Cognitive impairment in elderly patients with rheumatic disease and the effect of disease-modifying anti-rheumatic drugs

Association of Rheumatoid Arthritis With Progression of Cognitive Impairment and Risk of Mortality in People With Dementia

BACKGROUND AND OBJECTIVES

Rheumatoid arthritis (RA) has been linked to an increased risk of dementia, yet little is known about how RA affects the progression of cognitive impairment and the risk of mortality in people with dementia. We aimed to investigate whether RA is linked to an accelerated cognitive decline and a higher risk of all-cause mortality in patients with dementia.

METHODS

We conducted a propensity score-matched register-based cohort study based on the Swedish Registry for Cognitive/Dementia Disorders-SveDem. Patients diagnosed with dementia and registered in SveDem between May 1, 2007, and October 16, 2018, were included. The main outcome for the study was cognitive decline, measured by Mini-Mental State Examination (MMSE) score changes over years. The secondary outcome was all-cause death. We used mixed-effects models to examine the association between RA and cognitive decline, and Cox proportional hazards models to investigate the risk of all-cause mortality. We also conducted subgroup analyses to explore the potential effects of sociodemographic, baseline MMSE, comorbidities, and the use of dementia medications on the association between RA and outcomes.

RESULTS

We included 1,685 dementia patients with RA (mean [SD] age, 79.9 [6.7] years; 73.4% were women) and 5,055 dementia patients with non-RA (80.1 [7.5] years; 73.1% were women). The median follow-up was 2.9 years (interquartile range, 1.5-4.6 years) for non-RA and 2.6 years (interquartile range, 1.4-4.2 years) for RA. In total, 111,266 MMSE measurements were available for analysis. Compared with non-RA patients, patients with RA presented faster cognitive decline (β = -0.24 points/y; 95% CI -0.38 to -0.10) and an increased risk of death (hazard ratio 1.15; 95% CI 1.06-1.24). In subgroup analysis, significant interactions were observed between RA and baseline MMSE scores as well as living conditions regarding cognitive decline (p for interaction <0.05).

DISCUSSION

We identified a worse cognitive function and an increased mortality risk in dementia patients with RA compared with non-RA. However, we lacked information on the duration of RA before the onset of dementia and on disease activity, which could influence our findings. Further studies are needed to validate these results in comparable populations.

Cognitive disorders in patients with neuroimmunological disease

PURPOSE OF REVIEW

Autoimmune diseases such as systemic lupus erythematosus (SLE), multiple sclerosis (MS), and autoimmune encephalitis can directly and indirectly affect brain function, leading to cognitive dysfunction or well characterized neurocognitive syndromes. However, these are often poorly characterized in the literature. Here, we review evidence on clinical manifestations, risk factors, their assessment and outcomes, and evidence for underlying mechanisms and associated biomarkers, if available.

RECENT FINDINGS

Significant advances have been made in neurocognitive disorders associated with four categories of autoimmune disease: neurocognitive disorders due to autoimmune connective tissue diseases, neurocognitive disorders due to autoimmune demyelinating diseases of the CNS, neurocognitive disorders due to autoimmune encephalitis, and neurocognitive disorders due to cerebrovascular disease of autoimmune origin.

SUMMARY

Autoimmune diseases should be considered as critical causal factors underlying new cases of neurocognitive disorder, especially in young patients. These diseases are mediated by immune system reactions involving antibody production, T-cell-mediated damage, and demyelination. Although the prognosis seems favourable in most conditions after immunotherapy, the magnitude of the therapeutic effect of immunotherapy on cognitive functioning remains unclear.

