Associations Between Midlife Vascular Risk Factors and 25-Year Incident Dementia in the Atherosclerosis Risk in Communities (ARIC) Cohort

Association of Cardiovascular-Kidney-Metabolic Syndrome With Cognitive Decline and Dementia: The ARIC Study Insights

BACKGROUND

Cardiovascular-kidney-metabolic (CKM) syndrome is an emerging clinical entity emphasizing the need for a holistic approach to patient care. The relationship between CKM syndrome and cognitive decline or dementia remains undetermined.

METHODS

A total of 10 426 participants in the ARIC (Atherosclerosis Risk in Communities) study, classified into 4 CKM risk categories at baseline (visit 2: 1990-1992): low risk (≤5%), borderline risk (5%-7.4%), intermediate risk (7.5%-19.9%), and high risk (≥20%), were used to investigate the associations between CKM risk and cognitive decline or dementia using regression analysis.

RESULTS

Elevated CKM risk level is significantly associated with increased risks of cognitive decline and dementia incidence. Each 1-unit increase in CKM risk level is linked to a 6% higher risk of dementia progression in the fully adjusted model.

CONCLUSIONS

These findings highlight a strong association between CKM syndrome and cognitive decline or incident dementia, underscoring the importance of early interventions.

Association of Body Mass Index in Late Life, and Change from Midlife to Late Life, With Incident Dementia in the ARIC Study Participants

BACKGROUND AND OBJECTIVES

Midlife obesity is a risk factor of dementia, but late-life obesity has been associated with lower dementia risk. We investigated this paradox by exploring the relationship between late-life body mass index (BMI) category and dementia, with and without considering midlife to late-life BMI change.

METHODS

This observational cohort study included participants of the community-based Atherosclerosis Risk in Communities (ARIC) study who were dementia-free at visit 5 (2011-2013). Dementia was ascertained by expert-adjudicated, algorithmic classification from an in-person neuropsychological battery, as well as telephone interviews and International Classification of Diseases codes from medical records. We first assessed the association of incident dementia with visit 5 BMI categories (normal weight, overweight, obese). Next, we used a cross-classification of visit 5 BMI categories with visit 4-visit 5 BMI change (decrease [loss of ≥2 kg/m2], increase [gain of ≥2 kg/m2], or stable [loss or gain of <2 kg/m2]) occurring during the 15 years before baseline. Cox regression was used.

RESULTS

A total of 5,129 participants were included in the study (59% female; 22% identified as Black; mean (standard deviation) age at visit 5 of 75 (5) years). Over 8 years of follow-up, 20% of the sample developed dementia (n = 1,026). After covariate adjustment, participants with high late-life BMI had a lower risk of dementia; the hazard ratio (95% CI) was 0.86 (0.73-1.00) for overweight and 0.81 (0.68-0.96) for obesity. In stratified models, elevated dementia risk was observed only for participants of each late-life BMI category whose BMI had decreased from midlife to late life. Compared with normal-weight individuals who had maintained BMI from midlife to late life, the hazard ratio (95% CI) for those with BMI loss was 2.08 (1.62-2.67) for normal-weight individuals, 1.62 (1.25-2.10) for those with overweight, and 1.36 (1.00-1.85) for those with obesity.

DISCUSSION

Our results provide insight into the dementia obesity paradox at older ages, tempering a causal interpretation of high late-life BMI as protective against dementia. Instead, they highlight the importance of considering weight loss from midlife to late life in conjunction with late-life BMI in dementia risk stratification.

Sleep timing, sleep timing regularity, and cognitive performance in women entering late adulthood: the Study of Women's Health Across the Nation (SWAN)

STUDY OBJECTIVES

This study examined whether sleep timing and its regularity are associated with cognitive performance in older women and whether associations vary based on cardiometabolic risk factors.

METHODS

The cross-sectional analysis included 1177 community-dwelling females (mean age 65 years) from the observational Study of Women's Health Across the Nation (SWAN) annual visit 15. Sleep timing (mean midpoint from sleep onset to wake-up) and its regularity (standard deviation of midpoint) were assessed using actigraphy. Cognitive measures included immediate and delayed verbal memory, working memory, and processing speed. Cardiometabolic risk measures included central obesity, hypertension, diabetes, and the Atherosclerotic Cardiovascular Disease (ASCVD) risk score. Linear regression models, adjusted for covariates, tested associations between sleep and cognitive measures.

RESULTS

After covariate adjustment, early sleep timing was associated with worse delayed verbal memory (β = -0.37; p = .047) and late sleep timing was associated with worse processing speed (β = -1.80; p = .008). Irregular sleep timing was associated with worse immediate (β = -0.29; p = .020) and delayed verbal memory (β = -0.36; p = .006), and better working memory (β = 0.50; p = .004). Associations between early sleep timing and delayed verbal memory strengthened as ASCVD risk increased (interaction β = -8.83, p = .026), and sleep timing irregularity's effect on working memory was stronger among women with hypertension (interaction β = -3.35, p = .039).

CONCLUSIONS

Sleep timing and its regularity are concurrently associated with cognitive performance in older women. Cardiovascular disease risk may modify some of these associations. Future longitudinal studies are needed to clarify these relationships.

Vascular and glymphatic dysfunction as drivers of cognitive impairment in Alzheimer's disease: Insights from computational approaches

Alzheimer's disease (AD) is driven by complex interactions between vascular dysfunction, glymphatic system impairment, and neuroinflammation. Vascular aging, characterized by arterial stiffness and reduced cerebral blood flow (CBF), disrupts the pulsatile forces necessary for glymphatic clearance, exacerbating amyloid-beta (Aβ) accumulation and cognitive decline. This review synthesizes insights into the mechanistic crosstalk between these systems and explores their contributions to AD pathogenesis. Emerging machine learning (ML) tools, such as DeepLabCut and Motion sequencing (MoSeq), offer innovative solutions for analyzing multimodal data and enhancing diagnostic precision. Integrating ML with imaging and behavioral analyses bridges gaps in understanding vascular-glymphatic dysfunction. Future research must prioritize these interactions to develop early diagnostics and targeted interventions, advancing our understanding of neurovascular health in AD.

Multisystem failure, tipping points, and risk of Alzheimer's disease

INTRODUCTION

Medical conditions including obesity, diabetes, hyperlipidemia, and depression significantly increased risk of Alzheimer's disease (AD). However, effect of their duration, influenced by non-modifiable factors like chromosomal sex and apolipoprotein E (APOE) genotype, remains unclear.

METHODS

Data from 5644 UKBiobank participants were analyzed using Cox regression model to identify critical tipping points based on age of onset, risk factor (RF) duration and their interaction with sex and APOE genotype.

RESULTS

Hypertension or diabetes before age 62 exerted greater AD risk than APOEε4 alone. Obesity before age 62 increased AD risk by 54%, with the risk nearly tripling between ages 62-72. Hyperlipidemia and depression were associated with age-independent risk increases of 33% and 69%, respectively. After age 72, APOEε4 became the dominant RF.

DISCUSSION

Duration of AD-risk-factors can have a greater impact than APOEε4. Identification of critical age-related tipping points highlights temporal dynamics of AD progression and role of multisystem failure in AD progression.

HIGHLIGHTS

AD risk factors impact AD onset, especially diagnosed between ages 62 and 72. Later diagnoses of hypertension, diabetes, and obesity delayed AD onset. Hyperlipidemia and depression increased AD risk by 33% and 69%, age-independent. APOEε4 carriers regardless of sex exhibited a higher risk increasing with age. Trajectories differed between APOEε4 carriers and non-carriers across sex.

Type 2 diabetes and late-onset Alzheimer's disease and related dementia: A longitudinal cohort study integrating polygenic risk score

BackgroundThe inherent genetic effects were not established between type 2 diabetes (T2DM) and Alzheimer's disease and related dementia (ADRD).ObjectiveWe aimed to investigate the association between T2DM and ADRD by integrating T2DM polygenic risk score (PRS) and applying matching in every subgroup.MethodsWe utilized UK Biobank First-occurrences datasets. T2DM were 1:1 matched to non-T2DM using propensity scores generated by 8 covariates; age at diagnosis, sex, cerebrovascular disease, ischemic heart disease, hypertensive disorders, lipid disorders, obesity, and mood disorders. T2DM PRS was additionally matched in T2DM PRS matched analysis. Subgroup analyses by age at diagnosis, sex, and APOE4 genotype were performed with the same matching criteria within each subgroup. Cox proportional hazard and Fine & Gray competing risk model were utilized.ResultsIn T2DM PRS unmatched cohort, 24,583 T2DM were 1:1 matched to non-T2DM. The mean age at diagnosis was around 62 years old, with females constituting around 40%. Up to 25-year follow-up, ADRD rate/1000 person-years was 0.88 versus 1.52 (Non-T2DM versus T2DM); PRS unmatched (cHR: 1.72, 95% CI: 1.46-2.03) and matched (cHR:1.75, 95% CI: 1.47-2.09). Except for older age onset (≥75 years), the other subgroups demonstrated significantly increased ADRD risks in T2DM. T2DM PRS was higher in non-ADRD group across all subgroups. Contrarily, T2DM PRS was higher in ADRD in younger onset group (<55 years).ConclusionsT2DM is one of the strong risk factors of ADRD but genetic T2DM effect does not contribute to ADRD risk. However, a genetic link might be present in younger age onset group.

Cerebral small vessel disease and cognitive dysfunction in relation to central systolic blood pressure

BACKGROUND

Higher blood pressure (BP) is closely associated with cerebral small vessel disease (CSVD) and poor cognition. However, little is known about the association of CSVD and cognitive dysfunction with central BP.

