Long-term exposure to ambient air pollution and traffic noise and incident hypertension in seven cohorts of the European study of cohorts for air pollution effects (ESCAPE)

Aims

We investigated whether traffic-related air pollution and noise are associated with incident hypertension in European cohorts.

Methods and results

We included seven cohorts of the European study of cohorts for air pollution effects (ESCAPE). We modelled concentrations of particulate matter with aerodynamic diameter ≤2.5 µm (PM2.5), ≤10 µm (PM10), >2.5, and ≤10 µm (PMcoarse), soot (PM2.5 absorbance), and nitrogen oxides at the addresses of participants with land use regression. Residential exposure to traffic noise was modelled at the facade according to the EU Directive 2002/49/EC. We assessed hypertension as (i) self-reported and (ii) measured (systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg or intake of BP lowering medication (BPLM). We used Poisson regression with robust variance estimation to analyse associations of traffic-related exposures with incidence of hypertension, controlling for relevant confounders, and combined the results from individual studies with random-effects meta-analysis. Among 41 072 participants free of self-reported hypertension at baseline, 6207 (15.1%) incident cases occurred within 5-9 years of follow-up. Incidence of self-reported hypertension was positively associated with PM2.5 (relative risk (RR) 1.22 [95%-confidence interval (CI):1.08; 1.37] per 5 µg/m³) and PM2.5 absorbance (RR 1.13 [95% CI:1.02; 1.24] per 10 - 5m - 1). These estimates decreased slightly upon adjustment for road traffic noise. Road traffic noise was weakly positively associated with the incidence of self-reported hypertension. Among 10 896 participants at risk, 3549 new cases of measured hypertension occurred. We found no clear associations with measured hypertension.

Conclusion

Long-term residential exposures to air pollution and noise are associated with increased incidence of self-reported hypertension.

Body Mass Index Predicts Progression of Mild Cognitive Impairment to Dementia

AIMS

To examine the relationship between body mass index (BMI) and progression to dementia and Alzheimer's disease (AD) in mild cognitive impairment (MCI).

MATERIALS AND METHODS

Two hundred and twenty-eight MCI subjects (mean age 74.04 ± 6.94 years; 57% female) from a memory clinic were followed for 2.40 ± 1.58 years. Baseline height and weight were used to calculate the BMI. The main outcome was progression to dementia (DSM-IV criteria) and AD (NINCDS-ADRDA criteria). Cox proportional hazard models were used to assess the longitudinal association of BMI with dementia and AD, adjusting for a comprehensive set of covariates, including vascular risk factors/diseases and neuroimaging profiles.

RESULTS

Out of 228 subjects with MCI, 117 (51.3%) progressed to dementia. Eighty-nine (76%) of the incident dementia cases had AD. In both unadjusted and multi-adjusted models, a higher BMI was associated with a reduced risk of dementia (multi-adjusted HR 0.9; 95% CI 0.8-0.9) and AD (multi-adjusted HR 0.9; 95% CI 0.8-0.9). Being underweight increased the risk of all types of dementia (multi-adjusted HR 2.5; 95% CI 1.2-5.1) but was not specifically associated with AD (multi-adjusted HR 2.2; 95% CI 0.9-5.3).

CONCLUSIONS

BMI predicted progression of MCI to dementia and AD. In particular, a higher BMI was associated with a lower risk of dementia and AD, and underweight was associated with a higher risk of dementia. BMI assessment may improve the prognostic accuracy of MCI in clinical practice.

Weight Loss Predicts Progression of Mild Cognitive Impairment to Alzheimer's Disease

Background

Weight loss is common in people with Alzheimer’s disease (AD) and it could be a marker of impending AD in Mild Cognitive Impairment (MCI) and improve prognostic accuracy, if accelerated progression to AD would be shown.

Aims

To assess weight loss as a predictor of dementia and AD in MCI.

Methods

One hundred twenty-five subjects with MCI (age 73.8 ± 7.1 years) were followed for an average of 4 years. Two weight measurements were carried out at a minimum time interval of one year. Dementia was defined according to DSM-IV criteria and AD according to NINCDS-ADRDA criteria. Weight loss was defined as a ≥4% decrease in baseline weight.

Results

Fifty-three (42.4%) MCI progressed to dementia, which was of the AD-type in half of the cases. Weight loss was associated with a 3.4-fold increased risk of dementia (95% CI = 1.5–6.9) and a 3.2-fold increased risk of AD (95% CI = 1.4–8.3). In terms of years lived without disease, weight loss was associated to a 2.3 and 2.5 years earlier onset of dementia and AD.

Conclusions

Accelerated progression towards dementia and AD is expected when weight loss is observed in MCI patients. Weight should be closely monitored in elderly with mild cognitive impairment.

