Alzheimer's disease and co-morbidity: increased prevalence and possible risk factors of excess mortality in a naturalistic 7-year follow-up

The causal relationship of inflammation-related factors with osteoporosis: A Mendelian Randomization Analysis

BACKGROUND

We used Mendelian randomization (MR) approach to examine whether genetically determined inflammation-related risk factors play a role in the onset of osteoporosis (OP) in the European population.

METHODS

Genome-wide association studies (GWASs) summary statistics of estimated bone mineral density (eBMD) obtained from the public database GEnetic Factors for OSteoporosis Consortium (GEFOS) including 142,487 European people. For exposures, we utilized GWAS data of 9 risk factors including diseases chronic kidney disease (CKD) (41,395 cases and 439,303 controls), type 2 diabetes (T2D) (88,427 cases and 566,778 controls), Alzheimer's disease (AD) (71,880 cases, 383,378 controls) and major depression disorder (MDD) (9240 cases and 9519 controls) and lifestyle behaviors are from different consortiums. Inverse variance weighted (IVW) analysis was principal method in this study and random effect model was applied; MR-Egger method and weighted median method were also performed for reliable results. Cochran's Q test and MR-Egger regression were used to detect heterogeneity and pleiotropy and leave-one-out analysis was performed to find out whether there are influential SNPs.

RESULTS

We found that T2D (IVW: β = 0.05, P = 0.0014), FI (IVW: β = -0.22, P < 0.001), CKD (IVW: β = 0.02, P = 0.009), ALZ (IVW: β = 0.06, P = 0.005), Coffee consumption (IVW: β = 0.11, P = 0.003) were causally associated with OP (P<0.006after Bonferroni correction).

CONCLUSIONS

Our study revealed that T2D, FI, CKD, ALZ and coffee consumption are causally associated with OP. Future interventions targeting factors above could provide new clinical strategies for the personalized prevention and treatment of osteoporosis.

Associations of ischemic heart disease with brain glymphatic MRI indices and risk of Alzheimer's disease

BACKGROUND

The impact of ischemic heart disease (IHD) on the brain glymphatic MRI indices and risk of Alzheimer's disease (AD) remains largely unclear. This study aimed to investigate the associations between IHD, brain glymphatic MRI indices and risk of AD.

METHODS

A total of 1385 non-dementia subjects (55.2 % male, mean age 73.53) were included. Diffusivity along the perivascular space (DTI-ALPS), free water (FW) and choroid plexus volume were used to reflect glymphatic function. The associations of IHD with MRI derived glymphatic indices, PET amyloid, tau and cognitive performance were explored by multiple regression analysis. IHD were tested as predictors of clinical progression using cox proportional hazards modeling. The mediation effect of MRI derived glymphatic indices on the relationship between IHD and cognitive changes was investigated.

RESULTS

Individuals with IHD exhibited glymphatic dysfunction revealed by lower DTI-ALPS (p = 0.035), higher FW (p < 0.001), and higher choroid plexus volume (p = 0.019). IHD had poorer cognitive performance in MMSE (p = 0.022), ADNI-MEM (p = 0.001) and ADNI-MF (p = 0.006), and more amyloid deposition (p = 0.007). IHD had a higher diagnostic conversion risk (HR = 1.321, 95 % CI = 1.003-1.741). IHD was associated with longitudinal cognitive decline in all cognitive tests (p < 0.05 for all) and FW (β = 0.012, 95 % CI 0.001, 0.023, p = 0.038). FW demonstrated an indirect effect (β = -0.0009, 95 % CI: -0.0034, -0.0001) and mediated 13.85 % effect for the relationship between IHD and ADNI-EF decline.

CONCLUSION

IHD is independently associated with AD risk, and brain glymphatic dysfunction may partially mediate this relationship.

Bidirectional association between breast cancer and dementia: a systematic review and meta-analysis of observational studies

Background

Cognitive decline following cancer treatment can vary from mild cognitive impairment to severe dementia. However, there is inconsistent evidence regarding the relationship between breast cancer survivors and their risk of developing dementia. This meta-analysis aims to consolidate observational studies to explore the bidirectional association between breast cancer and dementia risk.

Methods

We conducted a comprehensive search using medical subject headings (MeSH) and keywords across PubMed, Cochrane Library, and Embase databases to identify cohort, case-control, and cross-sectional studies examining the link between breast cancer and dementia risk. Statistical analysis was performed using Stata version 14.0, with a random effects model employed to account for heterogeneity. Publication bias was assessed using funnel plots and Egger's test.

Results

This meta-analysis included 13 studies with a total of 346,051 participants, up to June 20, 2024. Of these, seven studies investigated the risk of dementia among patients with breast cancer, revealing a lower risk [OR = 0.56, 95% CI [0.27-1.18], I2 = 99.1%, P = 0.128]. Similarly, seven studies explored the risk of breast cancer in individuals with dementia, showing a lower risk as well [OR = 0.79, 95% CI [0.51-1.22], I2 = 94.5%, P = 0.290].

Conclusion

Our findings indicate that breast cancer is less likely to lead to dementia and that dementia is similarly low associated with risk of breast cancer. These insights are crucial for clinicians in guiding the prevention and monitoring of neurodegenerative conditions in patients with breast cancer.

