Estimating the Prevalence of Dementia and Mild Cognitive Impairment in the US: The 2016 Health and Retirement Study Harmonized Cognitive Assessment Protocol Project

Ethnic Differences in the Association Between Cognitive Performance and Informant-rated Cognitive Decline

OBJECTIVES

It is unknown whether cognitive test scores are equivalently associated with informant-rated cognitive decline across culturally and linguistically diverse older adults. We examined the association between cognitive domain scores on the Harmonized Cognitive Assessment Protocol (HCAP) and informant-rated cognitive decline in a harmonized population-based sample of older adults.

DESIGN, SETTING, AND PARTICIPANTS

We combined data from the HCAP sub-study of the Health and Retirement Study (HRS; 2016) and the Brain Attack Surveillance in Corpus Christi-Cognitive (BASIC-C; 2018-2020) study. We included Hispanic/Latino-a-e-x (H/L; n = 566) and non-H/L white (NHW; n = 2,145) older adults.

MEASUREMENT

Both studies included the HCAP cognitive assessment with domain scores for memory, attention/executive function (EF), language, visuospatial, orientation, and general cognitive performance (GCP). Informants rated cognitive decline with the Informant Questionnaire of Cognitive Decline in the Elderly (IQCODE).

RESULTS

Cognitive domain scores were more strongly associated with IQCODE scores for NHW than H/L participants for four of six domains (GCP, EF, visuospatial, and orientation) after adjusting for demographics (age, sex/gender, education) and study membership. Informants generally rated greater cognitive decline in NHW than H/L respondents for a given cognitive domain score, and the magnitude of this difference was greater for lower cognitive test scores.

CONCLUSIONS

We found generally weaker associations between cognitive performance and informant-rated cognitive decline in H/L compared to NHW older adults. These findings suggest cognitive measurement differences across culturally and linguistically diverse older adult populations, which may result in underestimation of cognitive impairment in H/L populations.

Social context matters: Neighborhood environment as a moderator of the longitudinal relationship between edentulism and cognitive function among older adults in the United States

BACKGROUND

Previous research has shown poor oral health and neighborhood environment are both risk factors for cognitive decline among older adults. Little research has assessed the synergistic effects of poor oral health and neighborhood environment on cognitive health. This study examined whether neighborhood environment moderates the relationship between edentulism and cognitive function over time.

METHODS

Using data from the Health and Retirement Study, we analyzed 9,994 adults aged 60 and older with 39,976 person-wave observations over 14 years (2006-2020). Cognitive function was measured using the modified Telephone Interview for Cognitive Status. Edentulism status was self-reported complete tooth loss. Neighborhood environment included perceived neighborhood cohesion and disorder. We used linear mixed-effect models to examine the moderation effect of neighborhood environment on the association between edentulism and cognitive function over time.

RESULTS

Edentulous participants (22.4 %) showed an accelerated decline over time in cognitive function compared to dentate participants (β = -0.57, 95 % CI: -0.98, -0.16). The analysis revealed that neighborhood cohesion moderated the relationship between edentulism and cognitive function over time (β = 0.08, 95 % CI: 0.01, 0.15). Specifically, among individuals reporting higher neighborhood cohesion, the negative effect of edentulism on cognitive decline was attenuated. Neighborhood disorder had no significant associations with cognitive function.

CONCLUSIONS

This study demonstrates the relationship between edentulism and cognitive function varies by levels of neighborhood cohesion. The findings highlight the significance of neighborhood context in understanding the relationship between oral health and cognitive aging and suggest interventions addressing community environment may be particularly relevant for older adults with oral health challenges.

Psychometric Reliability, Validity, and Generalizability of MoCA in American Indian Adults: The Strong Heart Study

Standardized neuropsychological instruments are used to evaluate cognitive impairment, but few have been psychometrically evaluated in American Indians. We collected Montreal Cognitive Assessment (MoCA) in 403 American Indians 70 to 95 years, as well as age, sex, education, bilingual status, depression symptoms, and other neuropsychological instruments. We evaluated inferences of psychometric validity, including scoring inference using confirmatory factor analysis and structural equation modeling, generalizability inference using reliability coefficient, and extrapolation inference by examining performance across different contexts and substrata. The unidimensional (total score) model had good fit criteria. Internal consistency reliability was high. MoCA scores were positively associated with crystallized cognition (ρ = 0.48, p < .001) and inversely with depression symptoms (ρ = -0.27, p < .001). Significant differences were found by education (d = 0.79, p < .05) depression (d = 0.484, p < .05), and adjudicated cognitive status (p = .0001) strata; however, MoCA was not sensitive or specific in discriminating cognitive impairment from normal cognition (area under the curve <0.5). MoCA scores had psychometric validity in older American Indians, but education and depression are important contextual features for score interpretability. Future research should evaluate cultural or community-specific adaptations, to improve test discriminability in this underserved population.

Artificial intelligence-driven natural language processing for identifying linguistic patterns in Alzheimer's disease and mild cognitive impairment: A study of lexical, syntactic, and cohesive features of speech through picture description tasks

BackgroundLanguage deficits often occur early in the neurodegenerative process, yet traditional methods frequently fail to detect subtle changes. Natural language processing (NLP) offers a novel approach to identifying linguistic patterns associated with cognitive impairment.ObjectiveWe aimed to analyze linguistic features that differentiate cognitively unimpaired (CU), mild cognitive impairment (MCI), and Alzheimer's disease (AD) groups.MethodsData was extracted from picture description tasks performed by 336 participants in the DementiaBank datasets. 53 linguistic features aggregated into 4 categories: lexical, structural, syntactic, and discourse domains, were identified using NLP toolkits. With normal diagnostic cutoffs, cognitive function was evaluated with the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA).ResultsWith age and education as covariates, ANOVA and post-hoc Tukey's HSD tests revealed that linguistic features such as pronoun usage, syntactic complexity, and lexical sophistication showed significant differences between CU, MCI, and AD groups (p < 0.05). Notably, past tense and personal references were higher in AD than both CU and MCI (p < 0.001), while pronoun usage differed between AD and CU (p < 0.0001). Correlations indicated that higher pronoun rates and lower syntactic complexity were associated with lower MMSE scores and although some features like conjunctions and determiners approached significance, they lacked consistent differentiation.ConclusionsWith the growing adoption of artificial intelligence (AI)-based scribing, these results emphasize the potential of targeted linguistic analysis as a digital biomarker to enable continuous screening for cognitive impairment.

How much can biomarkers explain sociodemographic inequalities in cognitive dysfunction and cognitive impairment? Results from a machine learning model in the Health and Retirement Study

BackgroundBiomarkers may be pathways by which social adversity affects cognitive aging and Alzheimer's disease and related dementias (ADRD) risk.ObjectiveHow much variance in cognitive dysfunction and cognitive impairment onset do blood-based and physiological biomarkers provide above and beyond easily attainable sociodemographic variables, and how much can biomarkers explain differences in cognitive functioning and ADRD by sociodemographic variables?MethodsWe utilize machine learning to generate measures of predicted cognitive dysfunction and cognitive impairment incidence based on 91 biomarkers, identify the relative importance of each biomarker, and examine how much these biomarkers mediate sociodemographic differences.ResultsMarkers related to cellular aging, neurodegeneration, diet and nutrition, immune functioning, and lung function were identified as important. Biomarkers mediated 47.2-77.3% of the variance associated with age, 22.7-35.2% of racial/ethnic differences in cognitive dysfunction, and 12.5-17.6% of educational differences.ConclusionsBiomarkers provide the potential to understand pathways linking sociodemographic characteristics to cognitive functioning and health. Future research should consider additional biomarkers and evaluate the specific systems that put people at risk for cognitive impairment.

"The Place Where Danger Waits": Ten Years of Incarceration After the 1994 Crime Bill and Cognitive Function among Older Adults

A likely determinant of cognitive function is incarceration. Structural racism directs adverse policing to differentially patrol groups racialized as Black increasing the chances of incarceration, leading to disproportionate representation in prisons. Direct and indirect exposure to incarceration produces chronic stress and trauma for adults racialized as Black. Due to the unique expansion of U.S. prisons after the Violent Crime Control and Law Enforcement Act of 1994, we examined the association between the 10-year average racialized disparity in prison population for the decade succeeding the Crime Bill, 1995-2005, with the overall 14-year cognitive test performance for older adults racialized as Black living in the same county between 2006 and 2020. This observational study linked the average county-level racialized disparity in U.S. prisons to biannual cognitive performance interviews for mid-to-late life adults racialized as Black (> 50 years; N = 1784) from the Health and Retirement Study using baseline county of residence. Cognitive performance was assessed using a 27-item global cognitive score from the modified Telephone Interview for Cognitive Status administered in-person or online. Mixed-effects regressions estimated that greater incarceration of people racialized as Black in prisons was associated with lower overall cognitive test performance among participants racialized as Black (mean difference per 1000 more incarcerated people per 1000 population racialized as Black vs White = - 0.172, 95% CI = - 0.331, - 0.014). As artist Marvin Gaye sang in his song Flyin' High (in the Friendly Sky), "I go to the place where danger waits me," which describes how structural racism via incarceration disparities occurring in one's surroundings increases cognitive health for people racialized as Black irrespective of population size.

