A multidomain intervention against cognitive decline in an at-risk-population in Germany: Results from the cluster-randomized AgeWell.de trial

Exploring the effect of multi-modal intervention against cognitive decline on atrophy and small vessel disease imaging markers in the AgeWell.de imaging study

BACKGROUND

Multimodal lifestyle interventions might help to maintain healthy cognition in older age and to delay onset of dementia. Here, we studied the effects of a multi-modal lifestyle-based intervention, based on the FINGER trial, on magnetic resonance imaging (MRI) markers of hippocampal-limbic atrophy and cerebral small vessel disease in older adults at increased risk for dementia in Germany.

METHODS

Leipzig participants of the multicenter AgeWell.de randomized controlled trial underwent neuroimaging before and after a two year intervention at 3 Tesla MRI. We extracted hippocampal volume and entorhinal cortex thickness (ECT), free water fraction (FW), peak width of skeletonized mean diffusivity (PSMD), white matter hyperintensity volume and mean gray matter cerebral blood flow and assessed the effect of the intervention on these imaging markers using linear mixed models. We also tested the effect of the intervention on the hippocampus-dependent Mnemonic Similarity Test and fixel-based white matter microstructure.

RESULTS

56 individuals (mean (sd) age: 68.8 (4.2) years, 26 females, 24/32 intervention/control group) were included at baseline and 41 returned after an average of 28 months for the second assessment. ECT and FW exhibited stronger decline in the intervention compared to the control group in preregistered models but not when adjusted for baseline differences. All other markers progressed similarly across groups, however sample size was smaller than expected. In exploratory analyses, cerebral blood flow increased more in the intervention group and this change was associated with decreases in systolic blood pressure.

CONCLUSIONS

In this group of older adults at risk for dementia, we find no conclusive evidence whether a multi-modal lifestyle intervention improves brain imaging markers of neurodegeneration and small vessel disease. Preliminary evidence suggested an association of the intervention, increased cerebral blood flow and systolic blood pressure reductions.

ABBREVIATIONS

ECT, entorhinal cortex thickness; FW, free water fraction; WHO, world health organization; AD, Alzheimer's disease; VCI, vascular cognitive impairment; FINGER, Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability; MTL, medial temporal lobe; MIND, Mediterranean-DASH Intervention for Neurodegenerative Delay diet; cSVD, cerebral small vessel disease; WMH, white matter hyperintensities of presumed vascular origin; PSMD, peak width of the mean diffusivity distribution; WW-FINGERS, world wide FINGER studies; CAIDE, Cardiovascular Risk Factors, Aging, and Incidence of Dementia; GPP, general practitioner praxis; MRI, magnetic resonance imaging; MST, Mnemonic Similarity Test; TE, echo time; TR, repetition time; FA, flip angle; FOV, field of view; GRAPPA, GeneRalized Autocalibrating Partial Parallel Acquisition; CMRR, Center for Magnetic Resonance Research; BOLD, blood oxygenation level dependent; pcASL: pseudo-continuous arterial spin labeling; EPI, echo-planar imaging; FLAIR, fluid attenuated inversion recovery; CBF, cerebral blood flow; QA, quality assessment; GM, gray matter; HCV, hippocampal volume; eICV, estimated intracranial volume; DWI, diffusion-weighted imaging; MD, mean diffusivity; FA, fractional anisotropy
TBSS: tract-based spatial statistics; CSF, cerebral spinal fluid; ISI, inter-stimulus interval; LDI, lure discrimination index; REC, recognition score; CG, control group; IG, intervention group; MoCA, Montreal Cognitive Assessment; CASMIN, Comparative Analysis of Social Mobility in Industrial Nations; BMI, body mass index; SBP/DBP, systolic/diastolic blood pressure; OSF, open science framework; LMM, linear mixed model; ANOVA, analysis of covariance.

Factors associated with a healthy diet and willingness to change dietary behavior in older adults at increased risk of dementia

BackgroundHealthy dietary patterns have been linked to reduced risks for cardiovascular diseases and dementia, making nutrition an essential part of a comprehensive approach for dementia prevention. Knowledge about factors associated with a healthy diet in people with increased dementia risk is scarce.ObjectiveTo analyze dietary habits and associated factors in older adults with increased dementia risk in Germany.MethodsWe used baseline-data of the AgeWell.de-trial (n = 1001, %female = 52.2, Mage = 69.0, SD = 4.9). Nutrition was assessed using a composite score, comprising 11 components covered by national recommendations for a healthy diet (range = 0-11 points). Linear regressions assessed associations of sociodemographic, social, health-related and psychological factors with consumption of a healthy diet. Further, we assessed stages of change based on the transtheoretical model of behavior change.ResultsConsumption of a healthy diet was moderate (Median = 4, IQR = 2). Female sex (b = 0.64, 95% CI: 0.41, 0.88), higher levels of motivation for healthy eating (b = 0.22, 95% CI: 0.10, 0.34) and higher self-efficacy (b = 0.33, 95% CI: 0.20, 0.46) were linked to a healthy diet. Regarding the stages of behavior change, the majority were in the maintenance stage (45.2%), followed by the contemplation (21.5%) and precontemplation (21.2%) stages.ConclusionsResults suggest room for improvement regarding a healthy diet in our sample. Lifestyle-based interventions in older adults should be tailored towards current levels of motivation and self-efficacy of participants. Including modules targeting motivation and self-efficacy might help maximize intervention effectiveness.

Alzheimer disease seen through the lens of sex and gender

Alzheimer disease (AD) is a life-limiting neurodegenerative disorder that disproportionately affects women. Indeed, sex and gender are emerging as crucial modifiers of diagnostic and therapeutic pathways in AD. This Review provides an overview of the interactions of sex and gender with important developments in AD and offers insights into priorities for future research to facilitate the development and implementation of personalized approaches in the shifting paradigm of AD care. In particular, this Review focuses on the influence of sex and gender on important advances in the treatment and diagnosis of AD, including disease-modifying therapies, fluid-based biomarkers, cognitive assessment tools and multidomain lifestyle interventional studies.