Traffic-related air pollution exposure and incidence of stroke in four cohorts from Stockholm

We investigated the risk of stroke related to long-term ambient air pollution exposure, in particular the role of various exposure time windows, using four cohorts from Stockholm County, Sweden. In total, 22,587 individuals were recruited from 1992 to 2004 and followed until 2011. Yearly air pollution levels resulting from local road traffic emissions were assessed at participant residences using dispersion models for particulate matter (PM10) and nitrogen oxides (NOX). Cohort-specific hazard ratios were estimated for time-weighted air pollution exposure during different time windows and the incidence of stroke, adjusted for common risk factors, and then meta-analysed. Overall, 868 subjects suffered a non-fatal or fatal stroke during 238,731 person-years of follow-up. An increment of 20 μg/m(3) in estimated annual mean of road-traffic related NOX exposure at recruitment was associated with a hazard ratio of 1.16 (95% CI 0.83-1.61), with evidence of heterogeneity between the cohorts. For PM10, an increment of 10 μg/m(3) corresponded to a hazard ratio of 1.14 (95% CI 0.68-1.90). Time-window analyses did not reveal any clear induction-latency pattern. In conclusion, we found suggestive evidence of an association between long-term exposure to NOX and PM10 from local traffic and stroke at comparatively low levels of air pollution.

Long-term exposure to ambient air pollution and incidence of cerebrovascular events: results from 11 European cohorts within the ESCAPE project

BACKGROUND

Few studies have investigated effects of air pollution on the incidence of cerebrovascular events.

OBJECTIVES

We assessed the association between long-term exposure to multiple air pollutants and the incidence of stroke in European cohorts.

METHODS

Data from 11 cohorts were collected, and occurrence of a first stroke was evaluated. Individual air pollution exposures were predicted from land-use regression models developed within the European Study of Cohorts for Air Pollution Effects (ESCAPE). The exposures were: PM2.5 [particulate matter (PM) ≤ 2.5 μm in diameter], coarse PM (PM between 2.5 and 10 μm), PM10 (PM ≤ 10 μm), PM2.5 absorbance, nitrogen oxides, and two traffic indicators. Cohort-specific analyses were conducted using Cox proportional hazards models. Random-effects meta-analysis was used for pooled effect estimation.

RESULTS

A total of 99,446 study participants were included, 3,086 of whom developed stroke. A 5-μg/m3 increase in annual PM2.5 exposure was associated with 19% increased risk of incident stroke [hazard ratio (HR) = 1.19, 95% CI: 0.88, 1.62]. Similar findings were obtained for PM10. The results were robust to adjustment for an extensive list of cardiovascular risk factors and noise coexposure. The association with PM2.5 was apparent among those ≥ 60 years of age (HR = 1.40, 95% CI: 1.05, 1.87), among never-smokers (HR = 1.74, 95% CI: 1.06, 2.88), and among participants with PM2.5 exposure < 25 μg/m3 (HR = 1.33, 95% CI: 1.01, 1.77).

CONCLUSIONS

We found suggestive evidence of an association between fine particles and incidence of cerebrovascular events in Europe, even at lower concentrations than set by the current air quality limit value.

Arterial blood pressure and long-term exposure to traffic-related air pollution: an analysis in the European Study of Cohorts for Air Pollution Effects (ESCAPE)

BACKGROUND

Long-term exposure to air pollution has been hypothesized to elevate arterial blood pressure (BP). The existing evidence is scarce and country specific.

OBJECTIVES

We investigated the cross-sectional association of long-term traffic-related air pollution with BP and prevalent hypertension in European populations.

METHODS

We analyzed 15 population-based cohorts, participating in the European Study of Cohorts for Air Pollution Effects (ESCAPE). We modeled residential exposure to particulate matter and nitrogen oxides with land use regression using a uniform protocol. We assessed traffic exposure with traffic indicator variables. We analyzed systolic and diastolic BP in participants medicated and nonmedicated with BP-lowering medication (BPLM) separately, adjusting for personal and area-level risk factors and environmental noise. Prevalent hypertension was defined as ≥ 140 mmHg systolic BP, or ≥ 90 mmHg diastolic BP, or intake of BPLM. We combined cohort-specific results using random-effects meta-analysis.

RESULTS

In the main meta-analysis of 113,926 participants, traffic load on major roads within 100 m of the residence was associated with increased systolic and diastolic BP in nonmedicated participants [0.35 mmHg (95% CI: 0.02, 0.68) and 0.22 mmHg (95% CI: 0.04, 0.40) per 4,000,000 vehicles × m/day, respectively]. The estimated odds ratio (OR) for prevalent hypertension was 1.05 (95% CI: 0.99, 1.11) per 4,000,000 vehicles × m/day. Modeled air pollutants and BP were not clearly associated.