Association between high plasma p-tau181 level and gait changes in patients with mild cognitive impairment

Previous studies on gait changes in mild cognitive impairment (MCI) are inconsistent. Alzheimer's disease (AD) plasma biomarkers, amyloid beta (Aβ) and phosphorylated-tau (p-tau), are relevant to gait disorders. This study explores gait changes in MCI and the relationship between gait performance and AD plasma biomarkers. 231 participants were recruited and stratified based on p-tau181 levels into: low p-tau181 with normal cognition (lT-NC), low p-tau181 with MCI (lT-MCI), and high p-tau181 with MCI (hT-MCI). The same cohort was subsequently stratified by Aβ42/Aβ40 levels into: high Aβ42/Aβ40 with normal cognition (hA-NC), high Aβ42/Aβ40 with MCI (hA-MCI), and low Aβ42/Aβ40 with MCI (lA-MCI). Demographic, cognitive and gait data were compared across groups. The hT-MCI and lA-MCI groups were older than the other groups. Significant differences in stride length were found between lT-NC and hT-MCI, lT-MCI and hT-MCI, but not between lT-NC and lT-MCI. Neuropsychological assessments revealed poorer performance in hT-MCI and lT-MCI groups relative to lT-NC, while global cognitive function was comparable between hT-MCI and lT-MCI groups. No such associations were observed between stride length and Aβ42/Aβ40 levels. Decreased stride length, which is generally considered to be indicative of poorer gait, was significantly associated with elevated p-tau181 levels and independent of global cognitive status. These findings highlight the potential of p-tau181 as a biomarker for tau-related motor dysfunction in MCI.

Disparities in Clinical Trial Participation for Hearing Loss Treatment and Cognitive Outcomes in the United States: A Scoping Review

OBJECTIVES

Emerging evidence suggests hearing loss treatment may have a varying impact on modifying the risk of cognitive decline or dementia across different populations. However, it remains unclear whether prior studies have adequately included a diverse range of patient characteristics and dementia risk factors. This study examines participant characteristics in U.S.-based clinical trials investigating associations between hearing aids (HA)/cochlear implants (CI) and cognitive decline.

DATA SOURCES

PubMed, Embase, and Cochrane (inception-December 2024).

REVIEW METHODS

Scoping review following PRISMA-ScR guidelines. Included U.S. trials in peer-reviewed journals on HA/CI and cognitive decline. Participant characteristics were summarized using descriptive statistics and compared to U.S. Census data.

RESULTS

Twenty-two studies (RCTs, non-RCTs, single arm and prospective trials) were included (n = 6-977; mean age: 72.0 years; 66.9% male). Twelve studies utilized HA, and 10 utilized CI. Participants were predominantly White (92.1% ± 9.2), with lower representation among Black (5.4% ± 9.5), Asian (0.1% ± 1.4), and Hispanic/Latino (0.05%; SD not calculatable) populations, reflecting the overrepresentation of White participants (Census 75.3%) and the underrepresentation of others (Census: Black 13.7%, Asian 6.4%, Hispanic/Latino 19.5%). Average education (11.3 ± 2.9 years) was comparable to U.S. averages, and hypertension and diabetes rates (67.2% and 20.1%, respectively) were lower than U.S. age-adjusted rates (74.5% hypertension, 33% diabetes).

CONCLUSIONS

This review of participants characteristics in studies on hearing loss treatment and cognitive decline revealed disparities, particularly in race/ethnicity. Systemic efforts are needed to recruit underrepresented groups to better understand the impact of hearing loss treatment across diverse populations. Bridging these gaps is essential to improving the representativeness of U.S. populations in clinical trials.

Harmonized prevalence estimates of dementia in Europe vary strongly with childhood education

Up-to-date, strictly cross-nationally comparable and nationally representative data on cognitive health are essential for our understanding of the dementia-related challenges in healthcare, to detect shortcomings in healthcare systems and to design effective prevention strategies. Such data have been missing in Europe. We use the most recent 2022 wave of the strictly harmonized Survey of Health, Ageing and Retirement in Europe (SHARE, 47,773 individuals age 65 and older) to obtain prevalence estimates of mild cognitive impairment and dementia for 27 European countries and Israel in 2022. The novelty of the paper is to validate these estimates using the Harmonized Cognitive Assessment Protocol (HCAP) as a validation tool. These new data exhibit much higher prevalence rates of dementia in the Mediterranean and Southeastern European countries and a much larger variation of cognitive impairment across Europe and Israel than previously known. Dementia prevalence ranges from 4.5% in Switzerland to 22.7% in Spain, MCI prevalence from 17.2% in Sweden to 31.1% in Portugal. Most of this variation can be explained by differences in education when respondents were young. Prevalence rates vary plausibly with other risk factors such as age and comorbidities associated with dementia.

Ethnic disparities in care needs among individuals with cognitive impairment

BackgroundAs more individuals with cognitive impairment and dementia (CID) remain at home, greater needs arise, necessitating additional support.ObjectiveTo examine ethnic differences in the needs of individuals with CID among Mexican American (MA) and non-Hispanic White (NHW) participants.MethodsAdults 65 + with possible cognitive impairment (Montreal Cognitive Assessment score < 26), and their caregivers living in Nueces County, Texas, were included. We used the Camberwell Assessment of Need for the Elderly (CANE) tool to study the needs (accommodations, self-care, continence, physical health, emotional well-being, social relationships, and availability of support networks) and their domains of individuals with CID including environmental, physical, psychological and social needs. Using negative binomial and Poisson regressions, ethnic differences were examined within each domain.ResultsA total of 473 participants were included. NHW participants (N = 150) were slightly older (75.5 versus 72.7 years) and had higher rates of MCI and dementia (55% versus 47%) compared to MA participants (N = 323). All participants reported high levels of needs (met or unmet). Furthermore, although NHW participants reported having fewer social needs (met or unmet) compared to MA participants (Incident Rate Ratio [IRR]=-0.79; 97.5%CI:0.63-0.98), NHW participants had a greater level of unmet needs when it came to social needs compared to MA participants (IRR = 1.85; 97.5%CI:1.33-2.57).ConclusionsFindings indicate high levels of needs among individuals with CID. There also exist ethnic differences, with NHW participants having greater unmet needs in social areas. Enhancing access to resources and support systems is essential for equitable support for individuals with CID across various ethnic backgrounds.

Assessing Cognitive Impairment in the Health and Retirement Study Harmonized Cognitive Assessment Protocol Project: Comparing a Diagnostic Algorithm With a Diagnostic Consensus Panel

BackgroundAccurate classification of cognitive impairment in population studies is challenging.ObjectiveTo compare the performance of a diagnostic algorithm with a clinical consensus panel.SampleIn 2016, the Health and Retirement Study (HRS) implemented the Harmonized Cognitive Assessment Protocol Project (HRS-HCAP) to streamline cognitive assessments for select HRS participants.MethodsThe Manly-Jones HCAP diagnostic classification was used to classify cognitive status as normal, mild cognitive impairment (MCI), or dementia. For this analysis, a consensus panel of five clinicians reviewed 50 cases with high diagnostic uncertainty, each reviewing 30 cases, blinded to the algorithm's classifications.AnalysisDiagnostic concordance was assessed using unweighted and weighted Cohen's kappa (κ).ResultsUnweighted concordance was 70% (35/50), with discordance mostly among MCI cases. Weighted concordance was 84%. Unweighted κ was 0.56 (95% CI 0.30-0.81) and weighted κ was 0.75 (95% CI 0.49-0.91), indicating moderate to substantial agreement between the two methods.

"It's Usually Not Dementia That's the Focus": Barriers and Facilitators of Dementia Care in Primary Care

BACKGROUND

Primary care provides most dementia care, yet providing high-quality dementia care within this setting remains a challenge. Medicare and health system initiatives create opportunities to improve quality of dementia care.

OBJECTIVE

To evaluate barriers and facilitators of high-quality dementia care in primary care with a secondary focus on interdisciplinary team-based primary care and health information technology.

DESIGN

Qualitative study using semi-structured interviews from July 2021 to January 2023.

PARTICIPANTS

Fifteen persons living with dementia (PLWD) and/or their 13 family caregivers, five primary care providers (PCPs), and 23 interdisciplinary primary care staff (nurses, medical assistants, care managers, social workers, pharmacists, practice administrators) across practices in a single health system.

APPROACH

We used qualitative content analysis to identify barriers and facilitators to dementia care within a framework of factors affecting whether clinicians follow clinical practice guidelines and how interdisciplinary teams and technology may support dementia care.

KEY RESULTS

Across all participants, there was limited knowledge of care practices and domains that constitute high-quality dementia care. Though PCP, staff, and caregiver attitudes were affected by their own prioritization of other medical conditions in primary care, all groups appreciated the importance of dementia care, and PCPs and staff were already addressing many relevant care domains. Barriers driving behavior were numerous and included time constraints, staffing challenges, and resource limitations in addition to patient or family-level factors. Interdisciplinary team-based care, telehealth, and patient portals can facilitate dementia care from PCP, staff, PLWD, and caregiver perspectives but interdisciplinary teams in particular are not yet used optimally.

CONCLUSIONS

PCPs, interdisciplinary staff, PLWD, and caregivers identify numerous barriers to high-quality dementia care. Implementing dementia care and primary care initiatives, optimizing interdisciplinary team functioning, patient portal and telehealth use for dementia care, PCP/staff dementia training, and addressing well-known primary care challenges could improve dementia care in select settings.

Individuals with Cognitive Impairment Entering Long-Term Care: Characteristics and Cumulative Incidence of Dementia after Care Entry

OBJECTIVES

To characterize individuals entering long-term care facilities (LTCFs) with evidence of cognitive impairment and without a diagnosis of dementia, and to ascertain the cumulative incidence of dementia after care entry.

DESIGN

Retrospective cohort study using the Registry of Senior Australians (ROSA) National Historical Cohort.

SETTING AND PARTICIPANTS

Individuals aged 65 to 105 years who entered LTCFs between 2009 and 2018, received a cognitive evaluation, and had no recorded dementia diagnosis at the time of care entry.

