Factors influencing attrition in 35 Alzheimer's Disease Centers across the USA: a longitudinal examination of the National Alzheimer's Coordinating Center's Uniform Data Set

Longitudinal changes in brain connectivity correlate with neuropsychological testing in brain tumor resection patients

Background

Patients undergoing brain tumor resection experience neurological and cognitive (i.e., neurocognitive) changes reflected in altered performance on neuropsychological tests. These changes can be difficult to explain or predict. Brain connectivity, measured with neuroimaging, offers one potential model for examining these changes. In this study, we evaluated whether longitudinal changes in brain connectivity correlated with changes in neurocognitive abilities in patients before and after brain tumor resection.

Methods

Patients underwent functional and diffusion MR scanning and neuropsychological evaluation before tumor resection followed by repeat scanning and evaluation 2 weeks post-resection. Using this functional and diffusion imaging data, we measured changes in the topology of the functional and structural networks. From the neuropsychological testing scores, we derived a composite score that described a patient's overall level of neurocognitive functioning. We then used a multiple linear regression model to test whether structural and functional connectivity measures were correlated with changes in composite scores.

Results

Multiple linear regression on 21 subjects showed that functional connectivity changes were highly correlated with changes in neuropsychological evaluation scores (R2 adjusted = 0.79, p < 0.001). Changes in functional local efficiency (p < 0.001) and global efficiency (p < 0.05) were inversely correlated with changes in composite score, while changes in modularity (p < 0.01) as well as the patient's age (p < 0.05) were directly correlated with changes in composite score.

Conclusion

Short interval changes in brain functional connectivity markers were strongly correlated with changes in the composite neuropsychological test scores in brain tumor resection patients. Our findings support the need for further exploration of brain connectivity as a biomarker relevant to brain tumor patients.

Feasibility of telephone and computerized cognitive testing as a secondary outcome in an acute stroke clinical trial: A mixed methods sub-study of the AcT Trial

INTRODUCTION

Post-stroke cognitive impairment is associated with impaired quality of life. Remote testing provides a potential avenue to measure cognitive outcomes efficiently.

PATIENTS AND METHODS

Prospective cognitive outcomes were collected at 90-180 days using both telephone MoCA (T-MoCA; range 0-22; <17 impairment) and Creyos, a computerized cognitive battery. Key variables associated with completion were assessed using logistic regressions. Mixed methods brief structured interviews and exit survey were performed to explore barriers to completing computer testing.

RESULTS

Of 791 potentially eligible patients (mean age 70 ± 14 years), there was low feasibility of remote cognitive testing, with only 401 (51%) completing the T-MoCA, and 242 (31%) completing Creyos. Our regression models show that age (ORT-MoCA: 0.95 (95% Confidence Interval (CI): 0.94-0.97); ORCreyos: 0.95 (95% CI: 0.94-0.96)), functional impairment (mRS 2-5; ORT-MoCA: 0.55 (95% CI: 0.37-0.81); ORCreyos: 0.66 (95% CI: 0.44-0.98)), quality of life (EQ-VAS; ORT-MoCA: 1.02 (95% CI: 1.01-1.03); ORCreyos: OR:1.02 (95% CI: 1.01-1.03)) and length of hospital stay (ORT-MoCA: 0.98 (95% CI: 0.96-0.99); ORCreyos: 0.97 (95% CI: 0.94-0.99)) predicted both telephone and computer cognitive test completion; computer literacy predicted computer test completion (ORCreyos: 1.12 (95% CI: 1.04-1.21)). In interviews, a preference for accessibility of computerized testing was reported.

DISCUSSION

Remote cognitive testing has limited feasibility as a secondary outcome in large acute stroke trials. Patients who are older, with worse quality of life, or severe functional impairment post-stroke are less likely to complete remote cognitive outcomes.

CONCLUSION

Innovative approaches to post-stroke cognitive outcomes in acute stroke trials are needed.Data AccessData available upon request.

Research Attitudes Questionnaire scores and retention in a recruitment registry

BACKGROUND

Recruitment registries are maximally effective when registrants are retained to the point of referral. The Research Attitudes Questionnaire (RAQ) has previously been shown to predict research participation behaviors, including Alzheimer's disease clinical trial completion.

OBJECTIVE

To test the hypothesis that RAQ score is associated with retention behaviors in a local recruitment registry.

METHODS

Using data from the UC Irvine Consent-to-Contact Registry, a recruitment registry that enrolls adults 18 years and older, we used logistic regression to quantify the association of RAQ score and the odds of first-year non-renewal. Covariates included demographic variables, comorbidities, and recruitment source. In longitudinal analyses, we used discrete proportional hazards and Cox proportional hazards models to quantify the relationship between RAQ score and time to non-renewal and time to active withdrawal, respectively.