METHODS

In 1447 participants (59.3 % women; mean age, 76.0 years) enrolled in the Atherosclerosis Risk in Communities (ARIC) study, we investigated the associations of MRI-defined CSVD, characterized by log-transformed white matter hyperintensity volumes (log-WMHv), and the presence of lacunar infarct, lobar and subcortical microhemorrhages, and cognitive function determined by the Mini Mental State Examination score with per 1-SD increment in central systolic BP (cSBP) derived by applanation tonometry. The model performance was assessed by the area under the receiver operating characteristic curve (AUC).

RESULTS

After adjusted for potential confounders, cSBP was associated with log-WMHv (β, 0.031; p = 0.003) and lobar (OR, 1.58; p < 0.001) and subcortical microhemorrhages (OR, 1.20; p = 0.011). Adding cSBP to the base model enhanced the model performance for the risk of lobar microhemorrhages (p = 0.042), while AUC did not statistically increase with the addition of peripheral SBP (p = 0.49). Irrespective of adjustments, the associations of cSBP with CSVD markers and cognitive dysfunction were much stronger for Blacks compared with Whites. Incorporating cSBP into the base model significantly improved AUC from 0.63 to 0.68 (p = 0.042) for subcortical microhemorrhages in Blacks.

CONCLUSION

cSBP was associated with CSVD and cognition impairment. Our observations highlight that cSBP may help further investigation for the prevention strategies of CSVD.

Blood pressure and the brain: the conundrum of hypertension and dementia

As the population ages, the anticipated rates of dementia worldwide are likely to increase dramatically, especially in low- and middle-income countries; thus, any opportunity to modify dementia risk is especially critical. Hypertension is one risk factor that is highly prevalent, consistently important for late-life brain health, and which could represent a target for prevention of dementia. Furthermore, hypertension is the most significant modifiable risk factor for stroke. This review will summarize existing literature linking hypertension with dementia and brain health more broadly, will discuss potential mechanisms linking hypertension with brain health, and will consider specific factors that may impact not only the relationship between hypertension and the brain but also the importance of treatment, including different associations over the life course.

Bioactive compounds and dietary patterns in Alzheimer's disease

Alzheimer's disease (AD) is a progressive neurodegenerative disorder that primarily affects the elderly, leading to severe cognitive decline and loss of autonomy. The accumulation of amyloid-β peptides and tau proteins in the brain is considered the central pathogenic mechanism, which results in neuronal dysfunction and cell death. Various metabolic disruptions, such as chronic oxidative stress and inflammatory processes, further exacerbate the progression of AD. This review, based on literature from PubMed, SciELO, MDPI, and ScienceDirect, evaluates the role of bioactive compounds and dietary patterns, specifically the Mediterranean and MIND diets, in mitigating the progression of AD. These diets, rich in vitamins, flavonoids, carotenoids, and omega-3 fatty acids, have shown potential in reducing oxidative damage and inflammation in the brain, offering neuroprotective benefits. The findings suggest that bioactive compounds such as vitamin E isomers and polyphenols may delay cognitive decline, presenting a promising avenue for future dietary interventions aimed at optimizing the consumption of these compounds to prevent or slow the onset of AD. Further research is needed to determine the optimal doses and combinations of these bioactive compounds to maximize their protective effects.

Cerebromicrovascular senescence in vascular cognitive impairment: does accelerated microvascular aging accompany atherosclerosis?

Vascular cognitive impairment (VCI) is a leading cause of age-related cognitive decline, driven by cerebrovascular dysfunction and cerebral small vessel disease (CSVD). Emerging evidence suggests that cerebromicrovascular endothelial senescence plays an important role in the pathogenesis of VCI by promoting cerebral blood flow dysregulation, neurovascular uncoupling, blood-brain barrier (BBB) disruption, and the development of cerebral microhemorrhages (CMHs). This review explores the concept of cerebromicrovascular senescence as a continuum of vascular aging, linking macrovascular atherosclerosis with microvascular dysfunction. It examines the mechanisms by which endothelial senescence drives neurovascular pathology and highlights the impact of cardiovascular risk factors in accelerating these processes. We examine preclinical and clinical studies that provide compelling evidence that atherosclerosis-induced microvascular senescence exacerbates cognitive impairment. In particular, findings suggest that targeting senescent endothelial cells through senolytic therapy can restore cerebrovascular function and improve cognitive outcomes in experimental models of atherosclerosis. Given the growing recognition of microvascular senescence as a therapeutic target, further research is warranted to explore novel interventions such as senolytics, anti-inflammatory agents, and metabolic modulators. The development of circulating biomarkers of vascular senescence (e.g., senescence-associated secretory phenotype [SASP] components and endothelial-derived extracellular vesicles) could enable early detection and risk stratification in individuals at high risk for VCI. Additionally, lifestyle modifications, including the Mediterranean diet, hold promise for delaying endothelial senescence and mitigating cognitive decline. In conclusion, cerebromicrovascular senescence is a key mechanistic link between atherosclerosis and cognitive impairment. Addressing microvascular aging as a modifiable risk factor through targeted interventions offers a promising strategy for reducing the burden of VCI and preserving cognitive function in aging populations.

Plasma Proteins Associated with the Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) Diet and Incident Dementia

BACKGROUND

The Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) diet slows cognitive decline and protects brain health, but the mechanisms are poorly understood.

OBJECTIVES

We aimed to determine the plasma proteins associated with the MIND diet score and their ability to predict incident dementia in the Atherosclerosis Risk in Communities study.

METHODS

We analyzed 10,230 Black and White participants at visit 3 (1993-1995) with food frequency questionnaire and proteomics data and randomly divided them into discovery (n = 6850) and replication (n = 3380) samples. We examined associations between the MIND diet score and 4955 proteins using multivariable linear regression and elastic net regression. C-statistics were calculated to assess if proteins improved the prediction of high MIND diet adherence beyond participant characteristics. Cox proportional hazards models were used to assess associations between significant diet-related proteins and incident dementia over 2 decades. C-statistics assessed the ability of significant proteins to improve dementia prediction beyond known risk factors.

RESULTS

Of 316 proteins associated with the MIND diet score in the discovery sample at a false discovery rate <0.05, 62 were internally replicated. Of these, 21 proteins selected by the elastic net individually improved MIND diet score prediction. After a median follow-up of 21 y, there were 2311 dementia cases. Five diet-related proteins, thrombospondin-2 [hazard ratio (HR): 1.19; 95% confidence interval (CI): 1.11, 1.29], protein ABHD14A (HR: 1.23; 95% CI: 1.11, 1.37), structural maintenance of chromosomes protein 3 (HR: 1.19; 95% CI: 1.08, 1.31), epidermal growth factor receptor (HR: 0.68; 95% CI: 0.53, 0.86), and interleukin-12 subunit beta (HR: 1.14; 95% CI: 1.05, 1.25) were significantly associated with incident dementia. All 5 proteins individually and together improved the prediction of dementia risk.

CONCLUSIONS

Using high-throughput proteomics, we identified candidate biomarkers of the MIND diet score and incident dementia, which are implicated in neural signaling, angiogenesis, and anti-inflammatory pathways.

Modifiable and Non-Modifiable Risk Factors for Dementia Among Non-Hispanic White and Black Populations Aged 50-64 in the United States, 2006-2016

BACKGROUND AND OBJECTIVES

Non-Hispanic Black populations (NHB) have a significantly higher prevalence of dementia than non-Hispanic Whites in the U.S., and the underlying risk factors may play a role in this racial disparity. We aimed to calculate risk scores for dementia among non-Hispanic White (NHW) and non-Hispanic Black populations aged 50-64 years over a period of 10 years, and to estimate potential differences of scores between NHW and NHB.

RESEARCH DESIGN AND METHODS

The Health and Retirement Study from 2006 to 2016 was used to calculate the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) risk score, a validated score for predicting dementia risk. Weighted average CAIDE score, as well as CAIDE score for modifiable factors hypertension, obese, hypercholesterolemia, physical inactivity), and non-modifiable factors (age, sex, education) were calculated for adults aged 50-64 years with normal cognition for 2006-2008, 2010-2012, 2014-2016. The associations of race with CAIDE score and elevated CAIDE score were examined.

RESULTS

A total of 10,871 participants were included in the analysis. The CAIDE score showed declining trends for NHB from 2006 to 2016, while NHB consistently had a higher total CAIDE score and CAIDE score for modifiable factors from 2006 to 2016, but not for non-modifiable factors.

DISCUSSION AND IMPLICATIONS

NHB had a higher level of dementia risk factors than NHW among adults aged 50-64 years in the U.S. from 2006 to 2016, and the difference is attributable to modifiable risk factors, which holds promise for risk reduction of dementia.

Cholinesterase inhibitors and reduced risk of hospitalization and mortality in patients with Alzheimer's dementia and heart failure

AIMS

Cholinesterase inhibitors (ChEIs) have beneficial effects on the heart. Associations between ChEI-use and reduced mortality and cardiovascular events in Alzheimer's disease (AD) have been shown. Whether these associations exist in those with both heart failure (HF) and AD is unknown.

METHODS AND RESULTS

A propensity score (PS) matched cohort with patients with HF and AD was obtained through linking registers for cognitive/dementia disorders, comorbidities, drug prescription, and death, in Sweden, to analyse associations between ChEI-use and risk of mortality or hospitalization for HF, stroke, or myocardial infarction, were examined. In 455 patients with and 455 without ChEI treatment, ChEI use was associated with reductions of mortality and hospitalization due to HF by 21% [0.79; (confidence interval) CI 0.66-0.96] and 47% (0.53; CI 0.38-0.75), respectively. Donepezil and galantamine but not rivastigmine were associated with a lower risk of death compared with non-users. Donepezil was associated with a lower risk of hospitalization due to HF compared with non-users. There was no significant difference in hospitalization for bradycardia, AV block, or implantation of pacemaker between ChEI use and non-use.