METHODS

Cognitive function was determined via the Psychogeriatric Assessment Scales-Cognitive Impairment Scales (PAS-CIS) and defined as none or minimal (PAS-CIS score 0 to <4), mild (4 to <10), or moderate to severe (10 to 21). The cumulative incidence of dementia, determined by aged care assessments, hospitalization, medication, or cause of death, was ascertained for the total cohort and by cognitive impairment status at care entry.

RESULTS

In total, 90,122 individuals [median age 85 years; interquartile range (IQR) 81-89; 64.6% female] were studied, of whom 76.6% (n = 69,075) had cognitive impairment, including 51.4% (n = 46,350) with mild and 25.2% (n = 22,725) with moderate to severe impairment. Over a median follow-up of 1.5 years (IQR 0.6-2.9), the cumulative incidence of dementia was 26.8% [95% confidence interval (CI), 26.5-27.1]. Stratification by cognitive impairment status showed the cumulative incidence of dementia was 17.4% (95% CI, 16.8-17.9) for none or minimal, 27.3% (95% CI, 26.9-27.8) for mild, and 35.3% (95% CI, 34.7-36.0) for moderate to severe.

CONCLUSIONS AND IMPLICATIONS

The cohort of people entering LTCFs with cognitive impairment had a high incidence of dementia diagnosis within 1.5 years after entry. Routine cognitive impairment assessments can inform dementia screening strategies by identifying individuals at higher risk of dementia.

Incremental Healthcare Costs of Dementia and Cognitive Impairment in Community-Dwelling Older Adults: A Prospective Cohort Study

BACKGROUND

Cognitive impairment and dementia are associated with higher healthcare costs; whether these increased costs are attributable to a greater comorbidity burden is unknown. We sought to determine associations of cognitive impairment and dementia with subsequent total and sector-specific healthcare costs after accounting for comorbidities and to compare costs by method of case ascertainment.

METHODS

Index examinations (2002-2011) of 4 prospective cohort studies linked with Medicare claims. 8 165 community-dwelling Medicare fee-for-service beneficiaries (4 318 women; 3 847 men). Cognitive impairment identified by self-or-proxy report of dementia and/or abnormal cognitive testing. Claims-based dementia and comorbidities derived from claims using Chronic Condition Warehouse algorithms. Annualized healthcare costs (2023 dollars) were ascertained for 36 months following index examinations.

RESULTS

521 women (12.1%) and 418 men (10.9%) met the criteria for cognitive impairment; 388 women (9%) and 234 men (6.1%) met the criteria for claims-based dementia. After accounting for age, race, geographic region, and comorbidities, mean incremental costs of cognitive impairment versus no cognitive impairment in women (men) were $6 883 ($7 276) for total healthcare costs, $4 160 ($4 047) for inpatient costs, $1 206 ($1 587) for skilled nursing facility (SNF) costs, and $689 ($668) for home healthcare (HHC) costs. Mean adjusted incremental total and inpatient costs associated with claims-based dementia were smaller in magnitude and not statistically significant. Mean adjusted incremental costs of claims-based dementia versus no claims-based dementia in women (men) were $759 ($1 251) for SNF costs and $582 ($535) for HHC costs.

CONCLUSIONS

Cognitive impairment is independently associated with substantial incremental total and sector-specific healthcare expenditures not fully captured by claims-based dementia or comorbidity burden.

Cognitive assessment of nursing home residents: Survey data on tools used and perceptions of use among social service professionals in one U.S. state

Background: Social service professionals routinely use screening tools to assess for cognitive decline or identify suspected dementia in nursing home residents. Published literature lacks details about the specific tools used and how professionals use and perceive them in practice. The aim of this study is to better understand cognitive screening roles performed by nursing home social service professionals and how they view their use and efficacy.Methods: An online survey was administered to all 230 nursing homes in the US state of Alabama between October 2021 and March 2022. Fifty-three social service professionals who conduct resident cognitive screenings responded to the survey.Results: In addition to completing the US-mandated Brief Interview of Mental Status (BIMS) quarterly, 75% of participants reported using additional tools, most notably the Mini Mental Status Examination (MMSE). Participants reported using different tools for varied purposes. Those who used both the BIMS and MMSE rated the BIMS significantly higher on ease and time to administer while rating the MMSE higher on reliability and validity. Although most participants reported high levels of confidence using the tools, over half of participants indicated interest in further training in cognitive assessment tools.Discussion: Findings provide evidence regarding who administers nursing home cognitive screenings, which tools are used, and their experiences using those tools. Participant responses reveal the value of using multiple screening tools for improved detection of cognitive status and decline for residents as well as a need for additional training in cognitive assessment. Findings also suggest that the primary tool used for cognitive screening may be quick and easy to use at the expense of perceived reliability and validity. Further evaluation of nursing home cognitive assessment is needed.

Prevalence of dementia diagnoses in a safety net health system

INTRODUCTION

Older adults from minoritized and socioeconomically disadvantaged backgrounds commonly receive health care in safety net health settings and may be at high risk of dementia. We assessed the prevalence of diagnosed dementia in a large safety net health system.

METHODS

International Classification of Disease 10th Revision codes were used to classify presence of dementia for 147,689 older adults with at least one ambulatory encounter in 2019 using electronic health record data. Prevalence was calculated for the sample overall and by age cohort, sex, and race/ethnicity.

RESULTS

Diagnosed dementia prevalence was 0.3% for adults 50 to 64 and 3.0% for adults aged ≥ 65. Adults with diagnosed dementia were older, less likely to speak English, and had more medical comorbidities and higher health-care use than those without.

DISCUSSION

This study's estimates of dementia prevalence were considerably lower than other samples, which may be due to incomplete coding or to underdiagnosis of dementia in a safety net setting.

HIGHLIGHTS

Six percent to 10% of older adults do not have Medicare and often receive health care in safety net health systems; however, little information exists about dementia care in this practice setting. The Los Angeles County Department of Health Services is the nation's second largest municipal health system and provides ambulatory care to > 30,000 older adults annually, of whom > 85% are from minoritized populations and 60% of whom do not have Medicare. We used International Classification of Disease 10th Revision codes and demographic and clinical information derived from the electronic health record to estimate age-adjusted prevalence of dementia in this safety net health setting. Prevalence of diagnosed dementia was significantly less than expected based on national samples, likely reflecting significant underdiagnosis and/or undercoding of dementia in this practice setting.

Review on pathogenesis and treatment of Alzheimer's disease

The rising incidence of Alzheimer's disease (AD) and the associated economic impacts has prompted a global focus in the field. In recent years, there has been a growing understanding of the pathogenic mechanisms of AD, including the aggregation of β-amyloid, hyperphosphorylated tau, and neuroinflammation. These processes collectively lead to neurodegeneration and cognitive decline, which ultimately results in the loss of autonomy in patients. Currently, there are three main types of AD treatments: clinical tools, pharmacological treatment, and material interventions. This review provides a comprehensive analysis of the underlying etiology and pathogenesis of AD, as well as an overview of the current prevalence of AD treatments. We believe this article can help deepen our understanding of the AD mechanism, and facilitate the clinical translation of scientific research or therapies, to address this global problem of AD.

High-Impact Pain Predicts Incidence of Subjective and Objective Cognitive Decline

Chronic pain is the most common health challenge for older adults and a significant risk factor for cognitive impairments and dementia. This study examined the relationship between high-impact pain (pain that limits daily activities) and subjective cognitive decline (SCD) in 13,763 adults aged 50 and older from the Health and Retirement Study (2004-2020). High-impact pain was associated with a higher prevalence and incidence of SCD as compared to no pain and low-impact pain, adjusted for sociodemographic and clinical factors. Additionally, high-impact pain predicted an increased risk of objective cognitive impairment, particularly in individuals without the APOE4 allele. Our findings suggest that high-impact pain is a stronger predictor of future cognitive impairments than SCD alone in most of the population who do not carry the APOE4 allele. Interventions targeting high-impact pain, starting in middle age, may help mitigate the risk of cognitive decline and dementia. Future research is needed to understand potential mechanisms and develop effective cognitive aging strategies considering the impact of pain itself on cognition.

Health System, Community-Based, or Usual Dementia Care for Persons With Dementia and Caregivers: The D-CARE Randomized Clinical Trial

Importance

The effectiveness of different approaches to dementia care is unknown.

Objective

To determine the effectiveness of health system-based, community-based dementia care, and usual care for persons with dementia and for caregiver outcomes.

Design, Setting, and Participants

Randomized clinical trial of community-dwelling persons living with dementia and their caregivers conducted at 4 sites in the US (enrollment June 2019-January 2023; final follow-up, August 2023).

Interventions

Participants were randomized 7:7:1 to health system-based care provided by an advanced practice dementia care specialist (n = 1016); community-based care provided by a social worker, nurse, or licensed therapist care consultant (n = 1016); or usual care (n = 144).

Main Outcomes and Measures

Primary outcomes were caregiver-reported Neuropsychiatric Inventory Questionnaire (NPI-Q) severity score for persons living with dementia (range, 0-36; higher scores, greater behavioral symptoms severity; minimal clinically important difference [MCID], 2.8-3.2) and Modified Caregiver Strain Index for caregivers (range, 0-26; higher scores, greater strain; MCID, 1.5-2.3). Three secondary outcomes included caregiver self-efficacy (range, 4-20; higher scores, more self-efficacy).