Adherence to lifestyle intervention activities in the SINgapore GERiatric to reduce cognitive decline and physical frailty (SINGER) study: A one-year preliminary analysis of process evaluation

OBJECTIVES

To evaluate adherence to lifestyle intervention activities in the SINgapore GERiatric Intervention Study to Reduce Cognitive Decline and Physical Frailty (SINGER) study's intensive intervention arm over one year, as part of ongoing process evaluation. The analysis identifies sociodemographic, psychosocial, and vascular risk factors associated with adherence to optimize intervention strategies and improve participant engagement.

METHODS

Adherence was categorised as non-adherent, low, moderate and high adherence based on participants' attendance. Total adherence was assessed in two ways, i) a composite of all attendance and ii) Latent Class Analysis (LCA) to identify distinct participant subgroups based on adherence to the SINGER study activities. Regression models assessed associations between individual factors with adherence to each type of intervention component and adherence profiles derived from LCA.

RESULTS

More than 70 % of participants achieving moderate to high adherence. LCA identified three distinct adherence profiles: Low, Moderate and High adherence. Participants showed higher adherence to vascular and diet components, followed by exercise components, and lower adherence to cognitive components. Factors such as being female and having higher education were associated with higher adherence while living alone was associated with lower adherence. Participants with hypertension had higher overall adherence but lower adherence to vascular management sessions. The complexity, delivery mode and frequency of the activities influenced adherence, with more complex and frequent activities showing lower adherence.

CONCLUSION

The intensive intervention arm showed satisfactory adherence. A comprehensive analysis highlighted the relationship between adherence, sociodemographic factors, and vascular risks, emphasizing the need for targeted strategies to support subgroups with lower adherence and optimize engagement.

PRACTICE IMPLICATIONS

The study team should enhance participant engagement by simplifying complex activities and tailoring strategies for subgroups with lower adherence. Ongoing monitoring of adherence patterns and participant feedback will be crucial for making timely adjustments to the intervention.

Adherence and intensity in multimodal lifestyle-based interventions for cognitive decline prevention: state-of-the-art and future directions

Preventing dementia and Alzheimer's disease (AD) is a global priority. Multimodal interventions targeting several risk factors and disease mechanisms simultaneously are currently being tested worldwide under the World-Wide FINGERS (WW-FINGERS) network of clinical trials. Adherence to these interventions is crucial for their success, yet there is significant heterogeneity in adherence reporting across studies, hindering the understanding of adherence barriers and facilitators. This article is a narrative review of available evidence from multimodal dementia prevention trials. A literature search was conducted using medical databases (MEDLINE via PubMed and SCOPUS) to select relevant studies: nonpharmacological multimodal interventions (i.e., combining three or more intervention domains), targeting individuals without dementia, and using changes in cognitive performance and/or incident mild cognitive impairment or dementia as primary outcomes. Based on the findings, we propose future adherence reporting to encompass both participation (average attendance to each intervention component) and lifestyle change using dementia risk scores (e.g., the LIBRA index). Moreover, we provide an estimation of the expected intensity of multimodal interventions, defined as the ratio of the expected dose (i.e., the overall amount of the intervention offered specified in the trial protocol) to duration (in months). Adjusting the expected dose by average adherence enables estimation of the observed dose and intensity, which could be informative for identifying optimal dosage thresholds that maximize cognitive benefits across different populations. Finally, this article provides an overview of the determinants of adherence to multimodal interventions, emphasizing the need for improved adherence reporting to inform the design and implementation of precision prevention interventions.

Potential for reducing dementia risk: association of the CAIDE score with additional lifestyle components from the LIBRA score in a population at high risk of dementia

OBJECTIVES

Various dementia risk scores exist that assess different factors. We investigated the association between the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) score and modifiable risk factors in the Lifestyle for Brain Health (LIBRA) score in a German population at high risk of Alzheimer's disease.

METHOD

Baseline data of 807 participants of AgeWell.de (mean age: 68.8 years (SD = 4.9)) were analysed. Stepwise multivariable regression was used to examine the association between the CAIDE score and additional risk factors of the LIBRA score. Additionally, we examined the association between dementia risk models and cognitive performance, as measured by the Montreal Cognitive Assessment.

RESULTS

High cognitive activity (β = -0.016, p < 0.001) and high fruit and vegetable intake (β = -0.032, p < 0.001) correlated with lower CAIDE scores, while diabetes was associated with higher CAIDE scores (β = 0.191; p = 0.032). Although all were classified as high risk on CAIDE, 31.5% scored ≤0 points on LIBRA, indicating a lower risk of dementia. Higher CAIDE and LIBRA scores were associated with lower cognitive performance.

CONCLUSION

Regular cognitive activities and increased fruit and vegetable intake were associated with lower CAIDE scores. Different participants are classified as being at-risk based on the dementia risk score used.

Adherence to intervention components: The key to success? Analysis on health-related outcomes of the AgeWell.de intervention to preserve cognition

BackgroundThe aim of the study was to analyze the impact of adherence to the intervention components on the effectiveness of AgeWell.de, a multi-domain lifestyle intervention against cognitive decline, on function in everyday activities, quality of life, depressiveness and social isolation.ObjectiveStudying the effect of adherence on health-related outcomes.MethodsParticipants were aged 60-77 years at baseline and at risk (Cardiovascular Risk Factors, Ageing and Dementia Score (CAIDE) ≥9). Adherence to the components nutrition, enhancement of physical and social activities and cognitive training was analyzed in two ways, first continual within the intervention group (n = 378, mean age = 69.1 years, 52.7% female) and second as dichotomous split (75% adherence) and in reference to the control group (received infomaterial and regular health advice; n = 441, mean age = 69 years, 53% female). Generalized linear regression models were then run on the health outcomes functioning in everyday activities, quality of life, depressive symptoms, and social inclusion.ResultsHealth-related quality of life and depressiveness were improved in participants with better adherence to nutritional counselling and enhancement of physical and social activities. Better adherence to social activities was relevant for function in everyday activities. Effects of high adherence to cognitive training was found for improvements in depressiveness when comparing it to the control group. No effect was found on social inclusion when considering the particular components.ConclusionsThe extent of adherence to most components influenced health-related outcomes such as health-related quality of life and depressiveness. With this study, the effectiveness of AgeWell.de can be understood in greater depth.Trial RegistrationGerman Clinical Trial Register (DRKS; ID: DRKS00013555).