CONCLUSION

This study suggests that in persons with HF and AD, treatment with ChEIs is associated with improved survival and a decreased risk of hospital care for HF, but results due to the type of ChEI vary.

Guidance for Prescribing Oral Antihypertensive Medications in the Emergency Department

PURPOSE OF REVIEW

To review the most current recommendations regarding assessment and treatment of asymptomatic hypertension treatment in the emergency department (ED) and to provide guidance for prescribing oral antihypertensive therapy for ED providers.

RECENT FINDINGS

There are varying management strategies for the treatment of asymptomatic hypertension in the ED likely due to a lack of direct guidelines for treatment. There is an increasing body of evidence for the safety of initiating therapy to treat chronic asymptomatic hypertension in the ED. Initiation and optimization of oral antihypertensive therapy in indicated patients can be done by ED providers to enhance and expediate transition of care for patients and can ultimately aid in prevention of cardiovascular disease (CVD). This review provides guidance of when oral antihypertensive therapy can be initiated, medication options depending on the patient's blood pressure and other concurrent medications (if applicable), as well as other factors that may influence choice of therapy are described. Oral antihypertensive therapies can be initiated and optimized in the ED for patients with asymptomatic chronic hypertension.

Proteomics-based aging clocks in midlife and late-life and risk of dementia

Background

Biological age can be quantified by composite proteomic scores, called aging clocks. We investigated whether biological age acceleration (a discrepancy between chronological and biological age) in midlife and late-life is associated with cognitive function and risk of dementia.

Methods

We used two population-based cohort studies: Atherosclerosis Risk in Communities (ARIC) Study and Multi-Ethnic Study of Atherosclerosis (MESA). Proteomics-based aging clocks (PACs) were created in ARIC at midlife (mean age: 58 years, n=11,758) and late-life (mean age: 77 years, n=4,934) using elastic net regression models in two-thirds of dementia-free participants and validated in the remaining one-third of participants. Age acceleration (AA) was calculated as residuals after regressing PACs on chronological age. We validated the midlife PAC in the MESA cohort (mean age: 62 years, n=5,829). We used multivariable linear and Cox proportional hazards regression to assess the association of AA with cognitive function and dementia incidence, respectively.

Results

In ARIC, every five years AA was associated with lower global cognitive function: difference: -0.11, 95% confidence interval (CI): -0.16, -0.06) using midlife AA and difference: -0.17, CI: -0.23, -0.12 using late-life AA. Consistently, midlife AA was associated with higher risk of dementia (hazard ratio [HR]: 1.20 [CI: 1.04, 1.36]) and more prominently when using late-life AA (HR: 2.14 [CI:1.67, 2.73]). Similar findings were observed in the MESA study: every five years AA was associated with lower global cognitive function (difference: -0.08 [CI: -0.14, -0.03]) and higher risk of dementia (HR:1.23 [CI: 1.04, 1.46]).

Conclusion

Accelerated biological age - as defined by the plasma proteome - is associated with lower cognitive function and predicts a higher risk of dementia in midlife and more prominently in late-life.

The role of the Mediterranean diet in reducing the risk of cognitive impairement, dementia, and Alzheimer's disease: a meta-analysis

Age-related cognitive impairment and dementia pose a significant global health, social, and economic challenge. While Alzheimer's disease (AD) has historically been viewed as the leading cause of dementia, recent evidence reveals the considerable impact of vascular cognitive impairment and dementia (VCID), which now accounts for nearly half of all dementia cases. The Mediterranean diet-characterized by high consumption of fruits, vegetables, whole grains, fish, and olive oil-has been widely recognized for its cardiovascular benefits and may also reduce the risk of cognitive decline and dementia. To investigate the protective effects of the Mediterranean diet on cognitive health, we conducted a systematic literature review using PubMed, Web of Science, and Google Scholar, focusing on studies published between 2000 and 2024. The studies included in the meta-nalysis examined the adherence to the Mediterranean diet and the incidence of dementia and AD. We applied a random-effects model to calculate pooled hazard ratios (HRs) with 95% confidence intervals (CIs) and assessed heterogeneity through I-square statistics. Forest plots, funnel plots, and Z-score plots were used to visualize study outcomes. Of the 324 full-text records reviewed, 23 studies met the inclusion criteria. The combined HR for cognitive impairment among those adhering to the Mediterranean diet was 0.82 (95% CI 0.75-0.89); for dementia, the HR was 0.89 (95% CI 0.83-0.95); and for AD, the HR was 0.70 (95% CI 0.60-0.82), indicating substantial protective effects. Significant heterogeneity was observed across studies, though Z-score plots suggested sufficient sample sizes to support reliable conclusions for each condition. In conclusion, this meta-analysis confirms that adherence to the Mediterranean diet is associated with an 11-30% reduction in the risk of age-related cognitive disorders, including cognitive impairment, dementia, and AD. These findings underscore the Mediterranean diet's potential as a central element in neuroprotective public health strategies to mitigate the global impact of cognitive decline and dementia and to promote healthier cognitive aging.

Lifetime history of gestational diabetes and cognitive function in parous women in midlife

AIMS/HYPOTHESIS

We aimed to determine whether a history of gestational diabetes mellitus (GDM) is associated with cognitive function in midlife.

METHODS

We conducted a secondary data analysis of the prospective Nurses' Health Study II. From 1989 to 2001, and then in 2009, participants reported their history of GDM. A subset participated in a cognition sub-study in 2014-2019 (wave 1) or 2018-2022 (wave 2). We included 15,906 parous participants (≥1 birth at ≥18 years) who completed a cognitive assessment and were free of CVD, cancer and diabetes before their first birth. The primary exposure was a history of GDM. Additionally, we studied exposure to GDM and subsequent type 2 diabetes mellitus (neither GDM nor type 2 diabetes, GDM only, type 2 diabetes only or GDM followed by type 2 diabetes) and conducted mediation analysis by type 2 diabetes. The outcomes were composite z scores measuring psychomotor speed/attention, learning/working memory and global cognition obtained with the Cogstate brief battery. Mean differences (β and 95% CI) in cognitive function by GDM were estimated using linear regression.

RESULTS

The 15,906 participants were a mean of 62.0 years (SD 4.9) at cognitive assessment, and 4.7% (n=749) had a history of GDM. In models adjusted for age at cognitive assessment, race and ethnicity, education, wave of enrolment in the cognition sub-study, socioeconomic status and pre-pregnancy characteristics, women with a history of GDM had lower performance in psychomotor speed/attention (β -0.08; 95% CI -0.14, -0.01) and global cognition (β -0.06; 95% CI -0.11, -0.01) than those without a history of GDM. The lower cognitive performance in women with GDM was only partially explained by the development of type 2 diabetes.

CONCLUSIONS/INTERPRETATION

Women with a history of GDM had poorer cognition than those without GDM. If replicated, our findings support future research on early risk modification strategies for women with a history of GDM as a potential avenue to decrease their risk of cognitive impairment.

Target Trial Emulation Using Cohort Studies: Estimating the Effect of Antihypertensive Medication Initiation on Incident Dementia

BACKGROUND

Observational studies link high midlife systolic blood pressure to increased dementia risk. However, the synthesis of evidence from randomized controlled trials has not definitively demonstrated that antihypertensive medication use reduces dementia risk. Here, we emulate target trials of antihypertensive medication initiation on incident dementia using three cohort studies, with attention to potential violations of necessary assumptions.

METHODS

We emulated trials of antihypertensive medication initiation on incident dementia using data from the Atherosclerosis Risk in Communities study, Cardiovascular Health Study, and Health and Retirement Study. We used data-driven methods to restrict participants to initiators and noninitiators with overlap in propensity scores and positive control outcomes to look for violations of positivity and exchangeability assumptions.

RESULTS

Analyses were limited by the small number of cohort participants who met eligibility criteria. Associations between antihypertensive medication initiation and incident dementia were inconsistent and imprecise (Atherosclerosis Risk in Communities: HR = 0.30 [0.05, 1.93]; Cardiovascular Health Study: HR = 0.66 [0.27, 1.64]; Health and Retirement Study: HR = 1.09 [0.75, 1.59]). More stringent propensity score restrictions had little effect on findings. Sensitivity analyses using a positive control outcome unexpectedly suggested antihypertensive medication initiation increased the risk of coronary heart disease in all three samples.

CONCLUSIONS

Positive control outcome analyses suggested substantial residual confounding in effect estimates from our target trials, precluding conclusions about the impact of antihypertensive medication initiation on dementia risk through target trial emulation. Formalized processes for identifying violations of necessary assumptions will strengthen confidence in target trial emulation and avoid inappropriate confidence in emulated trial results.

Diets to promote healthy brain ageing

Diet is a modifiable lifestyle factor with a proven role in cardiovascular disease risk reduction that might also play an important part in cognitive health. Evidence from observational studies has linked certain healthy dietary patterns to cognitive benefits. However, clinical trials of diet interventions have demonstrated either null or, at best, small effects on cognitive outcomes. In this Review, we summarize the currently available evidence from observational epidemiology and clinical trials regarding the potential role of diet in the prevention of cognitive decline and dementia. We further discuss possible methodological limitations that might have hindered the ability of previous diet intervention trials to capture potential neuroprotective effects. Considering the overwhelming and continuously expanding societal, economic and health-care burden of Alzheimer disease and other dementias, future nutritional research must address past methodological challenges to accurately and reliably inform clinical practice guidelines and public health policies. Within this scope, we provide a roadmap for future diet intervention trials for dementia prevention. We discuss study designs involving both intensive personalized interventions - to evaluate pharmacokinetic and pharmacodynamic properties, establish neuroprotective thresholds, and test hypothesized biological mechanisms and effects on brain health and cognition through sensitive and precise biomarker measures - and large-scale, pragmatic public health interventions to study population-level benefits.

