Diagnosis and Management of Dementia: Review

Effects of mixed metal exposures on MRI diffusion features in the medial temporal lobe

Background

Environmental exposure to metal mixtures is common and may be associated with increased risk for neurodegenerative disorders including Alzheimer's disease.

Objective

This study examined associations of mixed metal exposures with medial temporal lobe (MTL) MRI structural metrics and neuropsychological performance.

Methods

Metal exposure history, whole blood metal, and neuropsychological tests were obtained from subjects with/without a history of mixed metal exposure from welding fumes (42 exposed subjects; 31 controls). MTL structures (hippocampus, entorhinal and parahippocampal cortices) were assessed by morphologic (volume, cortical thickness) and diffusion tensor imaging [mean (MD), axial (AD), radial diffusivity (RD), and fractional anisotropy (FA)] metrics. In exposed subjects, correlation, multiple linear, Bayesian kernel machine regression, and mediation analyses were employed to examine effects of single- or mixed-metal predictor(s) and their interactions on MTL structural and neuropsychological metrics; and on the path from metal exposure to neuropsychological consequences.

Results

Compared to controls, exposed subjects had higher blood Cu, Fe, K, Mn, Pb, Se, and Zn levels (p's<0.026) and poorer performance in processing/psychomotor speed, executive, and visuospatial domains (p's<0.046). Exposed subjects displayed higher MD, AD, and RD in all MTL ROIs (p's<0.040) and lower FA in entorhinal and parahippocampal cortices (p's<0.033), but not morphological differences. Long-term mixed-metal exposure history indirectly predicted lower processing speed performance via lower parahippocampal FA (p=0.023). Higher whole blood Mn and Cu predicted higher entorhinal diffusivity (p's<0.043) and lower Delayed Story Recall performance (p=0.007) without overall metal mixture or interaction effects.

Discussion

Mixed metal exposure predicted MTL structural and neuropsychological features that are similar to Alzheimer's disease at-risk populations. These data warrant follow-up as they may illuminate the path for environmental exposure to Alzheimer's disease-related health outcomes.

Impaired mobility and MRI markers of vascular brain injury: Atherosclerosis Risk in Communities and UK Biobank studies

Background

Vascular brain injury (VBI) may be an under-recognised contributor to mobility impairment. We examined associations between MRI VBI biomarkers and impaired mobility.

Methods

We separately analysed Atherosclerosis Risk in Communities (ARIC) and UK Biobank (UKB) study cohorts. Inclusion criteria were no prevalent clinical stroke, and available brain MRI and balance and gait data. MRI VBI biomarkers were (ARIC: ventricular and white matter hyperintensity (WMH) volumes, non-lacunar and lacunar infarctions, microhaemorrhage; UKB: ventricular, brain and WMH volumes, fractional anisotropy (FA), mean diffusivity (MD), intracellular and isotropic free water volume fractions). Quantitative biomarkers were categorised into tertiles. Mobility impairment outcomes were imbalance and slow walk in ARIC and recent fall and slow walk in UKB. Adjusted multivariable logistic regression analyses were performed.

Results

We included 1626 ARIC (mean age 76.2 years; 23.4% imbalance, 25.0% slow walk) and 40 098 UKB (mean age 55 years; 15.8% falls, 2.8% slow walk) participants. In ARIC, imbalance associated with four of five VBI measures (all p values<0.05), most strongly with WMH (adjusted OR, aOR 1.64; 95% CI 1.18 to 2.29). Slow walk associated with four of five VBI measures, most strongly with WMH (aOR 2.32; 95% CI 1.66 to 3.24). In UKB, falls associated with all VBI measures except WMH, most strongly with FA (aOR 1.16; 95% CI 1.08 to 1.24). Slow walking associated with WMH, FA and MD, most strongly with FA (aOR 1.57; 95% CI 1.32 to 1.87).

Conclusions

VBI is associated with mobility impairment in community-dwelling, clinically stroke-free cohorts. Consequences of VBI may extend beyond clinically apparent stroke to include mobility.

Sex differences for clinical correlates of substantia nigra neuron loss in people with Lewy body pathology

BACKGROUND

Lewy body dementia (LBD) phenotype is associated with the presence and degree of Lewy body, Alzheimer's pathologies, and substantia nigra neuron loss. Nigral neuron loss is associated with parkinsonism in LBD, and females with LBD are less likely than males to have parkinsonism. As sex differences were reported for clinical correlates of Lewy body and Alzheimer's pathologies, we aimed to investigate whether there are also sex differences for correlates of nigral neuron loss.

METHODS

Data were obtained from the National Alzheimer's Coordinating Center for females (n = 159) and males (n = 263) with brainstem, limbic, and neocortical Lewy body pathology. Sex differences for the nigral neuron loss' association with Lewy body pathology staging and core clinical LBD features (cognitive fluctuations, visual hallucinations, rapid eye movement sleep behavior disorder, parkinsonism) during follow-up were analyzed with generalized linear models adjusting for age and Alzheimer's pathology staging. Whether any of the core clinical features at the time of dementia onset can predict underlying nigral neuron loss for females and males were also analyzed with generalized linear models.

RESULTS

Compared to males, females died older and had higher levels of Braak tau staging, but had similar levels of Lewy body pathology staging and nigral neuron loss. Females were less likely than males to have a clinical Lewy body disease diagnosis during follow-up. More advanced Lewy body pathology staging was associated with more nigral neuron loss, more so for males than females. More nigral neuron loss was associated with parkinsonism and clinical LBD diagnosis during follow-up, more so for males than females. Across the subgroup with dementia (40 females, 58 males), core LBD features at first visit with dementia were not associated with nigral neuron loss.

CONCLUSIONS

Nigral neuron loss' association with Lewy body pathology staging and core LBD features can differ by sex. Compared to males, females with Lewy body pathology have a higher risk of underdiagnosis. There is a need to elucidate the mechanisms underlying sex differences for pathology and clinicopathological correlations to advance diagnostic and therapeutic efforts in LBD.

Parkinson's Disease Dementia Patients: Expression of Glia Maturation Factor in the Brain

Parkinson's disease (PD) is the second most common progressive neurodegenerative disease characterized by the presence of dopaminergic neuronal loss and motor disorders. PD dementia (PDD) is a cognitive disorder that affects many PD patients. We have previously demonstrated the proinflammatory role of the glia maturation factor (GMF) in neuroinflammation and neurodegeneration in AD, PD, traumatic brain injury (TBI), and experimental autoimmune encephalomyelitis (EAE) in human brains and animal models. The purpose of this study was to investigate the expression of the GMF in the human PDD brain. We analyzed the expression pattern of the GMF protein in conjunction with amyloid plaques (APs) and neurofibrillary tangles (NFTs) in the substantia nigra (SN) and striatum of PDD brains using immunostaining. We detected a large number of GMF-positive glial fibrillary acidic protein (GFAP) reactive astrocytes, especially abundant in areas with degenerating dopaminergic neurons within the SN and striatum in PDD. Additionally, we observed excess levels of GMF in glial cells in the vicinity of APs, and NFTs in the SN and striatum of PDD and non-PDD patients. We found that the majority of GMF-positive immunoreactive glial cells were co-localized with GFAP-reactive astrocytes. Our findings suggest that the GMF may be involved in the pathogenesis of PDD.

Digital remote monitoring for screening and early detection of urinary tract infections

Urinary Tract Infections (UTIs) are one of the most prevalent bacterial infections in older adults and a significant contributor to unplanned hospital admissions in People Living with Dementia (PLWD), with early detection being crucial due to the predicament of reporting symptoms and limited help-seeking behaviour. The most common diagnostic tool is urine sample analysis, which can be time-consuming and is only employed where UTI clinical suspicion exists. In this method development and proof-of-concept study, participants living with dementia were monitored via low-cost devices in the home that passively measure activity, sleep, and nocturnal physiology. Using 27828 person-days of remote monitoring data (from 117 participants), we engineered features representing symptoms used for diagnosing a UTI. We then evaluate explainable machine learning techniques in passively calculating UTI risk and perform stratification on scores to support clinical translation and allow control over the balance between alert rate and sensitivity and specificity. The proposed UTI algorithm achieves a sensitivity of 65.3% (95% Confidence Interval (CI) = 64.3-66.2) and specificity of 70.9% (68.6-73.1) when predicting UTIs on unseen participants and after risk stratification, a sensitivity of 74.7% (67.9-81.5) and specificity of 87.9% (85.0-90.9). In addition, feature importance methods reveal that the largest contributions to the predictions were bathroom visit statistics, night-time respiratory rate, and the number of previous UTI events, aligning with the literature. Our machine learning method alerts clinicians of UTI risk in subjects, enabling earlier detection and enhanced screening when considering treatment.