Enhancing the effectiveness of immunotherapy in rheumatoid arthritis by delaying immunosenescence triggered by fibroblast-like synoviocytes

Rheumatoid arthritis (RA) is a prevalent autoimmune disorder primarily targeting the diarthrodial joints. During the progression of RA, fibroblast-like synoviocytes (FLSs) exhibit tumor-like behavior, including increased proliferation, inflammation mediation, and aggressive phenotypes, leading to bone erosion. Additionally, T cells in RA acquire pro-inflammatory characteristics, exacerbating the inflammatory environment in affected joints and associated tissues. Notably, senescent T cells contribute to inflammation, further accelerating the disease process. Metabolic changes in rheumatoid FLSs not only maintain their tumor-like properties but also trigger inflammatory cascades, particularly affecting T lymphocytes. This review examines the molecular alterations in RA FLSs in the context of systemic immune aging, with a focus on thymic insufficiency-associated T cell senescence, and explores potential therapeutic avenues.

Cognitive performance, psychiatric comorbidities, and quality of life in pediatric patients with juvenile idiopathic arthritis: a comparative analysis with healthy controls

This study aimed to assess the extent of cognitive impairment in children and adolescents with Juvenile Idiopathic Arthritis (JIA). While cognitive deficits are recognized in other systemic rheumatic diseases, exploration within the pediatric JIA population remains limited. The investigation utilized a comprehensive approach to examine neuropsychological test performance. A cohort of 160 participants (79 JIA, 81 healthy controls aged 8-17) underwent evaluations using the Pediatric Quality of Life Inventory (PedsQL), Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (K-SADS-PL), and the computerized neurocognitive test battery Central Nervous System Vital Signs (CNSVS). Children with JIA exhibited statistically significant cognitive deficits across various parameters (p < .05). This was associated with an increased prevalence of lifelong psychiatric illnesses and diminished overall quality of life compared to healthy counterparts (p < .05). Analysis highlighted that specific JIA subtypes, excluding Oligoarthritis, significantly elevated the risk of neurocognitive impairments, emphasizing the impact on various cognitive outcomes (OR range: 3.1-5.1, 95% CI: 1.163-19.980). Additionally, the active disease stage was identified as a specific risk factor, amplifying the likelihood of low executive functions by 4.3 times (OR: 4.363, 95% CI: 1.095-17.378). This study underscores the critical importance of recognizing and addressing neurocognitive impairments in children with JIA. Specific attention to disease subtypes and activity levels is crucial, with the potential for targeted interventions to enhance overall cognitive well-being and quality of life in this vulnerable population.

The association between arthritis and cognitive function impairment in the older adults: Based on the NHANES 2011-2014

OBJECTIVE

Arthritis has been postulated as a prevalent potential risk factor for the emergence of dementia and cognitive impairment. This conjecture prompted an examination of the correlation between arthritis and cognitive impairment using the National Health and Nutrition Examination Survey (NHANES) repository. The analysis was meticulously adjusted for potential confounders such as age and assorted systemic comorbidities, to ensure robustness in the results obtained.

METHODS

Among 2,398 adults aged 60 years and above, logistic regression and cubic spline models were employed to elucidate the relationship between arthritis and cognitive performance. This was assessed utilizing tests such as Immediate Recall test (IRT), Delayed Recall test (DRT), Animal Fluency Test (AFT), and Digit Symbol Substitution Test (DSST).

RESULTS

In our investigation, a total of 19931 individuals were analyzed, among which 2,398 patients (12.03%) were identified with arthritis. Subjects with arthritis inflammation had lower DSST and AFT scores compared to the healthy group, indicating cognitive decline. After adjusting for all covariates, arthritis was significantly associated with higher DSST and AFT scores by logistic regression modeling (OR: 0.796, 95% CI: 0.649-0.975; OR: 0.769, 95% CI: 0.611-0.968).

CONCLUSION

Our analysis underscores the potential linkage between arthritis prevalence and cognitive impairment within a nationally representative of US older adults.

The Role of Psychology in Pediatric Rheumatic Diseases

Pediatric rheumatic diseases (PRDs) are a heterogeneous group of diseases that can have a chronic unpredictable disease course that can negatively affect mood, functioning, and quality of life. Given the range of difficulties faced in managing PRDs, as well as the psychosocial issues youth with these diseases experience, pediatric psychologists can be well suited to address concerns that arise in care for youth with PRDs including adherence, cognitive assessment, pain management, functional disability, and mood. Potential ways that pediatric psychologists can address these concerns and be embedded within an interdisciplinary treatment plan for youth with PRDs are described.