Results

Among 2176 dyads (individuals with dementia, mean age, 80.6 years; 58.4%, female; and 20.6%, Black or Hispanic; caregivers, mean age, 65.2 years; 75.8%, female; and 20.8% Black or Hispanic), primary outcomes were assessed for more than 99% of participants, and 1343 participants (62% of those enrolled and 91% still alive and had not withdrawn) completed the study through 18 months. No significant differences existed between the 2 treatments or between treatments vs usual care for the primary outcomes. Overall, the least squares means (LSMs) for NPI-Q scores were 9.8 for health system, 9.5 for community-based, and 10.1 for usual care. The difference between health system vs community-based care was 0.30 (97.5% CI, -0.18 to 0.78); health system vs usual care, -0.33 (97.5% CI, -1.32 to 0.67); and community-based vs usual care, -0.62 (97.5% CI, -1.61 to 0.37). The LSMs for the Modified Caregiver Strain Index were 10.7 for health system, 10.5 for community-based, and 10.6 for usual care. The difference between health system vs community-based care was 0.25 (97.5% CI, -0.16 to 0.66); health system vs usual care, 0.14 (97.5% CI, -0.70 to 0.99); and community-based vs usual care, -0.10 (97.5% CI, -0.94 to 0.74). Only the secondary outcome of caregiver self-efficacy was significantly higher for both treatments vs usual care but not between treatments: LSMs were 15.1 for health system, 15.2 for community-based, and 14.4 for usual care. The difference between health system vs community-based care was -0.16 (95% CI, -0.37 to 0.06); health system vs usual care, 0.70 (95% CI, 0.26-1.14); and community-based vs usual care, 0.85 (95% CI, 0.42 to 1.29).

Conclusions and Relevance

In this randomized trial of dementia care programs, no significant differences existed between health system-based and community-based care interventions nor between either active intervention or usual care regarding patient behavioral symptoms and caregiver strain.

Trial Registration

ClinicalTrials.gov Identifier: NCT03786471.

Smartwatch- and smartphone-based remote assessment of brain health and detection of mild cognitive impairment

Consumer-grade mobile devices are used by billions worldwide. Their ubiquity provides opportunities to robustly capture everyday cognition. 'Intuition' was a remote observational study that enrolled 23,004 US adults, collecting 24 months of longitudinal multimodal data via their iPhones and Apple Watches using a custom research application that captured routine device use, self-reported health information and cognitive assessments. The study objectives were to classify mild cognitive impairment (MCI), characterize cognitive trajectories and develop tools to detect and track cognitive health at scale. The study addresses sources of bias in current cognitive health research, including limited representativeness (for example, racial/ethnic, geographic) and accuracy of cognitive measurement tools. We describe study design and provide baseline cohort characteristics. Next, we present foundational proof-of-concept MCI classification modeling results using interactive cognitive assessment data. Initial findings support the reliability and validity of remote MCI detection and the usefulness of such data in describing at-risk cognitive health trajectories in demographically diverse aging populations. ClinicalTrials.gov identifier: NCT05058950 .

Considerations in the clinical use of amyloid PET and CSF biomarkers for Alzheimer's disease

Amyloid-β (Aβ) positron emission tomography (PET) imaging and cerebrospinal fluid (CSF) biomarkers are now established tools in the diagnostic workup of patients with Alzheimer's disease (AD), and their use is anticipated to increase with the introduction of new disease-modifying therapies. Although these biomarkers are comparable alternatives in research settings to determine Aβ status, biomarker testing in clinical practice requires careful consideration of the strengths and limitations of each modality, as well as the specific clinical context, to identify which test is best suited for each patient. This article provides a comprehensive review of the pathologic processes reflected by Aβ-PET and CSF biomarkers, their performance, and their current and future applications and contexts of use. The primary aim is to assist clinicians in making better-informed decisions about the suitability of each biomarker in different clinical situations, thereby reducing the risk of misdiagnosis or incorrect interpretation of biomarker results. HIGHLIGHTS: Recent advances have positioned Aβ PET and CSF biomarkers as pivotal in AD diagnosis. It is crucial to understand the differences in the clinical use of these biomarkers. A team of experts reviewed the state of Aβ PET and CSF markers in clinical settings. Differential features in the clinical application of these biomarkers were reviewed. We discussed the role of Aβ PET and CSF in the context of novel plasma biomarkers.

Demographic and clinical characteristics of initial patients receiving amyloid-targeting treatments in the United States after regulatory approval

INTRODUCTION

Three treatments for Alzheimer's disease have been approved in the United States. Data are lacking on the characteristics of the initial treatment recipients.

METHODS

We identified treatment recipients in the full Medicare fee-for-service data for 2021 to 2023. We compared their age, sex, race/ethnicity, dual eligibility, comorbidities, and median household income and educational attainment in their residence's ZIP Code Tabulation Area (ZCTA) to those of the overall Medicare population aged 65+.

RESULTS

Treated patients were more likely to be non-Hispanic White (89% vs 82%) and less likely to be dually eligible (1% vs 8.8%). Average median household income ($97,136 vs $84,449) and proportion of residents with at least a bachelor's degree (41% vs 31%) were higher in treated patients' ZCTAs.

DISCUSSION

The first patients receiving amyloid-targeting treatment represent a more privileged subset. While needing to be confirmed with more data, these results point to the need for efforts to make access more equitable.

HIGHLIGHTS

Little is known about the initial 924 patients receiving amyloid-targeting treatments in the United States from 2021 to 2023. They were more likely to be White and less likely to be dually eligible than the Medicare population. They resided in wealthier and more highly educated areas. Comorbidity burden was similar to that observed in clinical trials. Those initial results point to the need to improve equitable access to treatment.

A predictive model of cognitive impairment risk in older adults with hypertension

BACKGROUND

Hypertension is one of the most common diseases in the world, impacting global life expectancy and associated with an increased risk of cognitive impairment.

OBJECTIVE

This study aimed to develop a nomogram that accurately predicts the risk of cognitive impairment in hypertensive patients using the National Health and Nutrition Examination Study (NHANES).

METHODS

A total of 1517 hypertensive patients from NHANES 2011-2014 were included in this study. The population was divided into two groups: 1065 cases (70 %) in the train set and 452 cases (30 %) in the test set. Lasso regression model and multivariate logistic regression analyses identified predictors significantly associated with cognitive impairment, and the nomogram was constructed using these predictors. The performance of the model was assessed using metrics such as area under the curve (AUC) of receiver operating characteristic (ROC), calibration curves, and decision curve analysis (DCA).

RESULTS

The nomogram identified seven predictors, including sex, age, education, poverty income ratio (PIR), depression, vigorous work activity, and creatinine. A web-based dynamic nomogram (https://cognitive-impairment-in-hypertension.shinyapps.io/DynNomapp/) was constructed based on these factors. The AUC of the train set was 0.802 and the AUC of the test set was 0.756, indicating that the model had excellent discriminative ability. The calibration curve showed that the model was well-calibrated. The DCA indicated that early intervention for those at risk would result in a net benefit.

CONCLUSION

The model performed well and was clinically predictive, making it easy for clinicians to use and screen for possible cognitive impairment in elderly hypertensive patients.

American's overall and equity-based societal valuation of a disease-modifying Alzheimer's treatment: Results from a discrete choice experiment

OBJECTIVES

To estimate Americans' willingness-to-pay (WTP) for universal access to a disease-modifying Alzheimer's disease (AD) treatment with a discrete choice experiment in a nationally representative sample. As part of this experiment, we examined whether providing information about the higher disease burden among minorities and persons of lower socioeconomic status (SES) changes WTP.

METHODS

We conducted an information experiment using the nationally representative Understanding America Study (UAS) panel. Participants were provided with general information about AD and a hypothetical treatment that reduces disease progression by 30 %. Two-thirds of the sample were randomized to receive additional information about the higher prevalence of Alzheimer's among either lower SES groups or racial/ethnic minorities. We measured participants' WTP for making the treatment nationally available as a fixed annual fee and income-proportionate fee. Differences in WTP between those exposed to the additional information and those who were not provide the societal valuation of the equity-enhancing effects of the AD treatment.

RESULTS

Average valuations were $252, $260 and $247 per year, and 0.59 %, 0.59 % and 0.61 % of earned income, for the control, race/ethnicity and SES frames, respectively-all statistically indistinguishable. These average results imply that Americans would be willing to pay $33.7 billion based on the fixed fee and $51.4 billion based on the income-related charge for universal access to an AD treatment annually, but their valuation does not further increase when informed about equity considerations.

CONCLUSIONS

While Americans value universal access to an AD treatment highly, health equity considerations did not significantly alter respondents' WTP.

Protocol for an intergenerational randomized controlled trial to enhance physical activity in older adults at risk for Alzheimer's disease

BACKGROUND

Physical inactivity is one of the most important modifiable risk factors for Alzheimer's disease in North America. Despite this, most older adults are physically inactive. It is currently unknown how to successfully motivate physical activity behavior in older adults at risk for Alzheimer's disease, and this knowledge is crucial for early and effective disease prevention. Prior research has shown that intergenerational social engagement and prosocial behaviours can enhance the health and well-being of older adults.

OBJECTIVES

This manuscript describes the design of a randomized controlled trial that will test the efficacy of a behavioral intervention to enhance physical activity in older adults at risk for Alzheimer's disease.

DESIGN/SETTING

This is a single-blinded, two-arm stratified randomized controlled trial that incorporates a hybrid efficacy and implementation design. Participants are randomized to an intervention or control condition in a 1:1 ratio and are stratified by a multimodal Alzheimer's disease risk score. All study visits are conducted remotely through videoconferencing.

PARTICIPANTS

The study aims to recruit 60 older adults with a first-degree family history of Alzheimer's disease from the PREVENT-AD cohort and 30 younger adults who are paired with older adults in the intervention condition.

INTERVENTION

Older participants in the intervention group will be paired with younger study partners and receive positive, daily messages over four weeks using a novel technology platform. The daily messages combine intergenerational social engagement (growing a virtual garden with a younger study partner) and prosocial goals (donations to charity after reaching step count goals).

MEASUREMENTS

The primary outcome is change in step count compared to baseline measured using a wrist-worn triaxial accelerometer. Secondary outcomes include time spent physically active, mood, generativity, loneliness, and cognition. Target mechanisms (social support and generativity) of physical activity engagement will be examined. Ease of use, acceptability, and feasibility of the technology as well as barriers and facilitators of participation will be assessed.