Sex-specific transcriptomic profiling reveals key players in bone loss associated with Alzheimer's disease

Alzheimer's disease (AD), a progressive neurodegenerative disorder, is frequently associated with musculoskeletal complications, including sarcopenia and osteoporosis, which substantially impair patient quality of life. Despite these clinical observations, the molecular mechanisms linking AD to bone loss remain insufficiently explored. In this study, we examined the femoral bone microarchitecture and transcriptomic profiles of APP/PS1 transgenic mouse models of AD to elucidate the disease's impact on bone pathology and identify potential gene candidates associated with bone deterioration. We performed micro-computed tomography (microCT) and RNA transcriptome analysis on the femoral bone of these mice. We observed a significant reduction in bone microstructure in both male and female APP/PS1 mice compared to their wild-type counterparts. Transcriptomic analysis of femoral bone tissue revealed substantial differential gene expression between AD mice and controls. Specifically, APP/PS1 mice exhibited differential expression in 289 protein-coding genes across both sexes. Notably, in female APP/PS1 mice, 664 genes were differentially expressed, with key genes such as Shh, Efemp1, Arg1, EphA2, Irx1, and PORCN potentially implicated in bone loss. In male APP/PS1 mice, 787 genes were differentially expressed, with Sel1l, Ffar4, Hspa1a, AMH, WFS1, and CLIC1 emerging as notable candidates in the context of bone deterioration. Gene Ontology (GO) enrichment analysis further revealed distinct sex-specific gene pathways between male and female APP/PS1 mice, underscoring the differential molecular underpinnings of bone pathology in AD. This study identifies novel sex-specific genes in the APP/PS1 mouse model and proposes potential therapeutic targets to mitigate bone loss in AD patients.

The Impact of Comorbid Dementia and Diabetes Mellitus on Hospital Patients' Outcomes: A Systematic Review and Meta-analysis

INTRODUCTION

Previous reviews have demonstrated that dementia and diabetes mellitus, separately, can worsen the hospital outcomes of patients. Unfortunately, there are no systematic evaluations regarding the hospital outcomes of patients with dementia and diabetes mellitus as a comorbidity. Therefore, our review aimed to determine any differences in hospital length of stay, hospital mortality, and hospital readmission between patients with the comorbidity and patients without.

METHODS

Searches were conducted of Medline, CINHAL, EMBASE, PsychINFO, Web of Science and Google Scholar for original studies. All studies were quality assessed using the Joanna Briggs Institute critical appraisal tools. Where possible, studies were pooled in a meta-analysis to generate odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Sixteen studies were included in this review. When comparing patients with the comorbidity to patients with dementia, the difference in length of stay was inconclusive, and there was no difference in the odds of hospital mortality (OR = 0.98, 95% CI 0.91-1.06). However, patients with the comorbidity had increased odds of 30-day readmission compared to patients with dementia alone (OR = 1.20, 95% CI 1.14-1.26). When comparing patients with the comorbidity to patients with diabetes, those with the comorbidity had a longer length of stay and but no difference in the odds of hospital mortality (OR = 1.48, 95% CI 0.84-2.62). Additionally, those with the comorbidity may have worse readmission outcomes than those with diabetes alone.

CONCLUSIONS

Our findings suggest that patients with comorbid dementia and diabetes mellitus may have worse hospital outcomes. Therefore, we recommend further research to assess these patients' hospital outcomes to resolve the discrepancies found.

Very high high-density lipoprotein cholesterol may be associated with higher risk of cognitive impairment in older adults

BACKGROUND

Previous studies have shown that high-density lipoprotein cholesterol (HDL-C) levels are positively associated with cognitive function across a range of concentrations. However, recent studies have suggested that very high HDL-C levels may lead to poorer outcomes. Therefore, we aimed to investigate the relationship between different concentrations of HDL-C and cognitive impairment risk.

METHODS

We collected data from 3632 participants aged over 60 years from the U.S. National Health and Nutrition Examination Survey (NHANES) between 2011 and 2014 to assess the relationship between HDL-C and cognitive function. Cognitive function was evaluated with the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) test, the animal fluency test (AFT), and the digit symbol substitution test (DSST). We used restricted cubic spline models and logistic regression to examine the association between HDL-C and cognitive function.

RESULTS

A U-shaped was observed between HDL-C and cognitive outcomes, individuals with higher risk in those with both low and very high HDL-C levels compared with those with midrange values. Very high HDL-C levels (≥ 2.50 mmol/L) were associated with increased risk of cognitive impairment (OR = 2.19; 95% CI, 1.12-4.28) compared with those with HDL-C levels in the range of 1.50 to 1.99 mmol/L in older adults after adjustment for confounding factors. Interaction test demonstrated that relationship between very high HDL-C and the risk of cognitive impairment was not changed in different sex and race group (P for interaction > 0.05).

CONCLUSIONS

Very high HDL-C levels were associated with an increased risk of cognitive impairment. HDL-C may not be a protective factor for maintaining brain health in older adults at very high levels.

DNA methylation of imprint control regions associated with Alzheimer's disease in non-Hispanic Blacks and non-Hispanic Whites

Alzheimer's disease (AD) prevalence is twice as high in non-Hispanic Blacks (NHBs) as in non-Hispanic Whites (NHWs). The objective of this study was to determine whether aberrant methylation at imprint control regions (ICRs) is associated with AD. Differentially methylated regions (DMRs) were bioinformatically identified from whole-genome bisulfite sequenced DNA derived from brain tissue of 9 AD (5 NHBs and 4 NHWs) and 8 controls (4 NHBs and 4 NHWs). We identified DMRs located within 120 regions defined as candidate ICRs in the human imprintome ( https://genome.ucsc.edu/s/imprintome/hg38.AD.Brain_track ). Eighty-one ICRs were differentially methylated in NHB-AD, and 27 ICRs were differentially methylated in NHW-AD, with two regions common to both populations that are proximal to the inflammasome gene, NLRP1, and a known imprinted gene, MEST/MESTIT1. These findings indicate that early developmental alterations in DNA methylation of regions regulating genomic imprinting may contribute to AD risk and that this epigenetic risk differs between NHBs and NHWs.