Rheumatic and Musculoskeletal Diseases and Risk of Dementia: A Nested Case-Control Study

OBJECTIVE

To investigate the associations between rheumatic and musculoskeletal diseases (RMDs) and incident dementia using population register-based data.

METHODS

This nested case-control study was conducted based on a cohort of residents in the Skåne region, Sweden, aged 50 years and older in 2009 without doctor-diagnosed dementia during 1998 to 2009 (n = 402,825). Individuals with a new main diagnosis of dementia during 2010 to 2019 were identified as incident patients with dementia (n = 22,131). Controls without diagnosed dementia were randomly matched 1:1 by sex, age, and Elixhauser comorbidity index using incidence density sampling. Separate conditional logistic regression analyses adjusted for confounders were fitted for the following RMDs, diagnosed at least 2 years before dementia diagnosis as exposure: gout, osteoarthritis, rheumatoid arthritis, spondyloarthropathies (SpA), and systemic connective tissue disorders. Subgroup analyses by dementia subtype, sex, age, comorbidity, and RMDs/dementia identification were conducted.

RESULTS

Although gout (adjusted rate ratio 0.88; 95% confidence interval 0.79-0.97), osteoarthritis (0.92; 0.88-0.96), and systemic connective tissue disorders (0.91; 0.83-0.99) were associated with decreased risk of dementia, the associations for rheumatoid arthritis (1.05; 0.92-1.19) and SpA (1.17; 0.94-1.45) were inconclusive. The associations between RMDs and incident dementia were similar across sex, age, and comorbidity subgroups with a few exceptions (eg, an adjusted rate ratio of 0.99 [95% confidence interval 0.71-1.39] in males vs 1.31 [0.99-1.74] in female patients for SpA).

CONCLUSION

Persons with diagnosed RMDs seem to have comparable or slightly lower risks of developing dementia compared with those without known RMD.

The Role of Depression and Anxiety in the Relationship Between Arthritis and Cognitive Impairment in Chinese Older Adults

BACKGROUND

Mental disorders and cognitive impairment are common in older patients with arthritis. While it is recognized that mental conditions may play a role in the connection between arthritis and cognitive impairment, the precise underlying relationship remains uncertain.

METHODS

The data was derived from the baseline survey of the Guangdong Mental Health Survey in South China, involving a sample of 3,764 citizens aged 65 and older. An array of aspects were explored, including socio-demographics, lifestyle behaviors, self-reported chronic conditions, depression, anxiety, and cognitive impairment. Logistic regression analyses examined the association between arthritis and cognitive impairment after adjustment for potential confounders. Serial mediation models were used to examine whether depression or anxiety played a mediating role in the arthritis-cognitive impairment linkage.

RESULTS

The prevalence rates of cognitive impairment and arthritis of the older adults were 28.9% and 12.1%, respectively. Compared to those without arthritis, participants with arthritis were at a higher risk of cognitive impairment (OR = 1.322, 95%CI: 1.022-1.709) after adjustment for socio-demographics, lifestyle behaviors, and mental health conditions. Serial mediation analyses indicated that depressive and anxiety symptoms co-played a serial mediating role in the association between arthritis and cognitive impairment (B1 = 0.025, 95%CI: 0.005-0.052; B2 = 0.050, 95%CI: 0.021-0.086).