Breaking barriers: a statistical and machine learning-based hybrid system for predicting dementia

Introduction: Dementia is a condition (a collection of related signs and symptoms) that causes a continuing deterioration in cognitive function, and millions of people are impacted by dementia every year as the world population continues to rise. Conventional approaches for determining dementia rely primarily on clinical examinations, analyzing medical records, and administering cognitive and neuropsychological testing. However, these methods are time-consuming and costly in terms of treatment. Therefore, this study aims to present a noninvasive method for the early prediction of dementia so that preventive steps should be taken to avoid dementia. Methods: We developed a hybrid diagnostic system based on statistical and machine learning (ML) methods that used patient electronic health records to predict dementia. The dataset used for this study was obtained from the Swedish National Study on Aging and Care (SNAC), with a sample size of 43040 and 75 features. The newly constructed diagnostic extracts a subset of useful features from the dataset through a statistical method (F-score). For the classification, we developed an ensemble voting classifier based on five different ML models: decision tree (DT), naive Bayes (NB), logistic regression (LR), support vector machines (SVM), and random forest (RF). To address the problem of ML model overfitting, we used a cross-validation approach to evaluate the performance of the proposed diagnostic system. Various assessment measures, such as accuracy, sensitivity, specificity, receiver operating characteristic (ROC) curve, and Matthew's correlation coefficient (MCC), were used to thoroughly validate the devised diagnostic system's efficiency. Results: According to the experimental results, the proposed diagnostic method achieved the best accuracy of 98.25%, as well as sensitivity of 97.44%, specificity of 95.744%, and MCC of 0.7535. Discussion: The effectiveness of the proposed diagnostic approach is compared to various cutting-edge feature selection techniques and baseline ML models. From experimental results, it is evident that the proposed diagnostic system outperformed the prior feature selection strategies and baseline ML models regarding accuracy.

Deregulation of the Glymphatic System in Alzheimer's Disease: Genetic and Non-Genetic Factors

Alzheimer's disease (AD) is the most prevalent form of dementia and is characterized by progressive degeneration of brain function. AD gradually affects the parts of the brain that control thoughts, language, behavior and mental function, severely impacting a person's ability to carry out daily activities and ultimately leading to death. The accumulation of extracellular amyloid-β peptide (Aβ) and the aggregation of intracellular hyperphosphorylated tau are the two key pathological hallmarks of AD. AD is a complex condition that involves both non-genetic risk factors (35%) and genetic risk factors (58-79%). The glymphatic system plays an essential role in clearing metabolic waste, transporting tissue fluid, and participating in the immune response. Both non-genetic and genetic risk factors affect the glymphatic system to varying degrees. The main purpose of this review is to summarize the underlying mechanisms involved in the deregulation of the glymphatic system during the progression of AD, especially concerning the diverse contributions of non-genetic and genetic risk factors. In the future, new targets and interventions that modulate these interrelated mechanisms will be beneficial for the prevention and treatment of AD.

PCA and logistic regression in 2-[18F]FDG PET neuroimaging as an interpretable and diagnostic tool for Alzheimer's disease

Objective.to develop an optimization and training pipeline for a classification model based on principal component analysis and logistic regression using neuroimages from PET with 2-[18F]fluoro-2-deoxy-D-glucose (FDG PET) for the diagnosis of Alzheimer's disease (AD).Approach.as training data, 200 FDG PET neuroimages were used, 100 from the group of patients with AD and 100 from the group of cognitively normal subjects (CN), downloaded from the repository of the Alzheimer's Disease Neuroimaging Initiative (ADNI). Regularization methods L1 and L2 were tested and their respective strength varied by the hyperparameter C. Once the best combination of hyperparameters was determined, it was used to train the final classification model, which was then applied to test data, consisting of 192 FDG PET neuroimages, 100 from subjects with no evidence of AD (nAD) and 92 from the AD group, obtained at the Centro de Diagnóstico por Imagem (CDI).Main results.the best combination of hyperparameters was L1 regularization andC≈ 0.316. The final results on test data were accuracy = 88.54%, recall = 90.22%, precision = 86.46% and AUC = 94.75%, indicating that there was a good generalization to neuroimages outside the training set. Adjusting each principal component by its respective weight, an interpretable image was obtained that represents the regions of greater or lesser probability for AD given high voxel intensities. The resulting image matches what is expected by the pathophysiology of AD.Significance.our classification model was trained on publicly available and robust data and tested, with good results, on clinical routine data. Our study shows that it serves as a powerful and interpretable tool capable of assisting in the diagnosis of AD in the possession of FDG PET neuroimages. The relationship between classification model output scores and AD progression can and should be explored in future studies.

"VR is the future": perspectives of healthcare professionals on virtual reality as a diagnostic tool for dementia status in primary care

BACKGROUND

Healthcare professionals (HPs) hold critical perspectives on the barriers and facilitating factors for the implementation of virtual reality (VR) dementia diagnosis tools in the clinical setting. This study aims to explore HP perspectives regarding the clinical implementation of dementia diagnosis tools using VR platforms.

METHODS

An exploratory qualitative interview study was carried out between July and September 2022. In-depth semi-structured interviews were conducted with HPs (n = 7) with clinical expertise in dementia diagnoses drawn from medicine, nursing and allied health practices. A hermeneutic phenomenological approach was used to frame the interview data across the dementia diagnosis pathway and application of new technology.

RESULTS

HPs were on average 36.29 years old (SD = 11.56) with 11.85 years of experience (SD = 12.80, range:4-42). Analyses identified three main themes related to the contemporary methods of dementia diagnosis, dementia diagnosis and the medical landscape and HP perspectives on the usefulness and barriers of VR implementation. VR was considered an innovative prospect, with improved ecological validity compared to commonplace, current cognitive assessments. Concerns of time commitments, monetary costs and the validity of the new technology were identified as key barriers to implementation. Overall, implementation of a new diagnostic tool was considered a complex process.

CONCLUSIONS

Our insight into general practice and nursing clinics can be supported to embed and integrate virtual reality platforms in primary care settings. Primary healthcare organizations require more funding and time related resources to produce a context in which VR tools could be implemented in a beneficial manner.

Comparison of multiple linear regression and machine learning methods in predicting cognitive function in older Chinese type 2 diabetes patients

INTRODUCTION

The prevalence of type 2 diabetes (T2D) has increased dramatically in recent decades, and there are increasing indications that dementia is related to T2D. Previous attempts to analyze such relationships principally relied on traditional multiple linear regression (MLR). However, recently developed machine learning methods (Mach-L) outperform MLR in capturing non-linear relationships. The present study applied four different Mach-L methods to analyze the relationships between risk factors and cognitive function in older T2D patients, seeking to compare the accuracy between MLR and Mach-L in predicting cognitive function and to rank the importance of risks factors for impaired cognitive function in T2D.

METHODS

We recruited older T2D between 60-95 years old without other major comorbidities. Demographic factors and biochemistry data were used as independent variables and cognitive function assessment (CFA) was conducted using the Montreal Cognitive Assessment as an independent variable. In addition to traditional MLR, we applied random forest (RF), stochastic gradient boosting (SGB), Naïve Byer's classifier (NB) and eXtreme gradient boosting (XGBoost).

RESULTS

Totally, the test cohort consisted of 197 T2D (98 men and 99 women). Results showed that all ML methods outperformed MLR, with symmetric mean absolute percentage errors for MLR, RF, SGB, NB and XGBoost respectively of 0.61, 0.599, 0.606, 0.599 and 0.2139. Education level, age, frailty score, fasting plasma glucose and body mass index were identified as key factors in descending order of importance.

CONCLUSION

In conclusion, our study demonstrated that RF, SGB, NB and XGBoost are more accurate than MLR for predicting CFA score, and identify education level, age, frailty score, fasting plasma glucose, body fat and body mass index as important risk factors in an older Chinese T2D cohort.

Causality between rheumatoid arthritis and the risk of cognitive impairment: a Mendelian randomization study

BACKGROUND

There is mounting proof that rheumatoid arthritis (RA) and cognitive decline are related. These studies, however, have not all been uniform, and others have not discovered such a correlation. It is essential to investigate the link between RA and cognitive decline.

METHOD

We conducted a Mendelian randomization analysis utilizing three different publicly accessible RA GWAS summary datasets and a variety of meticulously verified instrumental variables. We mostly used inverse variance weighting (IVW), as well as MR-Egger, weighted median, MR-PRESSO, and several sensitivity analyses, to figure out the link between RA and cognitive impairment (CI).

RESULTS

Our MR study identified the causality between RA and declining cognitive performance (β = - 0.010, 95% CI of - 0.017 to - 0.003, P = 4.33E-03) and cognitive function (β = - 0.029, 95% CI of - 0.053 to - 0.005, P = 1.93E-02). The consistent direction of the connection is revealed by sensitivity analysis utilizing the weighted median and the MR-Egger method. Furthermore, we reproduced our findings across two additional RA datasets and found identical outcomes, strengthening the validity of our findings.

CONCLUSION

This study offers proof of causality between RA and an increased risk of CI. Our findings highlight the importance of examining RA patients for cognitive ability, which may open up fresh ideas for the prevention of CI.

Impact of Different Diagnostic Measures on Drug Class Association with Dementia Progression Risk: A Longitudinal Prospective Cohort Study

Background

The Clinical Dementia Rating Scale Sum of Boxes (CDRSOB) score is known to be highly indicative of cognitive-functional status and is regularly employed for clinical and research purposes.

Objective

Our aim is to determine whether CDRSOB is consistent with clinical diagnosis in evaluating drug class associations with risk of progression to mild cognitive impairment (MCI) and dementia.

Methods

We employed weighted Cox regression analysis on longitudinal NACC data, to identify drug classes associated with disease progression risk, using clinical diagnosis and CDRSOB as the outcome.

Results

Aspirin (antiplatelet/NSAID), angiotensin II inhibitors (antihypertensive), and Parkinson's disease medications were significantly associated with reduced risk of progression to MCI/dementia and Alzheimer's disease medications were associated with increased MCI-to-Dementia progression risk with both clinical diagnosis and CDRSOB as the outcome. However, certain drug classes/subcategories, like anxiolytics, antiadrenergics, calcium (Ca2+) channel blockers, and diuretics (antihypertensives) were associated with reduced risk of disease progression, and SSRIs (antidepressant) were associated with increased progression risk only with CDRSOB. Additionally, metformin (antidiabetic medication) was associated with reduced MCI-to-Dementia progression risk only with clinical diagnosis as the outcome.