CONCLUSIONS

In this first comprehensive meta-analysis of European population-based cohorts, we observed a weak positive association of high residential traffic exposure with BP in nonmedicated participants, and an elevated OR for prevalent hypertension. The relationship of modeled air pollutants with BP was inconsistent.

Natural progression model of cognition and physical functioning among people with mild cognitive impairment and alzheimer's disease

BACKGROUND

Empirical models of the natural history of Alzheimer's disease (AD) may help to evaluate new interventions for AD.

OBJECTIVE

We aimed to estimate AD-free survival time in people with mild cognitive impairment (MCI) and decline of cognitive and physical function in AD cases.

METHODS

Within the Kungsholmen project, 153 incident MCI and 323 incident AD cases (international criteria) were identified during 9 years of follow-up in a cognitively healthy cohort of elderly people aged ≥75 at baseline (n = 1,082). Global cognitive function was assessed with the Mini-Mental State Examination (MMSE), and daily life function was evaluated with the Katz index of activities of daily living (ADL) at each follow-up examination. Data were analyzed using parametric survival analysis and mixed effect models.

RESULTS

Median AD-free survival time of 153 participants with incident MCI was 3.5 years. Among 323 incident AD cases, the cognitive decline was 1.84 MMSE points per year, which was significantly associated with age. Physical functioning declined by 0.38 ADL points per year and was significantly associated with age, education, and MMSE, but not with gender.

CONCLUSION

Elderly people with MCI may develop AD in approximately 3.5 years. Both cognitive and physical function may decline gradually after AD onset. The empirical models can be used to evaluate long-term disease progression of new interventions for AD.

Walking speed, processing speed, and dementia: a population-based longitudinal study

BACKGROUND

Slow walking speed has been shown to predict dementia. We investigated the relation of walking speed, processing speed, and their changes over time to dementia among older adults.

METHODS

This study included 2,938 participants (age 60+ years) in the population-based Swedish National study on Aging and Care in Kungsholmen, Sweden, who were free from dementia and severe walking impairment at baseline. Walking speed was assessed with participants walking at their usual pace and processing speed was defined by a composite measure of standard tests (digit cancellation, trail making test-A, pattern comparison). Dementia at 3- and 6-year follow-ups was diagnosed according to Diagnostic and Statistical Manual of Mental Disorders-IV criteria.

RESULTS

Of the 2,232 participants who were reassessed at least once, 226 developed dementia. Logistic regression models showed that each standard deviation slower baseline walking speed or decline in walking speed over time increased the likelihood of incident dementia (odds ratios 1.61, 95% confidence interval [CI] 1.31-1.98; and 2.58, 95% CI 2.12-3.14, respectively). Adjustment for processing speed attenuated these associations (odds ratios 1.26, 95% CI 1.01-1.58 and 1.76, 95% CI 1.33-2.34). Mixed-effects models revealed statistical interactions of time with dementia on change in walking and processing speed, such that those who developed dementia showed accelerated decline. At baseline, poorer performance in processing speed, but not in walking speed, was observed for persons who developed dementia during the study period.

CONCLUSIONS

Processing speed may play an important role for the association between walking speed and dementia. The slowing of walking speed appears to occur secondary to slowing of processing speed in the path leading to dementia.

Mild cognitive impairment: a concept in evolution

The construct of mild cognitive impairment (MCI) has evolved over the past 10 years since the publication of the new MCI definition at the Key Symposium in 2003, but the core criteria have remained unchanged. The construct has been extensively used worldwide, both in clinical and in research settings, to define the grey area between intact cognitive functioning and clinical dementia. A rich set of data regarding occurrence, risk factors and progression of MCI has been generated. Discrepancies between studies can be mostly explained by differences in the operationalization of the criteria, differences in the setting where the criteria have been applied, selection of subjects and length of follow-up in longitudinal studies. Major controversial issues that remain to be further explored are algorithmic versus clinical classification, reliability of clinical judgment, temporal changes in cognitive performances and predictivity of putative biomarkers. Some suggestions to further develop the MCI construct include the tailoring of the clinical criteria to specific populations and to specific contexts. The addition of biomarkers to the clinical phenotypes is promising but requires deeper investigation. Translation of findings from the specialty clinic to the population setting, although challenging, will enhance uniformity of outcomes. More longitudinal population-based studies on cognitive ageing and MCI need to be performed to clarify all these issues.