CONCLUSIONS

Arthritis may heighten cognitive impairment risk in Chinese older adults, and the relationship was potentially mediated by depressive and anxiety symptoms. Future interventions should be considered, integrating mental health assessments into arthritis care frameworks and being alert to possible cognitive impairment.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Impairment in cognitive function in patients with axial spondyloarthritis and psoriatic arthritis

Spondyloarthritis may contribute to deficits in cognition. The objective of this study was to compare cognitive abilities in patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) with matched reference groups. This investigator-initiated, cross-sectional, exploratory study of adults with axSpA or PsA was conducted at two German rheumatology centres (November 2018-September 2019). All data on patient and disease characteristics and cognitive abilities were collected at a single visit. Cognitive function was assessed by the previously validated Memory and Attention Test subscores of selective attention, episodic working memory, and episodic short-term memory and compared with subscores from healthy age-, sex-, and education-matched reference subjects. The mean patient age was 51.1 and 55.8 years in the axSpA (n = 101) and PsA (n = 117) groups, respectively, and mean symptom duration was 13.7 and 10.3 years. Compared with matched reference subjects, axSpA and PsA patients showed significant impairments in selective attention (mean difference of -6.5 and -4.5, respectively, on a 45-point scale; P < 0.001 for both) and no significant differences in episodic working memory. The PsA cohort, but not the axSpA cohort, had significantly better episodic short-term memory subscores compared with matched reference subjects (mean change of 2.0 on a 15-point scale; P < 0.001). Explorative subgroup analyses were unable to identify factors influencing cognitive changes, including disease activity, pain, and function, but may have been underpowered. We conclude that impairments in selective attention may impact the ability of axSpA and PsA patients to process information. These findings warrant additional studies, including longitudinal analyses, in patients with spondyloarthritis.

From Low-Grade Inflammation in Osteoarthritis to Neuropsychiatric Sequelae: A Narrative Review

Nowadays, osteoarthritis (OA), a common, multifactorial musculoskeletal disease, is considered to have a low-grade inflammatory pathogenetic component. Lately, neuropsychiatric sequelae of the disease have gained recognition. However, a link between the peripheral inflammatory process of OA and the development of neuropsychiatric pathology is not completely understood. In this review, we provide a narrative that explores the development of neuropsychiatric disease in the presence of chronic peripheral low-grade inflammation with a focus on its signaling to the brain. We describe the development of a pro-inflammatory environment in the OA-affected joint. We discuss inflammation-signaling pathways that link the affected joint to the central nervous system, mainly using primary sensory afferents and blood circulation via circumventricular organs and cerebral endothelium. The review describes molecular and cellular changes in the brain, recognized in the presence of chronic peripheral inflammation. In addition, changes in the volume of gray matter and alterations of connectivity important for the assessment of the efficacy of treatment in OA are discussed in the given review. Finally, the narrative considers the importance of the use of neuropsychiatric diagnostic tools for a disease with an inflammatory component in the clinical setting.

Causal association between systemic lupus erythematosus and the risk of dementia: A Mendelian randomization study

Introduction

It is well-documented that systemic lupus erythematosus (SLE) is associated with dementia. However, the genetic causality of this association remains unclear. Mendelian randomization (MR) was used to investigate the potential causal relationship between SLE and dementia risk in the current study.

Methods

We selected 45 single nucleotide polymorphisms (SNPs) associated with SLE from publicly available genome-wide association studies (GWAS). Summary level statistics were obtained from the dementia GWAS database. MR estimates were performed using the inverse variance weighted (IVW) method, MR-Egger method and weighted median (WM) method. Cochran's Q test, the intercept of MR-Egger, MR-Pleiotropy Residual Sum and Outlier method, leave-one-out analysis and funnel plot were applied for sensitivity analyses.

Results

No significant causal association was found between SLE and any type of dementia, including Alzheimer's disease, vascular dementia, frontotemporal dementia, and dementia with Lewy bodies. These findings were robust across several sensitivity analyses.

Conclusion

Overall, our findings do not support a causal association between SLE and dementia risk.

The Role of Psychology in Pediatric Rheumatic Diseases

Pediatric rheumatic diseases (PRDs) are a heterogeneous group of diseases that can have a chronic unpredictable disease course that can negatively affect mood, functioning, and quality of life. Given the range of difficulties faced in managing PRDs, as well as the psychosocial issues youth with these diseases experience, pediatric psychologists can be well suited to address concerns that arise in care for youth with PRDs including adherence, cognitive assessment, pain management, functional disability, and mood. Potential ways that pediatric psychologists can address these concerns and be embedded within an interdisciplinary treatment plan for youth with PRDs are described.