RESULTS

Among n = 4663 participants, we estimated that a 5-point higher baseline RAQ score was associated with a 15% lower odds of first-year non-renewal, after adjustment for potential confounding factors (OR: 0.85, 95% CI: (0.79, 0.92), p < 0.001). Older age and higher education were also associated with lower odds of non-renewal while Asian race, Hispanic ethnicity, and certain recruitment sources (e.g., doctor or friend referral) were associated with higher odds of non-renewal. Higher baseline RAQ and higher annually updated RAQ were both significantly associated with lower odds of non-renewal longitudinally. Age, education, and some recruitment sources, but not RAQ, were associated with active withdrawal.

CONCLUSIONS

Opportunities exist to identify predictors of registry retention behaviors and possible targets for intervention to improve related outcomes.

Predictors of Retention in the 1Florida Alzheimer's Disease Research Center (ADRC) Over Two Waves

Background: Attrition is a significant methodological concern in longitudinal studies. Sample loss can limit generalizability and compromise internal validity. Methods: Wave one (n = 346) and wave two follow-ups (n = 196) of the 1Florida ADRC clinical core were examined using a 24-month visit window. Results: The sample (59% Hispanic) demonstrated retention rates of 77.2% and 86.2% in waves one and two, respectively. Predictors of lower retention in wave one included older age, amnestic MCI or dementia, and lower cognition and function scores. Completing a baseline MRI and lack of hippocampal atrophy were associated with higher retention in both waves. In wave two, a greater neighborhood disadvantage score was associated with attrition. Discussion: Predictors of retention changed over time, possibly due to the early withdrawal of the most vulnerable in the initial wave. Understanding predictors of retention can facilitate retention strategies, reduce attrition, and increase the validity of findings.

Potential Implications of Slowing Disease Progression in Amyloid-Positive Early Alzheimer's Disease: Estimates from Real-World Data

BACKGROUND

Emerging therapies have shown promising results for slowing the progression of Alzheimer's disease (AD). However, the potential impact of these therapies on real-world outcomes remains to be explored.

OBJECTIVE

To examine the impact of slowing AD progression on functional abilities and behavioral symptoms.

DESIGN

Retrospective observational study.

SETTING

Data from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS) in the United States (06/2005-11/2021, primary analysis) and the Alzheimer's Disease Neuroimaging Initiative (ADNI) database (09/2005-03/2022, sensitivity analysis) were used.

PARTICIPANTS

Individuals with mild cognitive impairment (MCI) or mild dementia, Clinical Dementia Rating Scale Sum of Boxes (CDR-SB) score 0.5-9.0 (inclusive; first visit defined as the index date), and confirmed amyloid positivity were identified in NACC. In ADNI, individuals with at least one clinical center visit with a clinical assessment of MCI or mild dementia and confirmed amyloid positivity were identified.

MEASUREMENTS

Hypothetical effects of slowing disease progression as assessed by CDR-SB on functional and behavioral outcomes including the Functional Activities Questionnaire (FAQ) score, Neuropsychiatric Inventory Questionnaire (NPI-Q) score, and the probability of complete dependence over five years were evaluated using multivariable regression among NACC participants, separately for the subgroups with MCI and mild dementia at baseline, respectively. For the ADNI sensitivity analysis, the hypothetical effects of slowing disease progression were evaluated for FAQ score using multivariable regression among the MCI participants only.

RESULTS

Compared with natural disease progression, slowing progression by 20% over five years for NACC participants with MCI and mild dementia, respectively, would result in 1.7-point (10.8%) and 1.6-point (12.9%) less deterioration based on FAQ; 0.5-point (20.3%) and 0.5-point (19.3%) less deterioration based on NPI-Q; 4.7 percentage-point (22.2%) and 10.1 percentage-point (21.6%) lower probability of complete dependence. Among ADNI participants, delaying disease progression by 20% or 30% over 4 years would avert deterioration based on FAQ of 1.1 points (20.4%) and 1.6 points (29.6%), respectively, compared to natural disease progression.

CONCLUSIONS

Slowing early AD progression could result in preservation of functional and behavioral attributes and functional autonomy for longer.

Estimating attrition in mild-to-moderate Alzheimer's disease and mild cognitive impairment clinical trials

BACKGROUND

Participant retention is a key factor that affects clinical trial integrity. Trial protocols estimate attrition as a function of sample size calculations. Alzheimer's disease (AD) is an area of active treatment development. We aimed to quantify the association between trial duration and completion rates and provide guidance for estimating attrition in AD trial protocols.