Olfactory identification, cognition, depressive symptoms, and 5-year mortality in patients with subjective cognitive decline, mild cognitive impairment, and Alzheimer's disease

OBJECTIVE

An association between odor and cognitive impairment has been shown in many studies. The objective of the present hospital-based, single-center retrospective study was to assess the impact of odor impairment on the mortality of patients with Alzheimer's disease (AD), subjective cognitive decline (SCD), and mild cognitive impairment (MCI).

METHODS

Odor function was measured by Sniffin Sticks (Burghart Messtechnik, Holm, Germany) and the assessment of self-reported olfactory functioning and olfaction-related quality of life (ASOF) test. Cognitive performance was assessed by an extensive neuropsychological test battery, symptoms of depression were diagnosed with the Geriatric Depressive Scale (GDS). The influence of demographic factors such as gender, age, and education were examined.

RESULTS

Although the univariate analyses and pairwise post hoc comparison showed significant differences for some of the olfactory performance tests/subtests, the multivariate models showed no association between olfactory test performance and mortality among patients with cognitive impairment. "Attention," a domain of the Neuropsychological Test Battery Vienna (NTBV), as well as depressive symptoms, gender, and age, showed a significant influence on the mortality of the patient group.

CONCLUSION

Lower olfactory performance showed no impact on mortality. However, decreased cognitive function of "Attention" can be considered as an influential predictor for mortality.

Alterations in Alzheimer's disease microglia transcriptome might be involved in bone pathophysiology

Aging is a major risk factor for multiple chronic disorders in the elderly population, including Alzheimer's disease (AD) and Osteoporosis. AD is a progressive neurodegenerative disease characterized by memory loss. In addition to dementia, several studies have shown that AD patients experience an increased rate of musculoskeletal co-morbidities, such as osteoporosis. Since tissue-specific macrophages contribute to both diseases, this study analyzed the microglia transcriptome of AD mice to determine a common gene signature involved in osteoclast biology. After comparing differentially regulated genes from GEO data sets (GSE93824 and GSE212277), there were 35 common upregulated genes and 89 common downregulated genes. Of these common genes, seven genes are known to play an important role in bone homeostasis. CSF1, SPP1, FAM20C, and Cst7 were upregulated and are associated with osteoclastogenesis and inflammation. Among the downregulated genes, LILRA6, MMP9, and COL18A1 are involved in bone formation and osteoclast regulation. We further validated some of these genes (CSF1, Cst7, and SPP1) in the cortex and the bone of AD mice models. The dysregulation of these microglial genes in AD might provide insights into the co-occurrence of AD and osteoporosis and offer potential therapeutic targets to combat disease progression.

Health Conditions Associated with Alzheimer's Disease and Vascular Dementia

OBJECTIVE

We examined medical records to determine health conditions associated with dementia at varied intervals prior to dementia diagnosis in participants from the Baltimore Longitudinal Study of Aging (BLSA).

METHODS

Data were available for 347 Alzheimer's disease (AD), 76 vascular dementia (VaD), and 811 control participants without dementia. Logistic regressions were performed associating International Classification of Diseases, 9th Revision (ICD-9) health codes with dementia status across all time points, at 5 and 1 year(s) prior to dementia diagnosis, and at the year of diagnosis, controlling for age, sex, and follow-up length of the medical record.

RESULTS

In AD, the earliest and most consistent associations across all time points included depression, erectile dysfunction, gait abnormalities, hearing loss, and nervous and musculoskeletal symptoms. Cardiomegaly, urinary incontinence, non-epithelial skin cancer, and pneumonia were not significant until 1 year before dementia diagnosis. In VaD, the earliest and most consistent associations across all time points included abnormal electrocardiogram (EKG), cardiac dysrhythmias, cerebrovascular disease, non-epithelial skin cancer, depression, and hearing loss. Atrial fibrillation, occlusion of cerebral arteries, essential tremor, and abnormal reflexes were not significant until 1 year before dementia diagnosis.

INTERPRETATION

These findings suggest that some health conditions are associated with future dementia beginning at least 5 years before dementia diagnosis and are consistently seen over time, while others only reach significance closer to the date of diagnosis. These results also show that there are both shared and distinctive health conditions associated with AD and VaD. These results reinforce the need for medical intervention and treatment to lessen the impact of health comorbidities in the aging population. ANN NEUROL 2023;93:805-818.

Prevalence of visual impairment in older people living with dementia and its impact: a scoping review

BACKGROUND AND OBJECTIVES

Visual impairment (VI) and dementia both increase with age, and it is likely that many older people are living with both conditions. This scoping review aims to investigate the prevalence and types of VI among older people living with dementia, and the impact of VI on older people living with dementia and their caregivers.

METHODS

This scoping review used Arksey and O'Malley's methodological framework. Studies in any setting involving people living with dementia and some assessment of either VI, eye diseases causing VI or the impact of VI were included.

RESULTS

Thirty-six studies were included. Thirty-one studies reported the prevalence of VI in older people living with dementia, while ten studies reported on impacts of VI on people living with dementia. Only one study reported on impacts on caregivers. The prevalence of VI or specific eye diseases among older people living with dementia ranged from 0.2 to 74%. The impacts of VI on older people living with dementia included increased use of hospital services, increased disability and dependency, reduced social engagement, negative emotions, increased abnormal behaviours, loss of hobbies, difficulty in using visual aids or memory aids, and greater Neuropsychiatric Inventory symptoms. And the impacts on caregivers included increased conflict and physical exhaustion.

