inequalities. Such statistical tools can help obtain population-representative estimates from existing studies and inform efforts to reduce racial/ethnic disparities.
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Affiliation(s)
- Eleanor Hayes-Larson
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Taylor M. Mobley
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Dan Mungas
- Department of Neurology, University of California Davis Health, Sacramento, CA, USA
- Alzheimer’s Disease Center, University of California Davis Health, Sacramento, CA, USA
| | - Marissa Seamans
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - M. Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Paola Gilsanz
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Charles DeCarli
- Department of Neurology, University of California Davis Health, Sacramento, CA, USA
- Alzheimer’s Disease Center, University of California Davis Health, Sacramento, CA, USA
| | - Rachel A. Whitmer
- Alzheimer’s Disease Center, University of California Davis Health, Sacramento, CA, USA
- Department of Public Health Sciences, University of California Davis, Davis, CA, USA
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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Calmasini C, Swinnerton KN, Zimmerman SC, Peterson RL, George KM, Gilsanz P, Hayes-Larson E, Mayeda ER, Mungas DM, Whitmer RA, Glymour MM. Association of Social Integration with Cognitive Status in a Multi-Ethnic Cohort: Results From the Kaiser Healthy Aging and Diverse Life Experiences Study. J Geriatr Psychiatry Neurol 2022; 35:789-799. [PMID: 35077251 PMCID: PMC10020945 DOI: 10.1177/08919887211070259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
We evaluated overall and race-specific relationships between social integration and cognition in older adults. Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) cohort participants included 1343 Asian, Black, Latino, or non-Latino White Kaiser Permanente Northern California members. We estimated the effect of social integration on verbal episodic memory, semantic memory, and executive function derived from the Spanish and English Neuropsychological Assessment (SENAS) Scales. Social integration scores included marital status; volunteer activity; and contact with children, relatives, friends, and confidants. We estimated covariate-adjusted linear mixed-effects models for baseline and 17-month follow-up cognition. Social integration was associated with higher baseline cognitive scores (average β = 0.066 (95% confidence interval: 0.040, 0.092)) overall and in each racial/ethnic group. The association did not vary by race/ethnicity. Social integration was not associated with the estimated rate of cognitive change. In this cohort, more social integration was similarly associated with better late-life cognition across racial/ethnic groups.
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Affiliation(s)
- Camilla Calmasini
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Kaitlin N. Swinnerton
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Scott C. Zimmerman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Rachel L. Peterson
- Department of Public Health Sciences, University of California Davis, Davis, CA, USA
- Department of Neurology, University of California Davis Health, Sacramento, CA, USA
| | - Kristen M. George
- Department of Public Health Sciences, University of California Davis, Davis, CA, USA
- Department of Neurology, University of California Davis Health, Sacramento, CA, USA
| | - Paola Gilsanz
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Eleanor Hayes-Larson
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Dan M. Mungas
- Department of Neurology, University of California Davis Health, Sacramento, CA, USA
| | - Rachel A. Whitmer
- Department of Public Health Sciences, University of California Davis, Davis, CA, USA
| | - M. Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
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Hayes-Larson E, Fong J, Mobley TM, Gilsanz P, Whitmer RA, Gee GC, Brookmeyer R, Mayeda ER. The role of nativity in heterogeneous dementia incidence in a large cohort of three Asian American groups and white older adults in California. Alzheimers Dement 2022; 18:1580-1585. [PMID: 35103385 PMCID: PMC9339576 DOI: 10.1002/alz.12563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 12/02/2021] [Accepted: 12/05/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Literature shows lower dementia incidence in Asian American groups versus whites, varying by Asian ethnicity. One hypothesized driver is nativity differences (eg, healthy immigrant effect). METHODS We followed a cohort of 6243 Chinese, 4879 Filipino, 3256 Japanese, and 141,158 white Kaiser Permanente Northern California members for incident dementia (2002 to 2020), estimating age-adjusted dementia incidence rates by ethnicity and nativity, and hazard ratios (HR) for nativity on dementia incidence using ethnicity-stratified age- and sex-adjusted Cox proportional hazards models. RESULTS Dementia incidence appeared higher in foreign- versus US-born Filipinos (HR, 95% confidence interval: 1.39, 1.02 to 1.89); differences were small in Japanese (1.07, 0.88 to 1.30) and Chinese (1.07, 0.92 to 1.24). No nativity differences were observed among whites (1.00, 0.95 to 1.04). DISCUSSION Nativity does not explain lower dementia incidence in Asian Americans versus whites, but may contribute to heterogeneity across Asian ethnicities. Future research should explore differential impacts of social and cardiometabolic factors.