METHODS

Using the Alzforum and ClinicalTrials.gov databases, we analyzed retention data from 125 mild-to-moderate AD and 12 mild cognitive impairment (MCI) clinical trials. We compared the rates of completion between trial arms (active vs. control) and ran regression models to test the hypothesis that trials with longer study duration have lower trial completion using all available data and restricting to placebo data. Our primary outcome was the odds of trial completion for a 6-month increase in trial duration. From the regression model, we estimated the proportion of participants completing 6-, 12-, and 18-month trials.

RESULTS

We found that 21 (17%) mild-to-moderate AD trials and 1 (8%) MCI trial demonstrated greater dropout in treatment compared to placebo arms. For every 6-month increase in trial duration, there was a 27% decrease in the odds of trial completion (OR = 0.73; 95% CI 0.66, 0.81; p < 0.001) among participants in mild-to-moderate AD trials and a 55% decrease (OR = 0.45; 95% CI 0.36, 0.57; p < 0.001) among participants in MCI trials. The proportion of participants in the placebo group completing 6-, 12-, and 18-month trials were estimated to be 85.2%, 80.0%, and 73.3% for mild-to-moderate AD trials and 91.9%, 84.2%, and 71.3% for MCI trials, respectively.

CONCLUSIONS

Longer duration trials may be underpowered to demonstrate estimated treatment effects and may suffer from a greater risk of bias than do shorter trials.

The Prognostic Utility of Anticholinergic Burden Scales: An Integrative Review and Gap Analysis

BACKGROUND

Anticholinergic drugs are commonly prescribed, especially to older adults. Anticholinergic burden scales (ABS) have been used to evaluate the cumulative effects of multiple anticholinergics. However, studies have shown inconsistent results regarding the association between anticholinergic burden assessed with ABS and adverse clinical outcomes such as cognitive impairment, functional decline, and frailty. This review aims to identify gaps in research on the development, validation, and evaluation of ABS, and provide recommendations for future studies.

METHOD

A comprehensive search of five databases (MEDLINE, Embase, PsychInfo, CINAHL, CENTRAL) was conducted for relevant studies published from inception until 25 May 2023. Two reviewers screened for eligibility and assessed the quality of studies using different tools based on the study design and stage of the review framework. Research evidence was evaluated, and gaps were identified and grouped into evidence, knowledge, and methodological gaps, using evidence tables to summarize data.

RESULTS

Several evidence, knowledge, and methodological gaps in existing development, validation, and evaluation studies of ABS were identified. There is no universally accepted scale, and there is a need to define a clinically relevant threshold for measuring total anticholinergic burden. The current evidence has limitations, underrepresenting low- and middle-income countries, younger individuals, and populations with cognitive disabilities. The impact of anticholinergic burden on frailty is also understudied. Existing evaluation studies provide limited evidence on the benefit of reducing anticholinergic burden on clinical outcomes or the safety of anticholinergic deprescribing. There is also uncertainty regarding optimal reduction, clinically significant anticholinergic burden thresholds, and cost effectiveness.

CONCLUSIONS

Future research recommendations to bridge knowledge gaps include developing a risk assessment framework, refining ABS scales, establishing a standardized consensus scale, and creating a longitudinal measure of cumulative anticholinergic risk. Strategies to minimize bias, consider frailty, and promote multidisciplinary and multinational collaborations are also necessary to improve patient outcomes.

Exploring participant attrition in a longitudinal follow-up of older adults: the Global Longitudinal Study of Osteoporosis in Women (GLOW) Hamilton cohort

OBJECTIVE

We explored the magnitude of attrition, its pattern and risk factors for different forms of attrition in the cohort from the Global Longitudinal Study of Osteoporosis in Women.

DESIGN

Prospective cohort study.

SETTING

Participants were recruited from physician practices in Hamilton, Ontario.

PARTICIPANTS

Postmenopausal women aged ≥55 years who had consulted their primary care physician within the last 2 years.

OUTCOME MEASURES

Time to all-cause, non-death, death, preventable and non-preventable attrition.

RESULTS

All 3985 women enrolled in the study were included in the analyses. The mean age of the cohort was 69.4 (SD: 8.9) years. At the end of the follow-up, 30.2% (1206/3985) of the study participants had either died or were lost to follow-up. The pattern of attrition was monotone with most participants failing to return after a missed survey. The different types of attrition examined shared common risk factors including age, smoking and being frail but differed on factors such as educational level, race, hospitalisation, quality of life and being prefrail.

CONCLUSION

Attrition in this ageing cohort was selective to some participant characteristics. Minimising potential bias associated with such non-random attrition would require targeted measures to achieve maximum possible follow-rates among the high-risk groups identified and dealing with specific reasons for attrition in the study design and analysis.