CONCLUSION

VI is common in older people living with dementia and is associated with negative impacts on those with dementia and their caregivers. However, heterogeneity between studies in terms of setting and method for assessing and defining VI make it difficult to compare findings among studies. Further research is needed, particularly assessing the impact on caregivers.

Dysphagia in Alzheimer's disease: a systematic review

Dysphagia is described as a highly relevant comorbidity of Alzheimer's disease (AD). However, there is a scarcity of studies aiming at the characteristics and progression of dysphagia.

OBJECTIVE

The objective of this study was to identify the specific characteristics, progression, and prevalence of dysphagia in AD.

METHODS

Publications were searched in the PubMed (MEDLINE), EBSCO, ScienceDirect, and BASE databases. Critical appraisal and evidence-level analysis were conducted using the Joanna Briggs Institute and Effective Public Health Practice Project's (EPHPP) tools.

RESULTS

A total of 26 studies were reviewed. Symptoms begin in the early stage of AD, as oral phase impairments, and progress to pharyngeal symptoms and swallowing apraxia in the later stages of AD. Dysphagia progresses, as AD, along a continuum, with severity depending on individual variability. There were no studies found on prevalence.

CONCLUSIONS

Dysphagia is a complex and important comorbidity in AD that impacts the quality of life. No recent publications on prevalence may imply that is not being coded as a potential cause for pneumonia deaths in AD.

Trajectories of cognitive functioning in later life: Disparities by race/ethnicity, educational attainment, sex, and multimorbidity combinations

Evaluating multimorbidity combinations, racial/ethnic background, educational attainment, and sex associations with age-related cognitive changes is critical to clarifying the health, sociodemographic, and socioeconomic mechanisms associated with cognitive function in later life. Data from the 2011-2018 National Health and Aging Trends Study for respondents aged 65 years and older (N = 10,548, mean age = 77.5) were analyzed using linear mixed effect models. Racial/ethnic differences (mutually-exclusive groups: non-Latino White, non-Latino Black, and Latino) in cognitive trajectories and significant interactions with sex and education (<high school, high school, some college, and ≥ college degree) were evaluated. Models included sex, education, ever covered by Medicaid, coupled status, waist-height ratio, study cohort, and chronic disease category (no diseases; one disease; advanced cardiovascular multimorbidity; metabolic multimorbidity; advanced cardiovascular-metabolic multimorbidity; and neither advanced cardiovascular nor metabolic multimorbidity). In covariate-adjusted models, Black (b = -1.31, 95% CI: 1.74,-0.89) and Latino (b = -0.83, 95% CI: 1.58,-0.07) respondents had lower cognitive scores at age 65 and steeper declines with age (b = -0.08, 95% CI: -0.15,-0.01; b = -0.20, 95% CI: 0.34,-0.05, respectively) compared with White respondents. Cognitive scores were lower among respondents with advanced cardiovascular (b = -0.28, 95% CI: 0.54,-0.01) and advanced cardiovascular-metabolic (b = -0.56, 95% CI: 0.86,-0.27) multimorbidity compared with respondents with none of the chronic diseases of interest. In interaction models, protective associations by female sex and higher education were not observed among minority racial/ethnic groups. It is important to develop interventions to postpone cognitive decline among older Black and Latino adults.

No effect of thyroid hormones on 5-year mortality in patients with subjective cognitive decline, mild cognitive disorder, and Alzheimer's disease

The present study aimed to investigate differences in circulating thyroid hormone levels, gender, education, depressive symptoms, and cognitive performance among patients with cognitive impairment, and also to examine their associations, as well as that of cognitive decline, with 5-year mortality. Between 1998 and 2017, a hospital-based, single-centre (Neurology Department of the General Hospital in Vienna, Austria), retrospective follow-up study enrolled 2102 patients with mild to severe cognitive impairment (grouped into subjective cognitive decline, mild cognitive impairment, and Alzheimer's disease). Cox proportional hazards models were used to calculate hazard ratios (HRs), with 95% confidence intervals (CIs), as well as to calculate stepwise adjustments for demographic variables (age, gender, and education), depressive symptoms (Geriatric Depression Scale, GDS-15), and neuropsychological abilities (four domains of a neuropsychological test battery of Vienna, NTVB). In univariate analyses, total triiodothyronine (TT3) levels differed significantly between Alzheimer's disease and mild cognitive impairment patients (p_diff  = .001). No other differences in cognitive impairment subgroups with any of the measured thyroid hormones were observed. Furthermore, in multivariate models, circulating TT3 was not associated with mortality (multivariable-adjusted HR per unit increase in TT3 = 0.56; 95% CI = 0.29-1.07). In multivariate models, we observed significantly lower 5-year mortality among women (HR = 0.56; 95% CI = 0.43-0.73) and those who scored higher on any of the four domains of the NBTV (e.g., attention and perceptual speed, HR = 0.63; 95% CI = 0.54-0.72); we also observed significantly higher 5-year mortality among patients with depressive symptoms (HR per one point score increase in GDS-15 = 1.06; 95% CI = 1.02-1.10), regardless of cognitive impairment subgroup. Among patients with various degrees of cognitive impairment, we found no associations of thyroid hormone levels with 5-year mortality. Gender, neuropsychological abilities, and depressive symptoms were each significant predictors of 5-year mortality. These results suggest that a neurocognitive test performance could serve as an important predictor of 5-year mortality among patients with cognitive impairment, although further studies with a more complete adjustment for comorbidities are needed to confirm these findings.