Relationship of subjective cognitive impairment and cognitive impairment no dementia to chronic disease and multimorbidity in a nation-wide twin study

We investigated the relation of subjective cognitive impairment (SCI) and cognitive impairment no dementia (CIND) to common chronic diseases of the elderly and multimorbidity, and assessed the contribution of genetic background and shared familial environment to these associations. Subjects were 11,379 dementia-free twin individuals aged ≥ 65 from the Swedish Twin Registry. SCI was defined as subjective complaint of cognitive change without objective cognitive impairment and CIND was defined according to current criteria. In unmatched, fully-adjusted regression models, mental, musculoskeletal, respiratory, and urological diseases were all significantly associated with increased odds ratios (ORs) of SCI and CIND. Circulatory and gastrointestinal diseases were related to SCI only, while endocrine diseases were associated with CIND. The adjusted ORs of multimorbidity were 2.1 [95% confidence intervals (95% CI): 1.8-2.3] for SCI and 1.5 for CIND (95% CI: 1.3-1.8). A dose-dependent relationship was observed between number of chronic diseases and ORs for SCI but not for CIND. In co-twin control analyses, the chronic diseases-SCI association was largely unchanged. On the other hand, the chronic diseases-CIND association was no longer statistically significant, except for cancer, where an increased OR was observed. In conclusion, chronic morbidity is associated with both SCI and CIND but disease profiles do not always overlap between the two cognitive syndromes. The association is stronger when diseases co-occur, especially for SCI. Genetic and early-life environmental factors may partially explain the association of CIND but not that of SCI with chronic diseases.

Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project

OBJECTIVES

To study the effect of long term exposure to airborne pollutants on the incidence of acute coronary events in 11 cohorts participating in the European Study of Cohorts for Air Pollution Effects (ESCAPE).

DESIGN

Prospective cohort studies and meta-analysis of the results.

SETTING

Cohorts in Finland, Sweden, Denmark, Germany, and Italy.

PARTICIPANTS

100 166 people were enrolled from 1997 to 2007 and followed for an average of 11.5 years. Participants were free from previous coronary events at baseline.

MAIN OUTCOME MEASURES

Modelled concentrations of particulate matter <2.5 μm (PM2.5), 2.5-10 μm (PMcoarse), and <10 μm (PM10) in aerodynamic diameter, soot (PM2.5 absorbance), nitrogen oxides, and traffic exposure at the home address based on measurements of air pollution conducted in 2008-12. Cohort specific hazard ratios for incidence of acute coronary events (myocardial infarction and unstable angina) per fixed increments of the pollutants with adjustment for sociodemographic and lifestyle risk factors, and pooled random effects meta-analytic hazard ratios.

RESULTS

5157 participants experienced incident events. A 5 μg/m(3) increase in estimated annual mean PM2.5 was associated with a 13% increased risk of coronary events (hazard ratio 1.13, 95% confidence interval 0.98 to 1.30), and a 10 μg/m(3) increase in estimated annual mean PM10 was associated with a 12% increased risk of coronary events (1.12, 1.01 to 1.25) with no evidence of heterogeneity between cohorts. Positive associations were detected below the current annual European limit value of 25 μg/m(3) for PM2.5 (1.18, 1.01 to 1.39, for 5 μg/m(3) increase in PM2.5) and below 40 μg/m(3) for PM10 (1.12, 1.00 to 1.27, for 10 μg/m(3) increase in PM10). Positive but non-significant associations were found with other pollutants.

CONCLUSIONS

Long term exposure to particulate matter is associated with incidence of coronary events, and this association persists at levels of exposure below the current European limit values.

Does vascular burden contribute to the progression of mild cognitive impairment to dementia?

AIMS

To investigate the contribution of vascular risk factors (VRFs), vascular diseases (VDs) and white matter lesions (WMLs) to the progression of mild cognitive impairment (MCI) to dementia and Alzheimer's disease (AD).

METHODS

Two hundred forty-five consecutive subjects with MCI (age 74.09 ± 6.92 years) were followed for an average of 2.4 years. The Hachinski Ischemic Score and the Framingham Stroke Risk Profile were used to summarize VRFs and VDs. WMLs were graded using the Age-Related White Matter Changes Scale.

RESULTS

One hundred twenty-nine (52.6%) out of 245 subjects at risk converted to dementia, including 87 cases of AD. When hypertension occurred in MCI with deep WMLs, a 1.8-fold increased risk of dementia was observed (95% CI = 1.0-3.4). When deep WMLs occurred in MCI with high scores (≥4) on the Hachinski scale, a 3.5-fold (95% CI = 1.6-7.4) and 3.8-fold (95% CI = 1.2-11.5) risk of progression to dementia and AD was observed, respectively. Analogously, the joint effect of WMLs and high scores (≥14) on the Framingham scale nearly doubled the risk of dementia (hazard ratio = 1.9, 95% CI = 1.1-3.3).

CONCLUSIONS

Accelerated progression of MCI to dementia and AD is to be expected when VRFs and VDs occur together with WMLs.