Conclusions

Although the magnitude and direction of the effect were primarily similar for both diagnostic outcomes, we demonstrate that choice of diagnostic measure can influence the significance of risk/protection attributed to drug classes and consequently the conclusion of findings. A consensus must be reached within the research community with respect to the most accurate diagnostic outcome to identify risk and improve reproducibility.

Unveiling the link between systemic inflammation markers and cognitive performance among older adults in the US: A population-based study using NHANES 2011-2014 data

PURPOSE

This study aimed to evaluate the association between systemic inflammation markers and cognitive performance among older US adults.

METHODS

This cross-sectional study assessed 3,632 older participants from the 2011-2014 National Health and Nutrition Examination Survey (NHANES). The main analysis included participants aged over 60 years. Systemic inflammation markers were quantified by calculating the composite inflammation indicators from the blood routine count, and cognitive performance was assessed using Consortium to Establish a Registry for Alzheimer's Disease (CERAD) test, Animal Fluency test (AFT), and Digit Symbol Substitution test (DSST).

RESULTS

There were 2,743 individuals enrolled in the current analysis. The overall mean age was 64.9 years and 48.7 % were males. The levels of SIRI and PIV were significant negative associated with scores of CERAD, CERAD delayed recall, and DSST in the unadjusted models. Moreover, SII were significant negative associated with scores of CERAD and CERAD delayed recall. After adjusting the covariates of demographics, lifestyle factors, history of chronic diseases and BMI, significant negative association were observed between systematic inflammation markers and cognitive performance. Additionally, a progressive and significant decrease in the score of cognitive performance assessments with the increased levels of SIRI, SII, and PIV were respectively observed. Finally, the correlation between systemic inflammation markers and cognitive performance were evidenced in the sensitive analysis.

CONCLUSION

Findings support a strong inverse correlation between systemic inflammation markers and cognitive performance, suggesting that addressing inflammation could be a promising avenue for enhancing cognitive health and mitigating age-related cognitive decline.

Unveiling the Role of Novel miRNA PC-5P-12969 in Alleviating Alzheimer's Disease

Background

The intricate and complex molecular mechanisms that underlie the progression of Alzheimer's disease (AD) have prompted a concerted and vigorous research endeavor aimed at uncovering potential avenues for therapeutic intervention.

Objective

This study aims to elucidate the role of miRNA PC-5P-12969 in the pathogenesis of AD.

Methods

We assessed the differential expression of miRNA PC-5P-12969 in postmortem AD brains, AD animal and cell models using real-time reverse-transcriptase RT-PCR, we also checked the gene and protein expression of GSK3α and APP.

Results

Our investigation revealed a notable upregulation of miRNA PC-5P-12969 in postmortem brains of AD patients, in transgenic mouse models of AD, and in mutant APP overexpressing-HT22 cells. Additionally, our findings indicate that overexpression of miRNA PC-5P-12969 exerts a protective effect on cell survival, while concurrently mitigating apoptotic cell death. Further-more, we established a robust and specific interaction between miRNA PC-5P-12969 and GSK3α. Our luciferase reporter assays provided confirmation of the binding between miRNA PC-5P-12969 and the 3'-UTR of the GSK3α gene. Manipulation of miRNA PC-5P-12969 levels in cellular models of AD yielded noteworthy alterations in the gene and protein expression levels of both GSK3α and APP. Remarkably, the manipulation of miRNA PC-5P-12969 levels yielded significant enhancements in mitochondrial respiration and ATP production, concurrently with a reduction in mitochondrial fragmentation, thus unveiling a potential regulatory role of miRNA PC-5P-12969 in these vital cellular processes.

Conclusions

In summary, this study sheds light on the crucial role of miRNA PC-5P-12969 and its direct interaction with GSK3α in the context of AD.

Can Incorrect Analysis of Time-Dependent Exposure Explain Associations between PM2.5 Exposure and Risk of Dementia?

Background

Epidemiological studies have reported positive associations between long-term exposure to particulate matter of 2.5 microns or less in diameter (PM2.5) and risk of Alzheimer's disease and other clinical dementia. Many of these studies have analyzed data using Cox Proportional Hazards (PH) regression, which estimates a hazard ratio (HR) for the treatment (in this case, exposure) effect on the time-to-event outcome while adjusting for influential covariates. PM2.5 levels vary over time. As air quality standards for PM2.5 have become more stringent over time, average outdoor PM2.5 levels have decreased substantially.

Objective

Investigate whether a Cox PH analysis that does not properly account for exposure that varies over time could produce a biased HR of similar magnitude to the HRs reported in recent epidemiological studies of PM2.5 and dementia risk.

Methods

Simulation analysis.

Results

We found that the biased HR can affect statistical analyses that consider exposure levels at event times only, especially if PM2.5 levels decreased consistently over time. Furthermore, the direction of such bias is away from the null and of a magnitude that is consistent with the reported estimates of dementia risk in several epidemiological studies of PM2.5 exposure (HR≈1.2 to 2.0).

Conclusions

This bias can be avoided by correctly assigning exposure to study subjects throughout the entire follow-up period. We recommend that investigators provide a detailed description of how time-dependent exposure variables were accounted for in their Cox PH analyses when they report their results.

High-Fat Diets in Animal Models of Alzheimer's Disease: How Can Eating Too Much Fat Increase Alzheimer's Disease Risk?

High dietary intake of saturated fatty acids is a suspected risk factor for neurodegenerative diseases, including Alzheimer's disease (AD). To decipher the causal link behind these associations, high-fat diets (HFD) have been repeatedly investigated in animal models. Preclinical studies allow full control over dietary composition, avoiding ethical concerns in clinical trials. The goal of the present article is to provide a narrative review of reports on HFD in animal models of AD. Eligibility criteria included mouse models of AD fed a HFD defined as > 35% of fat/weight and western diets containing > 1% cholesterol or > 15% sugar. MEDLINE and Embase databases were searched from 1946 to August 2022, and 32 preclinical studies were included in the review. HFD-induced obesity and metabolic disturbances such as insulin resistance and glucose intolerance have been replicated in most studies, but with methodological variability. Most studies have found an aggravating effect of HFD on brain Aβ pathology, whereas tau pathology has been much less studied, and results are more equivocal. While most reports show HFD-induced impairment on cognitive behavior, confounding factors may blur their interpretation. In summary, despite conflicting results, exposing rodents to diets highly enriched in saturated fat induces not only metabolic defects, but also cognitive impairment often accompanied by aggravated neuropathological markers, most notably Aβ burden. Although there are important variations between methods, particularly the lack of diet characterization, these studies collectively suggest that excessive intake of saturated fat should be avoided in order to lower the incidence of AD.

[Polypharmacy in patients with dementia]

The number of patients with dementia is expected to grow in the coming years due to an aging population and an increasing life-expectancy. At the same time, in an aging society there will be an increase in multimorbidity and therefore polypharmacy. This combination presents numerous challenges particularly for people with dementia, as the correct administration of the drugs can frequently no longer be guaranteed. The drug treatment of neuropsychiatric symptoms of dementia are often treated with antipsychotics with potentially severe side effects and with limited efficacy. Moreover, many drugs have an anticholinergic potential, which may worsen the cognitive function even further in patients with dementia. The use of anticholinergic drugs should be handled with care and when possible be avoided in patients with dementia.

Impact of adverse pregnancy outcomes on brain vascular health and cognition

A State of the Art lecture titled "Impact of Adverse Pregnancy Outcomes on Brain Vascular Health and Cognition" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. Adverse pregnancy outcomes, encompassing conditions such as gestational hypertension, eclampsia, preeclampsia, preterm birth, fetal growth restriction, stillbirth, and gestational diabetes, may form part of an underrecognized pathway from early adulthood reproductive health factors to later-life vascular cognitive impairment and dementia in women. Adverse pregnancy outcomes are caused by dysregulated vascular and metabolic adaptations during pregnancy, and these pathophysiological changes may persist after delivery. Adverse pregnancy outcomes may contribute to the increased risk of cognitive impairment and dementia directly through vascular and metabolic dysregulation and subsequent development of cardiovascular diseases, or other biological processes may be at play, such as shared maternal risk factors. Extensive epidemiologic evidence has shown that many cognitive impairment and dementia cases may be prevented or delayed by strategies targeting midlife cardiovascular health. Despite the recognized importance of adverse pregnancy outcomes for cardiovascular health, the literature on associated long-term health outcomes is limited. In this State of the Art review article, we summarize the current epidemiologic evidence on the relationship between adverse pregnancy outcomes and cognitive impairment and dementia and provide an overview of the potential pathophysiological mechanisms. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.

Citicoline: A Cholinergic Precursor with a Pivotal Role in Dementia and Alzheimer's Disease

Background

Citicoline is a naturally occurring compound with pleiotropic effects on neuronal function and cognitive processes.

Objective

Based on previous studies, which shed light on the positive effects of citicoline 1 g when combined with acetylcholinesterase inhibitors (AChEIs) and/or memantine, we further investigated the benefits of citicoline in combination therapy in Alzheimer's disease and mixed dementia.