Rodrigues K, Pinz MP, Biondi JV, Becker NP, Blodorn E, Domingues WB, Larroza A, Campos VF, Alves D, Wilhelm EA, Luchese C. Prospecting for a quinoline containing selenium for comorbidities depression and memory impairment induced by restriction stress in mice

RATIONALE

Depression is often associated with memory impairment, a clinical feature of Alzheimer's disease (AD), but no effective treatment is available. 7-Chloro-4-(phenylselanyl) quinoline (4-PSQ) has been studied in experimental models of diseases that affect the central nervous system.

OBJECTIVES

The pharmacological activity of 4-PSQ in depressive-like behavior associated with memory impairment induced by acute restraint stress (ARS) in male Swiss mice was evaluated.

METHODS

ARS is an unavoidable stress model that was applied for a period of 240 min. Ten minutes after ARS, animals were intragastrically treated with canola oil (10 ml/kg) or 4-PSQ (10 mg/kg) or positive controls (paroxetine or donepezil) (10 mg/kg). Then, after 30 min, mice were submitted to behavioral tests. Corticosterone levels were evaluated in plasma and oxidative stress parameters; monoamine oxidase (MAO)-A and MAO -B isoform activity; mRNA expression levels of kappa nuclear factor B (NF-κB); interleukin (IL)-1β, IL-18, and IL-33; phosphatidylinositol-se-kinase (PI3K); protein kinase B (AKT2), as well as acetylcholinesterase activity were evaluated in the prefrontal cortex and hippocampus.

RESULTS

4-PSQ attenuated the depressive-like behavior, self-care, and memory impairment caused by ARS. Based on the evidence, we believe that effects of 4-PSQ may be associated, at least in part, with the attenuation of HPA axis activation, attenuation of alterations in the monoaminergic system, modulation of oxidative stress, reestablishment of AChE activity, modulation of the PI3K/AKT2 pathway, and reduction of neuroinflammation.

CONCLUSIONS

These results suggested that 4-PSQ exhibited an antidepressant-like effect and attenuated the memory impairment induced by ARS, and it is a promising molecule to treat these comorbidities.

Conceptualising comorbidity and multimorbidity in dementia: A scoping review and syndemic framework

Background

Older people and people with dementia experience a high prevalence of multiple health conditions. The terms 'comorbidity' and 'multimorbidity' are often used interchangeably to describe this, however there are key conceptual differences between these terms and their definitions. This has led to issues in the validity and comparability of research findings, potentially inappropriate intervention development and differences in quality of health care.

Objective

To review how the terms 'comorbidity' and 'multimorbidity' are defined within peer-reviewed dementia research and propose an operational framework.

Design

A scoping review of definitions within dementia research was carried out. Searches took place across five databases: Academic Search Premier, CINAHL Complete, MEDLINE, PsycARTICLES and PsycINFO. PRISMA-ScR guidelines were followed.

Results

Content analysis revealed five key themes, showing significant overlap and inconsistencies from both within, and between, the comorbidity and multimorbidity definitions; 1. Number of conditions; 2. Type of health conditions; 3. The co-occurrence of conditions; 4. The inclusion of an index disease (or not); 5. Use of medical language. The analysis also revealed gaps in how the underlying concepts of the definitions relate to people with dementia living with multiple health conditions.

Conclusion

This scoping review found that current definitions of comorbidity and multimorbidity are heterogeneous, reductionist and disease-focussed. Recommendations are made on the design of research studies including transparency and consistency of any terms and definitions used. A syndemic framework could be a useful tool for researchers, clinicians and policy makers to consider a more holistic picture of a person with dementia's health and wellbeing.

Association between Serum Lipid Parameters and Cognitive Performance in Older Adults

(1) Background: Previous studies have suggested the association between lipid profiles and cognitive function in older adults. However, they generated inconsistent results. We aim to determine the relationship between lipid profiles and cognitive performance in older adults. (2) Methods: We used the 2011–2014 National Health and Nutrition Examination Survey. This study included 2215 participants who were aged more than 60 years old and free of coronary heart disease or stroke. Lipid profiles included total cholesterol (TC), low density lipid cholesterol (LDL), high density lipid cholesterol (HDL), and triglyceride (TG). Cognitive function was assessed using the digit symbol substitution test (DSST). (3) Results: Positive correlations of DSST were observed with TC (r = 0.111; p < 0.0001), HDL (r = 0.127; p < 0.0001), and LDL (r = 0.107; p = 0.0005). However, there was no significant relationship between TG and DSST. A one-unit increase in HDL was associated with an increase in DSST score (beta coefficient: 0.036; p = 0.018); but the association was not significant for LDL, TG, and TC. In the categorical analysis, the high HDL group had a higher DSST score than the low HDL group (beta = 3.113; p < 0.0001) and the low TG group was more likely to show a lower DSST score than the high TC group (beta = −1.837; p = 0.0461). However, LDL and TC showed no statistically significant associations. Moreover, HDL was only associated with a 0.701 times increased risk of cognitive impairment (95% CI = 0.523–0.938) in the logistic regression analysis. (4) Conclusions: Higher blood concentrations of HDL levels were positively associated with DSST scores in older adults. We suggest that the high levels of HDL may be a protective factor against cognitive impairment.

Differences in survival and mortality in minority ethnic groups with dementia: A systematic review and meta-analysis

OBJECTIVES

Although there are disparities in both risk of developing dementia and accessibility of dementia services for certain minority ethnic groups in the United States and United Kingdom, disparities in survival after a dementia diagnosis are less well-studied. Our objective was to systematically review the literature to investigate racial/ethnic differences in survival and mortality in dementia.

METHODS

We searched Embase, Ovid MEDLINE, Global Health and PsycINFO from inception to November 2018 for studies comparing survival or mortality over time in at least two race/ethnicity groups. Studies from any country were included but analysed separately. We used narrative synthesis and random-effects meta-analysis to synthesise findings. The Newcastle-Ottawa Scale was used to assess quality and risk of bias in individual studies.