Differential distribution of subjective and objective cognitive impairment in the population: a nation-wide twin-study

We report the prevalence of subjective cognitive impairment (SCI) and cognitive impairment no dementia (CIND), their socio-demographic profile, and the contribution of genetic background and shared familial environment to SCI and CIND. Subjects were 11,926 dementia-free twin individuals aged ≥65 from the Swedish Twin Registry. SCI was defined as subjective complaint of cognitive change without objective cognitive impairment and CIND was defined according to current criteria. Overall prevalence rates of SCI and CIND were 39% (95% CI 38-39%) and 25% (95% CI 24-25%). In multivariate GEE models, both SCI and CIND were older compared with people without any cognitive impairment. CIND were also less educated, more likely to be unmarried and to have lower socioeconomic status (SES). SCI individuals differed from persons with CIND as they were older, more educated, more likely to be married, and to have higher SES. Co-twin control analysis, which corrects for common genetic and shared environmental background, confirmed the association of low education with CIND. Probandwise concordance for SCI and CIND was 63% and 52% in monozygotic twins, 63% and 50% in dizygotic same-sex twins, and 42% and 29% in dizygotic unlike-sex twins. Tetrachoric correlations showed no significant differences between monozygotic and dizygotic same-sex twins. We conclude that subjective and objective cognitive impairment are both highly prevalent among nondemented elderly yet have distinct sociodemographic profiles. Shared environmental influences rather than genetic background play a role in the occurrence of SCI and CIND.

The symptom of low mood in the prodromal stage of mild cognitive impairment and dementia: a cohort study of a community dwelling elderly population

OBJECTIVE

To investigate the symptom of low mood as a predictor of mild cognitive impairment (MCI) and its progression to dementia, taking into account: (i) MCI severity, (ii) time of assessment and (iii) interaction with other factors.

METHODS

764 cognitively healthy elderly subjects living in the community, from the Kungsholmen Project. Participants were assessed by direct interview to detect low mood. Subjects were then followed for 6 years to identify those who developed MCI. People with incident MCI were followed for a further 3 years to assess progression to dementia.

RESULTS

People with low mood at baseline had a 2.7-fold (95% CI 1.9 to 3.7) increased risk of developing MCI at follow-up. The association was stronger for amnestic MCI (aMCI: HR 5.8; 95% CI 3.1 to 10.9) compared with global cognitive impairment (other cognitive impairment no dementia, oCIND: HR 2.2; 95% CI 1.5 to 3.3). ApoE-ε4 interacted with low mood in a synergistic fashion, increasing the risk of aMCI, while no interaction with psychiatric, vascular, frailty related or psychosocial factors was observed. Low mood at baseline, as opposed to low mood co-occurring with MCI, was associated with a 5.3-fold (95% CI 1.2 to 23.3) increased risk of progression to dementia in aMCI. In contrast, no association was found in oCIND.

CONCLUSION

Low mood was more strongly associated with aMCI than with global cognitive impairment. Progression towards dementia was predicted only by low mood manifest in the prodromal stage of MCI. These findings indicate that low mood is particularly prominent in the very early stages of cognitive decline.

Epidemiological studies of cognitive impairment and dementia across Eastern and Middle European countries (epidemiology of dementia in Eastern and Middle European Countries)

OBJECTIVE

To determine the availability and the consistency of prevalence findings of epidemiological studies on cognitive impairment and dementia conducted in Eastern and Middle Europe.

METHODS

We adopted a stepwise multimethod study approach consisting of iterative literature searches for epidemiological articles published between 1990 and 2006 and subsequent data analyses of published material, reanalyses of existing accessible epidemiological data sets and expert inquiries in Eastern and Middle European countries. Systematic computer-assisted searches used the keywords: "dementia", "Alzheimer", "cognitive impairment", "incidence", "prevalence", "epidemiology" in combination with the name of the relevant countries or "Europe" in English and Polish language. We supplemented the literature search with a review of the references in the articles that were identified during the initial search.

RESULTS

We were able to find few regional and country-specific epidemiological studies of various kinds (population-based, cohort, cross-sectional studies) and conducted on different restricted population groups of patients (from neurological units, out-patients units, residential homes). No studies were identified from most of the countries taken under consideration and the ones we found were characterized by an immense diversity with a considerable degree of clinical and methodological variations. The few studies that there are suggest prevalence rates of dementia in Eastern Europe similar to those in Western Europe.

CONCLUSIONS

There is strong need for epidemiological studies in Eastern and Middle Europe, as well as for greater coordination and standardization of methods to improve the quality and comparability of epidemiological data to determine the prevalences' rates of dementia in all the EU countries.

Accelerated progression from mild cognitive impairment to dementia in people with diabetes

OBJECTIVE

The effect of diabetes on mild cognitive impairment (MCI) and its conversion to dementia remains controversial. We sought to examine whether diabetes and pre-diabetes are associated with MCI and accelerate the progression from MCI to dementia.