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Affiliation(s)
- Eleanor Hayes-Larson
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Joseph Fong
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Taylor M. Mobley
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA,Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Rachel A. Whitmer
- Alzheimer’s Disease Center, University of California, Davis, Sacramento, California, USA,Department of Public Health Sciences, University of California, Davis, California, USA
| | - Gilbert C. Gee
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Ron Brookmeyer
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, California, USA
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California, USA,Corresponding author contact information: 650 Charles E Young Dr. CHS 46-070, Los Angeles, CA 90095, , Ph: 310-825-5234 Fax: 310-206-6039
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Chan ML, Eng CW, Gilsanz P, Whitmer RA, Mungas D, Meyer O, Farias ST. Prevalence of Instrumental Activities of Daily Living Difficulties and Associated Cognitive Predictors Across Racial/Ethnic Groups: Findings From the KHANDLE Study. J Gerontol B Psychol Sci Soc Sci 2022; 77:885-894. [PMID: 34486659 PMCID: PMC9071392 DOI: 10.1093/geronb/gbab163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Cognitive functioning is associated with instrumental activity of daily living (IADL) performance among older adults. The present study examines potential differences in the prevalence of IADL difficulty and association with cognition across diverse groups. METHOD Participants included 455 non-Hispanic Whites, 395 Blacks, 370 Asians, and 296 Latinos aged 65 years and older without a current dementia diagnosis from the Kaiser Healthy Aging and Diverse Life Experience cohort. Participants' self-reported IADL functioning and cognition was measured across episodic memory and executive functioning. RESULTS Older age, male gender, and being Black were associated with more IADL difficulties. Executive functioning showed a stronger association with IADLs than memory, and it was independent of health status, whereas memory was not. In joint models including both cognitive domains, executive functioning remained a significant predictor of IADL difficulty, but memory did not. Results for both cognitive domains were attenuated with self-rated health added to the joint model. These relationships did not significantly differ across racial/ethnic groups. CONCLUSIONS Our study supports previous work suggesting that Black older adults are at increased risk for IADL disability. This is the first study we are aware of that examined the association between specific cognitive domains and IADL performance across multiple racial/ethnic groups. Findings indicate that cognitive functioning has similar associations with self-reported IADL disability across diverse groups, and that executive functioning plays a particularly important role in IADL disability among older adults without dementia; however, health status largely attenuates the relationship between IADL difficulty and cognition.
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Affiliation(s)
- Michelle L Chan
- Department of Neurology, University of California, Davis, California, USA
| | - Chloe W Eng
- Department of Epidemiology and Translational Science, University of California, San Francisco, California, USA
| | - Paola Gilsanz
- Kaiser Permanente Division of Research, Oakland, California, USA
| | - Rachel A Whitmer
- Department of Public Health Sciences, University of California, Davis, California, USA
| | - Dan Mungas
- Department of Neurology, University of California, Davis, California, USA
| | - Oanh Meyer
- Department of Neurology, University of California, Davis, California, USA
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Lacy ME, Moran C, Gilsanz P, Beeri MS, Karter AJ, Whitmer RA. Comparison of cognitive function in older adults with type 1 diabetes, type 2 diabetes, and no diabetes: results from the Study of Longevity in Diabetes (SOLID). BMJ Open Diabetes Res Care 2022; 10:10/2/e002557. [PMID: 35346969 PMCID: PMC8961108 DOI: 10.1136/bmjdrc-2021-002557] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 03/06/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION The incidence of both type 1 diabetes (T1D) and type 2 diabetes (T2D) is increasing. Life expectancy is improving in T1D, resulting in a growing population of elderly adults with diabetes. While it is well established that older adults with T2D are at increased risk of cognitive impairment, little is known regarding cognitive aging in T1D and how their cognitive profiles may differ from T2D. RESEARCH DESIGN AND METHODS We compared baseline cognitive function and low cognitive function by diabetes status (n=734 T1D, n=232 T2D, n=247 without diabetes) among individuals from the Study of Longevity in Diabetes (mean age=68). We used factor analysis to group cognition into five domains and a composite measure of total cognition. Using linear and logistic regression models, we examined the associations between diabetes type and cognitive function, adjusting for demographics, comorbidities, depression, and sleep quality. RESULTS T1D was associated with lower scores on total cognition, language, executive function/psychomotor processing speed, and verbal episodic memory, and greater odds of low executive function/psychomotor processing speed (OR=2.99, 95% CI 1.66 to 5.37) and verbal episodic memory (OR=1.92, 95% CI 1.07 to 3.46), compared with those without diabetes. T2D was associated with lower scores on visual episodic memory. Compared with T2D, T1D was associated with lower scores on verbal episodic memory and executive function/psychomotor processing speed and greater odds of low executive function/psychomotor processing speed (OR=1.74, 95% CI 1.03 to 2.92). CONCLUSIONS Older adults with T1D had significantly poorer cognition compared with those with T2D and those without diabetes even after accounting for a range of comorbidities. Future studies should delineate how to reduce risk in this vulnerable population who are newly surviving to old age.