RESULTS

We identified 22 articles, most from the United States (n = 17), as well as the United Kingdom (n = 3) and the Netherlands (n = 1). In a meta-analysis of US studies, hazard of mortality was lower in Black/African American groups (Pooled Hazard Ratio = 0.86, 95% CI = 0.82-0.91, I²  = 17%, from four studies) and Hispanic/Latino groups (Pooled HR = 0.65, 95% CI = 0.50-0.84, I²  = 86%, from four studies) versus comparison groups. However, study quality was mixed, and in particular, quality of reporting of race/ethnicity was inconsistent.

CONCLUSION

Literature indicates that Black/African American and Hispanic/Latino groups may experience lower mortality in dementia versus comparison groups in the United States, but further research, using clearer and more and consistent reporting of race/ethnicity, is necessary to understand what drives these patterns and their implications for policy and practice.

Sex differences in psychotropic and analgesic drug use before and after initiating treatment with acetylcholinesterase inhibitors

BACKGROUND/AIMS

The aim was to explore the impact of sex on prevalence, patterns and trends in the prescription of psychotropics and analgesics in users of acetylcholinesterase inhibitors (AChEIs), before and after AChEI initiation, compared to the general population.

METHODS

A prospective study applying data from the Norwegian Prescription Database (NorPD) in the period 2004-2016. Prescription of antidepressants, antipsychotics, analgesics including opioids, benzodiazepines and z-hypnotics in persistent AChEI users was studied in a follow-up period from four years before to two years after AChEI initiation in men and women of four age groups: 37-64, 65-72, 73-80 and 81-88 years.

RESULTS

Use of antidepressants, antipsychotics and weaker analgesics increased in both sexes during the follow-up period in 11.764 persistent AChEI users. Women with pre-dementia and dementia stages of AD showed a prescription pattern with more use of psychotropics and opioids than men, except for antipsychotics.

CONCLUSION

Female sex showed to have a significant influence on the prescriptions of psychotropics and analgesics in AD patients in a pre-dementia and dementia stage. The exception is for antipsychotics, that men used more than women. The prescription pattern showed a higher extent of polypharmacy of psychotropics and/or opioids in women than in men. The total prescription pattern of analgesics could indicate an undertreatment of pain in pre-dementia and dementia stages, most pronounced in men.

Dementia increases mortality beyond effects of comorbid conditions: A national registry-based cohort study

BACKGROUND AND PURPOSE

Mortality is known to be markedly increased in people with dementia. However, the association between multiple chronic conditions and mortality in dementia is not well clarified. The aim of this study was to investigate the impact of somatic and psychiatric diseases on mortality in dementia compared with the general elderly population.

METHODS

Using a cohort study design, nationwide registry data from 2006 to 2015 on dementia and psychiatric and somatic comorbidities defined by the Charlson Comorbidity Index (CCI) were linked. Impact of chronic conditions was assessed according to mortality rate ratios (MRRs) in all Danish residents aged ≥65 years with and without dementia.

RESULTS

Our population comprised 1,518,917 people, of whom 114,109 people were registered with dementia. The MRRs was 2.70 (95% confidence interval 2.68, 2.72) in people with dementia after adjusting for sex, age, calendar year, and comorbidities. MRRs increased with higher CCI score, and when comparing people with a similar comorbidity load, MRRs were significantly higher for people with dementia.

CONCLUSIONS

The comorbidity load was associated with increased mortality in both people with and without dementia. Mortality in dementia remained increased, even after adjusting for psychiatric and chronic somatic comorbidities. Our findings suggest that dementia disorders alone contribute to excess mortality, which may be further increased by comorbidities.

The effect of comorbidities on survival in persons with Alzheimer's disease: a matched cohort study

BACKGROUND

Alzheimer's disease (AD) is one of the leading causes of death world-wide, but little is known on the role of comorbidities on mortality among people with AD. We studied how comorbidities and age at AD diagnosis impact the survival of people with AD.

METHODS

The Medication Use and Alzheimer's disease (MEDALZ) cohort study included 70,718 community-dwelling persons in Finland with AD diagnosis from 2005 to 2011 and were matched 1:1 (age, gender, and hospital district) to people without AD (mean age 80 years, 65% women, and the mean follow-up 4.9 and 5.6 years, respectively). Covariates (age, gender, and socioeconomic position), comorbidities (cardiovascular disease, stroke, diabetes, asthma/ chronic obstructive pulmonary disease (COPD), hip fracture, cancer treatment, and mental or behavioral disorders excluding dementia) and survival data were obtained from nationwide registers. Cox proportional hazard models were used to compare risk of death between people with and without AD.

RESULTS

During the follow-up period a greater proportion of the AD cohort died compared to the non-AD cohort (63% versus 37%). In both cohorts, older age, male gender, lower socioeconomic position, and history of comorbidities were associated with shorter survival and higher risk of death. The associations of comorbidities with survival is weaker in the older age groups and people with AD. Hip fracture (adjusted HR 1.35, 95% CI 1.30-1.41), stroke (1.30, 1.27-1.34), and recent cancer treatment (1.29, 1.26-1.32) had the strongest associations in the AD cohort. Age modified the associations in both cohorts (weaker associations among older people).

CONCLUSION

Alzheimer's disease is the major factor affecting survival, but comorbidities further decrease survival also in individuals with Alzheimer's disease. Therefore, appropriate management of care of these comorbidities might affect not only survival but also the wellbeing of this vulnerable population.