CONCLUSIONS

This research will advance our understanding of mechanisms and individual differences underlying successful physical activity engagement in older adults who are at risk for Alzheimer's disease. This knowledge will contribute to strategies for promoting health behaviours that can prevent the risk of Alzheimer's disease.

The Associations of Sensory Impairment With 10-Year Risk of Dementia and Alzheimer's Disease: The Health and Retirement Study, 2010-2020

BACKGROUND

Studies have examined the association between dual sensory impairment and late-life cognitive outcomes in the U.S with inconsistent findings.

OBJECTIVE

To examine the associations between sensory impairment and 10-year risk of dementia or Alzheimer's disease among U.S. adults aged ≥ 50.

METHODS

A prospective cohort study based on the Health and Retirement Study from 2010 to 2020. Individuals aged ≥ 50 years without self-reported dementia and Alzheimer's disease in 2010 were included in the analysis. Self-reported visual and hearing impairments were measures in 2010. Main failure events included self-reported incident dementia and Alzheimer's disease over a 10-year follow-up period. Participants were categorized as having no visual or hearing impairment, visual impairment only, hearing impairment only, and dual sensory impairment. Fine-Gray competing risk regression model was applied to estimate the associations of sensory impairment with incident dementia and Alzheimer's disease, adjusted for demographic characteristics, health behaviors, and health conditions at baseline.

RESULTS

Of 20,248 identified individuals, 14.6% had visual impairment only, 11.2% had hearing impairment only, and 9.1% had dual impairment at baseline. After adjusting for all covariates, dual sensory impairment was associated with higher risk of dementia (HR = 1.46, 95% CI: 1.23-1.73) and Alzheimer's disease (HR = 1.35, 95% CI: 1.03-1.76). Visual impairment only was also associated with incident dementia and Alzheimer's disease among individuals <65 years.

CONCLUSION

Older adults in the U.S. with visual and hearing impairments simultaneously had a particularly greater risk of dementia and Alzheimer's disease, indicating the needs of targeted screening for timely treatment and further prevention of dementia and Alzheimer's disease.

Race and Incident Dementia Among Older Black and Older White Men

The objective of this study was to determine if racial differences exist between older Non-Hispanic Black (NHB) and White (NHW) men in incident dementia over 11 years (2011-2022) in the National Health and Aging Trends Study (NHATS). The analytic sample included 2395 community-dwelling NHB and NHW men free of dementia at baseline who self-identified as Non-Hispanic Black (NHB) and White (NHW). Dementia was assessed at each visit using a validated algorithm developed by NHATS. After adjusting for demographics, place, and health-related characteristics in the Cox proportional hazard models, older NHB men had an increased risk of dementia (hazard ratio: 1.63, 95% confidence interval: [1.22-2.17]) compared to older NHW men. There may be unique factors such as stressors, patterns of genes, or perhaps nutrition that older NHB men possess and experience throughout their lives that contribute to the increased incident dementia.

The association between dietary dark green vegetable intake and cognitive function in US older adults

Dark green vegetables include dark green leafy vegetables and broccoli. They are sources of many essential nutrients, including vitamins A, B and C, folate, fibre, carotenoids and flavonoids. This study aimed to explore the association between dietary dark green vegetable intake and cognitive function in US older adults. We included 2344 older adults (≥60 years old) from the National Health and Nutrition Examination Survey (NHANES) 2011-2014 cycles. Dark green vegetable consumption was assessed using a continuous variable (cups/day) and two categorical variables. The first categorical variable classified participants into non-consumers and consumers based on whether they consumed dark green vegetables. The second categorical variable grouped participants into four levels of dark green vegetable consumption (non-consumers, consumers with low intakes, consumers with moderate intakes and consumers with high intakes). We used five continuous variables with non-normal distribution to assess cognitive function, including a composite z-score and the standardised scores of four individual cognitive tests. The four cognitive tests included the Immediate Recall Test (IRT), the Delayed Recall Test (DRT), the Animal Mobility Test (AFT) and the Digit Symbol Substitution Test (DSST). The standardised scores of the four cognitive tests were calculated using the mean and standard deviation of each cognitive test score. The composite z-score was calculated by averaging the standardised scores of four cognitive tests to evaluate global cognition. We used multiple linear regression models to examine the association between dietary dark green vegetable intake and cognitive function. Our findings indicated that dark green vegetable intake was positively associated with global cognition (β [95% CI]: 0.17 [0.04, 0.30]; p = 0.016) and IRT (β [95% CI]: 0.26 [0.08, 0.43]; p = 0.009) and DRT (β [95% CI]: 0.21 [0.05, 0.36]; p = 0.012) standardised scores. Individuals with high intake of dark green vegetables showed notably better global cognition (β [95% CI]: 0.16 [0.05, 0.28]; p = 0.010) and showed higher IRT (β [95% CI]: 0.22 [0.07, 0.38]; p = 0.010) and DRT standardised scores (β [95% CI]: 0.21 [0.07, 0.36]; p = 0.007) compared with the non-consumers. Blood neutrophil counts mediated the cognitive benefits of dark green vegetables (Proportion: 9.5%, p = 0.006). In conclusion, our findings suggest that dark green vegetable consumption may have favourable effects on cognitive function in US older adults, especially on immediate and delayed learning abilities. The underlying mechanisms include the ability of dark green vegetables to reduce blood neutrophil levels, an indicator of decreased systemic inflammation. Increasing dietary intake of dark green vegetables may be a beneficial intervention to improve cognitive health in the older US population.

2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2025 AHA Statistical Update is the product of a full year's worth of effort in 2024 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. This year's edition includes a continued focus on health equity across several key domains and enhanced global data that reflect improved methods and incorporation of ≈3000 new data sources since last year's Statistical Update.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Does an Audio Wearable Lead to Agitation Reduction in Dementia: The Memesto AWARD Proof-of-Principle Clinical Research Study

BACKGROUND

Agitation is a common behavioral symptom in persons living with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD), especially in the setting of residential care. Pharmacologic and non-pharmacologic interventions are limited. Memesto is a wearable audio device designed to provide messages and music that can be scheduled or played on demand. The objective of this proof-of-principle study was to quantify whether Memesto can reduce agitation in persons with AD/ADRD.

METHODS

Persons living with AD/ADRD with a Clinical Global Impressions-Severity (CGI-S) average score of 4 or greater, one informal caregiver, and one formal caregiver (triad) were recruited from residential care facilities in the Midwest region of the United States. After consent and a two-week training period, the triad was monitored every two weeks from Baseline to Week 10 with the Neuropsychiatric Inventory (NPI) agitation domain subscale (primary endpoint) and the CGI-S scale (secondary endpoint) with the last observation carried forward. The average score on the NPI agitation domain subscale and the CGI-S scale at Baseline and Week 10 as rated by the two caregivers were compared. A 30% drop in the NPI agitation domain subscale in 50% of the persons living with AD/ADRD was considered a clinically meaningful finding.

RESULTS

Over thirteen months of recruitment, 9 triads were identified in 6 residential care facilities in three Midwestern states. For the NPI agitation domain, 6 of 9 (67%) persons with AD/ADRD had a 30% reduction in the average caregiver ratings at Week 10. No adverse events were identified associated with the use of the device. Device usability was rated as positive based on a survey.

DISCUSSION

This study provided quantitative data on psychometrically sound agitation scales regarding a 10-week treatment course with Memesto after a two-week training period. The results were limited by the inability to recruit the desired set of 20 triads due to disruptions in care and staff at residential care facilities. Further effectiveness testing in a larger cohort with a sham control device is necessary.

TRIAL REGISTRATION

www.

CLINICALTRIALS

gov. NCT05153161. First posted December 10, 2021.

Lessons Learned in Recruitment, Training, and Retention in a Pre-Loss Grief Support Intervention

Participant recruitment in dementia caregiver research is recognized as challenging. This article details the strategies, barriers, and successes of a recruitment approach of a clinical intervention trial for family caregivers of persons living with dementia. Throughout the study, we dealt with challenges both within and outside the researchers' control. These challenges included institutional barriers, community barriers, and individual barriers. To maximize our chances for success, we focused on building strong relationships between the research team and the participants. Using social workers as recruiters, maintaining frequent contact with participants, and flexibility in managing challenges promoted modest success in recruitment and retention.

Effectiveness of Robot-Assisted Board Games on Cognitive Function and Mental Health for Older Adults with Mild Cognitive Impairment: A Cluster Randomized Trial

The effectiveness of robot-assisted board games targeting older adults with mild cognitive impairment was investigated to improve their cognitive function, general self-efficacy, and life satisfaction and reduce depression. A quasiexperimental research design was adopted with 109 older adults from 8 long-term care facilities and day-care centers assigned to the experimental (n = 52) and comparison groups (n = 57). The experimental group underwent a 12-week cognitive training program. Both groups completed before-and-after and 3-month follow-up measurements for outcome variables, including cognitive function (scores of mini-mental state examination [MMSE] and Alzheimer's Disease Assessment Scale Cognitive Subscale [ADAS-Cog]), depression, general self-efficacy, and life satisfaction. The data were analyzed using the generalized estimating equation (GEE). The program's usability was assessed using the system usability scale (SUS). The GEE analyses revealed significant postintervention improvements in the experimental group's MMSE, ADAS-Cog, depression, general self-efficacy, and satisfaction with life scores. These effects persisted for the 3-month follow-up. The mean SUS score was 87.50, indicating the feasibility of robot-assisted interventions among older adults. These findings confirmed that interactive robot-assisted board games can improve cognitive function, general self-efficacy, and life satisfaction and reduce depression among older adults. The administration of long-term care facilities or day-care centers can adopt robot-assisted board games as a training tool to supplement health promotion activities to prevent cognitive deterioration and enhance mental health among older adults.