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Affiliation(s)
- Mary E Lacy
- Department of Epidemiology, University of Kentucky, Lexington, Kentucky, USA
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Chris Moran
- Academic Unit, Peninsula Clinical School, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Michal S Beeri
- Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Joseph Sagol Neuroscience, Sheba Medical Center, Tel Hashomer, Israel
| | - Andrew J Karter
- Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Rachel A Whitmer
- Division of Research, Kaiser Permanente, Oakland, California, USA
- Department of Epidemiology, University of California Davis School of Medicine, Davis, California, USA
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Lam JO, Lee C, Gilsanz P, Hou CE, Leyden WA, Satre DD, Flamm JA, Towner WJ, Horberg MA, Silverberg MJ. Comparison of dementia incidence and prevalence between individuals with and without HIV infection in primary care from 2000 to 2016. AIDS 2022; 36:437-445. [PMID: 34816805 PMCID: PMC8892590 DOI: 10.1097/qad.0000000000003134] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To compare dementia incidence and prevalence after age 50 years by HIV status. DESIGN Observational cohort, 2000-2016. METHODS People with HIV (PWH) on antiretroviral therapy (ART) and demographically similar people without HIV (PWoH), all aged 50 years and older, were identified from Kaiser Permanente healthcare systems in Northern California, Southern California, and Mid-Atlantic States (Maryland, Virginia, Washington DC). Dementia diagnoses were obtained from electronic health records. Incidence and prevalence of dementia, overall and by time period (i.e. 2000-2002, 2003-2004, …, 2015-2016), were calculated using Poisson regression. Trends were examined using Joinpoint regression. Rate ratios were used to compare dementia by HIV status with adjustment for sociodemographics, substance use, and clinical factors. RESULTS The study included 13 296 PWH and 155 354 PWoH (at baseline: for both, mean age = 54 years, 89% men; for PWH, 80% with HIV RNA <200 copies/ml). From 2000 to 2016, overall incidence of dementia was higher among PWH [adjusted incidence rate ratio (aIRR) = 1.80, 95% confidence interval (CI) = 1.60-2.04]. Dementia incidence decreased among both PWH and PWoH (-8.0 and -3.1% per period, respectively) but remained higher among PWH in the most recent time period, 2015-2016 (aIRR = 1.58, 95% CI = 1.18-2.12). The overall prevalence of dementia from 2000 to 2016 was higher among PWH [adjusted prevalence ratio (aPR) = 1.86, 95% CI = 1.70-2.04] and was also higher among PWH in 2015-2016 (aPR = 1.75, 95% CI = 1.56-1.97). CONCLUSION Reductions in dementia incidence are encouraging and may reflect ART improvement, but PWH are still more likely to have dementia than PWoH. Monitoring the burden of dementia among PWH is important as this population ages.