Canadian Stroke Best Practice Recommendations: Vascular cognitive impairment, 7th edition practice guidelines update, 2024

The Canadian Stroke Best Practice Recommendations (CSPR) 7th edition includes this new module on the diagnosis and management of vascular cognitive impairment (VCI) with or without neurodegenerative disease. An expert writing group and people with VCI lived experience (PWLE) reviewed current evidence. Existing recommendations were reviewed and revised, and new recommendations added. Sections include definitions, signs and symptoms, screening, assessment, diagnosis, pharmacological and non-pharmacological management, secondary prevention, rehabilitation, and end-of-life care. PWLE were actively involved in all aspects of the development, ensuring their experiences are integrated. A unique VCI journey map, developed by PWLE, is included, and helped to motivate and anchor the recommendations. We encourage it to be displayed across healthcare settings to raise awareness and support persons with VCI. These VCI CSBPRs emphasize the need for integrated multidisciplinary care across the continuum. Evidence for the diagnosis and management of VCI continues to emerge and gaps in knowledge should drive future research. HIGHLIGHTS: This Canadian Stroke Best Practice Recommendations module focuses specifically on VCI using a structured framework and validated methodology. A comprehensive set of evidence-based recommendations is presented that addresses the continuum from symptom onset to diagnosis, management, and end of life. The recommendations consider individuals who experience VCI because of stroke or because of other vascular pathologies such as atrial fibrillation or heart failure. A journey map of an individual's experience with VCI has been developed by individuals with lived experience. It is a valuable guide to inform educational content, approaches to caring for individuals and families with VCI, and systems planning.

Standardization and clinical applications of retinal imaging biomarkers for cardiovascular disease: a Roadmap from an NHLBI workshop

The accessibility of the retina with the use of non-invasive and relatively low-cost ophthalmic imaging techniques and analytics provides a unique opportunity to improve the detection, diagnosis and monitoring of systemic diseases. The National Heart, Lung, and Blood Institute conducted a workshop in October 2022 to examine this concept. On the basis of the discussions at that workshop, this Roadmap describes current knowledge gaps and new research opportunities to evaluate the relationships between the eye (in particular, retinal biomarkers) and the risk of cardiovascular diseases, including coronary artery disease, heart failure, stroke, hypertension and vascular dementia. Identified gaps include the need to simplify and standardize the capture of high-quality images of the eye by non-ophthalmic health workers and to conduct longitudinal studies using multidisciplinary networks of diverse at-risk populations with improved implementation and methods to protect participant and dataset privacy. Other gaps include improving the measurement of structural and functional retinal biomarkers, determining the relationship between microvascular and macrovascular risk factors, improving multimodal imaging 'pipelines', and integrating advanced imaging with 'omics', lifestyle factors, primary care data and radiological reports, by using artificial intelligence technology to improve the identification of individual-level risk. Future research on retinal microvascular disease and retinal biomarkers might additionally provide insights into the temporal development of microvascular disease across other systemic vascular beds.

Informing etiological heterogeneity of mild cognitive impairment and risk for progression to dementia with plasma p-tau217

BACKGROUND

Mild cognitive impairment (MCI) is a clinical diagnosis representing early symptom changes with preserved functional independence. There are multiple potential etiologies of MCI. While often presumed to be related to Alzheimer's disease (AD), other neurodegenerative and non-neurodegenerative causes are common. Wider availability of relatively non-invasive plasma AD biomarkers, such as p-tau217, can provide invaluable insights into MCI clinico-pathology and the associated implications for symptom etiology, prognosis (e.g., risk for progression to dementia), and treatment options.

OBJECTIVES

The main goal of this study was to evaluate differences between individuals with MCI with and without plasma p-tau217 biomarker evidence of AD (MCIAD+ and MCIAD-) as well as a control group of clinically normal older adults with negative AD biomarkers (CNAD-). We evaluated group differences in demographics, recruitment, clinical scales, fluid biomarkers, and brain imaging. We further probed these factors as independent contributors to symptoms among MCIAD- participants, for whom symptom etiology is most poorly understood. Lastly, in a subset of participants followed longitudinally, we investigated how these factors related to odds of clinical progression to dementia.

DESIGN

We conducted an observational cross-sectional and longitudinal clinical research study. Study groups were compared cross-sectionally on demographics, recruitment, clinical measures, and biomarkers (chi square analyses, analyses of covariance). Contributors to functional changes were evaluated with multiple linear regression. Factors associated with the odds of progression from MCI to dementia longitudinally were evaluated with binary logistic regression.

SETTING

1Florida Alzheimer's Disease Research Center.

PARTICIPANTS

Cross-sectional analyses included 378 older adults classified as CNAD- (N = 76, age 66.1 ± 7.2, 63.2% female, 23.7% non-Hispanic/White), MCIAD- (N = 198, age 68.9 ± 7.9, 51.5% female, 29.3% non-Hispanic/White), or MCIAD+ (N = 104, age 73.9 ± 7.4, 52.9% female, 49.0% non-Hispanic/White). Longitudinal analyses focused on 207 participants with MCI (68.5% of cross-sectional MCI sample) followed for an average of 3 years.

MEASUREMENTS

Demographics (age, sex, years of education, self-identified race and ethnicity, primary spoken language), National Alzheimer's Coordinating Center-defined clinical phenotypes (Clinically Normal, Impaired - Not MCI, Amnestic MCI, Nonamnestic MCI, Dementia), recruitment source (clinic-based versus community-based), genetics (APOE genotype), functional evaluation (Clinical Dementia Rating scale), global cognition (Mini Mental State Exam), vascular history (Vascular Burden Score), neuropsychiatric symptoms (NPI-Q Total score), plasma biomarkers (ALZPath p-tau217, Quanterix Simoa-based GFAP and NfL), and brain imaging (grey matter volume in select AD-relevant regions of interest, global white matter hyperintensity volume).

RESULTS

Among those with MCI, 104 (34.4%) had plasma biomarker evidence of AD. MCIAD+ participants were more frequently recruited from clinic-based settings than MCIAD- (74.8% vs. 47.5%, p<.001). Over half (51.5%) of MCIAD+ carried at least one APOE e4 allele compared to 26.6% of MCIAD- and 29.4% of CNAD- (p<.001). Both MCIAD+ (p<.001, Cohen's d = 0.93) and MCIAD- (p<.001, d = 0.75) reported more severe neuropsychiatric symptoms than CNAD. MCIAD+ had higher plasma GFAP and NfL than both MCIAD- (GFAP: p<.001, d = 0.88, NfL: p<.001, d = 0.86) and CNAD- (GFAP: p<.001, d = 0.80; NfL: p<.001, d = 0.89). For the AD signature region of interest, MCIAD+ had lower volume than both CNAD- (p<.001, d = 0.78) and MCIAD- (p=.018, d = 0.39). For the hippocampus, both MCIAD+ (p<.001, d = 0.87) and MCIAD- (p<.001, d = 0.64) had lower volume than CNAD-. Longitudinally, older age (OR=1.14 [1.06-1.22], p<.001), higher levels of p-tau217 (OR=10.37 [3.00-35.02], p<.001) and higher neuropsychiatric symptoms (OR=1.19 [1.02-1.39], p=.023) were associated with higher odds of progression to dementia.

CONCLUSIONS

MCI is etiologically heterogeneous. The presence of Alzheimer's pathology defined by elevated plasma p-tau217 in individuals with MCI significantly worsens prognosis. Neuropsychiatric symptoms may contribute to cognitive complaints and risk for progressive decline irrespective of AD pathology. Plasma p-tau217 can inform our understanding of base rates of different MCI phenotypes on a larger scale. As with other AD biomarkers, frequency of elevated plasma p-tau217 and odds of progression to dementia requires careful consideration of recruitment source (clinic- vs. community-based), especially across ethno-racially diverse older adults. Ongoing integration of emerging neurodegenerative disease biomarkers with detailed clinical evaluations will continue to improve treatment specificity and prognosis.

Plasma uric acid levels and risk of dementia in a population-based cohort study

BACKGROUND

Given the opposing properties of uric acid (UA), which are intracellular prooxidant action and extracellular antioxidant action, the association of circulating UA levels with dementia remains controversial. We aimed to ascertain whether both lower and higher plasma UA levels are associated with the risk of incident dementia among middle-aged and older population.

METHODS

1685 participants (530 men and 1155 women) aged 40-69 years at baseline (1990-1993) were randomly selected for plasma UA measurement from base cohort participants who responded to the baseline questionnaire and provided blood samples. They were followed for dementia (disabling dementia requiring care; hereinafter dementia) from 2006 to 2016 using certification records for national long-term care insurance in Japan. A Cox proportional hazards model adjusted for various lifestyle factors and past medical history (cardiometabolic disease) was applied for overall participants and sex.

RESULTS

Dementia was diagnosed in 240 participants (14.2 % overall: 16.0 % in men and 13.4 % in women). No statistically significant association with plasma UA was found in overall participants. Compared to participants with UA of 5.1-6.0 mg/dL, men with ≥6.1 mg/dL showed fully adjusted hazard ratios of 1.46 (95 % confidence interval: 0.78-2.75) for 6.1-7.0 mg/dL and 1.89 (0.97-3.66) for ≥7.1 mg/dL, while women with ≥6.1 mg/dL showed 1.13 (0.54-2.38).

CONCLUSIONS

No statistically significant association between plasma UA level and risk of dementia was found in overall participants or by sex.