Association of reported sleep disturbances with objectively assessed mild cognitive impairment among adults in the United States

Background

Sleep is a multifaceted phenomenon influenced by both duration and quality. Various sleep disturbances have been associated with mild cognitive impairment, but the role of specific disturbances in mild cognitive impairment pathophysiology remains unclear. This study investigated the associations between distinct sleep disturbances and mild cognitive impairment in adults aged 50 and older using nationally representative data.

Methods

Longitudinal data from the Health and Retirement Study were analyzed to explore the association between mild cognitive impairment and three types of sleep disturbances: trouble falling asleep, trouble waking up, and waking up too early. Logistic regression models estimated unadjusted (Model 1) and adjusted associations accounting for sex, race/ethnicity, age, social determinants of health (Model 2), general health (Model 3), depression (Model 4), and pain and physical activity (Model 5).

Results

The study cohort included 8877 participants aged ⩾50 years in 2018 (baseline) who were followed up in 2020. Overall, 15.4% reported trouble falling asleep, 23.2% reported trouble waking up, and 12.8% reported waking up too early and being unable to fall back asleep most of the time. Among older adults, approximately 13.1% reported experiencing mild cognitive impairment; The prevalence of mild cognitive impairment was even higher in those who experienced sleep disturbances. The unadjusted odds ratio (uOR) for experiencing trouble falling asleep most of the time was 1.69 (95% CI: 1.42-2.03), for trouble waking up most of the time was 1.31 (95% CI: 1.10-1.57), and for waking up early most of the time was 1.88 (95% CI: 1.51-2.35). However, these positive associations attenuated depending on the covariate adjustment.

Conclusions

Nearly one in seven adults had mild cognitive impairment. The relationship between sleep disturbances and mild cognitive impairment has been challenging to delineate. Our findings demonstrate a positive association between sleep disturbances and mild cognitive impairment, although these associations were sensitive to covariate adjustments. These findings suggest multifaceted pathways for reducing the risk of mild cognitive impairment.

Association of Longitudinal Trajectories of Physical Frailty With Dementia Status in Older Adults: A National Cohort Study

BACKGROUND AND OBJECTIVES

The longitudinal patterns of change in physical frailty and their associations with the subsequent dementia risk remain unclear. This study aimed to (1) explore the long-term trajectories of physical frailty over a 6-year period in older adults without dementia at baseline; (2) identify the socio-demographic and health-related factors associated with different physical frailty trajectories; and (3) examine the longitudinal relationships between different physical frailty trajectories and subsequent risk of dementia.

RESEARCH DESIGN AND METHODS

This national cohort study used data from the National Health and Aging Trends Study (NHATS) conducted in the United States from 2015 to 2021 and included adults aged ≥ 65 without dementia (n = 2245) at baseline in 2015. Group-based trajectory modeling was used to describe the longitudinal changes. Socio-demographic and health-related characteristics were compared across the identified physical frailty trajectories using bivariate analyses, employing Rao-Scott chi-square tests for categorical variables and design-based F-tests for continuous variables. Multinomial logistic regression analyses were conducted to examine the relationships between different frailty trajectories and subsequent dementia status.

RESULTS

Three frailty trajectories were identified: low-stable (74.00%), low-increasing (21.14%), and high-level (4.86%). Participants in the low-increasing and high-level groups were predominantly older, female, minorities, unmarried, and less educated and had a lower income, more comorbidities, and greater anxiety and depression symptoms (p < 0.001). Compared with the low-stable group, older adults in the low-increasing group had higher risk of possible dementia (RRR: 2.37, 95% CI: 1.41-3.97, p < 0.001) and probable dementia (RRR: 1.71, 95% CI: 1.08-2.73, p = 0.02); similarly, older adults in the high-level group had higher risks of possible dementia (RRR: 4.24, 95% CI: 1.74-10.36, p < 0.001) and probable dementia (RRR: 2.99, 95% CI: 1.32-6.76, p = 0.01). No significant differences were found in the risk of dementia between the high-level frailty group and the low-increasing frailty group (p > 0.05).

CONCLUSION AND IMPLICATIONS

This study highlighted the importance of regular frailty monitoring for early detection and informed future interventions that could delay frailty progression and potentially reduce dementia risk.

Unlocking ocular biomarkers for early detection of Alzheimer's disease

Recent evidence suggests that ocular testing holds promise as a non-invasive and cost-effective method for the early detection of Alzheimer's disease (AD). After interviews with neurologists, optometrists, primary care physicians, and ophthalmologists, the potential for ocular biomarker testing to become a standard clinical practice in the future was assessed. Ocular tests offer a non-invasive alternative to blood-based testing, capturing a substantial niche of ≈ 4 to 8 million individuals in the United States during routine eye exams. Technical requirements for broad adoption include high accuracy comparable to blood-based tests and 510(k) clearance. Ocular biomarker technology must meet the practical requirements of optometrists and ophthalmologists, including ease of implementation, automation, and a clear path to profitability. A sufficient body of evidence to support guideline inclusion, reimbursement, and clinical actionability will facilitate the adoption. As the field evolves, advances such as earlier detection of preclinical AD may further expand the role of ocular testing. HIGHLIGHTS: Ocular biomarkers offer another non-invasive alternative to blood-based Alzheimer's disease testing. Wide adoption will require accuracy akin to blood-based tests and 510(k) clearance. Ocular screening could benefit ≈ 4 to 8 million US individuals conducting routine eye exams. Current ocular offerings remain nascent, and advances could expand this reach. New technology must show ease of implementation, automation, and a path to profit.

Incidence and Prevalence of Alzheimer's Disease in Medicare Beneficiaries

INTRODUCTION

The availability of anti-amyloid therapy for mild cognitive impairment (MCI) due to Alzheimer's disease and mild Alzheimer's dementia (AD) has underscored the need for realistic estimates of the population with AD/MCI within the healthcare system to assure adequate preparedness. We hypothesize that administrative databases can provide real-world epidemiologic estimates reflecting the population with diagnosed (known) MCI and AD. This study was conducted to estimate diagnostic incidence and prevalence of AD and all-cause MCI among the Medicare fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries in the United States.

METHODS

This was a retrospective analysis of Medicare beneficiaries (aged 65 and older) with identified diagnoses of AD/MCI based on ≥ 2 diagnostic codes ≥ 30 days apart. Incidence/prevalence estimates were reported per 10,000 person-years.

RESULTS

In FFS, AD incidence (2008-2018) decreased (138 to 104); MCI incidence increased (8 to 47), but the sum (MCI + AD) was relatively stable (146 to 151). Prevalence (2008-2017) increased for AD (318 to 354), and MCI (13 to 99). In MA (2016) epidemiological estimates were consistent with FFS. In 2017, older age, female sex and the Northeastern region were consistently associated with higher AD/MCI prevalence among FFS beneficiaries.

CONCLUSION

In FFS, AD/MCI diagnostic prevalence increased over 10 years, especially for MCI; prevalence estimates in MA (2016) were comparable. Diagnostic prevalence in 2016 (FFS + MA) was 3.4% for AD and 0.85% for MCI. Our findings address the reality of Alzheimer's disease in clinical practice in the United States that is confronted by healthcare professionals, payors, healthcare decision-makers, patients, and caregivers, and may offer a realistic gauge for patient triage for treatment, healthcare resource allocation, and health-systems' operational prioritization. With the availability of anti-amyloid treatments, we anticipate that the population with diagnosed MCI/AD within the Medicare database may rise over time; therefore, periodic updates of incidence/prevalence estimates may provide support for timely healthcare decision-making.

Mechanisms underlying neurocognitive dysfunction following critical illness: a systematic review

INTRODUCTION

Cognitive impairment is a significant healthcare problem globally and its prevalence is projected to affect over 150 million people worldwide. Survivors of critical illness are impacted frequently by long-term neurocognitive dysfunction regardless of presenting illness, but the mechanisms are poorly understood. The goal of this review was to synthesise the existing evidence regarding potential mechanisms underlying neurocognitive dysfunction following critical illness in order to guide potential avenues for future research.

METHODS

We performed a systematic search of the literature for studies published between 1 January 1974 and 15 July 2023. We included publications involving adult patients with critical illness due to any aetiology that assessed for cognitive impairment following recovery from illness, and explored or investigated potential underlying causative mechanisms. The quality and risk of bias of the individual studies was assessed using the Newcastle-Ottawa scale.

RESULTS

Of the 7658 reviewed references, 37 studies comprising 4344 patients were selected for inclusion. Most studies were single centre with sample sizes of < 100 patients. The proportion of patients with long-term cognitive impairment ranged from 13% to 100%. A wide variety of theoretical mechanisms were explored, with biomarkers and neuroimaging utilised most frequently. Many studies reported associations between investigated mechanisms and reduced cognition; several of these mechanisms have been implicated in other forms of long-term neurodegenerative conditions. Increased levels of inflammatory cytokines during acute illness and white matter hyperintensities on neuroimaging following recovery were the associations reported most commonly.

DISCUSSION

The underlying pathophysiology of neurocognitive decline after critical illness is not yet understood fully. The mechanisms implicated in other neurodegenerative conditions suggest that this may represent an accelerated version of the same processes. Large scale studies are required to further elucidate the cause of this significant problem for survivors of critical illness.

Skilled home healthcare utilization and outcomes for older adults with dementia: A scoping review

OBJECTIVES

This study aims to summarize the existing research literature examining Medicare-skilled home health (HH) utilization and clinical outcomes for persons with dementia (PwD). We sought to answer the following questions: (1) How is dementia defined and classified in the HH literature? (2) What associations have been observed between dementia status and patterns of HH utilization? (3) What associations have been observed between dementia status and HH outcomes?