Methods

We integrated the datasets of CITIMEM and CITIDEMAGE, increasing the overall sample size to enhance statistical power. We analyzed data from these two investigator-initiated studies involving 295 patients. The primary outcome was the assessment over time of the effects of combined treatment versus memantine given alone or AChEI plus memantine on cognitive functions assessed by Mini-Mental State Examination (MMSE). The secondary outcomes were the influence of combined treatment on daily life functions, mood, and behavioral symptoms assessed by activities of daily life (ADL) and instrumental ADL, Geriatric Depression Scale, and Neuropsychiatric Inventory Scale. One-hundred-forty-three patients were treated with memantine and/or AChEI (control group), and 152 patients were treated with memantine and/or AChEI plus citicoline 1 g/day orally (Citicoline group).

Results

A significant difference in MMSE score was found in the average between the two groups of treatment at 6 and 12 months.

Conclusions

This study confirmed the effectiveness of combined citicoline treatment in patients with mixed dementia and Alzheimer's disease, with a significant effect on the increase of MMSE score over time. The treated group also showed a significant reduction in the Geriatric Depression Scale and a significant increase in the instrumental ADL scale.

The Role of Non-coding RNAs in Alzheimer's Disease: Pathogenesis, Novel Biomarkers, and Potential Therapeutic Targets

Long non-coding RNAs (IncRNAs) are regulatory RNA transcripts that have recently been associated with the onset of many neurodegenerative illnesses, including Alzheimer's disease (AD). Several IncRNAs have been found to be associated with AD pathophysiology, each with a distinct mechanism. In this review, we focused on the role of IncRNAs in the pathogenesis of AD and their potential as novel biomarkers and therapeutic targets. Searching for relevant articles was done using the PubMed and Cochrane library databases. Studies had to be published in full text in English in order to be considered. Some IncRNAs were found to be upregulated, while others were downregulated. Dysregulation of IncRNAs expression may contribute to AD pathogenesis. Their effects manifest as the synthesis of beta-amyloid (Aβ) plaques increases, thereby altering neuronal plasticity, inducing inflammation, and promoting apoptosis. Despite the need for more investigations, IncRNAs could potentially increase the sensitivity of early detection of AD. Until now, there has been no effective treatment for AD. Hence, InRNAs are promising molecules and may serve as potential therapeutic targets. Although several dysregulated AD-associated lncRNAs have been discovered, the functional characterization of most lncRNAs is still lacking.

Advances and Challenges in Gene Therapy for Alzheimer's Disease

Alzheimer's disease (AD) is a progressive neurodegenerative disorder characterized by cognitive decline, memory loss, and behavioral impairments. Despite extensive research efforts, effective treatment options for AD remain limited. Recently, gene therapy has emerged as a promising avenue for targeted intervention in the pathogenesis of AD. This review will provide an overview of clinical and preclinical studies where gene therapy techniques have been utilized in the context of AD, highlighting their potential as novel therapeutic strategies. While challenges remain, ongoing research and technological advancement continue to enhance the potential of gene therapy as a targeted and personalized therapeutic approach for AD.

Frailty is associated with the clinical expression of neuropsychological deficits in older adults

BACKGROUND AND PURPOSE

The aim was to determine whether frailty is associated with the relationship between neuropsychological markers and global cognition in older adults.

METHODS

Cross-sectional analyzes were conducted of baseline data from three large cohort studies: National Alzheimer's Coordinating Center (NACC), Rush Memory and Aging Project (MAP) and Alzheimer's Disease Neuroimaging Initiative (ADNI). Studies recruited North American participants along the spectrum of cognitive functioning (44% no cognitive impairment at baseline). A frailty index was computed in each dataset. Frailty indices, neuropsychological tests (including measures of processing speed, episodic, semantic and working memory) and Mini-Mental State Examination (MMSE) scores were the variables of interest, with age, sex, education and apolipoprotein E ε4 evaluated as confounders.

RESULTS

Across all studies, 23,819 participants aged 55-104 (57% female) were included in analyzes. Frailty index scores were significantly and inversely associated with MMSE scores and significantly moderated relationships between neuropsychological test scores and MMSE scores. In participants with higher frailty index scores, lower neuropsychological test scores were more strongly associated with lower MMSE scores (standardized interaction coefficients ranged from -0.19 to -1.17 in NACC, -0.03 to -2.27 in MAP and -0.04 to -0.38 in ADNI, depending on the neuropsychological test). These associations were consistent across the different databases and were mostly independent of the composition of frailty indices (i.e., after excluding possible symptoms of dementia).

CONCLUSIONS

Amongst older Americans, frailty is associated with the cognitive expression of neuropsychological deficits. Implementation of frailty assessment in routine neurological and neuropsychological practice should be considered to optimize care outcomes for older adults.

Serum neurofilament light chain and cognition decline in US elderly: A cross-sectional study

OBJECTIVE

Early identification of cognitive impairment in neurodegenerative diseases like Alzheimer's disease (AD) is crucial. Neurofilament, a potential biomarker for neurological disorders, has gained attention. Our study aims to investigate the relationship between serum neurofilament light (sNfL) levels and cognitive function in elderly individuals in the United States.

METHODS

This cross-sectional study analyzed data from participants aged 60 and above in the National Health and Nutrition Examination Survey (2013-2014). We collected sNfL levels, cognitive function tests, sociodemographic characteristics, comorbidities, and other variables. Weighted multiple linear regression models examined the relationship between ln(sNfL) and cognitive scores. Restricted cubic spline (RCS) visualization explored nonlinear relationships. The stratified analysis examined subgroups' ln(sNfL) and cognitive function association.

RESULTS

The study included 446 participants (47.73% male). Participants with ln(sNfL) levels between 2.58 and 2.81 pg/mL (second quintile) performed relatively well in cognitive tests. After adjusting for multiple factors, ln(sNfL) levels were negatively correlated with cognitive function, with adjusted β (95% CI) as follows: immediate recall test (IRT): -0.763 (-1.301 to -0.224), delayed recall test (DRT): -0.308 (-0.576 to -0.04), animal fluency test (AFT): -1.616 (-2.639 to -0.594), and digit symbol substitution test (DSST): -2.790 (-4.369 to -1.21). RCS curves showed nonlinear relationships between ln(sNfL) and DRT, AFT, with inflection points around 2.7 pg/mL. The stratified analysis revealed a negative correlation between ln(sNfL) and cognition in specific subgroups with distinct features, with an interaction between diabetes and ln(sNfL).

INTERPRETATION

Higher sNfL levels are associated with poorer cognitive function in the elderly population of the United States. sNfL shows promise as a potential biomarker for early identification of cognitive decline.

Alzheimer's disease and Alzheimer's disease-related dementias in Hispanics: Identifying influential factors and supporting caregivers

Alzheimer's disease (AD) and Alzheimer's disease-related dementias (ADRD) are the primary public health concerns in the United States and around the globe. AD/ADRD are irreversible mental illnesses that primarily impair memory and thought processes and may lead to cognitive decline among older individuals. The prevalence of AD/ADRD is higher in Native Americans, followed by African Americans and Hispanics. Increasing evidence suggests that Hispanics are the fastest-growing ethnic population in the USA and worldwide. Hispanics develop clinical symptoms of AD/ADRD and other comorbidities nearly seven years earlier than non-Hispanic whites. The consequences of AD/ADRD can be challenging for patients, their families, and caregivers. There is a significant increase in the burden of illness, primarily affecting Hispanic/Latino families. This is partly due to their strong sense of duty towards family, and it is exacerbated by the inadequacy of healthcare and community services that are culturally and linguistically suitable and responsive to their needs. With an increasing age population, low socioeconomic status, low education, high genetic predisposition to age-related conditions, unique cultural habits, and social behaviors, Hispanic Americans face a higher risk of AD/ADRD than other racial/ethnic groups. Our article highlights the status of Hispanic older adults with AD/ADRD. We also discussed the intervention to improve the quality of life in Hispanic caregivers.

Associations of Frailty with Neuropsychiatric Symptoms of Alzheimer's Disease: A Longitudinal Study

Background

Frailty is a vulnerability state increasing the risk of many adverse health outcomes, but little is known about the effects of frailty on neuropsychiatric health.

Objective

To explore the associations between frailty and the risk of neuropsychiatric symptoms (NPSs) in Alzheimer's disease (AD), especially in its different clinical stages.

Methods

We included 2,155 individuals assessed using modified frailty index-11 (mFI-11), Neuropsychiatric Inventory (NPI) and Neuropsychiatric Inventory Questionnaire (NPI-Q) in the Alzheimer's Disease Neuroimaging Initiative (ADNI). The relationships between frailty and NPSs were explored with logistic regression models and Cox proportional hazard regression models. Causal mediation analyses were conducted to explore the mediation factors between frailty and NPSs.

Results

Among mild cognitive impairment (MCI) participants, frailty was cross-sectionally associated with an increased risk of apathy, and longitudinally associated with increased risk of depression and apathy. Among AD participants, frailty was cross-sectionally associated with increased risk of depression and anxiety, and longitudinally associated with an increased risk of apathy. Among participants with cognitive progression, frailty was associated with increased risk of depression and apathy. In MCI participants, the influence of frailty on NPSs was partially mediated by hippocampus volume, whole brain volume, and monocytes, with mediating proportions ranging from 8.40% to 9.29%.

Conclusions

Frailty was associated with NPSs such as depression, anxiety, and apathy among MCI, AD, and cognitive progression participants. Atrophy of the hippocampus and whole brain, as well as peripheral immunity may be involved in the potential mechanisms underlying the above associations.