Medical Comorbidities and Association With Mortality Risk in Alzheimer's Disease: Population-Based Study of 132,405 Geriatric Inpatients

Objectives

We used the Nationwide Inpatient Sample (NIS) to identify the demographic predictors and study the impact of chronic comorbidities on the risk of in-hospital mortality in Alzheimer’s disease (AD).

Methods

We included 132,405 AD patients from the NIS (2012-2014). We used descriptive statistics to discern the differences in demographics and comorbidities by in-hospital mortality. Logistic regression analysis was used to evaluate the predictors and impact of comorbidities that increase the risk of association with in-hospital mortality.

Results

The in-hospital mortality in AD inpatients is 1.69%, and a greater proportion were female (58.4%) and white (81.5%). Male and hispanic had a higher mortality risk than their counterparts. Hypertension (72%) is the most prevalent comorbidity. Congestive cardiac failure (CCF) and renal failure were significantly associated with a higher risk of in-hospital mortality in AD inpatients by 1.4 and 1.5 times, respectively. Psychiatric comorbidities (depression 20.4%, and psychosis 21.4%) were prevalent in AD inpatients but were negatively associated with mortality. Comorbid tumors without metastasis (1.2%) and metastatic cancer (0.3%) were least prevalent but significantly increased the risk of in-hospital mortality by 1.6 times and 2.2 times, respectively.

Conclusion

CCF and renal failure were significantly associated with a higher risk of in-hospital mortality in AD patients. Less prevalent comorbidities, tumors with/without metastasis increased in-hospital mortality by 59% to 117%. An integrated care model is required to manage comorbidities in AD patients to improve health-related quality of life and reduce morbidity and mortality.

Alcohol dependence and physical comorbidity: Increased prevalence but reduced relevance of individual comorbidities for hospital-based mortality during a 12.5-year observation period in general hospital admissions in urban North-West England

Purpose:

Alcohol dependence (AD) is associated with an increase in physical comorbidities. The effects of these diseases on general hospital-based mortality are unclear. Consequently, we conducted a mortality study in which we investigated if the burden of physical comorbidities and their relevance on general hospital-based mortality differs between individuals with and without AD during a 12.5-year observation period in general hospital admissions.

Methods:

During 1 January 2000 and 30 June 2012, 23,371 individuals with AD were admitted at least once to seven General Manchester Hospitals. Their physical comorbidities with a prevalence ≥ 1% were compared to those of 233,710 randomly selected hospital controls, group-matched for age and gender (regardless of primary admission diagnosis or specialized treatments). Physical comorbidities that increased the risk of hospital-based mortality (but not outside of the hospital) during the observation period were identified using multiple logistic regression analyses.

Results:

Hospital-based mortality rates were 20.4% in the AD sample and 8.3% in the control sample. Individuals with AD compared to controls had a higher burden of physical comorbidities, i.e. alcoholic liver and pancreatic diseases, diseases of the conducting airways, neurological and circulatory diseases, diseases of the upper gastrointestinal tract, renal diseases, cellulitis, iron deficiency anemia, fracture neck of femur, and peripheral vascular disease. In contrast, coronary heart related diseases, risk factors of cardiovascular disease, diverticular disease and cataracts were less frequent in individuals with AD than in controls. Thirty-two individual physical comorbidities contributed to the prediction of hospital-based mortality in univariate analyses in the AD sample; alcoholic liver disease (33.7%), hypertension (16.9%), chronic obstructive pulmonary disease (14.1%), and pneumonia (13.3%) were the most frequent diagnoses in deceased individuals with AD. Multiple forward logistic regression analysis, accounting for possible associations of diseases, identified twenty-three physical comorbidities contributing to hospital-based mortality in individuals with AD. However, all these comorbidities had an equal or even lower impact on hospital-based mortality than in the comparison sample.

Conclusion:

The excess of in-hospital deaths in general hospitals in individuals with AD is due to an increase of multiple physical comorbidities, even though individual diseases have an equal or even reduced impact on general hospital-based mortality in individuals with AD compared to controls.

Drug Use before and after Initiating Treatment with Acetylcholinesterase Inhibitors

Background/Aims

The aim was to study the prevalence of use of different drugs prescribed for behavioral and psychological symptoms of dementia in persistent users of acetylcholinesterase inhibitors (AChEIs) before and after AChEI initiation, and to compare with the use in the general population.

Methods

Use of antidepressants, antipsychotics, and analgesics in the 4 years before and 2 years after AChEI initiation was studied based on data from the Norwegian Prescription Database 2004–2016.

Results

The prevalence of use of antidepressants and antipsychotics the year before AChEI initiation was twice the prevalence in the age-adjusted general population and continued to rise in the first 2 years after initiation of AChEIs. The prevalence of weak analgesics and antipsychotics increased strongly in the last year before AChEI initiation. The increase in the use of antidepressants started at least 4 years before initiation of AChEIs. Opioid use was generally lower than in the general population and was not influenced by AChEI initiation.

Conclusion

Increased use of antidepressants and antipsychotics was observed both before and after initiation of AChEIs and may indicate that behavioral symptoms occur in a preclinical or early phase of Alzheimer's disease. The prescription pattern of analgesics with a low use of opioids may indicate an undertreatment of pain in people with dementia.

Cardiovascular and metabolic comorbidities in patients with Alzheimer's disease and vascular dementia compared to a psychiatric control cohort

BACKGROUND

Multimorbidity in dementia is associated with an increased risk of complications and a higher need for care. Having knowledge of cardiovascular and metabolic comorbidities is crucial when making decisions about diagnostic procedures and therapies. We compared the prevalence of comorbidities in hospitalized patients with Alzheimer's disease (AD), vascular dementia, and psychiatric diseases other than dementia. Additionally, we compared clinically relevant health-care indicators (length of hospital stay, rate of re-hospitalization) between these groups.