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.

Acceptability and fidelity of the multidomain 'Brain Bootcamp' dementia risk reduction program: a mixed-methods approach

BACKGROUND

Interventions targeting dementia prevention typically lack comprehensive exploration of feasibility, acceptability, and long-term translation factors prior to deployment. Our study aimed to explore the acceptability, fidelity and participants' experiences with Brain Bootcamp, a multi-domain behaviour change intervention targeting reduced dementia risk and increased dementia risk factor awareness for older adults.

METHODS

Conducted in New South Wales, Australia, from January to August 2021, our concurrent single-group mixed-methods feasibility study involved post-intervention surveys and qualitative interviews with community-dwelling older adults. Descriptive statistics were used to assess acceptability of the methods, outcome measures, and fidelity to the program components. Thematic analysis of semi-structured interviews explored participant experiences, preferences, barriers, and recommendations.

RESULTS

Out of 853 enrolled participants, only 355 completed the program (41.6%). Among these participants, 79.1% agreed that the intervention improved their awareness of dementia risk factors, and 92.4% expressed intent to continue maintaining brain healthy behaviours post- program. Participants typically set 2-4 modifiable risk factor lifestyle goals, which were most often related to physical activity (83.7%). A majority (91.5%) successfully achieved at least one brain health goal. Qualitative analyses (n = 195) identified three overarching themes on the role of education on behaviour modification (i.e., the transformative role of the program in enhancing knowledge about dementia prevention and fostering behavioral modifications), psychological considerations (e.g., intrinsic versus extrinsic motivation on their engagement and perception of the program) and future directions (e.g., sustainability concerns and the need for tailored strategies for specific demographics).

CONCLUSIONS

While Brain Bootcamp had low completion rates, those who completed the program reported high acceptability. Future refinements, incorporating targeted strategies and enhanced participant support and communication, will facilitate pragmatic initiatives.

CLINICAL TRIAL NUMBER

ACTRN12621000165886.

Searching for responders to multidomain dementia prevention in late life: A pooled analysis of individual participant data from the MAPT and preDIVA trials

INTRODUCTION

It is unknown in which, if any, subgroups of older adults multidomain interventions are effective at reducing long-term dementia incidence.

METHODS

We pooled up to 12 years of follow-up data from 5205 participants aged > 70 from the Multidomain Alzheimer Preventive Trial (MAPT) and Prevention of Dementia by Intensive Vascular Care (preDIVA) studies. The primary outcome was incident all-cause dementia. Pre-specified subgroups were defined by dementia risk factors (age, sex, education, apolipoprotein E [APOE] genotype, cognitive status, and cardiovascular risk factors).

RESULTS

Four hundred eighty-six participants developed dementia during 37,782 person-years of follow-up. Higher incidence was associated with baseline age, APOE ε4 genotype, physical inactivity, Mini-Mental State Examination, and blood pressure. Multidomain intervention had no effect on incident dementia overall (hazard ratio = 0.98, 95% confidence interval 0.80-1.21), or in any pre-specified subgroup. A recursive partitioning algorithm also did not detect any subgroups, defined by single or multiple risk factors, showing a differential intervention effect.

DISCUSSION

We did not identify any subgroups of older adults in whom multidomain interventions significantly reduced incident dementia.

CLINICAL TRIAL REGISTRATION

MAPT: NCT00672685 (clinicaltrials.gov); PreDIVA: ISRCTN29711771 (ISRCTN registry) HIGHLIGHTS: We pooled up to 12 years of follow-up data from two multidomain prevention trials. Five thousand two hundred five participants aged ≥ 70 were included. Subgroups were pre-defined by modifiable and non-modifiable dementia risk factors. A data-driven recursive partitioning algorithm was also used. Multidomain intervention did not lower incident dementia overall or in any subgroup.

Complex interactions and composite burden of risk factors in vascular cognitive impairment

Vascular cognitive impairment (VCI) stresses the vascular contributions to cognitive decline, ranging from mild to major forms. Except for symptomatic treatment for relevant vascular diseases, the other recommended strategy is to intervene in key vascular risk factors (VRFs) as early as possible. A considerable amount of previous research delineated the association of a specific factor with dementia, involving each risk factor discussed in the present review. However, due to the heterogeneity and complexity of VCI, managing a single factor is insufficient to reduce its incidence and prevalence. Ongoing studies suggest differences in the impact of various combinations of risk factors on dementia. Here in this review, we aimed to provide an updated overview of clinical evidence and implications of complex interactions among various risk factors of VCI, including common VRFs and modifiable dementia-related risk factors. Understating the effect of comorbid risk factors on VCI and underlying mechanisms of them during VCI progression is essential for identifying high-risk population and developing preventive strategies. Furthermore, we summarized common composite risk scores and models used for risk evaluation and prediction of VCI, involving conventional risk scores, subclinical vascular composites, and novel risk models driven by intelligent algorithms. Lastly, we discussed potential gaps and research directions on searching specific clinical risk profiles, constructing effective risk scores, and implementing targeted risk interventions.