[Indicators of cognitive impairment of varying severity in the acute period of ischemic stroke]

OBJECTIVE

To assess phenotype and identify biomarkers of cognitive impairment (CI) of varying severity in patients in the acute period of ischemic stroke (IS) based on the analysis of clinical and paraclinical indicators.

MATERIAL AND METHODS

Two hundred and forty patients with diagnosed IS and presence of CI were examined. Depending on the scores on the Montreal Cognitive Assessment Scale, patients were divided into two groups: group 1 (n=182) with mild CI, group 2 (n=58) with dementia. On admission, stroke severity according to the National Institutes of Health Stroke Scale (NIHSS), activities of daily living assessed by the Barthel Scale and patient independence assessed by the modified Rankin Scale (mRS) were determined. Neuropsychological examination was performed on day 14 and included investigation of episodic memory, executive functions, speech, gnosis, praxis, and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) parameters. Immunological diagnostics included a study of the concentration of cytokines of various groups (interleukin (IL)-1b, IL-6, IL-16, granulocyte-macrophage colony-stimulating factor (GM-CSF), chemokines CXCL10, CXCL11, CXCL9, tumor necrosis factor α (TNFα)). Neuroimaging parameters were assessed using brain MRI data with verification of the STRIVE criteria and the medial temporal lobe atrophy scale (MTA). The standard application software package SPSS Statistics, Pandas and SciPy libraries were used for statistical analysis.

RESULTS

Patients of group 2 had lower scores in all cognitive domains with the greatest reduction in perception, constructive praxis, semantic information processing and mnestic function. These analyses revealed a higher degree of IQCODE, prevalence of features corresponding to STRIVE/MTA criteria in patients of group 2, while patients of group 1 had higher NIHSS and mRS scores. When serum concentrations of cytokines were assessed, patients of group 1 showed higher concentrations of IL-1b, IL-6, GM-CSF and TNFα, while group 2 patients had higher concentrations of cytokine CXCL10.

CONCLUSION

The presence of pre-stroke CI, baseline indicators of the patient's functional status, neuroimaging parameters of MTA/STRIVE and age are reflected in the structure and severity of cognitive deficit in the acute period of IS. Investigation of the role of interleukins, GM-CSF, TNFα and CXCL10 in the pathogenesis of IS and their association with the progression of post-stroke CI requires further studies with a larger sample size and longer follow-up period.

Hypertension and Mild Cognitive Impairment: Understanding the Complexities of the Relationship in Understudied Populations

The association between hypertension and mild cognitive impairment (MCI) is complex. Both are increasing in prevalence worldwide and will have disproportionate effects on lower income countries across Latin America. Despite this, there is insufficient evidence investigating this relationship in this region or those of Hispanic or Latino ancestry in higher income countries. In this context, the Study of Latinos-Investigation of Neurocognitive Aging represents a unique dataset. Although more research is required, Márquez and colleagues show that hypertension in this population in the United States is associated with decline in cognitive measures and greater odds of MCI over seven years follow-up.

An overview of systematic reviews of acupuncture for neurodegenerative disease

BACKGROUND

Acupuncture has been widely used in the treatment of neurodegenerative diseases and a large number of systematic reviews (SRs) have been published, but the results are controversial. Therefore, it is necessary to comprehensively summarize and objectively evaluate the clinical evidence of acupuncture for neurodegenerative diseases.

OBJECTIVE

To evaluate the SRs that assess the efficacy and safety of acupuncture for neurodegenerative diseases. This overview is intended to provide evidence for clinical decision making by healthcare providers and policymakers and to provide evidence for clinical decision making by healthcare providers and policymakers and to provide recommendations for researchers to conduct high quality SRs and clinical studies.

METHODS

We searched four Chinese databases (SinoMed, CNKI, Wanfang and VIP) and four international databases (Cochrane Library, Embase, PubMed and Web of Science) for SRs of acupuncture for neurodegenerative diseases. The search period ran from the beginning of the database to March 5, 2023. Literature screening and data extraction were performed independently by two individuals. Methodological quality, risk of bias and associated evidence levels were assessed for all SRs using AMSTER 2, ROBIS and GRADE tools. In addition, the RCT overlap between SRs was calculated by corrected coverage area (CCA). We also conducted quantitative synthesis or descriptive analysis of the relevant data.

RESULTS

Finally, we identified 53 SRs (three were qualitative descriptions and fifty were meta-analyses). Under AMSTAR 2, only one SR was rated as moderate quality, six SRs as low quality and 46 SRs as very low quality. According to ROBIS, 33 SRs were rated as a high risk of bias and 20 as a low risk of bias. Cognitive functions in neurodegenerative diseases, activities of daily living and the motor and non-motor outcomes associated with PD were included to summary description. The pooled results show that acupuncture combined with conventional treatment may have an overall advantage over conventional treatment, but the quality of evidence is low. Specific adverse reactions/events were reported in 20 SRs. Common needle-related adverse events included pain, dizziness, bleeding, or subcutaneous hematoma. No severe adverse events were reported in any SRs.

CONCLUSION

Evidence suggests that acupuncture is generally effective and relatively safe for cognitive function and activities of daily living in neurodegenerative diseases. In addition, acupuncture may have some benefits in improving motor and non-motor symptoms in patients with PD. However, high-quality RCTs and SRs are still needed to further clarify the efficacy and safety of acupuncture in treating neurodegenerative diseases.

The Usefulness of 18F-FDG PET to Differentiate Subtypes of Dementia: The Systematic Review and Meta-Analysis

Background and Purpose

Dementia subtypes, including Alzheimer's dementia (AD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD), pose diagnostic challenges. This review examines the effectiveness of 18F-Fluorodeoxyglucose Positron Emission Tomography (18F-FDG PET) in differentiating these subtypes for precise treatment and management.

Methods

A systematic review following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines was conducted using databases like PubMed and Embase to identify studies on the diagnostic utility of 18F-FDG PET in dementia. The search included studies up to November 16, 2022, focusing on peer-reviewed journals and applying the gold-standard clinical diagnosis for dementia subtypes.

Results

From 12,815 articles, 14 were selected for final analysis. For AD versus FTD, the sensitivity was 0.96 (95% confidence interval [CI], 0.88-0.98) and specificity was 0.84 (95% CI, 0.70-0.92). In the case of AD versus DLB, 18F-FDG PET showed a sensitivity of 0.93 (95% CI 0.88-0.98) and specificity of 0.92 (95% CI, 0.70-0.92). Lastly, when differentiating AD from non-AD dementias, the sensitivity was 0.86 (95% CI, 0.80-0.91) and the specificity was 0.88 (95% CI, 0.80-0.91). The studies mostly used case-control designs with visual and quantitative assessments.

Conclusions

18F-FDG PET exhibits high sensitivity and specificity in differentiating dementia subtypes, particularly AD, FTD, and DLB. This method, while not a standalone diagnostic tool, significantly enhances diagnostic accuracy in uncertain cases, complementing clinical assessments and structural imaging.

Toward a generalizable machine learning workflow for neurodegenerative disease staging with focus on neurofibrillary tangles

Machine learning (ML) has increasingly been used to assist and expand current practices in neuropathology. However, generating large imaging datasets with quality labels is challenging in fields which demand high levels of expertise. Further complicating matters is the often seen disagreement between experts in neuropathology-related tasks, both at the case level and at a more granular level. Neurofibrillary tangles (NFTs) are a hallmark pathological feature of Alzheimer disease, and are associated with disease progression which warrants further investigation and granular quantification at a scale not currently accessible in routine human assessment. In this work, we first provide a baseline of annotator/rater agreement for the tasks of Braak NFT staging between experts and NFT detection using both experts and novices in neuropathology. We use a whole-slide-image (WSI) cohort of neuropathology cases from Emory University Hospital immunohistochemically stained for Tau. We develop a workflow for gathering annotations of the early stage formation of NFTs (Pre-NFTs) and mature intracellular (iNFTs) and show ML models can be trained to learn annotator nuances for the task of NFT detection in WSIs. We utilize a model-assisted-labeling approach and demonstrate ML models can be used to aid in labeling large datasets efficiently. We also show these models can be used to extract case-level features, which predict Braak NFT stages comparable to expert human raters, and do so at scale. This study provides a generalizable workflow for various pathology and related fields, and also provides a technique for accomplishing a high-level neuropathology task with limited human annotations.

Alzheimer's Disease-Related Proteins Targeted by Secondary Metabolite Compounds from Streptomyces: A Scoping Review

Background

Alzheimer's disease (AD) is a neurodegenerative disease that is characterized as rapid and progressive cognitive decline affecting 26 million people worldwide. Although immunotherapies are ideal, its clinical safety and effectiveness are controversial, hence, treatments are still reliant on symptomatic medications. Concurrently, the Streptomyces genus has attracted attention given its pharmaceutically beneficial secondary metabolites to treat neurodegenerative diseases.

Objective

To present secondary metabolites from Streptomyces sp. with regulatory effects on proteins and identified prospective target proteins for AD treatment.

Methods

Research articles published between 2010 and 2021 were collected from five databases and 83 relevant research articles were identified. Post-screening, only 12 research articles on AD-related proteins were selected for further review. Bioinformatics analyses were performed through the Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) network, PANTHER Go-Slim classification system (PANTHER17.0), and Kyoto Encyclopedia of Genes and Genomes (KEGG) Mapper.