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Affiliation(s)
- Jennifer O Lam
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Catherine Lee
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Paola Gilsanz
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Craig E Hou
- South San Francisco Medical Center, Kaiser Permanente Northern California, South San Francisco
| | - Wendy A Leyden
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco
| | - Jason A Flamm
- Sacramento Medical Center, Kaiser Permanente Northern California, Sacramento
| | - William J Towner
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, Maryland, USA
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Gilsanz P, Young JG, Glymour MM, Tchetgen Tchetgen EJ, Eng CW, Koenen KC, Kubzansky LD. Marginal Structural Models for Life-Course Theories and Social Epidemiology: Definitions, Sources of Bias, and Simulated Illustrations. Am J Epidemiol 2022; 191:349-359. [PMID: 34668974 PMCID: PMC8897994 DOI: 10.1093/aje/kwab253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/09/2021] [Accepted: 10/08/2021] [Indexed: 11/14/2022] Open
Abstract
Social epidemiology aims to identify social structural risk factors, thus informing targets and timing of interventions. Ascertaining which interventions will be most effective and when they should be implemented is challenging because social conditions vary across the life course and are subject to time-varying confounding. Marginal structural models (MSMs) may be useful but can present unique challenges when studying social epidemiologic exposures over the life course. We describe selected MSMs corresponding to common theoretical life-course models and identify key issues for consideration related to time-varying confounding and late study enrollment. Using simulated data mimicking a cohort study evaluating the effects of depression in early, mid-, and late life on late-life stroke risk, we examined whether and when specific study characteristics and analytical strategies may induce bias. In the context of time-varying confounding, inverse-probability-weighted estimation of correctly specified MSMs accurately estimated the target causal effects, while conventional regression models showed significant bias. When no measure of early-life depression was available, neither MSMs nor conventional models were unbiased, due to confounding by early-life depression. To inform interventions, researchers need to identify timing of effects and consider whether missing data regarding exposures earlier in life may lead to biased estimates.
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Affiliation(s)
- Paola Gilsanz
- Correspondence to Dr. Paola Gilsanz, Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612 (e-mail: )
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Mungas D, Shaw C, Hayes‐Larson E, DeCarli C, Farias ST, Olichney J, Saucedo HH, Gilsanz P, Glymour MM, Whitmer RA, Mayeda ER. Cognitive impairment in racially/ethnically diverse older adults: Accounting for sources of diagnostic bias. Alzheimers Dement (Amst) 2021; 13:e12265. [PMID: 35005198 PMCID: PMC8719430 DOI: 10.1002/dad2.12265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 10/14/2021] [Accepted: 10/21/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study enrolled Asian, Black, Latino, and White adults ages 65+ without prior dementia diagnosis (N = 1709). We evaluated the prevalence of cognitive impairment (mild cognitive impairment or dementia) accounting for potential biases. METHODS A random subgroup (N = 541) received clinical evaluation and others were evaluated if they failed a cognitive screen. Diagnoses were made under two conditions: (1) demographics-blind, based on clinical exam and demographically adjusted neuropsychological test scores; and (2) all available information (clinical exam, demographics, and adjusted and unadjusted test scores). RESULTS Cognitive impairment prevalence was 28% for blinded-adjusted diagnosis and 25% using all available information. Black participants had higher impairment rates than White (both conditions) and Latino (blinded-adjusted diagnosis) participants. Incomplete assessments negatively biased prevalence estimates for White participants. DISCUSSION Racial/ethnic disparities in cognitive impairment were amplified by attrition bias in White participants but were unaffected by type of test norms and diagnosticians' knowledge of demographics.