Robust estimation of dementia prevalence from two-phase surveys with non-responders via propensity score stratification

BACKGROUND

Missing diagnoses are common in cross-sectional studies of dementia, and this missingness is usually related to whether the respondent has dementia or not. Failure to properly address this issue can lead to underestimation of prevalence. To obtain accurate prevalence estimates, we propose different estimation methods within the framework of propensity score stratification (PSS), which can significantly reduce the negative impact of non-response on prevalence estimates.

METHODS

To obtain accurate estimates of dementia prevalence, we calculated the propensity score (PS) of each participant to be a non-responder using logistic regression with demographic information, cognitive tests and physical function variables as covariates. We then divided all participants into five equal-sized strata based on their PS. The stratum-specific prevalence of dementia was estimated using simple estimation (SE), regression estimation (RE), and regression estimation with multiple imputation (REMI). These stratum-specific estimates were integrated to obtain an overall estimate of dementia prevalence.

RESULTS

The estimated prevalence of dementia using SE, RE, and REMI with PSS was 12.24%, 12.28%, and 12.20%, respectively. These estimates showed higher consistency than the estimates obtained without PSS, which were 11.64%, 12.33%, and 11.98%, respectively. Furthermore, considering only the observed diagnoses, the prevalence in the same group was found to be 9.95%, which is significantly lower than the prevalence estimated by our proposed method. This suggested that prevalence estimates obtained without properly accounting for missing data might underestimate the true prevalence.

CONCLUSION

Estimating the prevalence of dementia using the PSS provides a more robust and less biased estimate.

Multimorbid Patterns and Cognitive Performance in the Presence of Informative Dropout Among Community-Dwelling Taiwanese Older Adults

Background and Objectives

Longitudinal studies among older adults often feature elevated dropout rates and multiple chronic conditions. How Taiwanese multimorbid patterns relate to different cognitive domains remains unclear. This study aims to identify sex-specific multimorbid patterns and associate them with cognitive performance while modeling the risk for dropout.

Research Design and Methods

A prospective cohort study (2011-19) in Taiwan recruited 449 Taiwanese older adults without dementia. Global and domain-specific cognition were assessed biennially. We used exploratory factor analysis to identify baseline sex-specific multimorbid patterns of 19 self-reported chronic conditions. We utilized a joint model incorporating longitudinal and time-to-dropout data to examine the association between multimorbid patterns and cognitive performance accounting for the informative dropout via the shared random effect.

Results

At the end of the study, 324 participants (72.1%) remained in the cohort, with an average annual attrition rate of 5.5%. We found that advanced age, low levels of physical activities, and poor cognition at baseline were associated with increased dropout risks. Besides, 6 multimorbid patterns were identified, labeled Mental, Renal-vascular, and Cancer-urinary patterns in men, and Mental, Cardiometabolic, and Cancer-endocrine patterns in women. For men, as the follow-up time increased, the Mental pattern was associated with poor global cognition and attention; the Renal-vascular pattern was associated with poor executive function. For women, the Mental pattern was associated with poor memory; as follow-up time increased, and Cardiometabolic patterns were related to poor memory.

Discussion and Implications

Sex-specific multimorbid patterns identified in the Taiwanese older population showed differences (notably Renal-vascular pattern in men) from patterns found in Western countries and were differentially associated with cognitive impairment over time. When informative dropout is suspected, appropriate statistical methods should be applied.

Disease Progression and Longitudinal Clinical Outcomes of Lewy Body Dementia in the NACC Database

INTRODUCTION

As the identification of Lewy body dementia (LBD) is often confirmed postmortem, there is a paucity of evidence on the progression of disease antemortem. This study aimed to comprehensively assess the course of LBD over time across cognitive, functional, and neuropsychiatric outcomes using real-world data.

METHODS

Adults with at least one visit to an Alzheimer's Disease Center with a diagnosis of mild cognitive impairment/dementia (index date), indication of LBD, and at least one follow-up visit were identified in the National Alzheimer's Coordinating Center database (September 2005-June 2020). Participant characteristics, medication use, comorbidities, and changes in outcomes were assessed over a 5-year follow-up period and stratified by disease severity based on the Clinical Dementia Rating (CDR®) Dementia Staging Instrument-Sum of Boxes (CDR-SB) score at index.

RESULTS

A total of 2052 participants with LBD (mean age at index 73.4 years) were included (mild, 219; moderate, 988; severe, 845). Mean annualized increase over 5 years was 0.9 points for CDR-Global Score, 5.6 points for CDR-SB, 10.4 points for the Functional Activities Questionnaire, and 2.0 points for the Neuropsychiatric Inventory-Questionnaire. Disease progression was greater among participants with moderate and severe LBD at index compared with those with mild LBD.