Results

A total of 20 target proteins were identified from the 12 shortlisted articles. Amyloid-β, BACE1, Nrf-2, Beclin-1, and ATG5 were identified as the potential target proteins, given their role in initiating AD, mitigating neuroinflammation, and autophagy. Besides, 10 compounds from Streptomyces sp., including rapamycin, alborixin, enterocin, bonnevillamides D and E, caniferolide A, anhydroexfoliamycin, rhizolutin, streptocyclinone A and B, were identified to exhibit considerable regulatory effects on these target proteins.

Conclusions

The review highlights several prospective target proteins that can be regulated through treatments with Streptomyces sp. compounds to prevent AD's early stages and progression. Further identification of Streptomyces sp. compounds with potential anti-AD properties is recommended.

Diagnostic performance of the cingulate island sign ratio for differentiating dementia with Lewy bodies from Alzheimer's disease changes depending on the mini-mental state examination score

BACKGROUND

The cingulate island sign (CIS) ratio is a diagnostic adjunct for differentiating dementia with Lewy bodies (DLB) from Alzheimer's disease (AD). A recent study showed that the CIS ratio in DLB changed depending on the Mini-Mental State Examination (MMSE) score. We aimed to evaluate whether the diagnostic performance (sensitivity and specificity) of the CIS ratio for differentiating DLB from AD changes depending on the MMSE score.

METHODS

Twenty-two patients with DLB and 26 amyloid-positive patients with AD, who underwent 18F-FDG PET and completed an MMSE examination, were classified into three groups according to MMSE scores: Group A (MMSE >24), Group B (20 ≤ MMSE ≤24), and Group C (MMSE <20). In each group, we compared the CIS ratio between patients with DLB and AD and conducted receiver operating characteristic (ROC) curve analysis to calculate the sensitivity and specificity.

RESULTS

Within Group B, the CIS ratio in DLB was significantly higher than that in AD (p = 0.0005), but not within Groups A (p = 0.5117) and C (p = 0.8671). ROC curve analyses showed that the sensitivities and specificities of the CIS ratio for differentiating DLB from AD were 66.7% and 77.8% in Group A, 91.7% and 100.0% in Group B, and 75.0% and 66.7% in Group C, respectively.

CONCLUSIONS

The present study suggests that the diagnostic performance of the CIS ratio for differentiating DLB from AD changes depending on the MMSE score, with higher sensitivity and specificity at MMSE scores of 20-24.

Early intervention and adding effective doses of EGb761 like Ginkgo extract slow down dementia progression: insights to the neurovascular unit

Background

Dementia is a progressive neurodegenerative disorder characterized by cognitive decline, memory impairment, and functional deterioration. Pharmacological interventions play a crucial role in managing dementia symptoms and potentially slowing down disease progression.

Objectives

This study aimed to investigate the impact of pharmacological interventions, including acetylcholinesterase inhibitors (AChEIs), memantine, and Gingko extract, on the progression of dementia, with a specific focus on mild cognitive impairment (MCI), Alzheimer's disease (AD), and non-Alzheimer dementias.

Methods

A total of 547 participants out of 3,547 cases in a specific dataset followed by the same author, including healthy controls, individuals with MCI, AD, and non-Alzheimer dementias, were included in this study. The follow-up duration was up to 211 months, allowing for a minimum 3 visits comprehensive assessment of disease progression. The treatment approaches included AChEIs, memantine, and combination therapy, with variations in the starting time for these treatments based on the dementia type.

Results

The use of AChEIs and memantine showed efficacy in improving cognitive function and overall function in individuals with MCI, AD, and non-AD dementias. Combination therapy EGb761 like Gingko extract with AChEIs and/or Memantine demonstrated a slower progression compared to AChEIs alone in individuals with prodromal dementia (MCI) and AD. The starting time for memantine and combination therapy was earlier in non-AD dementia cases compared to AD dementia cases and prodromal dementia.

Conclusion

Pharmacological interventions, particularly the use of AChEIs and memantine, can have a positive impact on cognitive function and overall function in individuals with dementia. The combination of AChEIs with EGb761 like Gingko extract may provide additional benefits in slowing down disease progression in AD cases. Early recognition and accurate classification of MCI subtypes are crucial, and the use of EGb761 like Gingko extract is recommended for symptomatic treatment. Future personalized risk predictions based on biomarker constellations may further enhance the multi-target treatment approaches of MCI and different dementia types.

One step beyond the lab and clinic: "walking the dementia conversation"

Millions of dollars have been lost in dementia research over the last 30 years owing to unsuccessful clinical trials aimed at finding an effective treatment for the condition. Although two promising drugs have been identified, the research effort is insufficient. The dehumanization of patients and the pressure to publish have led to a decline in the quality and usefulness of scientific research. One way to tackle these problems is establishing close contact with those who put their faith in researchers. Fine-tuning the participation of patients with dementia and caregivers in research design and improving their connection and communication with researchers could positively contribute to enhancing the perspectives and designing strategies for scientists in order to generate a new and enriching vision. The Walking the Talk for Dementia event showed that people can still live with dementia despite their condition. Approximately 300 people participated in the all-week "Santiago's Camino" symposium. People living with dementia, caregivers, healthcare professionals, activists, clinicians, and researchers participated in this event. The "Walking the Talk for Dementia" (WTD) event vividly demonstrated a strong commitment to upholding Global Brain Health Institute's (GBHI) core values of Authenticity, Fairness, Openness, Respect, Courage, and Empathy (A FORCE) to advance equity in brain health. These values provide clear guidance for their advocacy initiatives aimed at mitigating the global impact of dementia. Research and development are essential across scientific fields, especially in clinical contexts where involving patients and caregivers is critical. The WTD initiative exemplifies this aspect by bringing together researchers, caregivers, and dementia patients on the Camino de Santiago in Spain.

Exploring Huntington's Disease Diagnosis via Artificial Intelligence Models: A Comprehensive Review

Huntington's Disease (HD) is a devastating neurodegenerative disorder characterized by progressive motor dysfunction, cognitive impairment, and psychiatric symptoms. The early and accurate diagnosis of HD is crucial for effective intervention and patient care. This comprehensive review provides a comprehensive overview of the utilization of Artificial Intelligence (AI) powered algorithms in the diagnosis of HD. This review systematically analyses the existing literature to identify key trends, methodologies, and challenges in this emerging field. It also highlights the potential of ML and DL approaches in automating HD diagnosis through the analysis of clinical, genetic, and neuroimaging data. This review also discusses the limitations and ethical considerations associated with these models and suggests future research directions aimed at improving the early detection and management of Huntington's disease. It also serves as a valuable resource for researchers, clinicians, and healthcare professionals interested in the intersection of machine learning and neurodegenerative disease diagnosis.

Serum vitamin B12 concentration is associated with improved memory in older individuals with higher adherence to the Mediterranean diet

BACKGROUND & AIMS

Vitamin B12 plays a crucial role in cognition, but its effect might be regulated by the presence of other micronutrients, such as folate. The aim was to evaluate the effects of vitamin B12 on cognitive performance according to adherence to the Mediterranean diet, and whether the Mediterranean diet also results in increased folate or vitamin B12 levels.

METHODS

This is a cohort study nested in a randomized controlled clinical trial performed in Hospital Clinic in Barcelona, Spain. A total of 170 participants of the PREDIMED trial (Barcelona - Hospital Clinic site) aged 55-80 years at high cardiovascular risk were included. Adherence to the Mediterranean diet was assessed using a validated 14-item questionnaire, memory function was evaluated with a battery of neuropsychological tests and serum vitamin B12 and folate were determined using an automated electrochemiluminiscence immunoassay system.

RESULTS

In the multivariable adjusted linear regression model, serum vitamin B12 concentration presented a significant correlation with memory function (r2 = 0.57; P = 0.028) in participants with high adherence to the Mediterranean diet whereas the correlation was weak and inverse for those who presented a low adherence to the Mediterranean diet (r2 = 0.37, P = 0.731). Mediterranean diet adherence showed a positive association with serum folate, but not with serum vitamin B12.

CONCLUSIONS

In an older Mediterranean population at high cardiovascular risk, changes in serum vitamin B12 correlate with better memory function only in the context of a high adherence to the Mediterranean pattern, suggesting that the effects of vitamin B12 goes further than a mere nutritional requirement.

INSTITUTIONAL REVIEW BOARD STATEMENT

The study was conducted according to the guidelines of the Declaration of Helsinki and was approved by the Institutional Review Board of the 11 participating centres. The study was registered with the International Standard Randomized Controlled Trial Number (ISRCTN) 35739639 (https://www.isrctn.com/ISRCTN35739639).

Family History of AD/Dementia, Polygenic Risk Score for AD, and Parkinson's Disease

Background

Co-occurrence of Alzheimer's disease (AD) and Parkinson's disease (PD) has been observed. However, there is limited knowledge on how family history of AD is associated with PD.

Objectives

To prospectively examine the associations of family history of AD/dementia and polygenic risk score for AD (AD-PRS) with PD risk.

Methods

The study included 477,190 participants from UK Biobank who were free of PD at baseline (2006-2010) and had complete data on the studied exposure variables, family history of AD and AD-PRS. Cox proportional hazards model was used to examine the hazard ratios (HRs) and their 95% confidence intervals (CIs) of family history of AD/dementia and AD-PRS for PD risk. We also conducted mediation analysis to examine the proportion of the association between family history of AD/dementia and PD risk that could be mediated by AD-PRS.

Results

During a median follow-up of 12.5 years, we identified 2550 incidences of PD. Family history of AD/dementia (adjusted HR = 1.21; 95% CI 1.09-1.35) and AD-PRS (adjusted HR = 1.10 per 1 unit increment; 95% CI 1.05-1.14) were associated with PD risk, after adjustment for age, sex, lifestyle factors, and other potential confounders. The association between family history of AD/dementia and PD risk was mediated by 13.1% by the AD-PRS. As expected, we observed significant associations of family history of AD/dementia and AD-PRS with risks of dementia and AD (P < 0.001 for all).