METHODS

Using Arksey and O'Malley's framework for scoping reviews, we searched PubMed, Google Scholar, and select relevant journals for quantitative studies conducted in the United States between 2000 and 2023 examining Medicare HH use and outcomes for PwD. We describe and compare approaches to classify dementia, identify findings related to HH utilization and outcomes supported by the preponderance of evidence, and comment on existing gaps and areas of ambiguity in the literature.

RESULTS

Thirty-two articles met the inclusion criteria. Most used claims-based data to classify dementia, leveraged national data, and were limited to traditional Medicare beneficiaries. Studies found meaningful differences in HH utilization by dementia status; most notably, PwD were more likely to access HH without a preceding hospitalization, had longer lengths of stay, and incurred higher HH costs. Literature relating to clinical outcomes was more difficult to interpret, due to significant variation in study objectives, samples, and outcome measures which prompted more nuanced and even contradictory conclusions. There is a dearth of research identifying how specific HH care pathways (e.g., service types, visit frequency) impact outcomes for this patient population.

CONCLUSIONS

This review supports the understanding that PwD are a unique subpopulation of HH patients who require special attention in policy development and evaluation. Critical research is needed to examine clinical outcomes in PwD further to inform practice and improve care quality.

Clinician contributions to central nervous system-active polypharmacy among older adults with dementia in the United States

BACKGROUND

Exposure to central nervous system (CNS)-active polypharmacy-overlapping exposure to three or more CNS-active medications-is potentially harmful yet common among persons living with dementia (PLWD). The extent to which these medications are prescribed to community-dwelling PLWD by individual clinicians versus distributed across multiple prescribers is unclear.

METHODS

We identified community-dwelling Medicare beneficiaries with a dementia diagnosis and Medicare Parts A, B, and D coverage for at least one month in 2019. Using fill date and days' supply for prescriptions filled between January 1, 2019 and December 31, 2019, we identified beneficiaries exposed to CNS-active polypharmacy (i.e., >30 days of overlapping exposure to three or more antidepressant, antipsychotic, antiseizure, benzodiazepine, opioid, nonbenzodiazepine benzodiazepine receptor agonists, or skeletal muscle relaxant medications). We examined the number and type of clinicians who contributed to polypharmacy person-days among PLWD.

RESULTS

The cohort included 955,074 PLWD who were primarily female (64.0%), were White (78.5%), and had a mean age of 83.4 years (standard deviation 8.0). Notably, 14.3% were exposed to CNS-active polypharmacy. At the person level, 24.6% of PLWD experienced polypharmacy prescribed by a single clinician. Considering total days of exposure, 45.3% of polypharmacy person-days were prescribed by a single clinician. Primary care physicians prescribed 63.0% of polypharmacy person-days and accounted for the plurality of days for all seven medication classes, followed by psychiatrists for antipsychotics and benzodiazepines and primary care advanced practice providers (APPs) for antidepressants and antiseizure medications.

CONCLUSION

In this cross-sectional analysis of Medicare claims data, primary care clinicians (both physicians and APPs) prescribed the majority of medications that contributed to CNS-active polypharmacy for PLWD. Future research is needed to identify strategies to support primary care clinicians in appropriate prescribing of CNS-active medications to PLWD.

Exploring the Association Between Overactive Bladder (OAB) and Cognitive decline: mediation by depression in elderly adults, a NHANES weighted analysis

Overactive bladder (OAB) is a prevalent condition among older adults and may be linked to cognitive health. This study explored a relationship between OAB and cognitive health among adults aged 60 ≥ years in the United States, using NHANES 2011-2014. A cross-sectional analysis was conducted using a nationally representative sample of 2,324 (45.95% male, 54.05% female), within 755 individuals have OAB. Cognitive health was assessed using the Consortium to Establish a Registry for Alzheimer's Disease-Word Learning (CERAD W-L), Animal Fluency Test (AFT), and Digit Symbol Substitution Test (DSST). OAB was defined by a score more than 3 on the Overactive Bladder Syndrome Symptom Score (OABSS). Depression incidence was also recorded. Weighted linear regression models adjusted for demographic, behavioral factors, and comorbidities (e.g., diabetes, kidney disease etc.), were employed to examine the independent association between cognitive health and OAB. The results indicated that cognitive scores were significantly lower in the OAB group compared to the non-OAB group across all cognitive tests (p<0.001). The incidence of depression was significantly higher in the OAB group (15%) compared to the non-OAB group (6.05%) (p<0.001). Regression analysis revealed that a 14% decrease in cognitive health z-scores in patients with OAB (β=-0.14, CI (95%) [-0.22, -0.06]). Furthermore, depression was found to mediate 34.56% of the association between OAB and cognitive health relationship [CI (95%): 0.20, 0.69]. This negative association was robust in subgroups by demographics, behavioral factors, and comorbidities. This study's findings, supported by mediation analysis, smoothed curve analysis, and sensitivity analysis, suggest that lower cognitive health is significantly associated with OAB, and depression plays an important mediating role in this association.

Dispersion-based cognitive intra-individual variability in former American football players: Association with traumatic encephalopathy syndrome, repetitive head impacts, and biomarkers

Background: Exposure to repetitive head impacts (RHI), such as those experienced in American football, is linked to cognitive dysfunction later in life. Traumatic encephalopathy syndrome (TES) is a proposed clinical syndrome thought to be linked to neuropath-ology of chronic traumatic encephalopathy (CTE), a condition associated with RHI from football. Cognitive intra-individual variability (d-CIIV) measures test-score dispersion, indicating cognitive dysfunction. This study examined d-CIIV in former football players and its associations with TES diagnosis, RHI exposure, and DTI and CSF biomarkers. Methods: Data included 237 males (45-74 years) from DIAGNOSE CTE Research Project, including former professional and college football players (COL) (n = 173) and asymptomatic men without RHI or TBI (n = 55). Participants completed neuropsychological tests. TES diagnosis was based on 2021 NINDS TES criteria. Years of football play and a cumulative head impact index (CHII) measured RHI exposure. Lumipulse technology was used for CSF assays. DTI fractional anisotropy assessed white matter integrity. Coefficient of variation (CoV) measured d-CIIV. ANCOVA compared d-CIIV among groups (football versus control; TES-status). Pearson correlations and linear regressions tested associations between d-CIIV, RHI exposure, and CSF and DTI biomarkers. Results: Former professional players had higher d-CIIV than controls (F(7, 194) = 2.87, p = .007). d-CIIV was associated with TES diagnosis (F(8, 146) = 9.063, p < .001), with highest d-CIIV in TES Possible/Probable-CTE. Higher d-CIIV correlated with higher CHII scores (r = 0.19), reduced CSF Aβ1-42 (β = -0.302), increased p-tau181 (β = 0.374), and reduced DTI FA (β = -0.202). Conclusion: d-CIIV is linked to RHI exposure and TES diagnosis in former football players, with associated changes in CSF biomarkers and white matter integrity.

Efficacy of butylphthalide in preventing cognitive decline in ischaemic stroke survivors: a 12-month prospective following-up study

BACKGROUND

Cognitive decline is a significant concern for stroke survivors, affecting their quality of life and increasing their burden on the healthcare system. DL-3-n-butylphthalide (butylphthalide) has shown efficacy in the short-term treatment of various cognitive impairments. This study evaluated the efficacy of butylphthalide in preventing cognitive decline over a 12-month period in patients with ischaemic stroke.

METHODS

This prospective following-up study involved patients newly diagnosed with ischaemic stroke between 1 month and 6 months after stroke onset and not in the acute phase. Patients were assigned to either the butylphthalide or control group. Cognitive function was assessed using the mini-mental state examination (MMSE) at baseline and at the 12-month follow-up. Statistical analyses included t-tests, χ2 tests and multivariate regression analyses.

RESULTS

Butylphthalide was negatively associated with the MMSE D-value (β=-0.122; 95% CI -1.932 to -0.298; p=0.003) and the MMSE D-value percentage (β=-0.117; 95% CI -0.057 to -0.011; p=0.004). A multivariate analysis indicated that butylphthalide treatment was negatively associated with both changes in orientation and language score. Additionally, the incidence of cognitive decline was significantly lower in the butylphthalide group (OR, 0.612; p=0.020) than the control group. An age of ≥60 years and lower educational level were identified as risk factors for lower cognitive score and cognitive decline.

CONCLUSION

This study demonstrated that butylphthalide is effective in preventing cognitive decline in patients with ischaemic stroke. These findings have significant implications for clinical practice, suggesting that butylphthalide could be incorporated into standard post-stroke care regimens to improve patient outcomes and reduce the healthcare burden. Additional multicentre double-blind trials are recommended to confirm these results in diverse populations.

Race/Ethnicity and the Measurement of Cognition in the National Social Life, Health, and Aging Project: Recommendations for Robustness

OBJECTIVES

In this study, we examine the measurement of cognition in different racial/ethnic groups to move toward a less biased and more inclusive set of measures for capturing cognitive change and decline in older adulthood.

METHODS

We use data from Round 2 (N = 3,377) and Round 3 (N = 4,777) of the National Social Life, Health, and Aging Project (NSHAP) and examine the study's Survey Adjusted version of the Montreal Cognitive Assessment (MoCA-SA). We employ exploratory factor analyses to explore configural invariance by racial/ethnic group. Using modification indexes, 2-parameter item response theory models, and split-sample testing, we identify items that seem robust to bias by race. We test the predictive validity of the full (18-item) and short (4-item) MoCA-SAs using self-reported dementia diagnosis, instrumental activities of daily living, proxy reports of dementia, proxy reports of dementia-related death, and National Death Index reports of dementia-related death.