Cost-effectiveness of a multicomponent intervention against cognitive decline

INTRODUCTION

The societal costs of dementia and cognitive decline are substantial and likely to increase during the next decades due to the increasing number of people in older age groups. The aim of this multicenter cluster-randomized controlled trial was to assess the cost-effectiveness of a multi-domain intervention to prevent cognitive decline in older people who are at risk for dementia.

METHODS

We used data from a multi-centric, two-armed, cluster-randomized controlled trial (AgeWell.de trial, ID: DRKS00013555). Eligible participants with increased dementia risk at baseline (Cardiovascular Risk Factors, Aging, and Incidence of Dementia/CAIDE Dementia Risk Score ≥ 9), 60-77 years of age, were recruited by their general practitioners, and assigned randomly to a multi-domain lifestyle intervention or general health advice. We performed a cost-effectiveness analysis from the societal perspective. The time horizon was 2 years. Health care utilization was measured using the "Questionnaire for Health-Related Resource Use in Older Populations." As effect measure, we used quality-adjusted life-years (QALYs) based on the 5-level EQ-5D version (EQ-5D-5L). We calculated the incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves (CEAC) using the net-benefit approach. Exploratory analyses considering women and the EQ visual analogue scale (EQ VAS) were conducted.

RESULTS

Data were available for 819 participants (mean age 69.0 [standard deviation (SD)5-level EQ-5D version 4.9]); 378 were treated in the intervention group and 441 in the control group. The participants in the intervention group caused higher costs (+€445.88 [SD: €1,244.52]) and gained additional effects (+0.026 QALY [SD: 0.020]) compared to the participants in the control group (the difference was statistically significant). The ICER was €17,149.23/QALY. The CEAC showed that the probability of the intervention being cost-effective was moderate, reaching 59% at a willingness-to-pay (WTP) of €50,000/QALY. The exploratory analyses showed promising results, especially in the female subsample.

DISCUSSION

Considering aspects like the WTP and the limited time horizon, the multi-domain intervention was cost-effective compared to general health advice.

Highlights

The first German randomized controlled trial (RCT) evaluating a multicomponent approach against cognitive decline.We found a favorable incremental cost-effectiveness ratio.The probability of cost-effectiveness reached 78.6%.Women could be an important target group.A longer time horizon is needed.

Dietary changes following a lifestyle-based intervention for dementia risk reduction - results from the AgeWell.de study

PURPOSE

We investigated the effects of a multidomain lifestyle intervention conducted in older adults at increased risk for dementia on participants' diet.

METHODS

Secondary analyses of the cluster-randomized AgeWell.de-trial, testing a multidomain intervention (optimization of nutrition and medication, enhancement of physical, social and cognitive activity) in older adults at increased dementia risk. Intervention effects on a healthy diet (composite score) and its components were analyzed using Poisson- and logistic regression analyses. Stages of behavior change (transtheoretical model), and respective changes between baseline and follow-up were analyzed using mixed regression analyses.

RESULTS

A total of 819 individuals were analyzed (Mage = 69.0, SD = 4.9, nintervention/control group = 378/441). We observed a significant intervention effect on the healthy diet score (b = 0.06, IRR: 1.06, 95% CI: 1.01, 1.11). Changes were particularly due to increased fruit- and vegetable consumption, while other food components were not improved by the intervention. The intervention did not induce transitions to advanced stages of behavior change regarding a healthy diet, however, participants in the control group moved to initial stages of behavior change (OR = 1.95, 95% CI: 1.30, 2.92).

CONCLUSION

A multidomain lifestyle intervention improved participants' diet and maintained motivation to change in an at-risk-sample. However, only fruit- and vegetable consumption increased. Additional support might be necessary to encourage older adults to integrate new, healthier food components into their diet. Control group participants transitioned to initial stages of behavior change, stressing the need to encourage older adults to maintain a healthy diet as they age. AGEWELL.DE WAS PROSPECTIVELY REGISTERED IN THE GERMAN CLINICAL TRIALS REGISTER (DRKS; IDENTIFIER: DRKS00013555) ON DECEMBER 7TH, 2017: DRKS00013555.

The Systematic Multi-domain Alzheimer's Risk Reduction Trial (SMARRT) intervention: A personalized approach to dementia risk reduction

BACKGROUND

Addressing modifiable risk factors such as physical inactivity and social isolation could reduce risk of Alzheimer's disease and all-cause dementia, but little is known about which factors individuals are most willing to address or how they prefer to address them.

OBJECTIVE

To examine and describe behavior change goals set by participants during the Systematic Multi-domain Alzheimer's Risk Reduction Trial (SMARRT).

METHODS

In SMARRT, older adults worked with a health coach and nurse over 2 years to set incremental, personalized goals to reduce dementia risk. We performed quantitative analyses to summarize the numbers of goals per risk factor and qualitative content analyses of health coach and nurse notes to describe types of goals and useful strategies.

RESULTS

82 dementia-free adults (70 to 89 years) with at least two dementia risk factors participated in the SMARRT intervention arm (mean age, 76 ± 5 years; 72% women; 11% Black/African American, 4% Asian, 3% Hispanic, 7% another non-White race). Participants set a median of 12 health coach goals and 1 nurse goals. The risk factors participants chose to work on most frequently were physical activity (95%), hypertension (72%), and cognitive activity (60%). Participants reported that the most useful strategies included support and accountability from the health coach/nurse, setting small goals, and learning to manage setbacks.

CONCLUSIONS

When given support, older adults at increased risk for dementia set a wide range of goals to reduce dementia risk. A flexible, personalized approach that focuses on setting feasible goals and managing setbacks provides a useful framework for dementia risk reduction.