Glibenclamide alters serotonin and dopamine levels in the rat striatum and hippocampus, reducing cognitive impairment

RATIONALE

Glibenclamide (GD) is a widely used medical drug; therefore, identifying the mechanisms underlying its pleiotropic effects in the central nervous system is urgent.

OBJECTIVES

The aim of this work was to determine the ability of GD to modulate serotonin (5-hydroxytryptamine, 5-HT) and dopamine (DA) transmission and to assess the dose-dependent effect of GD on cognitive function in rats during natural ageing.

METHODS

In Experiment 1, rats received 10, 25, or 50 μg/kg GD intraperitoneally for 10 days. In Experiment 2, rats received 50 μg/kg GD intraperitoneally for 30 days. Spatial and working memory was assessed in the MWM and Y-maze tests, respectively. In both experiments, the levels of DA and 5-HT, their metabolites, and turnover rate were analysed by HPLC-ED in the rat hippocampus and striatum.

RESULTS

Changes in DA and 5-HT levels occurred only with a dose of 50 μg/kg GD. Therefore, in the second experiment, we administered a dose of 50 μg/kg GD. At this dose, GD prevented the development of impairments in spatial and working memory. The hippocampal concentrations of DA and DOPAC decreased, and the striatal concentrations of DA, DOPAC, 5-HT, and 5-HIAA increased.

CONCLUSION

One of the possible mechanisms of the precognitive effect of GD is its ability to modulate monoamine transmission. Thus, in translating our results to humans, GD can be recommended as a prophylactic agent for natural ageing to reduce the risk of developing cognitive impairments.

Longitudinal Study of Cognitive Functioning in Adults with Juvenile Idiopathic Arthritis

OBJECTIVE

To prospectively evaluate possible decline of cognitive functions in adult patients with juvenile idiopathic arthritis (JIA) and identify associated factors.

PATIENTS AND METHODS

We performed a 24-month prospective observational study of adults (≥16 years) with JIA. The primary outcome measure was decline in cognitive function defined as a worsening of ≥2 points on the scales of the subsets administered to evaluate the different cognitive areas using the Wechsler Adult Intelligence Scale (WAIS) after 24 months: attention/concentration (digit span); verbal function (vocabulary); visual-spatial organization (block design); working memory (letter-number sequencing); and problem solving (similarities). Other variables included average inflammatory activity using C-reactive protein and composite activity indexes, comorbidity, and treatment. Logistic regression was performed to identify factors associated with cognitive decline.

RESULTS

The study population comprised 52 patients with JIA. Of these, 15 (28.8%) had cognitive decline at V24. The most affected functions were working memory (17.3%), attention/concentration (9.6%), verbal function (7.7%), visual-spatial organization (7.7%), and problem solving (3.8%). There were no significant differences in the median direct or scale scores for the cognitive functions evaluated between V0 and V24 for the whole sample. The factors associated with cognitive decline in patients with JIA were average C-reactive protein (OR [95% CI], 1.377 [1.060-1.921]; p = 0.039), depression (OR [95% CI], 3.691 [1.294-10.534]; p = 0.015), and treatment with biologics (OR [95% CI], 0.188 [0.039-0.998]; p = 0.046).

CONCLUSION

Cognitive decline was detected in almost one third of adults with JIA after 24 months of follow-up. Systemic inflammatory activity in JIA patients was related to cognitive decline. Patients treated with biologics had a lower risk of decline in cognitive functions.