CONCLUSION

Participants with LBD experienced decline across all outcomes over time, and impairment increased with disease severity. Findings highlight the substantial clinical burden associated with LBD and the importance of earlier diagnosis and effective treatment. Further research is needed to understand the predictors of cognitive and functional decline in LBD which may help inform clinical trials.

Retention of Study Partners in Longitudinal Studies of Alzheimer Disease

BACKGROUND

Study partners are required for all participants at Alzheimer's Disease Research Centers (ADRCs). Study partners' attitudes and beliefs may contribute to missed visits and negatively impact retention of participants in longitudinal AD studies.

OBJECTIVE

Study partners (N = 212) of participants (Clinical Dementia Rating® [CDR]≤2) at four ADRCs were randomly surveyed to examine their facilitators and barriers to continued participation in AD studies.

METHODS

Reasons for participation were analyzed with factor analysis and regression analysis. Effects of complaints and goal fulfillment on attendance were estimated with fractional logistic models. Open-ended responses were characterized with a Latent Dirichlet Allocation topic model.

RESULTS

Study partners participated for personal benefit and altruism. They emphasized personal benefits more when their participants had a CDR > 0 than when they had a CDR = 0. This difference declined with participant age. The majority of study partners rated their ADRC participation as positive and meeting their goals. Although half reported at least one complaint, very few regretted participating. Those who reported that ADRC participation fulfilled their goals or had fewer complaints were more likely to have perfect attendance. Study partners requested more feedback about test results and better management of study visits.

CONCLUSION

Study partners are motivated by both personal and altruistic goals. The salience of each goal depends on their trust in researchers and the participant's cognitive status and age. Retention may improve with perceived goal fulfillment and fewer complaints. Potential areas for improving retention are providing more information about the participant's test results and better management of study visits.

Factors associated with dropout in the longitudinal Vogel study of cognitive decline

Dementia, including Alzheimer's disease, is a growing problem worldwide. Prevention or early detection of the disease or a prodromal cognitive decline is necessary. By means of our long-term follow-up 'Vogel study', we aim to predict the pathological cognitive decline of a German cohort (mean age was 73.9 ± 1.55 years at first visit) with three measurement time points within 6 years per participant. Especially in samples of the elderly and subjects with chronic or co-morbid diseases, dropouts are one of the biggest problems of long-term studies. In contrast to the large number of research articles conducted on the course of dementia, little research has been done on the completion of treatment. To ensure unbiased and reliable predictors of cognitive decline from study completers, our objective was to determine predictors of dropout. We conducted multivariate analyses of covariance and multinomial logistic regression analyses to compare and predict the subject's dropout behaviour at the second visit 3 years after baseline (full participation, partial participation and no participation/dropout) with neuropsychiatric, cognitive, blood and lifestyle variables. Lower performance in declarative memory, attention and visual-spatial processing predicted dropout rather than full participation. Lower performance in visual-spatial processing predicted partial participation as opposed to full participation. Furthermore, lower performance in mini-mental status examination predicted whether subjects dropped out or participated partially instead of full participation. Baseline cognitive parameters are associated with dropouts at follow-up with a loss of impaired participants. We expect a bias into a healthier sample over time.

Heterogeneity in Alzheimer's Disease Diagnosis and Progression Rates: Implications for Therapeutic Trials

The clinical presentation and the pathological processes underlying Alzheimer's disease (AD) can be very heterogeneous in severity, location, and composition including the amount and distribution of AB deposition and spread of neurofibrillary tangles in different brain regions resulting in atypical clinical patterns and the existence of distinct AD variants. Heterogeneity in AD may be related to demographic factors (such as age, sex, educational and socioeconomic level) and genetic factors, which influence underlying pathology, the cognitive and behavioral phenotype, rate of progression, the occurrence of neuropsychiatric features, and the presence of comorbidities (e.g., vascular disease, neuroinflammation). Heterogeneity is also manifest in the individual resilience to the development of neuropathology (brain reserve) and the ability to compensate for its cognitive and functional impact (cognitive and functional reserve). The variability in specific cognitive profiles and types of functional impairment may be associated with different progression rates, and standard measures assessing progression may not be equivalent for individual cognitive and functional profiles. Other factors, which may govern the presence, rate, and type of progression of AD, include the individuals' general medical health, the presence of specific systemic conditions, and lifestyle factors, including physical exercise, cognitive and social stimulation, amount of leisure activities, environmental stressors, such as toxins and pollution, and the effects of medications used to treat medical and behavioral conditions. These factors that affect progression are important to consider while designing a clinical trial to ensure, as far as possible, well-balanced treatment and control groups.

Retaining Participants in Longitudinal Studies of Alzheimer's Disease

BACKGROUND

Retention of study participants is essential to advancing Alzheimer's disease (AD) research and developing therapeutic interventions. However, recent multi-year AD studies have lost 10% to 54% of participants.