RESULTS

We found that 4 measures out of the 18 used in NSHAP's MoCA-SA formed a scale that was more robust to racial bias. The shortened form predicted consequential outcomes as well as NSHAP's full MoCA-SA. The short form was also moderately correlated with the full form.

DISCUSSION

Although sophisticated structural equation modeling techniques would be preferable for assuaging measurement invariance by race in NSHAP, the shortened form of the MoCA-SA provides a quick way for researchers to carry out robustness checks and to see if the disparities and associations by race they document are "real" or the product of artifactual bias.

Abdominal Myosteatosis and Cognitive Decline in a Biracial Cohort: Insights from CARDIA Study

Objective

Skeletal muscle fat infiltration (myosteatosis) increases with age and is an emerging risk factor for dementia. We aimed to determine the association between myosteatosis and cognitive decline among middle-aged White and Black Americans.

Methods

Data were on men (n=1,080; 41.9% Black) and women (n=1,432; 49.0% Black) from the CARDIA study. CT-measured abdominal intermuscular fat (IMAT) volume was assessed at baseline. Cognition was assessed by Digit Symbol Substitution (DSST), Rey Auditory Verbal Learning (RAVLT), and Stroop Test at baseline and 5-year follow-up. Multivariable linear regression was used to assess associations of IMAT with cognitive change.

Results

Participants were aged 50.2 (3.6) years and had IMAT of 2.3 (1.6) cm 3 , 5-year change in DSST of -2.8% (21.8), RAVLT 2.8% (17.5) and Stroop 6.5% (49.5). Greater IMAT was associated with steeper DSST decline (β =-0.52 points per SD, p-value=0.035), but not with Stroop or RAVLT. Stratified by race, greater IMAT predicted DSST decline among White (β =-0.73, p =0.044), but not Black (β =-0.44, p =0.195), participants.

Conclusions

Abdominal myosteatosis may be a novel risk factor for decline in psychomotor speed, especially in middle-aged Whites. Further research on mechanisms, including metabolic mediators, is warranted to understand myosteatosis's role in mid-life cognitive decline.

Risk prediction model of cognitive performance in older people with cardiovascular diseases: a study of the National Health and Nutrition Examination Survey database

Background and aim

Changes in cognitive function are commonly associated with aging in patients with cardiovascular diseases. The objective of this research was to construct and validate a nomogram-based predictive model for the identification of cognitive impairment in older people suffering from cardiovascular diseases.

Methods and results

This retrospective study included 498 participants with cardiovascular diseases aged >60 selected from the NHANES 2011-2014. The study employed the Minor Absolute Shrinkage and Selection Operator (LASSO) regression model, in conjunction with multivariate logistic regression analysis, to identify relevant variables and develop a predictive model. We used statistical techniques as in the Minor Absolute Shrinkage (MAS) and the Selection Operator (LASSO) regression model, in conjunction with multivariate logistic regression analysis, to identify variables that were significantly predictive of the outcome. After which, based on the selected relevant variables, we developed a machine learning model that was predictive of cognitive impairment such as Alzheimer's diseases in the older people. The effectiveness of the resultant nomogram was evaluated by assessing its discriminative capability, calibration, and conducting decision curve analysis (DCA). The constructed predictive nomogram included age, race, educational attainment, poverty income ratio, and presence of sleep disorder as variables. The model demonstrated robust discriminative capability, achieving an area under the receiver-operating characteristic curve of 0.756, and exhibited precise calibration. Consistent performance was confirmed through 10-fold cross-validation, and DCA deemed the nomogram clinically valuable.

Conclusion

We constructed a NHANES cardiovascular-based nomogram predictive model of cognitive impairment. The model exhibited robust discriminative ability and validity, offering a scientific framework for community healthcare providers to assess and detect the risk of cognitive decline in these patients prematurely.

Neighborhood environment associations with cognitive function and structural brain measures in older African Americans

BACKGROUND

Since older adults spend significant time in their neighborhood environment, environmental factors such as neighborhood socioeconomic disadvantage, high racial segregation, low healthy food availability, low access to recreation, and minimal social engagement may have adverse effects on cognitive function and increase susceptibility to dementia. DNA methylation, which is associated with neighborhood characteristics as well as cognitive function and white matter hyperintensity (WMH), may act as a mediator between neighborhood characteristics and neurocognitive outcomes.

METHODS

In this study, we examined whether DNA methylation in peripheral blood leukocytes mediates the relationship between neighborhood characteristics and cognitive function (N = 542) or WMH (N = 466) in older African American (AA) participants without preliminary evidence of dementia from the Genetic Epidemiology Network of Arteriopathy (GENOA).

RESULTS

For a 1-mile buffer around a participant's residence, each additional fast food destination or unfavorable food store with alcohol per square mile was nominally associated with a 0.05 (95%CI: 0.01, 0.09) and a 0.04 (0.00, 0.08) second improvement in visual conceptual tracking score, respectively. Also, each additional alcohol drinking place per square mile was nominally associated with a 0.62 (0.05, 1.19) word increase in delayed recall score, indicating better memory function (all p < 0.05). Neighborhood characteristics were not associated with WMH. We did not find evidence that DNA methylation mediates the observed associations between neighborhood characteristics and cognitive function.

CONCLUSIONS

The presence of fast food destinations and unfavorable food stores with alcohol was associated cognitive measures, possibly due to greater social interaction provided in these venues. However, replication of these findings is necessary. Further examination of the potential pathways between the neighborhood environment and cognitive function/WMH may allow the development of potential behavioral, infrastructural, and pharmaceutical interventions to facilitate aging in place and healthy brain aging in older adults, especially in marginal populations that are most at risk.

Acute Needs, ACUTE Response: Development and Delivery of a Mental Health Urgent Care in the Bronx

As mental health needs rise, creative and timely solutions are essential. Leveraging the expansion and flexibility of virtual services to create telehealth and hybrid offerings is crucial for addressing systemic barriers in mental health, enhancing accessibility, and providing flexible, comprehensive care options for diverse patient populations. This article discusses the development of a mental health urgent care program within a large medical system in a densely populated, under-resourced community. The program was designed to address common community mental health barriers across multiple care entry points, including ambulatory settings, emergency care, and consultation services. Using a multipronged approach, this program aims to improve patient access, care continuity, and outcomes. The authors encourage others to consider adopting a similar programmatic infrastructure to reduce mental health care barriers in their communities.

Examining Help-Seeking Behavior in People Living Alone With Cognitive Impairment

More than 4 million people in the United States live alone with cognitive impairment or early dementia, yet research on their experiences is limited. Previous research has shown this population has higher levels of unmet care needs and lower financial resources than their married peers. By exploring the experiences of people living alone with cognitive impairment (PLACI), this research examines the successes and barriers within their journey to inform how interventions can improve their quality of life. We conducted qualitative interviews with 15 PLACI (median age 69, 87% white, and 80% female) to explore perceptions of future care needs and resources. Through a modified ideal-type analysis, participants' thought processes and actions regarding help-seeking were mapped to the five stages of the transtheoretical model. These perspectives suggest opportunities such as connecting them to community social work that could help facilitate their understanding of their needs, help them identify resources, and promote proactive aging.

Exposure to School Racial Segregation and Late-Life Cognitive Outcomes

Importance

Disparities in cognition, including dementia occurrence, persist between non-Hispanic Black (hereinafter, Black) and non-Hispanic White (hereinafter, White) older adults, and are possibly influenced by early educational differences stemming from structural racism. However, the association between school racial segregation and later-life cognition remains underexplored.

Objective

To investigate the association between childhood contextual exposure to school racial segregation and cognitive outcomes in later life.

Design, Setting, and Participants

This cross-sectional study examined a nationally representative sample of US older adults from the Health and Retirement Study. Both restricted childhood residence data and publicly available cognitive assessment data (survey years 1995-2018) were used for Black and White participants aged 65 years and older. Data analyses were performed from March 2, 2023, to October 22, 2024.

Exposures

State-level Black and White dissimilarity index for public elementary schools in the late 1960s (range, 0-100) was used to measure school segregation. States were categorized into high segregation (≥83.6) and low segregation (<83.6) based on the top quintile.

Main Outcomes and Measures

Cognitive scores, cognitive impairment, and dementia were assessed using the Telephone Interview for Cognitive Status and proxy assessment. Multilevel regression analyses were conducted stratified by race and ethnicity, adjusting for sociodemographic covariates. Potential early-life and midlife mediators, including educational attainment, were assessed.

Results

The study sample included 3566 Black (16 104 observations) and 17 555 White (90 874 observations) participants. The mean (SD) age of the sample was 75.6 (7.5) years, and 62 187 (58.1%) were female. Participants exposed to high vs low segregation exhibited lower cognitive scores (13.6 vs 14.5) and a higher prevalence of cognitive impairment (37.0% vs 28.0%) and dementia (14.1% vs 9.3%). Multilevel analyses revealed a significant negative association between school segregation and later-life cognitive outcomes among Black participants, but not among White participants, after adjusting for covariates. Potential mediators across the life course, including educational attainment, explained 57.6% to 72.6% of the association, yet the findings were significant among Black participants for all outcomes. In the model including all mediators and covariates, Black participants exposed to high segregation exhibited significantly lower cognitive scores (coefficient, -0.26; 95% CI, -0.43 to -0.09) and a higher likelihood of cognitive impairment (adjusted odds ratio [AOR], 1.35; 95% CI, 1.12-1.63) and dementia (AOR, 1.26; 95% CI, 1.03-1.54).

Conclusions and Relevance

This cross-sectional study of Black and White older individuals found that childhood exposure to school segregation was associated with late-life cognition among the Black population. Given the increasing amount of school segregation in the US, educational policies aimed at reducing segregation are needed to address health inequities. Clinicians may leverage patients' early-life educational circumstances to promote screening, prevention, and management of cognitive disorders.