Conclusions

Family history of AD/dementia appeared to be associated with PD risk, and this association could be mediated partially by AD-related genetic factors.

Investigating the associations between upper limb motor function and cognitive impairment: a scoping review

Upper limb motor function is a potential new biomarker of cognitive impairment and may aid discrimination from healthy ageing. However, it remains unclear which assessments to use. This study aimed to explore what methods have been used and to describe associations between upper limb function and cognitive impairment. A scoping review was conducted using PubMed, CINAHL and Web of Science. A systematic search was undertaken, including synonyms for key concepts 'upper limb', 'motor function' and 'cognitive impairment'. Selection criteria included tests of upper limb motor function and impaired cognition in adults. Analysis was by narrative synthesis. Sixty papers published between 1998 and 2022, comprising 41,800 participants, were included. The most common assessment tasks were finger tapping, Purdue Pegboard Test and functional tasks such as writing. Protocols were diverse in terms of equipment used and recording duration. Most participants were recruited from clinical settings. Alzheimer's Disease was the most common cause of cognitive impairment. Results were mixed but, generally, slower speed, more errors, and greater variability in upper limb movement variables was associated with cognitive impairment. This review maps the upper limb motor function assessments used and summarises the available evidence on how these associate with cognitive impairment. It identifies research gaps and may help guide protocols for future research. There is potential for upper limb motor function to be used in assessments of cognitive impairment.

High prevalence of subjective cognitive decline in older Chinese adults: a systematic review and meta-analysis

Background

Subjective cognitive decline (SCD) is considered a preclinical stage of Alzheimer's disease. However, reliable prevalence estimates of SCD in the Chinese population are lacking, underscoring the importance of such metrics for policymakers to formulate appropriate healthcare strategies.

Objective

To systematically evaluate SCD prevalence among older Chinese adults.

Methods

PubMed, Web of Science, The Cochrane Library, Embase, CNKI, Wanfang, VIP, CBM, and Airiti Library databases were searched for studies on SCD in older Chinese individuals published before May 2023. Two investigators independently screened the literature, extracted the information, and assessed the bias risk of the included studies. A meta-analysis was then conducted using Stata 16.0 software via a random-effects model to analyze SCD prevalence in older Chinese adults.

Results

A total of 17 studies were included (n = 31,782). The SCD prevalence in older Chinese adults was 46.4% (95% CI, 40.6-52.2%). Further, subgroup analyzes indicated that SCD prevalence was 50.8% in men and 58.9% among women. Additionally, SCD prevalence in individuals aged 60-69, 70-79, and ≥ 80 years was 38.0, 45.2, and 60.3%, respectively. Furthermore, SCD prevalence in older adults with BMI <18.5, 18.5-24.0, and > 24.0 was 59.3, 54.0, and 52.9%, respectively. Geographically, SCD prevalence among older Chinese individuals was 41.3% in North China and 50.0% in South China. In terms of residence, SCD prevalence was 47.1% in urban residents and 50.0% among rural residents. As for retired individuals, SCD prevalence was 44.2% in non-manual workers and 49.2% among manual workers. In the case of education, individuals with an education level of "elementary school and below" had an SCD prevalence rate of 62.8%; "middle school, "52.4%; "high school, "55.0%; and "college and above, "51.3%. Finally, SCD prevalence was lower among married individuals with surviving spouses than in single adults who were divorced, widowed, or unmarried.

Conclusion

Our systematic review and meta-analysis identified significant and widespread SCD prevalence in the older population in China. Therefore, our review findings highlight the urgent requirement for medical institutions and policymakers across all levels to prioritize and rapidly develop and implement comprehensive preventive and therapeutic strategies for SCD.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023406950, identifier: CRD42023406950.

Ketone bodies mediate alterations in brain energy metabolism and biomarkers of Alzheimer's disease

Alzheimer's disease (AD) is the most common form of dementia. AD is a progressive neurodegenerative disorder characterized by cognitive dysfunction, including learning and memory deficits, and behavioral changes. Neuropathology hallmarks of AD such as amyloid beta (Aβ) plaques and neurofibrillary tangles containing the neuron-specific protein tau is associated with changes in fluid biomarkers including Aβ, phosphorylated tau (p-tau)-181, p-tau 231, p-tau 217, glial fibrillary acidic protein (GFAP), and neurofilament light (NFL). Another pathological feature of AD is neural damage and hyperactivation of astrocytes, that can cause increased pro-inflammatory mediators and oxidative stress. In addition, reduced brain glucose metabolism and mitochondrial dysfunction appears up to 15 years before the onset of clinical AD symptoms. As glucose utilization is compromised in the brain of patients with AD, ketone bodies (KBs) may serve as an alternative source of energy. KBs are generated from the β-oxidation of fatty acids, which are enhanced following consumption of ketogenic diets with high fat, moderate protein, and low carbohydrate. KBs have been shown to cross the blood brain barrier to improve brain energy metabolism. This review comprehensively summarizes the current literature on how increasing KBs support brain energy metabolism. In addition, for the first time, this review discusses the effects of ketogenic diet on the putative AD biomarkers such as Aβ, tau (mainly p-tau 181), GFAP, and NFL, and discusses the role of KBs on neuroinflammation, oxidative stress, and mitochondrial metabolism.

Research Progress on Natural Plant Molecules in Regulating the Blood-Brain Barrier in Alzheimer's Disease

Alzheimer's disease (AD) is a prevalent neurodegenerative disorder. With the aging population and the continuous development of risk factors associated with AD, it will impose a significant burden on individuals, families, and society. Currently, commonly used therapeutic drugs such as Cholinesterase inhibitors, N-methyl-D-aspartate antagonists, and multiple AD pathology removal drugs have been shown to have beneficial effects on certain pathological conditions of AD. However, their clinical efficacy is minimal and they are associated with certain adverse reactions. Furthermore, the underlying pathological mechanism of AD remains unclear, posing a challenge for drug development. In contrast, natural plant molecules, widely available, offer multiple targeting pathways and demonstrate inherent advantages in modifying the typical pathologic features of AD by influencing the blood-brain barrier (BBB). We provide a comprehensive review of recent in vivo and in vitro studies on natural plant molecules that impact the BBB in the treatment of AD. Additionally, we analyze their specific mechanisms to offer novel insights for the development of safe and effective targeted drugs as well as guidance for experimental research and the clinical application of drugs for the prevention and treatment of AD.

Hippocampal glial inflammatory markers are differentially altered in a novel mouse model of perimenopausal cerebral amyloid angiopathy

Dementia is often characterized by age-dependent cerebrovascular pathology, neuroinflammation, and cognitive deficits with notable sex differences in risk, disease onset, progression and severity. Women bear a disproportionate burden of dementia, and the onset of menopause (i.e., perimenopause) may be a critical period conferring increased susceptibility. However, the contribution of early ovarian decline to the neuroinflammatory processes associated with cerebrovascular dementia risks, particularly at the initial stages of pathology that may be more amenable to proactive intervention, is unknown. To better understand the influence of early ovarian failure on dementia-associated neuroinflammation we developed a model of perimenopausal cerebral amyloid angiopathy (CAA), an important contributor to dementia. For this, accelerated ovarian failure (AOF) was induced by 4-vinylcyclohexene diepoxide (VCD) treatment to isolate early-stage ovarian failure comparable to human perimenopause (termed "peri-AOF") in transgenic SWDI mice expressing human vasculotropic mutant amyloid beta (Aβ) precursor protein, that were also tested at an early stage of amyloidosis. We found that peri-AOF SWDI mice showed increased astrocyte activation accompanied by elevated Aβ in select regions of the hippocampus, a brain system involved in learning and memory that is severely impacted during dementia. However, although SWDI mice showed signs of increased hippocampal microglial activation and impaired cognitive function, this was not further affected by peri-AOF. In sum, these results suggest that elevated dysfunction of key elements of the neurovascular unit in select hippocampal regions characterizes the brain pathology of mice at early stages of both CAA and AOF. However, neurovascular unit pathology may not yet have passed a threshold that leads to further behavioral compromise at these early periods of cerebral amyloidosis and ovarian failure. These results are consistent with the hypothesis that the hormonal dysregulation associated with perimenopause onset represents a stage of emerging vulnerability to dementia-associated neuropathology, thus providing a selective window of opportunity for therapeutic intervention prior to the development of advanced pathology that has proven difficult to repair or reverse.

Music Therapy Enhances Episodic Memory in Alzheimer's and Mixed Dementia: A Double-Blind Randomized Controlled Trial

Objective: This study aimed to assess whether a music therapy (MT) intervention could improve memory decline in older adults with and without cognitive impairment. A dual-retrieval model of episodic memory was employed to estimate memory processes. Methods: Forty-three older adults with a mean age of 76.49 years (n = 25 with Alzheimer's disease (AD) and mixed dementia, and n = 18 healthy older adults) were randomly selected for the experimental and control groups. The study design was a double-blind randomized controlled clinical trial and a certified music therapist delivered the MT. The primary outcomes were measures of working memory, episodic memory, and autobiographical memory. Results: In the primary outcome measures, MT effects were restricted to episodic memory measures like the Figure Memory Test of the BCSB and the Speech and Sing Memory Test. In both tests, the experimental group improved from pre-test to post-test in delayed recall, but in the Speech and Sing Memory Test, the improvement was restricted to the AD and mixed dementia group. MT had no effects on the secondary outcome measures. Conclusions: These findings suggest that a structured MT intervention can be promising for rehabilitating episodic memory in older adults with dementia.