RESEARCH DESIGN AND METHODS

In the Kungsholmen Project, 963 cognitively intact participants and 302 subjects with MCI (120 with amnestic MCI [aMCI] and 182 with other cognitive impairment no dementia [oCIND]) age ≥ 75 years were identified at baseline. The two cohorts were followed for 9 years to detect the incident MCI and dementia following international criteria. Diabetes was ascertained based on a medical examination, hypoglycemic medication use, and random blood glucose level ≥ 11.0 mmol/l. Pre-diabetes was defined as random blood glucose level of 7.8-11.0 mmol/l in diabetes-free participants. Data were analyzed using standard and time-dependent Cox proportional-hazards models.

RESULTS

During the follow-up period, in the cognitively intact cohort, 182 people developed MCI (42 aMCI and 140 oCIND), and 212 developed dementia. In the MCI cohort, 155 subjects progressed to dementia, the multi-adjusted hazard ratio (95% CI) of dementia was 2.87 (1.30-6.34) for diabetes, and 4.96 (2.27-10.84) for pre-diabetes. In a Kaplan-Meier survival analysis, diabetes and pre-diabetes accelerated the progression from MCI to dementia by 3.18 years. Diabetes and pre-diabetes were neither cross-sectionally nor longitudinally associated with MCI.

CONCLUSIONS

Diabetes and pre-diabetes substantially accelerate the progression from MCI to dementia, and anticipate dementia occurrence by more than 3 years in people with MCI. The association of diabetes with the development of MCI is less evident in old people.

Rehabilitation of attention in two patients with traumatic brain injury by means of ‘attention process training’

PRIMARY OBJECTIVE

This case study aims to evaluate the effectiveness of the Solhberg and Mateer's Attention Process Training (APT) using a comprehensive evaluation of various attentional processes.

METHODS AND PROCEDURES

Two patients with severe traumatic brain injury were given the APT in a chronic phase. Attentional processes were evaluated at various stages before, during and after treatment, using the Testbatterie zur Aufmerksamkeitsprufung and the Test of everyday attention.

MAIN OUTCOMES AND RESULTS

Both patients showed some degree of recovery, particularly in attentional tasks with a selective component. Lesser improvement was present in the case of tasks mapping on the intensity dimension of attention (alertness, vigilance). Training achievements were confirmed by the use of a functional scale evaluating attention, pointing to the generality of improvements.

CONCLUSION

The results indicate selective training effects of APT on the attentional disturbances of TBI patients.

Occurrence of cognitive impairment and dementia in the community: a 9-year-long prospective study

OBJECTIVE

To determine incidence rates of non-dementia cognitive impairment, to examine the impact of attrition due to death on the observed incidence estimates, and to compare the observed and corrected estimates of non-dementia cognitive impairment with dementia incidence rates.

METHODS

A total of 1,435 persons without dementia aged 75+ from the Kungsholmen Project were evaluated for occurrence of dementia over 9 years. A total of 1,070 cognitively unimpaired subjects were also followed using amnestic mild cognitive impairment (aMCI) and other cognitive impairment, no dementia (OCIND) definitions. To correct the observed incidence rates for attrition due to death, cognitive status for subjects lost due to death was imputed using information on previous cognitive and health status. Observed and corrected incidence rates (IR) and 95% CIs were calculated with the person-years method, using Poisson distribution.

RESULTS

Incidence rates per 1,000 person-years were as follows: dementia IR = 70.4 (64.0 to 77.4); aMCI observed IR = 11.4 (8.6 to 15.1), corrected IR = 13.7 (10.3 to 18.2); OCIND observed IR = 33.8 (28.7 to 39.8), corrected IR = 42.1 (36.5 to 48.6). Both aMCI and OCIND incidence increased with advancing age. Observed incidence of aMCI and OCIND together was similar to that of dementia at age 75 to 79 but lower at more advanced ages. However, the cognitive impairment incidence after age 79 increased substantially when the estimates were corrected for attrition due to death during follow-up.

CONCLUSIONS

Non-dementia cognitive impairment is common and often underestimated in population studies that do not adjust for attrition.

Can faith protect from emotional distress after stroke?

BACKGROUND AND PURPOSE

Emotional distress is common in the aftermath of stroke and can impact negatively on the outcome. The study was aimed at evaluating whether religious beliefs can protect from emotional distress.

METHODS

Data were collected from 132 consecutive inpatients who were hospitalized for stroke rehabilitation and met the research requirements. At admission all study participants received a semi-structured interview on religious beliefs (Royal Free Interview for religious and spiritual beliefs) and were assessed on their mood with the Hospital Anxiety and Depression Scale. The relationship between religious beliefs and mood was explored, adjusting for possible confounders.