OBJECTIVE

We surveyed a random sample of 443 participants (Clinical Dementia Rating [CDR]≤1) at four Alzheimer Disease Research Centers to elucidate perceived facilitators and barriers to continued participation in longitudinal AD research.

METHODS

Reasons for participation were characterized with factor analysis. Effects of perceived fulfillment of one's own goals and complaints on attendance and likelihood of dropout were estimated with logistic regression models. Open-ended responses suggesting study improvements were analyzed with a Latent Dirichlet Allocation topic model.

RESULTS

Factor analyses revealed two categories, personal benefit and altruism, as drivers of continued participation. Participants with cognitive impairment (CDR > 0) emphasized personal benefits more than societal benefits. Participants with higher trust in medical researchers were more likely to emphasize broader social benefits. A minority endorsed any complaints. Higher perceived fulfillment of one's own goals and fewer complaints were related to higher attendance and lower likelihood of dropout. Facilitators included access to medical center support and/or future treatment, learning about AD and memory concerns, and enjoying time with staff. Participants' suggestions emphasized more feedback about individual test results and AD research.

CONCLUSION

The results confirmed previously identified facilitators and barriers. Two new areas, improved communication about individual test results and greater feedback about AD research, emerged as the primary factors to improve participation.

Understanding loss to follow-up in a longitudinal study of people with traumatic brain injury

OBJECTIVE

To examine factors related to attrition in a traumatic brain injury (TBI) study sample assessed up to 15 years after injury.

PARTICIPANTS

One thousand twenty-eight participants with TBI who completed the year 1 follow-up assessment at a TBI Model Systems Center between 1992 and 2018.

METHOD

Secondary analysis of data from a prospective longitudinal cohort study considering follow-up data collection completion status at years 1, 2, 5, 10, and 15.

RESULTS

In univariable analyses, multiple factors were associated with loss to follow-up (LOFU) including being a member of a socially disadvantaged group, substance use history, residence, payor, cause of injury, and results of earlier follow-up attempts. In a multiple logistic regression analysis examining the prediction of follow-up condition at 10 or 15 years post-injury, only payor and race/ethnicity were significant predictors. Hispanic ethnicity was associated with higher odds of LOFU, and these participants often spoke Spanish and were born outside of the United States.

CONCLUSIONS

The findings suggest a need to understand sociodemographic variables and their influence on participant attrition in longitudinal TBI research. With a better understanding of these predictors, procedures can be developed to address retention of participants who are identified as being at increased risk for study drop out.

Classification, Prediction, and Concordance of Cognitive and Functional Progression in Patients with Mild Cognitive Impairment in the United States: A Latent Class Analysis

Background:

Progression trajectories of patients with mild cognitive impairment (MCI) are currently not well understood.

Objective:

To classify patients with incident MCI into different latent classes of progression and identify predictors of progression class.

Methods:

Participants with incident MCI were identified from the US National Alzheimer’s Coordinating Center Uniform Data Set (09/2005-02/2019). Clinical Dementia Rating (CDR^®) Dementia Staging Instrument-Sum of Boxes (CDR-SB), Functional Activities Questionnaire (FAQ), and Mini-Mental State Examination (MMSE) score longitudinal trajectories from MCI diagnosis were fitted using growth mixture models. Predictors of progression class were identified using multivariate multinomial logistic regression models; odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

Results:

In total, 21%, 22%, and 57% of participants (N = 830) experienced fast, slow, and no progression on CDR-SB, respectively; for FAQ, these figures were 14%, 23%, and 64%, respectively. CDR-SB and FAQ class membership was concordant for most participants (77%). Older age (≥86 versus≤70 years, OR [95% CI] = 5.26 [1.78–15.54]), one copy of APOE ɛ4 (1.94 [1.08–3.47]), higher baseline CDR-SB (2.46 [1.56–3.88]), lower baseline MMSE (0.85 [0.75–0.97]), and higher baseline FAQ (1.13 [1.02–1.26]) scores were significant predictors of fast progression versus no progression based on CDR-SB (all p < 0.05). Predictors of FAQ class membership were largely similar.

Conclusion:

Approximately a third of participants experienced progression based on CDR-SB or FAQ during the  4-year follow-up period. CDR-SB and FAQ class assignment were concordant for the vast majority of participants. Identified predictors may help the selection of patients at higher risk of progression in future trials.