Comorbid Conditions Are Associated With Cognitive Impairment in Native Hawaiians and Pacific Islanders

We examined the association between comorbid conditions and mild cognitive impairment (MCI) in Native Hawaiians and Pacific Islanders (NHPI) (n = 54). Cross-sectional, self-reported questionnaires were utilized to collect demographic, comorbid conditions, and MCI (via the AD8 index) data. Separate logistic regression models were conducted to investigate the relationship between comorbid conditions and MCI, adjusting for other covariates. We found significantly increased odds of MCI in those reporting high blood pressure (OR = 5.27; 95% CI: [1.36, 20.46]; p = 0.016), high cholesterol (OR = 7.30; 95% CI: [1.90, 28.14], p = 0.004), and prediabetes or borderline diabetes (OR = 4.53; 95% CI: [1.27, 16.16], p = 0.02) compared with those not reporting these respective conditions. These data show that hypertension, hypercholesterolemia, and prediabetes are associated with MCI in the NHPI community, suggesting that preventive strategies to reduce chronic conditions may also potentially slow cognitive decline in underrepresented/understudied NHPI.

Association of the number of pregnancies and births with cognitive performance in older postmenopausal women: a cross-sectional study

OBJECTIVE

Cognitive impairment in the elderly is a serious public health problem. However, the effect of the number of pregnancies and births in the early years of life on cognitive function in postmenopausal women remains controversial. This study aims to investigate the relationship between these two factors.

METHODS

We used the National Health and Nutrition Examination Survey 2011-2014 data on women aged ≥60 years. This study included sociodemographic data, history of estrogen use, and contraceptive use as confounding variables. The combined scores of the Consortium to Establish a Registry for Alzheimer's Disease Word Learning (CERAD-WL), delayed word recall (CERAD-DR), the Animal Fluency test (AF), and the Digit Symbol Substitution Test (DSST) were used to assess the cognitive performance of participants. Hierarchical multiple regression analysis explored the relationship between the number of pregnancies and births and cognitive function.

RESULTS

The study screened 1,259 postmenopausal women and found that 24.3% had low cognitive performance. The study found a significant increase in low cognitive performance among older adults, Mexican Americans, those with a lower education level and poverty-income ratio, those who were widowed, and those with diabetes and hypertension (P < 0.001). In the multiple regression analysis, the number of pregnancies remained a significant determinant of cognitive performance (B = -0.188, P < 0.001).

CONCLUSIONS

The number of pregnancies was associated with cognitive performance in a population of postmenopausal women in the United States. A lower number of pregnancies is associated with better cognitive performance.

Traumatic brain injury, posttraumatic stress disorder, and vascular risk are independently associated with white matter aging in Vietnam-Era veterans

OBJECTIVE

Traumatic brain injury (TBI), mental health conditions (e.g., posttraumatic stress disorder [PTSD]), and vascular comorbidities (e.g., hypertension, diabetes) are highly prevalent in the Veteran population and may exacerbate age-related changes to cerebral white matter (WM). Our study examined (1) relationships between health conditions-TBI history, PTSD, and vascular risk-and cerebral WM micro- and macrostructure, and (2) associations between WM measures and cognition.

METHOD

We analyzed diffusion tensor images from 183 older male Veterans (mean age = 69.18; SD = 3.61) with (n = 95) and without (n = 88) a history of TBI using tractography. Generalized linear models examined associations between health conditions and diffusion metrics. Total WM hyperintensity (WMH) volume was calculated from fluid-attenuated inversion recovery images. Robust regression examined associations between health conditions and WMH volume. Finally, elastic net regularized regression examined associations between WM measures and cognitive performance.

RESULTS

Veterans with and without TBI did not differ in severity of PTSD or vascular risk (p's >0.05). TBI history, PTSD, and vascular risk were independently associated with poorer WM microstructural organization (p's <0.5, corrected), however the effects of vascular risk were more numerous and widespread. Vascular risk was positively associated with WMH volume (p = 0.004, β=0.200, R2 = 0.034). Higher WMH volume predicted poorer processing speed (R2 = 0.052).

CONCLUSIONS

Relative to TBI history and PTSD, vascular risk may be more robustly associated with WM micro- and macrostructure. Furthermore, greater WMH burden is associated with poorer processing speed. Our study supports the importance of vascular health interventions in mitigating negative brain aging outcomes in Veterans.

Cognitive impairment in individuals with rheumatic diseases: the role of systemic inflammation, immunomodulatory medications, and comorbidities

Inflammation is an important risk factor, a potential therapeutic target for cognitive decline and dementia, and an inherent feature of autoimmune and immune-mediated rheumatic diseases. The risk of cognitive impairment and dementia is increased in individuals with immune-mediated rheumatic diseases, particularly in those with cardiovascular risk factors and cardiovascular disease. Immunomodulatory medications have been associated with a reduced risk of dementia, but whether this effect is mediated through their anti-inflammatory immunomodulating properties or other mechanisms, such as cardiovascular risk reduction, is unclear. A better understanding of the role of chronic inflammation as a modifiable risk factor for cognitive performance in rheumatic diseases will help inform opportunities for the management of cognitive impairment in people with rheumatic diseases and other chronic inflammatory diseases. In this Series paper, we discuss the epidemiology, risk factors, and current evidence on the role of immunomodulatory medications in cognitive impairment and dementia in people with rheumatic diseases.

Linking peripheral atherosclerosis to blood-brain barrier disruption: elucidating its role as a manifestation of cerebral small vessel disease in vascular cognitive impairment

Aging plays a pivotal role in the pathogenesis of cerebral small vessel disease (CSVD), contributing to the onset and progression of vascular cognitive impairment and dementia (VCID). In older adults, CSVD often leads to significant pathological outcomes, including blood-brain barrier (BBB) disruption, which in turn triggers neuroinflammation and white matter damage. This damage is frequently observed as white matter hyperintensities (WMHs) in neuroimaging studies. There is mounting evidence that older adults with atherosclerotic vascular diseases, such as peripheral artery disease, ischemic heart disease, and carotid artery stenosis, face a heightened risk of developing CSVD and VCID. This review explores the complex relationship between peripheral atherosclerosis, the pathogenesis of CSVD, and BBB disruption. It explores the continuum of vascular aging, emphasizing the shared pathomechanisms that underlie atherosclerosis in large arteries and BBB disruption in the cerebral microcirculation, exacerbating both CSVD and VCID. By reviewing current evidence, this paper discusses the impact of endothelial dysfunction, cellular senescence, inflammation, and oxidative stress on vascular and neurovascular health. This review aims to enhance understanding of these complex interactions and advocate for integrated approaches to manage vascular health, thereby mitigating the risk and progression of CSVD and VCID.

Brain-immune interactions: implication for cognitive impairments in Alzheimer's disease and autoimmune disorders

Progressive memory loss and cognitive dysfunction, encompassing deficits in learning, memory, problem solving, spatial reasoning, and verbal expression, are characteristics of Alzheimer's disease and related dementia. A wealth of studies has described multiple roles of the immune system in the development or exacerbation of dementia. Individuals with autoimmune disorders can also develop cognitive dysfunction, a phenomenon termed "autoimmune dementia." Together, these findings underscore the pivotal role of the neuroimmune axis in both Alzheimer's disease and related dementia and autoimmune dementia. The dynamic interplay between adaptive and innate immunity, both in and outside the brain, significantly affects the etiology and progression of these conditions. Multidisciplinary research shows that cognitive dysfunction arises from a bidirectional relationship between the nervous and immune systems, though the specific mechanisms that drive cognitive impairments are not fully understood. Intriguingly, this reciprocal regulation occurs at multiple levels, where neuronal signals can modulate immune responses, and immune system-related processes can influence neuronal viability and function. In this review, we consider the implications of autoimmune responses in various autoimmune disorders and Alzheimer's disease and explore their effects on brain function. We also discuss the diverse cellular and molecular crosstalk between the brain and the immune system, as they may shed light on potential triggers of peripheral inflammation, their effect on the integrity of the blood-brain barrier, and brain function. Additionally, we assess challenges and possibilities associated with developing immune-based therapies for the treatment of cognitive decline.

High Blood Pressure and Impaired Brain Health: Investigating the Neuroprotective Potential of Magnesium

High blood pressure (BP) is a significant contributor to the disease burden globally and is emerging as an important cause of morbidity and mortality in the young as well as the old. The well-established impact of high BP on neurodegeneration, cognitive impairment, and dementia is widely acknowledged. However, the influence of BP across its full range remains unclear. This review aims to explore in more detail the effects of BP levels on neurodegeneration, cognitive function, and dementia. Moreover, given the pressing need to identify strategies to reduce BP levels, particular attention is placed on reviewing the role of magnesium (Mg) in ageing and its capacity to lower BP levels, and therefore potentially promote brain health. Overall, the review aims to provide a comprehensive synthesis of the evidence linking BP, Mg and brain health. It is hoped that these insights will inform the development of cost-effective and scalable interventions to protect brain health in the ageing population.

Deprescribing of Antihypertensive Medications and Cognitive Function in Nursing Home Residents

Importance

Antihypertensive medication deprescribing is common among nursing home residents, yet its association with cognitive decline remains uncertain.

Objective

To investigate the association of deprescribing antihypertensive medication with changes in cognitive function in nursing home residents.

Design, Setting, and Participants

This cohort study using a target trial emulation approach included VA long-term care residents aged 65 years or older with stays of at least 12 weeks from 2006 to 2019. Residents who were not prescribed antihypertensive medication, with blood pressure greater than 160/90 mm Hg, or with heart failure were excluded. Eligible residents with stable medication use for 4 weeks were classified into deprescribing or stable user groups and followed for 2 years or until death or discharge for intention-to-treat (ITT) analysis. Participants switching treatment groups were censored in the per-protocol analysis. Cognitive function measurements during follow-up were analyzed using an ordinal generalized linear mixed model, adjusting for confounders with inverse probability of treatment weighting. Per-protocol analysis included inverse probability of censoring weighting. Data analyses were performed from May 1, 2023, and July 1, 2024.