Vascular cognitive impairment and dementia: Mechanisms, treatment, and future directions

Worldwide, around 50 million people live with dementia, and this number is projected to triple by 2050. It has been estimated that 20% of all dementia cases have a predominant cerebrovascular pathology, while perhaps another 20% of vascular diseases contribute to a mixed dementia picture. Therefore, the vascular contribution to dementia affects 20 million people currently and will increase markedly in the next few decades, particularly in lower- and middle-income countries.In this review, we discuss the mechanisms of vascular cognitive impairment (VCI) and review management. VCI refers to the spectrum of cerebrovascular pathologies that contribute to any degree of cognitive impairment, ranging from subjective cognitive decline, to mild cognitive impairment, to dementia. While acute cognitive decline occurring soon after a stroke is the most recognized form of VCI, chronic cerebrovascular disease, in particular cerebral small-vessel disease, can cause insidious cognitive decline in the absence of stroke. Moreover, cerebrovascular disease not only commonly co-occurs with Alzheimer's disease (AD) and increases the probability that AD pathology will result in clinical dementia, but may also contribute etiologically to the development of AD pathologies.Despite its enormous health and economic impact, VCI has been a neglected research area, with few adequately powered trials of therapies, resulting in few proven treatments. Current management of VCI emphasizes prevention and treatment of stroke and vascular risk factors, with most evidence for intensive hypertension control. Reperfusion therapies in acute stroke may attenuate the risk of VCI. Associated behavioral symptoms such as apathy and poststroke emotionalism are common. We also highlight novel treatment strategies that will hopefully lead to new disease course-modifying therapies. Finally, we highlight the importance of including cognitive endpoints in large cardiovascular prevention trials and the need for an increased research focus and funding for this important area.

[Prevention of cognitive decline in old age : Selected primary preventive approaches]

There are currently 1.8 million people in Germany affected by dementia. Despite advances in research and new treatments, there is no cure for most cases of dementia. The evidence regarding the prevention of cognitive decline in old age is unclear. In addition to the optimized adjustment of drug treatment (e.g., arterial hypertension and diabetes mellitus), preventive measures that can be influenced by individuals themselves play an important role. These include areas such as physical and cognitive activity, remedying hearing loss, sleep, social contacts, abstaining from alcohol as well as tobacco consumption and nutrition. Multimodal concepts and digital approaches appear to be promising and an increase in evidence is expected in the coming years.

The impact of MIND diet consumption and physical activity on cognitive functioning in healthy aging older adults

Objective: Modifiable lifestyle factors evidence great promise in reducing cognitive decline in older adults. Greater consumption to the MIND diet (Morris et al.) and increased daily physical activity (Buchman et al.) are associated with higher cognitive functioning. The interactive effects of lifestyle factors on cognition in older adults has not been investigated extensively. The present study examined the interaction between MIND diet consumption and intensity of physical activity on cognition in community-dwelling older adults. Methods: The sample included 215 older adults (159 female, Mage=79.8; Medu=15.5) from the Memory and Aging Project (Bennet et al.). The measures included the food frequency questionnaire (FFQ, MIND diet consumption), a portable actigraph worn 24 h a day for ten days (activity intensity), and a neuropsychological battery (cognitive variables). Results: Controlling for age and education, multiple regression analyses revealed that MIND diet consumption significantly predicted global cognition (ps< .05). Physical activity significantly predicted global cognition (ps< .05), and processing speed (ps< .01). Interaction effects were significant in global cognition (ps< .05), and episodic memory (ps< .01) revealing a pattern that those with the lowest MIND diet consumption may experience greater cognitive benefits from physical activity in than those with higher diet consumption. Conclusions: Findings suggest that older adults who do not consume the MIND diet closely may experience greater benefit in cognitive functioning from exercise than individuals who more greatly consume the diet.

Quality over quantity - rethinking social participation in dementia prevention: results from the AgeWell.de trial

BACKGROUND

Social participation as a protective factor against cognitive decline was one of the targets in the AgeWell.de study, a multi-domain interventional trial in a sample of older adults at increased risk for dementia. This study aimed to examine differential effects of the intervention and other influencing factors on social participation throughout the trial.

METHODS

A longitudinal analysis of study data at the primary follow-up after 24 months (n = 819) was conducted. The Lubben Social Network Scale (LSNS-6) was used to assess quantitative aspects of social networks, and self-reported social activities were classified using a three-tiered categorical framework to capture qualitative aspects.

RESULTS

A positive effect of the intervention was observed at the qualitative framework level, with an OR of 1.38 [95% CI: 1.05-1.82] for achieving or maintaining higher social participation at follow-up, while no effect could be detected on quantitative social network characteristics. Later phases of the Covid-19 pandemic showed a negative impact on the level of social participation at follow-up with an OR of 0.84 [95% CI: 0.75-0.95].

CONCLUSIONS

These findings suggest that by focusing on qualitative aspects of social participation as a component of dementia prevention, future interventions can promote enriched social interactions within established social networks.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS) ID DRKS00013555.

Effect of long-term physical exercise and multidomain interventions on cognitive function and the risk of mild cognitive impairment and dementia in older adults: A systematic review with meta-analysis

INTRODUCTION

Recent studies have suggested that sustained multidomain interventions, including physical exercise, may be beneficial in preventing cognitive decline. This review aims to assess the impact of prolonged physical exercise and multidomain strategies on overall cognitive faculties and dementia risk among community-dwelling older adults without dementia.

METHODS

We systematically searched PubMed, Web of Science, PsychInfo, and CINHAL databases from inception until April 1, 2024, for randomized controlled trials that investigated the effects of long-term (≥ 12 months) physical exercise or multidomain interventions on non-demented, community-dwelling older adults. The primary outcomes assessed were changes in global cognition and the risk of mild cognitive impairment (MCI) or dementia. Standardized mean differences (SMD) and risk ratios (RR) with 95 % confidence intervals were computed using a random-effects inverse-variance method with the Hartung-Knapp-Sidik-Jonkman adjustment for effect size calculation. The Cochrane Risk-of-Bias-2 tool (RoB-2) was used for bias assessment, and the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was applied to evaluate the certainty of evidence.