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Affiliation(s)
- Dan Mungas
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | - Crystal Shaw
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Eleanor Hayes‐Larson
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA
| | - Charles DeCarli
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | | | - John Olichney
- Department of NeurologyUniversity of California, DavisSacramentoCaliforniaUSA
| | | | - Paola Gilsanz
- Kaiser Permanente Division of ResearchOaklandCaliforniaUSA
| | - M Maria Glymour
- Department of Epidemiology and BiostatisticsUniversity of CaliforniaSan FranciscoCaliforniaUSA
| | - Rachel A Whitmer
- Department of Public Health SciencesUniversity of CaliforniaDavisDavisCaliforniaUSA
| | - Elizabeth Rose Mayeda
- Department of EpidemiologyFielding School of Public HealthUniversity of CaliforniaLos AngelesCaliforniaUSA
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Peterson RL, George KM, Gilsanz P, Mayeda ER, Meyer OL, Barnes LL, Glymour MM, Mungas DM, Whitmer RA. Frequent leisure activity participation and cognitive change in the Study of Healthy Aging in African Americans (STAR). Alzheimers Dement 2021. [DOI: 10.1002/alz.054119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | - Elizabeth Rose Mayeda
- University of California, Los Angeles Fielding School of Public Health Los Angeles CA USA
| | - Oanh L Meyer
- University of California, Davis School of Medicine Sacramento CA USA
| | - Lisa L Barnes
- Department of Neurological Sciences, Rush University Medical Center Chicago IL USA
| | - M Maria Glymour
- University of California, San Francisco San Francisco CA USA
| | - Dan M Mungas
- University of California, Davis School of Medicine Sacramento CA USA
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Dugger BN, Jin L, Vargo V, Johal S, DeCarli CS, Gilsanz P, Mungas DM, Kawas CH, Corrada MM, Whitmer RA. Neuropathology in the LifeAfter90 study: A new ethnically diverse cohort study of oldest‐old. Alzheimers Dement 2021. [DOI: 10.1002/alz.051412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Lee‐Way Jin
- University of California Davis Sacramento CA USA
| | | | - Sharan Johal
- University of California Davis Sacramento CA USA
| | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | - Dan M. Mungas
- University of California Davis School of Medicine Sacramento CA USA
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Lor Y, Gilsanz P, George KM, Hayes‐Larson E, Peterson RL, Meyer OL, Barnes LL, Whitmer RA. Association of adverse childhood experiences and late‐life cognition in Black Americans from the Study of Healthy Aging in African Americans (STAR). Alzheimers Dement 2021. [DOI: 10.1002/alz.055358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Yi Lor
- University of California Davis Davis CA USA
| | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | | | | | - Oanh L Meyer
- University of California, Davis School of Medicine Sacramento CA USA
| | - Lisa L Barnes
- Department of Neurological Sciences, Rush University Medical Center Chicago IL USA
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Calmasini C, Swinnerton KN, Zimmerman SC, Peterson RL, George KM, Gilsanz P, Hayes‐Larson E, Mungas DM, Whitmer RA, Glymour MM. Association of social integration with cognitive status: results from the Kaiser Healthy Aging and Diverse Life Experiences (KHANDLE) study. Alzheimers Dement 2021. [DOI: 10.1002/alz.053202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | - Dan M Mungas
- University of California, Davis School of Medicine Sacramento CA USA
| | | | - M Maria Glymour
- University of California, San Francisco San Francisco CA USA
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Corrada MM, Gilsanz P, Kawas CH, DeCarli CS, Vieira KE, Hayes‐Larson E, Farias ST, Mayeda ER, Mungas DM, Glymour MM, Whitmer RA. Memory concerns and cognitive decline in a multi‐ethnic cohort of oldest‐old individuals: The LifeAfter90 study. Alzheimers Dement 2021. [DOI: 10.1002/alz.055325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | | | | | | | | | | | - Dan M. Mungas
- University of California, Davis School of Medicine Sacramento CA USA
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Cintron DW, Glymour MM, Whitmer RA, Mungas DM, Gilsanz P, Barnes LL, Calmasini C, Eng CW, George KM, Peterson RL. Does discrimination mediate the association between education and later‐life cognitive outcomes in a cohort of Black Americans? An example of parametric g‐estimation with latent variables in the STAR study. Alzheimers Dement 2021. [DOI: 10.1002/alz.055252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - M Maria Glymour
- University of California, San Francisco San Francisco CA USA
| | | | - Dan M Mungas
- University of California, Davis School of Medicine Sacramento CA USA
| | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | - Lisa L Barnes
- Department of Neurological Sciences, Rush University Medical Center Chicago IL USA
| | | | - Chloe W Eng
- University of California, San Francisco San Francisco CA USA
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Eng CW, Gilsanz P, Fletcher EM, Kornak J, George KM, DeCarli CS, Barnes LL, Glymour MM, Whitmer RA. Education, white matter hyperintensities, and cognition in diverse cohorts of older adults. Alzheimers Dement 2021. [DOI: 10.1002/alz.056709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Chloe W Eng
- Kaiser Permanente Division of Research Oakland CA USA
- University of California, San Francisco San Francisco CA USA
| | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | - John Kornak
- University of California, San Francisco San Francisco CA USA
| | | | | | - Lisa L Barnes
- Department of Neurological Sciences, Rush University Medical Center Chicago IL USA
| | - Maria M Glymour
- University of California, San Francisco San Francisco CA USA
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