Cognitive Impairment and Dementia After Stroke: Design and Rationale for the DISCOVERY Study

Stroke is a leading cause of the adult disability epidemic in the United States, with a major contribution from poststroke cognitive impairment and dementia (PSCID), the rates of which are disproportionally high among the health disparity populations. Despite the PSCID's overwhelming impact on public health, a knowledge gap exists with regard to the complex interaction between the acute stroke event and highly prevalent preexisting brain pathology related to cerebrovascular and Alzheimer disease or related dementia. Understanding the factors that modulate PSCID risk in relation to index stroke event is critically important for developing personalized prognostication of PSCID, targeted interventions to prevent it, and for informing future clinical trial design. The DISCOVERY study (Determinants of Incident Stroke Cognitive Outcomes and Vascular Effects on Recovery), a collaborative network of thirty clinical performance clinical sites with access to acute stroke populations and the expertise and capacity for systematic assessment of PSCID will address this critical challenge. DISCOVERY is a prospective, multicenter, observational, nested-cohort study of 8000 nondemented ischemic and hemorrhagic stroke patients enrolled at the time of index stroke and followed for a minimum of 2 years, with serial cognitive evaluations and assessments of functional outcome, with subsets undergoing research magnetic resonance imaging and positron emission tomography and comprehensive genetic/genomic and fluid biomarker testing. The overall scientific objective of this study is to elucidate mechanisms of brain resilience and susceptibility to PSCID in diverse US populations based on complex interplay between life-course exposure to multiple vascular risk factors, preexisting burden of microvascular and neurodegenerative pathology, the effect of strategic acute stroke lesions, and the mediating effect of genomic and epigenomic variation.

Predictors of attrition in a longitudinal population-based study of aging

BACKGROUND

Longitudinal studies predictably experience non-random attrition over time. Among older adults, risk factors for attrition may be similar to risk factors for outcomes such as cognitive decline and dementia, potentially biasing study results.

OBJECTIVE

To characterize participants lost to follow-up which can be useful in the study design and interpretation of results.

METHODS

In a longitudinal aging population study with 10 years of annual follow-up, we characterized the attrited participants (77%) compared to those who remained in the study. We used multivariable logistic regression models to identify attrition predictors. We then implemented four machine learning approaches to predict attrition status from one wave to the next and compared the results of all five approaches.

RESULTS

Multivariable logistic regression identified those more likely to drop out as older, male, not living with another study participant, having lower cognitive test scores and higher clinical dementia ratings, lower functional ability, fewer subjective memory complaints, no physical activity, reported hobbies, or engagement in social activities, worse self-rated health, and leaving the house less often. The four machine learning approaches using areas under the receiver operating characteristic curves produced similar discrimination results to the multivariable logistic regression model.

CONCLUSIONS

Attrition was most likely to occur in participants who were older, male, inactive, socially isolated, and cognitively impaired. Ignoring attrition would bias study results especially when the missing data might be related to the outcome (e.g. cognitive impairment or dementia). We discuss possible solutions including oversampling and other statistical modeling approaches.

Agitation in Alzheimer's disease: Novel outcome measures reflecting the International Psychogeriatric Association (IPA) agitation criteria

Introduction

The 2017 European Union‐North American Clinical Trials in Alzheimer's Disease Task Force recommended development of clinician‐rated primary outcome measures for Alzheimer's disease (AD) agitation trials, incorporating International Psychogeriatric Association (IPA) criteria.

Methods

In a modified Delphi process, Cohen‐Mansfield Agitation Inventory (CMAI) and Neuropsychiatric Inventory‐Clinician (NPI‐C) items were mapped to IPA agitation domains generating novel instruments, CMAI‐IPA and NPI‐C‐IPA. Validation in the Agitation and Aggression AD Cohort (A3C) assessed minimal clinically important differences (MCIDs), change sensitivity, and predictive validity.

Results

MCID was –17 (odds ratio [OR] = 14.9, 95% confidence interval [CI] = 6.8–32.6) for CMAI; –5 (OR = 9.3, 95% CI = 4.0–21.2) for CMAI‐IPA; –3 (OR = 11.9, 95% CI = 4.1–34.8) for NPI‐C‐A+A; and –5 (OR = 7.8, 95% CI = 3.4–17.9) for NPI‐C‐IPA at 3 months. Areas under the curve suggested no scale better predicted global clinician ratings. Sensitivity to change for all measures was high.

Conclusion

Internal consistency and reliability analyses demonstrated better accuracy for the NPI‐C‐IPA than for the CMAI‐IPA and can be used for agitation clinical trial inclusion, and for response to intervention.

Association of Dilated Perivascular Spaces With Cognitive Decline and Incident Dementia

OBJECTIVE

To determine whether severe perivascular space (PVS) dilation is associated with longitudinal cognitive decline and incident dementia over 4 and 8 years, respectively, we analyzed data from a prospective cohort study.