Exposures

Deprescribing was defined as a reduction in the total number of antihypertensive medications or a decrease in medication dosage by 30%, sustained for a minimum of 2 weeks.

Main Outcomes and Measures

Cognitive Function Scale (CFS) was classified as cognitively intact (CFS = 1), mildly impaired (CFS = 2), moderately impaired (CFS = 3), and severely impaired (CFS = 4).

Results

Of 45 183 long-term care residents, 12 644 residents (mean [SD] age 77.7 [8.3] years; 329 [2.6%] females and 12 315 [97.4%] males) and 12 053 residents (mean [SD] age 77.7 [8.3] years; 314 [2.6%] females and 11 739 [97.4%] males) met eligibility for ITT and per-protocol analyses, respectively. At the end of the follow-up, 12.0% of residents had a worsened CFS (higher score) and 7.7% had an improved CFS (lower score) with 10.8% of the deprescribing group and 12.1% of the stable user group showing a worsened CFS score. In the per-protocol analysis, the deprescribing group had a 12% reduction in the odds of progressing to a worse CFS category per 12-week period (odds ratio, 0.88; 95% CI, 0.78-0.99) compared to the stable user group. Among residents with dementia, deprescribing was associated with 16% reduced odds of cognitive decline (odds ratio, 0.84; 95% CI, 0.72-0.98). These patterns remained consistent in the ITT analysis.

Conclusions and Relevance

This cohort study indicates that deprescribing is associated with less cognitive decline in nursing home residents, particularly those with dementia. More data are needed to understand the benefits and harms of antihypertensive deprescribing to inform patient-centered medication management in nursing homes.

Circulating Interleukin-17A is associated with executive function in middle aged adults with and without type 2 diabetes

Midlife cardiovascular risk factors such as Type 2 Diabetes (T2DM) and obesity are associated with the later development of cognitive impairment and dementia. Systemic inflammation is postulated as a crucial mechanism, yet there are few studies examining this at the earliest stages prior to overt cognitive impairment. To assess this, we recruited a cohort of middle-aged cognitively-unimpaired individuals with and without uncomplicated T2DM. Comprehensive neuropsychological assessment was performed at baseline and at 4-year follow-up. Ten serum chemokines and cytokines (Eotaxin, MCP-1, MIP-1β, CXCL10, IL-6, IL-10, IL12p70, IL-17A, IFN-γ and TNF-α) were measured at both baseline and follow-up using high-sensitivity assays. Overall, 136 participants were recruited including 90 with uncomplicated midlife T2DM (age 52.6 ± 8.3; 47% female) and 46 without (age 52.9 ± 8.03; 61% female). Cognitive trajectories were stable over time and did not differ with T2DM. Yet on cross-sectional analyses at both baseline and follow-up, greater circulating IL-17A was consistently associated with poorer performance on tests of executive function/attention (β: 0.21; -0.40, -0.02, p = 0.03 at baseline; β: 0.26; -0.46, -0.05, p = 0.02 at follow-up). Associations persisted on covariate adjustment and did not differ by T2DM status. In summary, we provide evidence that greater circulating IL-17A levels were associated with poorer executive function in midlife, independent of T2DM. Long-term follow-up of this and other cohorts will further elucidate the earliest stages in the relationship between systemic inflammation and cognitive decline to provide further mechanistic insights and potentially identify those at greatest risk for later cognitive decline.

Association between risk of Alzheimer's disease and related dementias and angiotensin receptor Ⅱ blockers treatment for individuals with hypertension in high-volume claims data

BACKGROUND

Findings regarding the protective effect of Angiotensin II receptor blockers (ARBs) against Alzheimer's disease and related dementias (AD/ADRD) and cognitive decline have been inconclusive.

METHODS

Individuals with hypertension who do not have any prior ADRD diagnosis were included in this retrospective cohort study from Optum's de-identified Clinformatics® Data Mart. We identified antihypertensive medication (AHM) drug classes and subclassified ARBs by blood-brain barrier (BBB) permeability. We compared baseline characteristics and used the Kaplan-Meier (KM) survival curve and adjusted Cox proportional hazards (PH) model for survival analyses.

FINDINGS

From 6,390,826 individuals with hypertension, there were 1,839,176 ARB users, 3,366,841 non-ARB AHM users, and 1,184,809 AHM non-users. The unadjusted KM curve showed that ARB users had lower cumulative hazard than other AHM users or AHM non-users (P < 0.0001). In Cox PH analysis, ARB users showed a 20% lower adjusted hazard of developing ADRD compared to angiotensin-converting enzyme inhibitor (ACEI) users and a 29% and 18% reduced hazard when compared to non-ARB/ACEI AHM users and AHM non-users (all P < 0.0001). Consumption of BBB-crossing ARBs was linked to a lower hazard of ADRD development than non-BBB-crossing ARBs, undetermined ARBs, and non-consumption of AHMs by 11%, 25%, and 31% (all P < 0.0001).

INTERPRETATION

This study suggests that ARBs are superior to ACEIs, non-ARB/ACEI AHMs, or non-use of AHMs in reducing the hazard of ADRD among patients with hypertension. Also, BBB-permeability in ARBs was associated with lower ADRD incidence. There is no cure for AD, ADRD, or vascular dementia; hence, these findings are significant in preventing those disorders in an inexpensive, convenient, and safe way. Limitations in claims data should be considered when interpreting our findings.

FUNDING

This research was supported by the National Institute on Aging grants (R01AG084236, R01AG083039, RF1AG072799, R56AG074604).

A single risk assessment for the most common diseases of ageing, developed and validated on 10 cohort studies

BACKGROUND

We aimed to develop risk tools for dementia, stroke, myocardial infarction (MI), and diabetes, for adults aged ≥ 65 years using shared risk factors.

METHODS

Data were obtained from 10 population-based cohorts (N = 41,755) with median follow-up time (years) for dementia, stroke, MI, and diabetes of 6.2, 7.0, 6.8, and 7.4, respectively. Disease-free participants at baseline were included, and 22 risk factors (sociodemographic, medical, lifestyle, laboratory biomarkers) were evaluated. Two risk tools (DemNCD and DemNCD-LR based on Fine and Gray sub-distribution and logistic regression [LR], respectively) were developed and validated. Predictive accuracies of these risk tools were assessed using Harrel's C-statistics and area under the curve (AUC) and 95% confidence interval (CI). Model calibration was conducted using Hosmer-Lemeshow goodness of fit test along calibration plots.

RESULTS

Both the DemNCD and DemNCD-LR resulted in similar predictive accuracy for each outcome. The overall AUC (95% CI) for dementia, stroke, MI, and diabetes risk tool were 0·68 (0·65, 0·70), 0·58 (0·54, 0·61), 0·65 (0·61, 0·68), and 0·68 (0·64, 0·72), respectively, for males. For females, these figures were 0·65 (0·63, 0·67), 0·55 (0·52, 0·57), 0·65 (0·62, 0·68), and 0·61 (0·57, 0·65).

CONCLUSIONS

The DemNCD is the first tool to predict both dementia and multiple cardio-metabolic diseases using comprehensive risk factors and provided similar predictive accuracy to existing risk tools. It has similar predictive accuracy as tools designed for single outcomes in this age-group. DemNCD has the potential to be used in community and clinical settings as it includes self-reported and routinely available clinical measures.

Cognitive impairment among older persons with chronic illness attending primary care and its association with cardiovascular risk using the Framingham risk score

BACKGROUND

Dementia is a major public health burden, particularly among the older persons with significant implications for individuals, caregivers, and society. Identifying mild cognitive impairment early can facilitate timely intervention and care.This cross-sectional study aims to investigate the association between Framingham risk score (FRS), a widely used tool for cardiovascular disease (CVD) risk prediction, and cognitive impairment among older persons with chronic illness in Malaysia.

METHODS

A total of 289 participants aged 60 years and above with chronic illness were recruited from Klinik Primer Hospital Tuanku Chanselor Muhriz via simple random sampling via computer generator. The Montreal Cognitive Assessment Bahasa Malaysia version (MoCA-BM) was used to assess cognitive function and the FRS was calculated on the basis of CVD risk factors.

RESULTS

The prevalence of cognitive impairment among the participants was found to be 19.7%. Multiple Logistic Regression revealed that age (AOR 1.101, 95% CI = 1.041,1.163, p < 0.001), systolic blood pressure (AOR 1.048, 95%CI = 1.024, 1.072, p < 0.001) diabetes (AOR 2.655, 95% CI = 1.194, 5.906, p = 0.017) increased the odds of having cognitive impairment among older persons with chronic illness whereas secondary education ( AOR 0.087, 95% CI = 0.008, 0.963, p = 0.047) and higher education ( AOR 0.037, 95% CI = 0.002, 0.833, p = 0.038) reduced the likelihood of having cognitive impairment. Individuals with higher FRS were more likely to have cognitive impairment (AOR 1.099, 95% CI = 1.049, 1.172, p < 0.001). The optimal cutoff point for the FRS to determine cognitive impairment is 30 for males with a sensitivity and specificity of 84.4% and 51.2% while the optimal cut off point for females is 18.5 with a sensitivity and specificity of 76% and 63.1% respectively.

CONCLUSIONS

These findings suggest that the FRS which was originally designed for CVD risk assessment may also serve as a valuable predictive tool for cognitive impairment among older persons with chronic illness. Integrating FRS into routine primary care assessments could enhance the early identification of individuals at risk and enable appropriate cognitive screenings and interventions. Further research such as a longitudinal cohort study in a larger and more diverse population is warranted to validate the association of CVD risks with the development of dementia.