Frontal lobe microglia, neurodegenerative protein accumulation, and cognitive function in people with HIV

Microglia are implicated in Alzheimer's Disease (AD) pathogenesis. In a middle-aged cohort enriched for neuroinflammation, we asked whether microgliosis was related to neocortical amyloid beta (A[Formula: see text]) deposition and neuronal phosphorylated tau (p-tau), and whether microgliosis predicted cognition. Frontal lobe tissue from 191 individuals autopsied with detectable (HIV-D) and undetectable (HIV-U) HIV infection, and 63 age-matched controls were examined. Immunohistochemistry (IHC) was used to evaluate A[Formula: see text] plaques and neuronal p-tau, and quantitate microgliosis with markers Iba1, CD163, and CD68 in large regions of cortex. Glia in the A[Formula: see text] plaque microenvironment were quantitated by immunofluorescence (IF). The relationship of microgliosis to cognition was evaluated. No relationship between A[Formula: see text] or p-tau accumulation and overall severity of microgliosis was discerned. Individuals with uncontrolled HIV had the greatest microgliosis, but fewer A[Formula: see text] plaques; they also had higher prevalence of APOE [Formula: see text]4 alleles, but died earlier than other groups. HIV group status was the only variable predicting microgliosis over large frontal regions. In contrast, in the A[Formula: see text] plaque microenvironment, APOE [Formula: see text]4 status and sex were dominant predictors of glial infiltrates, with smaller contributions of HIV status. Cognition correlated with large-scale microgliosis in HIV-D, but not HIV-U, individuals. In this autopsy cohort, over large regions of cortex, HIV status predicts microgliosis, whereas in the A[Formula: see text] plaque microenvironment, traditional risk factors of AD (APOE [Formula: see text]4 and sex) are stronger determinants. While microgliosis does not predict neurodegenerative protein deposition, it does predict cognition in HIV-D. Increased neuroinflammation does not initiate amyloid deposition in a younger group with enhanced genetic risk. However, once A[Formula: see text] deposits are established, APOE [Formula: see text]4 predicts increased plaque-associated inflammation.

Rheumatoid Arthritis, Cognitive Impairment, and Neuroimaging Biomarkers: Results from the Mayo Clinic Study of Aging

BACKGROUND

Observational studies suggested that dementia risk in patients with rheumatoid arthritis (RA) is higher than in the general population.

OBJECTIVE

To examine the associations of RA with cognitive decline and dementia, and neuroimaging biomarkers of aging, Alzheimer's disease, and vascular pathology in adult participants in the Mayo Clinic Study of Aging (MCSA).

METHODS

Participants with RA were matched 1:3 on age, sex, education, and baseline cognitive diagnosis to participants without RA. RA cases with MRI were also matched with non-cases with available MRI. All available imaging studies (i.e., amyloid and FDG PET, sMRI, and FLAIR) were included. The study included 104 participants with RA and 312 without RA (mean age (standard deviation, SD) 75.0 (10.4) years, 33% male and average follow-up (SD) 4.2 (3.8) years).

RESULTS

Groups were similar in cognitive decline and risk of incident dementia. Among participants with neuroimaging, participants with RA (n = 33) and without RA (n = 98) had similar amyloid burden and neurodegeneration measures, including regions sensitive to aging and dementia, but greater mean white matter hyperintensity volume relative to the total intracranial volume (mean (SD)% : 1.12 (0.57)% versus 0.76 (0.69)% of TIV, p = 0.01), and had higher mean (SD) number of cortical infarctions (0.24 (0.44) versus 0.05 (0.33), p = 0.02).

CONCLUSION

Although cognitive decline and dementia risk were similar in participants with and without RA, participants with RA had more abnormal cerebrovascular pathology on neuroimaging. Future studies should examine the mechanisms underlying these changes and potential implications for prognostication and prevention of cognitive decline in RA.

Antirheumatic drugs in older adults and polypharmacy issues

Older individuals experience various noninflammatory and autoimmune inflammatory rheumatic diseases. Given the increased incidence of rheumatic conditions in older adults, it is of great importance for healthcare providers to be aware of the potential benefits and risks of antirheumatic drugs. The present article aims to provide a comprehensive review regarding antirheumatic drug use in older patients, particularly by focusing on safety issues and polypharmacy. Antirheumatic medications include nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids and disease-modifying antirheumatic drugs (DMARDs), which comprise conventional synthetic DMARDs, targeted synthetic DMARDs and biological DMARDs. Due to the alteration in drug pharmacokinetics and pharmacodynamics in old people, antirheumatic drug efficiency and safety may be different than in the younger population. Polypharmacy and multimorbidity are other potential challenges to be faced during the treatment of older patients with rheumatic diseases. The current review also discusses the strategies to minimize adverse reactions due to antirheumatic drugs.