RESULTS

Subjects with over-threshold Hospital Anxiety and Depression Scale scores had significantly lower Royal Free Interview scores (odds ratio, 0.95; CI, 92 to 98). The direction and magnitude of the association did not change after adjusting for possible confounders (odds ratio, 0.95; CI, 91 to 98). The same pattern was observed when analyzing separately Hospital Anxiety and Depression Scale anxiety and depression subscales. The other significant variable was functional dependence.

CONCLUSIONS

The strength of religious beliefs influences the ability to cope after a stroke event, with stronger religious beliefs acting as a possible protective factor against emotional distress.

Determinants of the subjective functional outcome of total joint arthroplasty

The aim of the study is three-fold: (i) to analyze association between early subjective functional outcome of total joint arthroplasty (TJA) and patient-related risk factors; (ii) to evaluate the six-month subjective functional outcome of TJA as compared with subjective functional status of non-operated outpatients; (iii) to evaluate TJA self-perceived amelioration rates compared to the status of an age-matched sample from a general medical practice. A prospective consecutive study was performed upon 100 elderly inpatients with recent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) for osteoarthritis. Interviews on preoperative status and short-term outcome were performed at admission and six months after surgical intervention with Western Ontario and MacMasters Universities Osteoarthritis Index (WOMAC). One hundred aged-matched consecutive outpatients were screened for osteoarthritis and interviewed with the same questionnaire in a single session. Differences between baseline and follow-up scores were evident and statistically significant for both TJA groups, although THA patients showed more improvement. The comparison between TJA patients at baseline and age-matched osteoarthritis outpatients highlighted less impairment among outpatients. The situation reversed six months after the intervention. Objective functional outcome of post-operative rehabilitation has not revealed predictive value for the six-month outcome of TJA in terms of self-perceived functional status. Logistic regression analysis indicated that preoperative status was the only significant predictor of higher WOMAC scores six months after TJA. The survey confirms the early benefit of THA or TKA for osteoarthritis, but a less favorable subjective functional outcome is expected at six months when preoperative subjective functional status is severely compromised.

Self-perceived distress and self-perceived functional recovery after recent total hip and knee arthroplasty

The research was aimed at verifying whether psychological distress and depression are associated to reduced functional improvement following arthroplasty. Thirty-six patients with total knee arthroplasty (TKA) and 36 patients total hip arthroplasty (THA) were enrolled at the beginning of their rehabilitation. The mean age in TKA patients was 71.3+/-7.8 years (S.D.). The mean age in THA patients was 67.9+/-8.4 years. The Western Ontario and MacMasters Universities Osteoarthritis Index (WOMAC) and the Hospital Anxiety and Depression (HAD) were applied. Forty-four percent of THA and 58% of TKA showed over-threshold HAD scores at admission. The proportion was even higher considering HAD-Depression sub-scale, where 55% of THA and 61% of TKA patients had over-threshold scores. Lack of depression prompted better functional outcome in TKA. The effect of depression on TKA functional improvement was still significant after adjusting for age and sex. No association was found for THA patients. In order to maximize rehabilitation benefit it is then suggested that patients with recent TKA intervention are screened for distress and depression at admission and that psychological symptoms are treated if over-threshold.

Italian validation of the Royal Free Interview for Religious and Spiritual Beliefs

Interest in the relevance of religion and spirituality to medicine is growing and concerns the possible association between religiousness, spirituality and well-being. In the rehabilitation field these factors may affect outcome. We translated the "Royal Free Interview for Religious and Spiritual Beliefs" into Italian and validated the Italian language version. The translation the Royal Free Interview was accomplished in several steps. Certain adaptations were necessary in order to take into account certain peculiarities of the Italian language and of the Italian-speaking world. The Italian translation presented in this study shows internal consistency: Cronbach's alpha coefficient 0.82 (spiritual scale) and 0.80 (philosophical scale) in the 53 healthy volunteers; alpha coefficient 0.79 (spiritual scale) and 0.64 (philosophical scale) in the stroke patients. Test-retest reliability, evaluated by means of the intraclass correlation coefficient, was 0.83 (spiritual scale) and 0.99 (philosophical scale). There are two main reasons why an Italian translation of a religious coping scale was deemed necessary: i) there is a growing awareness of the possible impact of faith on stress and on the outcome of many disabling diseases; ii) Italy has a large and aging population and thus a high prevalence of disabled patients.

[Variability of epidemiological measures in mild cognitive impairment and dementia]

Variability in occurrence estimates is one of the basic features of the epidemiology of dementia and mild cognitive impairment (MCI). This review will cover two levels of variability that affect epidemiological research on dementia and MCI: the conceptual and the operational level. More specifically, it is highlighted how the lack of a precise definition of MCI leads to a greater variability in the occurrence estimates of this condition, when compared to dementia. Variability will decrease only when more precise criteria and aims of the concept "MCI" will be specified.