Empty nest but better off? Association between empty nest status and cognitive function among older adults with chronic diseases in rural China

BACKGROUND

The increasing prevalence of cognitive impairment poses substantial risks to older adults, particularly those with chronic diseases. While existing studies have examined the connection between the empty nest phenomenon and cognitive function, few have attempted to consider endogeneity issues within this relationship, with limited attention given to older adults with chronic diseases. This study investigates the impact of empty nest status on cognitive function among rural Chinese older adults with chronic diseases and explores the possible mechanisms underlying this effect.

METHODS

A cross-sectional study involved 365 older adults aged 60 or above with chronic diseases in rural areas of Shaanxi province, northwest China. Cognitive function was measured using the Mini-Mental State Examination. Multiple regression models and the instrumental variable (IV) method were employed to examine the association between empty nest and cognitive function.

RESULTS

Among the 365 older adults aged 60 or above with chronic diseases, 43% experienced cognitive impairment. Results from both multiple regression and IV analyses consistently demonstrate a significant association between empty nest status and higher cognitive function scores (β = 1.757, p = 0.007; β = 3.682, p = 0.034, respectively). Mechanism analysis further supports that the positive association may arise from empty nesters receiving more social support from children and friends, and perceiving loneliness experiences as inadequate. Heterogeneity analysis reveals that the association between empty nest status and cognitive function is more pronounced among male adults with chronic diseases.

CONCLUSIONS

This study challenges the notion that empty nest status is a risk factor for cognitive decline in older adults with chronic diseases in rural China. The positive impact is attributed to the robust social relationships of empty nesters, encompassing sustained support from their social network, and the absence of an increase in loneliness. Therefore, future interventions aimed at improving cognitive function in older adults may benefit from promoting the development of social relationships.

Associations of metabolic heterogeneity of obesity with the risk of dementia in middle-aged adults: three prospective studies

BACKGROUND

The associations of different obesity and metabolic phenotypes during midlife with the risk of incident dementia remain unclear. This study aimed to investigate the associations between metabolic heterogeneity of obesity and long-term risk of dementia.

METHODS

We conducted prospective analyses from three cohorts, including the UK Biobank (UKB), Atherosclerosis Risk in Communities (ARIC) study, and Framingham Offspring Study (FOS). Eligible participants were those aged 45-65 years with valid assessments of body mass index (BMI) and metabolic status at the study baseline. Obesity was defined as a BMI of ≥ 30.0 kg/m2, while metabolic abnormality was defined as meeting ≥ 2 of the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) criteria. Metabolic heterogeneity of obesity was evaluated based on obesity and metabolic phenotypes and grouped as metabolically normal non-obesity (MNNO), metabolically abnormal non-obesity (MANO), metabolically normal obesity (MNO), and metabolically abnormal obesity (MAO).

RESULTS

Included in this study were 295,823 participants aged 56.3 ± 5.9 years from the UKB, 12,547 participants aged 54.0 ± 5.7 years from the ARIC, and 2,004 participants aged 53.9 ± 5.9 years from the FOS. Over 4,348,208 person-years, a total of 6,190 participants (3,601 in the UKB, 2,405 in the ARIC, and 184 in the FOS) developed incident dementia. In the pooled analysis of three cohorts, metabolic abnormality was associated with a hazard ratio (HR) of 1.41 (95% confidence interval [CI]: 1.10-1.80) for dementia, while obesity was associated with an HR of 1.20 (1.03-1.41). Compared with MNNO, individuals with MANO and MAO had increased risks of dementia (pooled HR: 1.33, 95% CI: 1.04-1.71 for MANO and 1.48, 1.16-1.89 for MAO). However, there was no significant difference in the risk of dementia among MNO (pooled HR: 1.10, 95% CI: 0.98-1.24). In addition, participants who recovered from MANO to MNNO had a lower risk of dementia (pooled HR: 0.79, 95% CI: 0.64-0.97), as compared with stable MANO.

CONCLUSIONS

Metabolic abnormality has a stronger association with dementia than obesity. Metabolically abnormal non-obesity and obesity, but not metabolically normal obesity, are associated with higher risks of incident dementia as compared with metabolically normal non-obesity. Recovering from an abnormal metabolic status to normal reduces the risk of dementia in populations without obesity. Our findings highlight the important role of metabolic status in the development of dementia and recommend the stratified management of obesity based on metabolic status.

Serum proteomics reveal APOE-ε4-dependent and APOE-ε4-independent protein signatures in Alzheimer's disease

A deeper understanding of the molecular processes underlying late-onset Alzheimer's disease (LOAD) could aid in biomarker and drug target discovery. Using high-throughput serum proteomics in the prospective population-based Age, Gene/Environment Susceptibility-Reykjavik Study (AGES) cohort of 5,127 older Icelandic adults (mean age, 76.6 ± 5.6 years), we identified 303 proteins associated with incident LOAD over a median follow-up of 12.8 years. Over 40% of these proteins were associated with LOAD independently of APOE-ε4 carrier status, were implicated in neuronal processes and overlapped with LOAD protein signatures in brain and cerebrospinal fluid. We identified 17 proteins whose associations with LOAD were strongly dependent on APOE-ε4 carrier status, with mostly consistent associations in cerebrospinal fluid. Remarkably, four of these proteins (TBCA, ARL2, S100A13 and IRF6) were downregulated by APOE-ε4 yet upregulated due to LOAD, a finding replicated in external cohorts and possibly reflecting a response to disease onset. These findings highlight dysregulated pathways at the preclinical stages of LOAD, including those both independent of and dependent on APOE-ε4 status.

Intracranial Atherosclerotic Disease and Incident Dementia: The ARIC Study (Atherosclerosis Risk in Communities)

BACKGROUND

Studies of the neurovascular contribution to dementia have largely focused on cerebral small vessel disease (CSVD), but the role of intracranial atherosclerotic disease (ICAD) remains unknown in the general population. The objective of this study was to determine the risk of incident dementia from ICAD after adjusting for CSVD and cardiovascular risk factors in a US community-based cohort.

METHODS

We acquired brain magnetic resonance imaging examinations from 2011 through 2013 in 1980 Black and White participants in the ARIC study (Atherosclerosis Risk in Communities), a prospective cohort conducted in 4 US communities. Magnetic resonance imaging examinations included high-resolution vessel wall magnetic resonance imaging and magnetic resonance angiography to identify ICAD. Of these participants, 1590 without dementia, without missing covariates, and with adequate magnetic resonance image quality were followed through 2019 for incident dementia. Associations between ICAD and incident dementia were assessed using Cox proportional hazard ratios adjusted for CSVD (characterized by white matter hyperintensities, lacunar infarctions, and microhemorrhages), APOE4 genotype (apolipoprotein E gene ε4), and cardiovascular risk factors.

RESULTS

The mean age (SD) of study participants was 77.4 (5.2) years. ICAD was detected in 34.6% of participants. After a median follow-up of 5.6 years, 286 participants developed dementia. Compared with participants without ICAD, the fully adjusted hazard ratios (95% CIs) for incident dementia in participants with any ICAD, with ICAD only causing stenosis ≤50%, and with ICAD causing stenosis >50% in ≥1 vessel were 1.57 (1.17-2.11), 1.41 (1.02-1.95), and 1.94 (1.32-2.84), respectively. ICAD was associated with dementia even among participants with low white matter hyperintensities burden, a marker of CSVD.

CONCLUSIONS

ICAD was associated with an increased risk of incident dementia, independent of CSVD, APOE4 genotype, and cardiovascular risk factors. The increased risk of dementia was evident even among participants with low CSVD burden, a group less likely to be affected by vascular dementia, and in participants with ICAD causing only low-grade stenosis. Our results suggest that ICAD may partially mediate the effect that cardiovascular risk factors have on the brain leading to dementia. Both ICAD and CSVD must be considered to understand the vascular contributions to cognitive decline.

What have observational studies taught us about brain health? An exploration of select cardiovascular risks and cognitive function

Observational research studies serve as the cornerstone for gathering evidence on risk factors and contributors to cognitive decline and impairment. The evidence can then be combined with data from preclinical studies and randomized controlled trials to ultimately inform the development of effective interventions and the content of guidance statements. Observational cohort designs on modifiable risk factors and brain health can be particularly beneficial for studying questions that are unethical or impractical for a clinical trial setting, associations with dementia which may develop over decades, and underrepresented populations typically not included in clinical trials. This chapter will review the major observational, epidemiologic studies pertaining to the traditional vascular risk factors - hypertension, diabetes mellitus, hypercholesterolemia, smoking, and physical inactivity - and how they may impact brain health.

Impairment of Cognitive Function Increases Mortality Risk in Relation to Cardiac Sympathetic Denervation and Renal Dysfunction in Patients With Systolic Heart Failure

BACKGROUND

In contrast to the well-known prognostic values of the cardiorenal linkage, it remains unclear whether impaired cognitive function affects cardiac prognosis in relation to cardiac sympathetic innervation and renal function in patients with heart failure (HF).

METHODS AND RESULTS

A total of 433 consecutive HF patients with left ventricular ejection fraction (LVEF) <50% underwent the Mini-Mental State Examination (MMSE) and a neuropsychological test for screening of cognition impairment or subclinical dementia. Following metaiodobenzylguanidine (MIBG) scintigraphy, patient outcomes with a primary endpoint of lethal cardiac events (CEs) were evaluated for a mean period of 14.8 months. CEs were documented in 84 HF patients during follow-up. MMSE score, estimated glomerular filtration rate (eGFR) and standardized heart-to-mediastinum ratio of MIBG activity (sHMR) were significantly reduced in patients with CEs compared with patients without CEs. Furthermore, overall multivariate analysis revealed that these parameters were significant independent determinants of CEs. The cutoff values of MMSE score (<26), sHMR (<1.80) and eGFR (<47.0 mL/min/1.73 m2) determined by receiver operating characteristic (ROC) analysis successfully differentiated HF patients at more increased risk for CEs from other HF patients.