Pharmacogenomics of Dementia: Personalizing the Treatment of Cognitive and Neuropsychiatric Symptoms

Dementia is a syndrome of global and progressive deterioration of cognitive skills, especially memory, learning, abstract thinking, and orientation, usually affecting the elderly. The most common forms are Alzheimer's disease, vascular dementia, and other (frontotemporal, Lewy body disease) dementias. The etiology of these multifactorial disorders involves complex interactions of various environmental and (epi)genetic factors and requires multiple forms of pharmacological intervention, including anti-dementia drugs for cognitive impairment, antidepressants, antipsychotics, anxiolytics and sedatives for behavioral and psychological symptoms of dementia, and other drugs for comorbid disorders. The pharmacotherapy of dementia patients has been characterized by a significant interindividual variability in drug response and the development of adverse drug effects. The therapeutic response to currently available drugs is partially effective in only some individuals, with side effects, drug interactions, intolerance, and non-compliance occurring in the majority of dementia patients. Therefore, understanding the genetic basis of a patient's response to pharmacotherapy might help clinicians select the most effective treatment for dementia while minimizing the likelihood of adverse reactions and drug interactions. Recent advances in pharmacogenomics may contribute to the individualization and optimization of dementia pharmacotherapy by increasing its efficacy and safety via a prediction of clinical outcomes. Thus, it can significantly improve the quality of life in dementia patients.

Uric acid levels and risk of cognitive impairment: Dose-response meta-analysis of prospective cohort studies

PURPOSE

Studying the effects of uric acid levels on cognitive function and quantifying the dose-response relationship.

METHODS

Based on PubMed and Embase search terms, we identified prospective cohort studies that included blood uric acid as a risk factor and cognitive impairment as a result up to September 2022. We extracted pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs).

RESULTS

Nine reports (including 488,915 participants and 5516 cognitive impairment cases) with median follow-up of 8.8-22 years were eligible for analyses. Compared with lowest category of blood uric acid concentration, the combined RR of cognitive impairment events in the highest classification was 0.81 (95% CI: 0.70-0.92, P < 0.001). Dose-response analysis of eight reports (including 484,297 participants and 5059 cognitive impairment cases) showed that there was no evidence of a curvilinear relationship between blood uric acid levels and cognitive impairment (P = 0.51 for nonlinear relationship). The summary RR of cognitive impairment for an increase of 1 mg/dL blood uric acid level was 0.98 (95% CI: 0.95-1.00; linear trend P = 0.07, I2 = 67.1%, heterogeneity P < 0.05). There was also a linear negative association between blood uric acid levels and cognitive impairment risk in the male subgroup analysis (RR = 0.97, 95% CI: 0.95-0.99, P < 0.05).

CONCLUSION

Levels of blood uric acid are not related to risk of cognitive impairment. A subgroup analysis shows that the rise in blood uric acid levels in the male population is related to a decreased risk of cognitive impairment. These results need to be confirmed by further studies.

Clozapine for the treatment of aggressiveness and agitation in advanced dementia

BACKGROUND

Distressing behavioural symptoms, particularly agitation and aggressiveness, remain a difficult problem in everyday clinical practice in the treatment of multimorbid patients with dementia. Clozapine may be an effective therapeutic alternative in this context.

METHODS

In a retrospective study, patients who had a diagnosis of dementia and had been treated in a specialized geriatric psychiatry unit with clozapine between August 2018 and February 2022 were included, and medical records were systematically reviewed. The Clinical Global Impressions Scale was used to assess improvement, and the Pittsburgh Agitation Scale for symptom reduction. In addition, side effects and clinical features were documented in detail.

RESULTS

A total of 31 patients (median age 82 years) were identified with a mean clozapine dose of 47.2 (SD 35.6) mg. A total of 13 patients tolerated clozapine very well, 10 showed tolerable side effects, and in 10 patients side effects were the reason for stopping clozapine. Behavioural symptoms improved significantly, as indicated by the assessment scores.

CONCLUSIONS

In summary, clozapine was effective and well tolerated in 23 patients, suggesting that low-dose clozapine may help to alleviate the suffering of difficult-to-treat multimorbid patients with advanced dementia and their caregivers. However, particular attention should be paid to adverse drug reactions, especially in patients with cardiovascular and pulmonary impairment.

Gastrointestinal biopsy of normal mucosa or nonspecific inflammation and risk of neurodegenerative disease: Nationwide matched cohort study

BACKGROUND AND PURPOSE

Evidence has accumulated to support the early involvement of altered gastrointestinal (GI) function in neurodegenerative disease. However, risk of Alzheimer disease (AD) and Parkinson disease (PD) among individuals with a GI biopsy of normal mucosa or nonspecific inflammation is unknown.

METHODS

This matched cohort study included all individuals in Sweden with a GI biopsy of normal mucosa (n = 480,346) or nonspecific inflammation (n = 655,937) during 1965-2016 (exposed group) as well as their individually matched population references and unexposed full siblings. A flexible parametric model and stratified Cox model were used to estimate hazard ratio (HR) and its 95% confidence interval (CI).

RESULTS

Individuals with normal mucosa or nonspecific inflammation had a higher risk of AD and PD during the 20 years after biopsy. Compared with the population references, individuals with normal mucosa had an increased risk of AD (incidence rate [IR] difference = 13.53 per 100,000 person-years, HR [95% CI] = 1.15 [1.11-1.20]) and PD (IR difference = 6.72, HR [95% CI] = 1.16 [1.10-1.23]). Elevated risk was also observed for nonspecific inflammation regarding AD (IR difference = 13.28, HR [95% CI] = 1.11 [1.08-1.14]) and PD (IR difference = 6.83, HR [95% CI] = 1.10 [1.06-1.14]). Similar results were observed in subgroup and sensitivity analyses and when comparing with their unexposed siblings.

CONCLUSIONS

Individuals with a GI biopsy of normal mucosa or nonspecific inflammation had an increased risk of AD and PD. This adds new evidence of the early involvement of GI dysfunction in neurodegenerative disease.

Effects of Dl-3-n-butylphthalide on cognitive functions and blood-brain barrier in chronic cerebral hypoperfusion rats

Vascular cognitive impairment (VCI) has been one of the major types of cognitive impairment. Blood-brain barrier damage plays an essential part in the pathogenesis of VCI. At present, the treatment of VCI is mainly focused on prevention, with no drug clinically approved for the treatment of VCI. This study aimed to investigate the effects of DL-3-n-butylphthalide (NBP) on VCI rats. A modified bilateral common carotid artery occlusion (mBCCAO) model was applied to mimic VCI. The feasibility of the mBCCAO model was verified by laser Doppler, 13N-Ammonia-Positron Emission Computed Tomography (PET), and Morris Water Maze. Subsequently, the Morris water maze experiment, Evans blue staining, and western blot of tight junction protein were performed to evaluate the effect of different doses of NBP (40 mg/kg, 80 mg/kg) on the improvement of cognitive impairment and BBB disruption induced by mBCCAO. Immunofluorescence was employed to examine the changes in pericyte coverage in the mBCCAO model and the effect of NBP on pericyte coverage was preliminarily explored. mBCCAO surgery led to obvious cognitive impairment and the decrease of whole cerebral blood flow, among which the blood flow in the cortex, hippocampus and thalamus brain regions decreased more significantly. High-dose NBP (80 mg/kg) improved long-term cognitive function in mBCCAO rats, alleviated Evans blue leakage and reduced the loss of tight junction proteins (ZO-1, Claudin-5) in the early course of the disease, thereby exerting a protective effect on the blood-brain barrier. No significant changes in pericyte coverage were observed after mBCCAO. High-dose NBP improved cognitive function in mBCCAO rats. High-dose NBP protected the integrity of BBB by upregulating TJ protein expression, rather than regulating pericyte coverage ratio. NBP could be a potential drug for the treatment of VCI.

The Challenges of Pain Assessment in Geriatric Patients With Dementia: A Review

Pain in dementia patients is common, poorly measured, and undertreated. It is important to discuss the challenges in the pain assessment and management to find a possible solution for adequate pain management. The aim of this article is to discuss the challenges in the assessment of pain in geriatric patients with dementia. An extensive online database search was conducted via multiple websites using the following keywords: "dementia," "pain assessments," "pain assessment with dementia," "causes of pain with dementia," "pain assessments using recent technology," "geriatric," and "old age" to identify the relevant articles. Our inclusion criteria were articles that focused on pain in geriatric patients diagnosed with dementia, in English, published between January 2018 and January 2023, and available as free full text and those which were clinical trials, observational studies, review articles, systemic reviews, meta-analysis, or case series. The exclusion criteria were articles that did not have pain in geriatric patients diagnosed with dementia as their primary focus, involving geriatric or non-geriatric patients with major psychological distress, not in the English language, not published between January 2018 and January 2023, and not available as free full-text and those which were case reports and editorial articles. After manually excluding the articles that did not meet our inclusion criteria, we ended up with 38 articles. In conclusion, any instruments have been made for the pain assessment in patients with dementia. The two most common tools used to assess pain in this vulnerable population are the Pain Assessment in Advanced Dementia (PAINAD) and Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) scales. The utilization of new technology may offer promising solutions for the pain assessment in patients with dementia.