Association of Socioeconomic Status With Dementia Diagnosis Among Older Adults in Denmark

IMPORTANCE

Low socioeconomic status (SES) has been identified as a risk factor for the development of dementia. However, few studies have focused on the association between SES and dementia diagnostic evaluation on a population level.

OBJECTIVE

To investigate whether household income (HHI) is associated with dementia diagnosis and cognitive severity at the time of diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This population- and register-based cross-sectional study analyzed health, social, and economic data obtained from various Danish national registers. The study population comprised individuals who received a first-time referral for a diagnostic evaluation for dementia to the secondary health care sector of Denmark between January 1, 2017, and December 17, 2018. Dementia-related health data were retrieved from the Danish Quality Database for Dementia. Data analysis was conducted from October 2019 to December 2020.

EXPOSURES

Annual HHI (used as a proxy for SES) for 2015 and 2016 was obtained from Statistics Denmark and categorized into upper, middle, and lower tertiles within 5-year interval age groups.

MAIN OUTCOMES AND MEASURES

Dementia diagnoses (Alzheimer disease, vascular dementia, mixed dementia, dementia with Lewy bodies, Parkinson disease dementia, or other) and cognitive stages at diagnosis (cognitively intact; mild cognitive impairment but not dementia; or mild, moderate, or severe dementia) were retrieved from the database. Univariable and multivariable logistic and linear regressions adjusted for age group, sex, region of residence, household type, period (2017 and 2018), medication type, and medical conditions were analyzed for a possible association between HHI and receipt of dementia diagnosis.

RESULTS

Among the 10 191 individuals (mean [SD] age, 75 [10] years; 5476 women [53.7%]) included in the study, 8844 (86.8%) were diagnosed with dementia. Individuals with HHI in the upper tertile compared with those with lower-tertile HHI were less likely to receive a dementia diagnosis after referral (odds ratio, 0.65; 95% CI, 0.55-0.78) and, if diagnosed with dementia, had less severe cognitive stage (β, -0.16; 95% CI, -0.21 to -0.10). Individuals with middle-tertile HHI did not significantly differ from those with lower-tertile HHI in terms of dementia diagnosis (odds ratio, 0.92; 95% CI, 0.77-1.09) and cognitive stage at diagnosis (β, 0.01; 95% CI, -0.04 to 0.06).

CONCLUSIONS AND RELEVANCE

The results of this study revealed a social inequality in dementia diagnostic evaluation: in Denmark, people with higher income seem to receive an earlier diagnosis. Public health strategies should target people with lower SES for earlier dementia detection and intervention.

Cognitive Decline in Rheumatoid Arthritis: Insight into the Molecular Pathogenetic Mechanisms

Cognitive decline refers to a deterioration of intellectual and learning abilities and related memory problems, and is often associated with behavioral alterations, which prevents sufferers from carrying out the most common daily activities, such as maintaining normal productive interpersonal relationships, communicating, and leading an autonomous life. Numerous studies have highlighted the association between cognitive decline and autoimmune disorders, including rheumatoid arthritis (RA). RA is a chronic, inflammatory, autoimmune disease that involves systems and organs other than the bones and joints, with varying severity among patients. Here, we review the studies investigating the link between cognitive decline and RA, focusing on the main molecular pathogenetic mechanisms involved. The emerging body of data suggests that clinical, psychological, and biological factors may contribute to the pathogenesis of cognitive decline in RA, including cardiovascular complications, chronic pain, depression, inflammatory factors, changes in hormone levels, drug side effects, and genetics. Further studies are warranted in order to fully clarify the basis underlying the association between cognitive decline and RA and to find new possible diagnostic strategies and therapeutic targets for RA patients.