CONCLUSIONS

Impairment of cognitive function is not only independently related to but also synergistically increases cardiac mortality risk in association with cardiac sympathetic function and renal function in patients with HF.

DiADEM-Dance against Dementia-Effect of a Six-Month Dance Intervention on Physical Fitness in Older Adults with Mild Cognitive Impairment: A Randomized, Controlled Trial

Background: Preserving health and physical fitness is critical to ensure independent living across the lifespan. Lower levels of physical fitness are associated with age-related cognitive decline and a higher prevalence of mild cognitive impairment (MCI). Thus, this study investigates the influence of a six-month dance intervention on selected measures of physical fitness in older adults with MCI. Methods: In this randomized controlled trial, 55 patients with MCI were randomized into a sportive dance training (IG; n = 26; age: 70.7 ± 5.6 years; 62% female) or an inactive control group (CG; n = 24; age: 69.1 ± 6.8 years; 46% female). The dance group received two 90 min dance training sessions per week over a duration of six-months, which focused on learning dance movement patterns. During the training sessions, heart rate was measured to control exercise intensity. Physical fitness was assessed using cardiopulmonary exercise testing (CPET), lower limb functional fitness via sit-to-stand test, handgrip strength, and heart rate variability (HRV). Results: We observed that the dance intervention preserved the cardiorespiratory fitness as measured by maximal oxygen uptake (VO2max) during CPET, which decreased in the CG. Furthermore, participants in the IG demonstrated increases in leg and handgrip strength, although these were not statistically significant. HRV displayed a non-significant decrease following the intervention. Conclusions: The results of this randomized controlled trial suggest that sportive dance training can preserve elements of physical fitness (i.e., cardiorespiratory fitness) in older adults with MCI. Although improvements in the other parameters (i.e., leg and handgrip strength) were statistically non-significant, likely due to the small sample size, stabilizing muscular fitness and preventing age-related decline in older adults with MCI is important for maintaining functional independence. For future studies, we recommend a longer training duration paired with precise control of regular physical activity levels, an important confounding factor.

Cervical cancer and risk of dementia: real-world insights from a nationwide cohort study in Taiwan

OBJECTIVE

Cervical cancer, linked to human papillomavirus (HPV), ranks fourth among women's cancers globally. Several studies have found an association between viral infections or cancer and dementia, which is a major public health concern. This study aimed to provide real-world data on the association between cervical cancer and the risk of dementia.

METHODS

This population-based cohort study, utilizing Taiwan's National Health Insurance Research Database, included 53 905 patients, with 10 781 having cervical cancer, matching with 43 124 controls in a 1:4 ratio based on age and indexed date. Incidence density rates were used to calculate the incidence rate of dementia. Adjusting for comorbidities, a multivariable Cox proportional hazards regression model was used to estimate the hazard ratios and 95% confidence intervals. Additionally, the risk of dementia was further verified using the cumulative incidence analyzed by the Kaplan-Meier method.

RESULTS

This study indicated a significantly higher dementia risk in the cervical cancer cohort compared with the non-cervical cancer cohort (adjusted HR (aHR)=1.64, 95% CI 1.16 to 2.26; p<0.001), suggesting a 1.64-fold increased risk. Notably, cervical cancer posed a greater risk of dementia (aHR=1.69, 95% CI 1.21 to 2.29; p<0.001) compared with carcinoma in situ of the cervix (p=0.18) and cervical intraepithelial neoplasia (p=0.23). The cumulative incidence of dementia in the cervical cancer group was significantly higher (log-rank test, p<0.001) than the control group.

CONCLUSIONS

Cervical cancer (invasive disease) was associated with a significant risk of dementia, unlike carcinoma in situ of the cervix and cervical intraepithelial neoplasia (pre-invasive diseases), suggesting HPV infections may play a role in dementia, particularly oncogenic types. This highlights the importance of further investigation into the underlying mechanisms of the association between cervical cancer and dementia.

Cerebrovascular reactivity MRI as a biomarker for cerebral small vessel disease-related cognitive decline: Multi-site validation in the MarkVCID Consortium

INTRODUCTION

Vascular contributions to cognitive impairment and dementia (VCID) represent a major factor in cognitive decline in older adults. The present study examined the relationship between cerebrovascular reactivity (CVR) measured by magnetic resonance imaging (MRI) and cognitive function in a multi-site study, using a predefined hypothesis.

METHODS

We conducted the study in a total of three analysis sites and 263 subjects. Each site performed an identical CVR MRI procedure using 5% carbon dioxide inhalation. A global cognitive measure of Montreal Cognitive Assessment (MoCA) and an executive function measure of item response theory (IRT) score were used as outcomes.

RESULTS

CVR and MoCA were positively associated, and this relationship was reproduced at all analysis sites. CVR was found to be positively associated with executive function.

DISCUSSION

The predefined hypothesis on the association between CVR and a global cognitive score was validated in three independent analysis sites, providing support for CVR as a biomarker in VCID.

HIGHLIGHTS

This study measured a novel functional index of small arteries referred to as cerebrovascular reactivity (CVR). CVR was positively associated with global cognition in older adults. This finding was observed in three independent cohorts at three sites. Our statistical analysis plan was predefined before beginning data collection.

Cerebral arteriolosclerosis, lacunar infarcts, and cognition in older Black adults

INTRODUCTION

Older Black adults are at risk of cerebral small vessel disease (CSVD), which contributes to dementia risk. Two subtypes of CSVD, arteriolosclerosis and ischemic lacunar infarcts, have been independently linked to lower cognition and higher dementia risk, but their combined effects on cognition in older Black adults are unclear.

METHODS

Mixed models were used to examine the associations of in vivo measures of arteriolosclerosis (ARTS) and ischemic lacunar infarcts to cognitive level and change in 370 older Black adults without dementia.  RESULTS: Modeled together, higher ARTS load accounted for lower levels of global cognition, episodic memory, semantic memory, and perceptual speed, whereas higher infarct load accounted for lower levels of working memory. There were no associations with rate of cognitive change.

DISCUSSION

Both arteriolosclerosis and ischemic infarcts impact the cognitive health of older Black adults, but arteriolosclerosis affects cognition more broadly and offers promise as an in vivo biomarker of dementia risk.

HIGHLIGHTS

Older Black adults are at risk of cerebral small vessel disease (CSVD) and dementia. Examined magnetic resonance imaging-derived measure of arteriolosclerosis (ARTS), infarcts, and cognition. ARTS load was widely associated with lower cognition after adjusting for infarct load. Infarct load was specifically associated with lower complex attention. More within-Black in vivo studies of CSVD subtypes and cognition are needed.

The association between liver fibrosis score and incident dementia: A nationwide retrospective cohort study

BACKGROUND

We assessed the relationship of liver fibrosis score with incident dementia in a large, national sample.

METHODS

For this retrospective cohort study, data of dementia-free individuals aged 40-69 years were derived from electronic records of the largest healthcare provider in Israel. The association between liver fibrosis score (FIB-4), assessed from routine laboratory measurements, and incident dementia was explored through multivariate cox regression models.

RESULTS

Of the total sample (N = 826,578, mean age 55 ± 8 years at baseline), 636,967 (77%) had no fibrosis, 180,114 (21.8%) had inconclusive fibrosis status and 9497 (1.2%) had high risk for advanced fibrosis. Over a median follow-up of 17 years, 41,089 dementia cases were recorded. Inconclusive liver fibrosis and advanced fibrosis were associated with increased dementia risk (HR = 1.09, 95%CI: 1.07-1.11 and HR = 1.18, 95%CI: 1.10-1.27, respectively). This association remained robust through seven sensitivity analyses.

CONCLUSIONS

Liver fibrosis assessed through a serum-based algorithm may serve as a risk factor for dementia in the general population.

HIGHLIGHTS

Liver fibrosis may predict dementia diagnosis in the general population. Inconclusive liver fibrosis was associated with 9% increased dementia risk. Advanced liver fibrosis was associated with 18% increased dementia risk. Findings remained robust in sensitivity analyses and after adjustments.

Forecasting the Burden of Cardiovascular Disease and Stroke in the United States Through 2050-Prevalence of Risk Factors and Disease: A Presidential Advisory From the American Heart Association

BACKGROUND

Cardiovascular disease and stroke are common and costly, and their prevalence is rising. Forecasts on the prevalence of risk factors and clinical events are crucial.

METHODS

Using the 2015 to March 2020 National Health and Nutrition Examination Survey and 2015 to 2019 Medical Expenditure Panel Survey, we estimated trends in prevalence for cardiovascular risk factors based on adverse levels of Life's Essential 8 and clinical cardiovascular disease and stroke. We projected through 2050, overall and by age and race and ethnicity, accounting for changes in disease prevalence and demographics.

RESULTS

We estimate that among adults, prevalence of hypertension will increase from 51.2% in 2020 to 61.0% in 2050. Diabetes (16.3% to 26.8%) and obesity (43.1% to 60.6%) will increase, whereas hypercholesterolemia will decline (45.8% to 24.0%). The prevalences of poor diet, inadequate physical activity, and smoking are estimated to improve over time, whereas inadequate sleep will worsen. Prevalences of coronary disease (7.8% to 9.2%), heart failure (2.7% to 3.8%), stroke (3.9% to 6.4%), atrial fibrillation (1.7% to 2.4%), and total cardiovascular disease (11.3% to 15.0%) will rise. Clinical CVD will affect 45 million adults, and CVD including hypertension will affect more than 184 million adults by 2050 (>61%). Similar trends are projected in children. Most adverse trends are projected to be worse among people identifying as American Indian/Alaska Native or multiracial, Black, or Hispanic.

CONCLUSIONS

The prevalence of many cardiovascular risk factors and most established diseases will increase over the next 30 years. Clinical and public health interventions are needed to effectively manage, stem, and even reverse these adverse trends.