METHODS

A total of 414 community-dwelling older adults aged 72-92 years were assessed at baseline and biennially for up to 8 years, with cognitive assessments, consensus dementia diagnoses, and 3T MRI. The numbers of PVS in 2 representative slices in the basal ganglia (BG) and centrum semiovale (CSO) were counted and severe PVS pathology defined as the top quartile. The effects of severe PVS pathology in either region or both regions and those with severe BG PVS and severe CSO PVS were examined. White matter hyperintensity volume, cerebral microbleed number, and lacune number were calculated.

RESULTS

Participants with severe PVS pathology in both regions or in the CSO alone had greater decline in global cognition over 4 years, even after adjustment for the presence of other small vessel disease neuroimaging markers. The presence of severe PVS pathology in both regions was an independent predictor of dementia across 8 years (odds ratio 2.91, 95% confidence interval 1.43-5.95, p = 0.003). The presence of severe PVS pathology in all groups examined was associated with greater dementia risk at either year 4 or 6.

CONCLUSIONS

Severe PVS pathology is a marker for increased risk of cognitive decline and dementia, independent of other small vessel disease markers. The differential cognitive associations for BG and CSO PVS may represent differences in their underlying pathology.

Examining the Family Support Role of Older Hispanics, African Americans, and Non-Hispanic Whites and Their Breast Cancer Screening Behaviors

Disparities in breast cancer mortality rates among older Black and Hispanic women are due in part to low participation in cancer screening. Participation in cancer screening could be affected by an array of factors, including social support. Understanding the complex interplay between social support and breast cancer screening among older female adults, specifically among groups with higher mortality rates, is extremely important for timely and appropriate interventions to increase survival rates. Thus, utilizing the social network theory as the conceptual framework, this study aims to examine effects of social support on receiving a mammogram among a representative sample of older adults, specifically African American and Hispanic populations in the United States. Logistic regression models were conducted using the 2008 and 2012 Health and Retirement Study data. Findings from this study indicate that specific aspects of social support influence breast cancer screening participation among older Hispanic and non-Hispanic White women. However, this was not the case for the older Black women after adjusting for the sociodemographic factors. Given the role that family members play in the care of older adults, it is critical that social workers consider both the possible positive and negative interactions older women may have and how these interactions may affect their cancer screening behaviors. Findings can provide formative data to develop public health and social work interventions to increase positive social support and reduce negative social support by spouses and children to enhance breast cancer screening among older adults.

Cognitive impairment and sedentary behavior predict health-related attrition in a prospective longitudinal Parkinson's disease study

INTRODUCTION

In Parkinson's disease (PD), the high burden of motor and non-motor symptoms, such as cognitive impairment or falls, is associated with rapid disease progression and mortality. This is often reflected by an increased drop-out rate of PD patients in longitudinal studies. Active physical behavior can impact the disease course beneficially and has an overall positive effect on health. Contrarily, sedentary behavior is associated with cognitive impairment in PD. The aim of this study was to investigate whether sedentary physical behavior assessed in the home environment and cognitive impairment can predict health-related study attrition due to sickness and death in PD.

METHODS

Data of 45 PD patients, longitudinally assessed, were analyzed. Of those, 20 patients completed six yearly visits, 16 dropped out due to sickness or death, and nine for other reasons. All patients wore a mobile device to assess physical behavior and completed cognitive testing.

RESULTS

Logistic regression revealed global cognition was the primary predictor for health-related drop-out in varying models (p ≤ .04). In the survival analysis, cognitive impairment (p = .005) and longer sedentary mean bout length (p = .02) were associated with drop-out due to sickness and death. The occurrence of health-related study drop-out or death was highest in patients with both impaired cognition and longer sedentary bouts.

CONCLUSIONS

Cognition was the primary predictor for study drop-out due to sickness and death. However, it seems that sedentary behavior might have a potential negative influence on PD patients' health, especially those with cognitive impairment.

Controlling for selective dropout in longitudinal dementia data: Application to the SveDem registry

Introduction

Loss to follow‐up in dementia studies is common and related to cognition, which worsens over time. We aimed to (1) describe dropout and missing cognitive data in the Swedish dementia registry, SveDem; (2) identify factors associated with dropout; and (3) estimate propensity scores and use them to adjust for dropout.

Methods

Longitudinal cognitive data were obtained from 53,880 persons from the SveDem national quality dementia registry. Inverse probability of censoring weights (IPCWs) were estimated using a logistic regression model on dropout.

Results

The mean annualized rate of change in Mini‐Mental State Examination (MMSE) in those with a low MMSE (0 to 10) was likely underestimated in the complete case analysis (+1.5 points/year) versus the IPCW analysis (−0.3 points/year).

Discussion

Handling dropout by IPCWs resulted in plausible estimates of cognitive decline. This method is likely of value to adjust for biased dropout in longitudinal cohorts of dementia.