RESULTS

Sixteen trials, including 11,402 participants (mean age 73.2 [±5.5] years; 62.3 % female) were examined. The risk of bias was low. Moderate-certainty evidence indicated that physical exercise interventions had modest to no effect on cognitive function (k= 9, SMD: 0.05; 95 % CI: -0.04-0.13; p = 0.25), whereas multidomain interventions were significantly impactful (k=7, SMD: 0.09; 95 % CI: 0.04-0.15; p < 0.01). Physical exercise interventions did not alter MCI risk (k= 4, RR: 0.98; 95 % CI: 0.73-1.31; p = 0.79) or dementia onset (k= 4, RR: 0.61; 95 % CI: 0.25-1.52; p = 0.19), with very low-to low-certainty evidence, respectively.

CONCLUSIONS

Integrative multidomain strategies incorporating physical exercise may benefit the global cognitive function of older adults. However, long-term physical exercise alone did not yield any cognitive gains. The effectiveness of such exercise interventions to mitigate the overall risk of incident MCI and dementia warrants further research.

Profiles of Met and Unmet Care Needs in the Oldest Old Primary Care Patients with Cognitive Disorders and Dementia: Results of the AgeCoDe and AgeQualiDe Study

INTRODUCTION

The prevalence of mild cognitive impairment (MCI) and dementia is increasing as the oldest old population grows, requiring a nuanced understanding of their care needs. Few studies have examined need profiles of oldest old patients with MCI or dementia. Therefore, this study aimed to identify patients' need profiles.

METHODS

The data analysis included cross-sectional baseline data from N = 716 primary care patients without cognitive impairment (n = 575), with MCI (n = 97), and with dementia (n = 44) aged 85+ years from the multicenter cohort AgeQualiDe study "needs, health service use, costs and health-related quality of life in a large sample of oldest old primary care patients [85+]". Patients' needs were assessed using the Camberwell Assessment of Needs for the Elderly (CANE), and latent class analysis identified need profiles. Multinomial logistic regression analyzed the association of MCI and dementia with need profiles, adjusting for sociodemographic factors, social network (Lubben Social Network Scale [LSNS-6]), and frailty (Canadian Study of Health and Aging-Clinical Frailty Scale [CSHA-CFS]).

RESULTS

Results indicated three profiles: "no needs," "met physical and environmental needs," and "unmet physical and environmental needs." MCI was associated with the met and unmet physical and environmental needs profiles; dementia was associated with the unmet physical and environmental needs profile. Patients without MCI or dementia had larger social networks (LSNS-6). Frailty was associated with dementia.

CONCLUSIONS

Integrated care should address the needs of the oldest old and support social networks for people with MCI or dementia. Assessing frailty can help clinicians to identify the most vulnerable patients and develop beneficial interventions for cognitive disorders.

INTRODUCTION

The prevalence of mild cognitive impairment (MCI) and dementia is increasing as the oldest old population grows, requiring a nuanced understanding of their care needs. Few studies have examined need profiles of oldest old patients with MCI or dementia. Therefore, this study aimed to identify patients' need profiles.

METHODS

The data analysis included cross-sectional baseline data from N = 716 primary care patients without cognitive impairment (n = 575), with MCI (n = 97), and with dementia (n = 44) aged 85+ years from the multicenter cohort AgeQualiDe study "needs, health service use, costs and health-related quality of life in a large sample of oldest old primary care patients [85+]". Patients' needs were assessed using the Camberwell Assessment of Needs for the Elderly (CANE), and latent class analysis identified need profiles. Multinomial logistic regression analyzed the association of MCI and dementia with need profiles, adjusting for sociodemographic factors, social network (Lubben Social Network Scale [LSNS-6]), and frailty (Canadian Study of Health and Aging-Clinical Frailty Scale [CSHA-CFS]).

RESULTS

Results indicated three profiles: "no needs," "met physical and environmental needs," and "unmet physical and environmental needs." MCI was associated with the met and unmet physical and environmental needs profiles; dementia was associated with the unmet physical and environmental needs profile. Patients without MCI or dementia had larger social networks (LSNS-6). Frailty was associated with dementia.

CONCLUSIONS

Integrated care should address the needs of the oldest old and support social networks for people with MCI or dementia. Assessing frailty can help clinicians to identify the most vulnerable patients and develop beneficial interventions for cognitive disorders.

Effects of a multidomain intervention against cognitive decline on dementia risk profiles - Results from the AgeWell.de trial

INTRODUCTION

Dementia risk scores constitute promising surrogate outcomes for lifestyle interventions targeting cognitive function. We investigated whether dementia risk, assessed using the LIfestyle for BRAin health (LIBRA) index, was reduced by the AgeWell.de intervention.

METHODS

Secondary analyses of the AgeWell trial, testing a multicomponent intervention (including optimization of nutrition, medication, and physical, social, and cognitive activity) in older adults with increased dementia risk. We analyzed data from n = 461 participants with complete information on risk/protective factors comprised by LIBRA at the 24-month follow-up. Intervention effects on LIBRA and LIBRA components were assessed using generalized linear models.

RESULTS

The intervention reduced LIBRA scores, indicating decreased dementia risk at follow-up (b = -0.63, 95% confidence interval [CI]: -1.14, -0.12). Intervention effects were particularly due to improvements in diet (odds ratio [OR]: 1.60, 95% CI: 1.16, 2.22) and hypertension (OR: 1.61, 95% CI: 1.19, 2.18).

DISCUSSION

The AgeWell.de intervention reduced dementia risk. However, several risk factors did not improve, possibly requiring more intensive interventions.

HIGHLIGHTS

The AgeWell.de intervention reduced dementia risk according to LIfestyle for BRAin health (LIBRA) scores. Beneficial effects on LIBRA are mainly due to changes in diet and blood pressure. A pragmatic lifestyle intervention is apt to reduce dementia risk in an at-risk population.