Criterion validity of the center for epidemiological studies depression (CES-D) scale in a sample of rehabilitation inpatients

The criterion validity of the Center for Epidemiological Studies Depression (CES-D) scale was evaluated among 101 orthopaedic and 50 neurological inpatients of a rehabilitation centre. The structured clinical interview for the DSM-IV (SCID-I) was used as criterion. Sensitivity of the CES-D to current major depressive disorder was 100% in both groups, while specificity was 57% (95% confidence interval = 48-67, likelihood ratio = +2.34) in orthopaedic patients and 36% (95% confidence interval = 23-49, likelihood ratio = +1.56) in neurological patients. Positive predictive value of the CES-D for current major depressive disorder was 24% (95% confidence interval = 10-32, likelihood ratio = +2.34) in orthopaedic patients and 31% in neurological patients (95% confidence interval = 18-43, likelihood ratio = +1.56), while negative predictive value was 100% in both groups. When a broader range of depressive disorders was considered, sensitivity dropped to 89% (95% confidence interval = 83-95, likelihood ratio = +3.52) and 96% (95% confidence interval = 91-100, likelihood ratio = +2.21) while specificity increased to 75% (95% confidence interval = 66-83, likelihood ratio = +3.52) and 57% (95% confidence interval = 43-70, likelihood ratio = +2.21), respectively.

Cardiac effects of slow-release lanreotide, a slow-release somatostatin analog, in acromegalic patients

Cardiac involvement, mostly characterized by left ventricular hypertrophy associated with various degrees of cardiac dysfunction, greatly contributes to the increased mortality and morbidity observed in acromegaly. Lanreotide is a new SRIF analog characterized by a slow-release (SR) formulation with the peculiarity of a 30-mg im administration every 10-14 days. In this study, 13 patients with postoperative active acromegaly (9 females, 4 males, 45.9 +/- 16.3 yr old) underwent an echo-Doppler and hormonal study before and during a 12-month period of treatment with SR-lanreotide. GH and insulin-like growth factor I plasma levels (mean +/- SD) decreased significantly throughout the study period (from 10.1 +/- 2.2 to 3.9 +/- 0.9 ng/mL for GH, P < 0.005; and from 511.0 +/- 33.0 to 305.0 +/- 34.2 ng/mL for insulin-like growth factor I, P < 0.0001). Left ventricular mass index (mean +/- SD, 137.1 +/- 7.5 g/m2 at baseline) decreased after 3 months (120.0 +/- 5.4 g/m2), 6 months (111.7 +/- 5.7 g/m2), and 12 months (110.3 +/- 5.2 g/m2) of treatment (P < 0.005 at each time-point). This reduction in left ventricular mass index was accompanied by an improvement in some indexes of left ventricular diastolic function, especially the isovolumetric relaxation time (mean +/- SD, 109.1 +/- 4.6 m/sec at baseline), which decreased after 3 months (91.9 +/- 2.8 m/sec), 6 months (92.3 +/- 3.2 m/sec), and 12 months (92.2 +/- 3.0 m/sec) of treatment (P < 0.005 at each time-point). We conclude that SR-lanreotide is able to improve cardiac morphology and functional abnormalities in acromegaly; whether such beneficial effects on cardiac parameters will contribute to improve life expectancy in these patients should be further investigated.

Acute effects of octreotide, cabergoline and a combination of both drugs on GH secretion in acromegalic patients

PURPOSE

The acute GH lowering effects of a single dose of either octreotide (OCT) or cabergoline (CAB), given alone and in combination, were studied in a series of 21 patients with acromegaly.

PATIENTS AND METHODS

Plasma GH was measured for 8 hours after a single subcutaneous injection of OCT (100 micrograms) and for 48 hours after a single oral dose of CAB (0.5 mg) in all patients. Fourteen patients, who did not suppress GH levels below 5 micrograms/L after either OCT or CAB given alone, also received a combination of both drugs (OCT 100 micrograms s.c. + CAB 0.5 mg p.o. 24 h before OCT).

RESULTS

GH levels were acutely suppressed by more than 50% in 15/21 cases after OCT alone and in 5/21 after CAB alone, respectively (P < 0.01). In the 14 patients who received the combined test, the magnitude of GH suppression was significantly higher than after OCT alone 4, 6 and 8 hours after OCT administration (P < 0.02). In patients with mixed GH/PRL-secreting tumors, the additive effect of OCT and CAB was observed at each time point.

CONCLUSION

These results suggest that combined therapy with OCT and CAB may be more effective in suppressing GH secretion than either compound given alone, especially in patients with GH/PRL-secreting adenomas.