Adherence to a lifestyle intervention - just a question of self-efficacy? Analysis of the AgeWell.de-intervention against cognitive decline

BACKGROUND

Aim of this study was to detect predictors of better adherence to the AgeWell.de-intervention, a two-year randomized multi-domain lifestyle intervention against cognitive decline.

METHODS

Data of 317 intervention group-participants comprising a risk group for dementia (Cardiovascular Risk Factors, Ageing and Dementia (CAIDE) score of  ≥ 9; mean age 68.9 years, 49.5% women) from the AgeWell.de intervention study were analysed. Regression models with four blocks of predictors (sociodemographic, cognitive and psychosocial, lifestyle factors and chronic conditions) were run on adherence to the components of nutrition, enhancement of social and physical activity and cognitive training. Adherence to each component was operationalised by assessing the degree of goal achievement per component at up to seven time points during the intervention period, measured using a 5-point Likert scale (mean score of goal achievement).

RESULTS

Increasing age was negatively associated with adherence, while higher education positively predicted adherence. Participants with better mental state (Montreal Cognitive Assessment (MoCA)-score > 25) at baseline and higher self-efficacy adhered better. Diabetes and cardiovascular conditions were not associated with adherence, whereas smoking negatively affected adherence. Highest education and quitting smoking in the past were the only predictors associated with all four intervention components.

CONCLUSION

Results identified predictors for better and worse adherence. Particularly self-efficacy seems to be of considerable influence on adherence. This should be considered when designing future intervention trials.

TRIAL REGISTRATION

German Clinical Trials Register (ref. number: DRKS00013555).

A multidomain lifestyle intervention to maintain optimal cognitive functioning in Dutch older adults-study design and baseline characteristics of the FINGER-NL randomized controlled trial

BACKGROUND

Evidence on the effectiveness of multidomain lifestyle interventions to prevent cognitive decline in older people without dementia is mixed. Embedded in the World-Wide FINGERS initiative, FINGER-NL aims to investigate the effectiveness of a 2-year multidomain lifestyle intervention on cognitive functioning in older Dutch at risk individuals.

METHODS

Multi-center, randomized, controlled, multidomain lifestyle intervention trial with a duration of 24 months. 1210 adults between 60-79 years old with presence of ≥ 2 modifiable risk factors and ≥ 1 non-modifiable risk factor for cognitive decline were recruited between January 2022 and May 2023 via the Dutch Brain Research Registry and across five study sites in the Netherlands. Participants were randomized to either a high-intensity or a low-intensity intervention group. The multidomain intervention comprises a combination of 7 lifestyle components (physical activity, cognitive training, cardiovascular risk factor management, nutritional counseling, sleep counseling, stress management, and social activities) and 1 nutritional product (Souvenaid®) that could help maintain cognitive functioning. The high-intensity intervention group receives a personalized, supervised and hybrid intervention consisting of group meetings (on-site and online) and individual sessions guided by a trained lifestyle coach, and access to a digital intervention platform that provides custom-made training materials and selected lifestyle apps. The low-intensity intervention group receives bi-monthly online lifestyle-related health advice via the digital intervention platform. Primary outcome is 2-year change on a cognitive composite score covering processing speed, executive function, and memory.

RESULTS

Within 17 months, participant recruitment has been successfully completed (N = 1210; mean age: 67.7 years (SD: 4.6); 64% female). Modifiable risk factors commonly present at baseline were physical inactivity (89%), low mental/cognitive activity (50%), low social engagement (39%), hypertension (39%) and high alcohol consumption (39%). The mean body mass index of participants was 28.3 (SD: 4.2) and the total serum cholesterol was 5.4 mmol/L (SD: 1.2).

CONCLUSIONS

Baseline lifestyle and clinical measurements showed successful recruitment of participants with sufficient potential for prevention. Results of FINGER-NL will provide further insight into the efficacy of a multidomain lifestyle intervention to prevent cognitive decline in older adults.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NCT05256199)/2022-01-11.

A Pilot Study of BRAIN BOOTCAMP, a Low-Intensity Intervention on Diet, Exercise, Cognitive Activity, and Social Interaction to Improve Older Adults' Dementia Risk Scores

BACKGROUND

Little is known about the impact of short, low-intensity multidomain dementia risk reduction interventions in older adults.

OBJECTIVES

To examine the effectiveness and feasibility of a low-intensity multidomain lifestyle intervention on dementia risk and dementia literacy in Australian older adults.

DESIGN

Single-group pre-post design.

SETTING

Community-dwelling.

PARTICIPANTS

A total of 853 older Australians (Mean age=73.3 years, SD=6.1) recruited from the community.

INTERVENTION

A 3-month dementia risk reduction program, BRAIN BOOTCAMP, including education, personalised risk information, physical cues for healthier choices and goal setting and planning to target four modifiable risk factors of diet, exercise, cognitive activity and social interaction in older adults.

MEASUREMENTS

The 'LIfestyle for BRAin health' (LIBRA) index was used to assess participants' modifiable dementia risk based on 12 factors, with higher scores indicating greater risk. Dementia literacy was measured using a modified questionnaire derived from Dutch and British surveys, encompassing knowledge, risk reduction, and awareness aspects. Paired t-tests were used to compare dementia risk scores and dementia literacy before and after the program. Multivariate regressions were performed to identify sociodemographic and psychological factors associated with change in the LIBRA index.

RESULTS

Program attrition was high (58.3%). Participants who completed the program had decreased dementia risk scores (Cohen's d=0.59, p<0.001), increased dementia literacy and awareness (Cohen's d=0.64, p<0.001) and increased motivation to change lifestyle behaviors (Cohen's d=0.25-0.52, p<0.016). Participants with higher motivational beliefs had greater dementia risk reduction.

CONCLUSIONS

Improving older adults' motivation and knowledge may help modify lifestyle behaviors to reduce dementia risk. However, program attrition remains a challenge, suggesting the need for strategies to enhance participant engagement and retention in such interventions.

Multidomain Intervention Trial for Preventing Cognitive Decline among Older Adults with Type 2 Diabetes: J-MIND-Diabetes

BACKGROUND

No multidomain intervention trials have been designed for the prevention of cognitive decline in older adults with type 2 diabetes.

OBJECTIVES

To investigate the efficacy of a multidomain intervention in preventing cognitive decline in older adults with type 2 diabetes and cognitive impairment.

DESIGN

Eighteen-month, multi-centered, randomized controlled trial.

SETTING

Twelve hospitals in Japan.

PARTICIPANTS

Outpatients with type 2 diabetes aged 70-85 years with cognitive impairment.

INTERVENTION

The multidomain intervention program includes management of metabolic and vascular risk factors, exercise, nutritional counseling, and promotion of social participation. Participants in the control group received usual care and treatment for type 2 diabetes.

MEASUREMENTS

The primary outcome was the change in a composite score combining several neuropsychological tests from baseline to the 18-month follow-up. To assess the differences in cognitive changes between the intervention and control groups, a mixed-effects model for repeated measures was used.

RESULTS

Between March 13, 2019, and May 8, 2020, 361 participants were screened, and 154 were randomly assigned to either the intervention group (n = 81) or the control group (n = 73). Finally, 110 participants completed the trial. The between-group difference in the composite score changes was 0.068 (95% confidence interval, -0.091 to 0.226). Analyses for secondary outcomes indicated a positive impact of the intervention on memory and indicated that the intervention led to changes in dietary habits with increased intakes of niacin and meat, along with weight reduction compared to the control group.

CONCLUSION

The multidomain intervention did not demonstrate efficacy in preventing cognitive decline. However, this trial provided proof-of-concept evidence that multidomain interventions may offer cognitive benefits and contribute to changes in dietary behavior and weight reduction in older adults with type 2 diabetes and cognitive impairment. These findings should be confirmed in future studies.

Mediating Factors Associated With Physical Activity in Older Adults at Increased Dementia Risk

While regular physical-activity (PA) is beneficial, multimorbid individuals at increased dementia risk may exhibit reduced PA levels. Thus, a more comprehensive understanding of mediating factors responsible for inactivity in this population is needed. This study investigated the impact of a multimodal intervention on PA changes at 24-month follow-up and associated mediating factors among community-dwelling patients aged 60-77, with increased dementia risk determined by the CAIDE Dementia Risk Score. Of 1030 participants recruited, 819 completed the assessment. Thus, a generalized estimating equations model initially assessed differences in PA over 24 months, followed by a tree analysis identifying mediating factors influencing PA changes post-intervention. While no significant effect on regular PA was found during the follow-up (P = .674), subgroup analysis revealed improved self-efficacy (P = .000) associated with increased engagement in PA. Incorporating self-efficacy elements into future strategies is crucial for promoting PA among individuals with multimorbidity and at increased dementia risk.

Multidomain Dementia Risk Reduction in Primary Care is Feasible: A Proof-of-concept study

Background

Dementia risk reduction is a public health priority, but interventions that can be easily implemented in routine care are scarce.

Objective

To evaluate the feasibility of integrating dementia risk reduction in regular consultations in primary care and the added value of a dedicated smartphone app ('MyBraincoach').

Methods

188 participants (40-60 years), with modifiable dementia risk factors were included from ten Dutch general practices in a cluster-randomized trial (NL9773, 06/10/2021). Practices were randomly allocated (1 : 1) to provide a risk-reduction consultation only or to additionally provide the app. During the consultation, participants learned about dementia risk reduction and how to improve their risk profile. The app group received daily microteaching-notifications about their personally relevant risk factors. Feasibility was evaluated after 3 months using questionnaires assessing knowledge on dementia risk reduction and health behavior change. The primary outcome was change in the validated "LIfestyle for BRAin health" (LIBRA) score. In-depth interviews were conducted with participants and primary care providers (PCPs).

Results

The interventions were positively perceived, with 72.0% finding the consultation informative and 69.2% considering the app useful. Drop-out was low (6.9%). LIBRA improved similarly in both groups, as did Mediterranean diet adherence and body mass index. Knowledge of dementia risk reduction increased, but more in the app group. Interviews provided insight in participants' and PCPs' needs and wishes.

Conclusions

Integrating dementia risk reduction in primary care, supported by a smartphone app, is a viable approach towards dementia risk reduction. Larger trials are needed to establish (cost-)effectiveness.

Factors Associated with Lower Social Activity in German Older Adults at Increased Risk of Dementia: A Cross-Sectional Analysis

Background

Studies demonstrate associations between low social activity in older adults and cognitive decline. Little has been investigated regarding which factors are associated with low social activity in older adults at increased risk of dementia.

Objective

We investigate which sociodemographic, psychological, health-related, and environmental factors are associated with low social activity in older adults at increased risk of dementia. Additionally, we describe the stages of health behavior change, the types of social activities, and the duration of the current level of social activity.

Methods

We used baseline data of 1,015 participants from the AgeWell.de trial. We conducted logistic and Poisson regression analyses to investigate factors associated with low social activity. We report descriptive statistics on the stages of change in the sample, the types of social activities most frequently pursued, and the duration of the current level of social activity.

Results

Lower income, non-usage of public transport, depressive symptoms, cognitive, mobility, and hearing impairment were negatively associated with social activity. The majority of the sample was in the maintenance stage, followed by the precontemplation stage. The most common social activities were traveling and hobbies with others. Participants have maintained their current level of social activity for several years.

Conclusions

We identified a lack of resources (income, transport), depressive symptoms and poorer health (cognitive, mobility and hearing impairment) as barriers to social activity. Interventions promoting social activity in older adults at risk of dementia may specifically target individuals with these risk factors. Low-threshold opportunities for social activity may be particularly beneficial.