METHODS

We used information from a database of treatment-relevant indicators from psychiatric and psychosomatic hospitals throughout Germany. This database contains routinely recorded data collected from 85 German hospitals from 2011 to 2015. In total, 14 411 AD cases, 7156 vascular dementia cases, and 34 534 cases involving non-demented psychiatric patients (used as controls) were included. To analyze comorbidities and health-care indicators, χ² tests and t-tests were used.

RESULTS

Diabetes mellitus, lipoprotein disorders, coronary artery diseases, cardiac arrhythmia and insufficiency, and atherosclerosis were significantly more prevalent in patients with vascular dementia than in those with AD and psychiatric controls. Hypertension and coronary artery diseases were less frequently associated with AD than with non-demented psychiatric controls (P < 0.001). Additionally, dementia patients with cardiovascular or metabolic diseases exhibited longer hospital stays (+ 1.4 days, P < 0.001) and were more often re-hospitalized within 3 weeks (P < 0.001) and 1 year (P < 0.001) compared to dementia patients without these comorbidities.

CONCLUSIONS

Awareness of somatic comorbidities in patients with dementia is crucial to avoid complications during inpatient treatment. The occurrence of comorbid disorders was associated with longer and more frequent hospital stays, which potentially lead to higher health-care costs. Further studies should evaluate the causative association between somatic comorbidities and inpatient costs in dementia patients.

Peripheral Blood Brain-Derived Neurotrophic Factor as a Biomarker of Alzheimer's Disease: Are There Methodological Biases?

Mounting evidence that alterations in brain-derived neurotrophic factor (BDNF) levels and signaling may be involved in the etiopathogenesis of Alzheimer's disease (AD) has suggested that its blood levels could be used as a biomarker of the disease. However, higher, lower, or unchanged circulating BDNF levels have all been described in AD patients compared to healthy controls. Although the reasons for such different findings are unclear, methodological issues are likely to be involved. The heterogeneity of participant recruitment criteria and the lack of control of variables that influence circulating BDNF levels regardless of dementia (depressive symptoms, medications, lifestyle, lack of overlap between serum and plasma, and experimental aspects) are likely to bias result and prevent study comparability. The present work reviews a broad panel of factors, whose close control could help reduce the inconsistency of study findings, and offers practical advice on their management. Research directed at elucidating the weight of each of these variables and at standardizing analytical methodologies is urgently needed.

Estimating the survival of elderly patients diagnosed with dementia in Taiwan: A longitudinal study

Background

Dementia is characterized by prolonged progressive disability. Therefore, predicting mortality is difficult. An accurate prediction tool may be useful to ensure that end-of-life patients with dementia receive timely palliative care.

Purpose

This study aims to establish a survival prediction model for elderly patients with dementia in Taiwan.

Methods

Data from the 2001 to 2010 National Health Insurance Research Database in Taiwan were used to identify 37,289 patients with dementia aged ≥65 years for inclusion in this retrospective longitudinal study. Moreover, this study examined the mortality indicators for dementia among demographic characteristics, chronic physical comorbidities, and medical procedures. A Cox proportional hazards model with time-dependent covariates was used to estimate mortality risk, and risk score functions were formulated using a point system to establish a survival prediction model. The prediction model was then tested using the area under the receiver operating characteristic curve.

Results

Thirteen mortality risk factors were identified: age, sex, stroke, chronic renal failure, liver cirrhosis, cancer, pressure injury, and retrospectively retrieved factors occurring in the 6 months before death, including nasogastric tube placement, supplemental oxygen supply, ≥2 hospitalization, receiving ≥1 emergency services, ≥2 occurrences of cardiopulmonary resuscitation, and receiving ≥2 endotracheal intubations. The area under the receiver operating characteristic curves for this prediction model for mortality at 6 and 12 months were 0.726 and 0.733, respectively.

Conclusions

The survival prediction model demonstrated moderate accuracy for predicting mortality at 6 and 12 months before death in elderly patients with dementia. This tool may be valuable for helping health care providers and family caregivers to make end-of-life care decisions.

Donepezil may reduce the risk of comorbidities in patients with Alzheimer's disease: A large-scale matched case-control analysis in Japan

Introduction

Few studies have focused on the association between donepezil and physical comorbid conditions in Alzheimer's disease patients.

Methods

We investigated the association between donepezil prescription and the occurrences of comorbidities in Alzheimer's disease patients, by using an electronic medical records database which contains case-based information on approximately three million patients from more than 60 hospitals across Japan.

Results

Nine thousand seven hundred forty-nine patients had at least one diagnosis of Alzheimer's disease between 2001 and 2015. To test the robustness of the results, we used a risk set sampling method, and the matched cohorts based on age, sex, comorbidity level, and duration of illness consisted of 1406 cases and an equal number of controls. From the multivariate logistic regression analysis adjusted for covariance, less occurrence of physical comorbidities was associated with donepezil prescription in the matched cohort.

Discussion

Although the mechanisms are unknown, donepezil may have positive effects on both cognition and physical status.

Polymorphonuclear Neutrophil Functions are Differentially Altered in Amnestic Mild Cognitive Impairment and Mild Alzheimer's Disease Patients

The mechanisms of neurodegeneration in Alzheimer's disease (AD) remain under investigation. Alterations in the blood-brain barrier facilitate exchange of inflammatory mediators and immune cells between the brain and the periphery in AD. Here, we report analysis of phenotype and functions of polymorphonuclear neutrophils (PMN) in peripheral blood from patients with amnestic mild cognitive impairment (aMCI, n = 13), patients with mild AD (mAD, n = 15), and healthy elderly controls (n = 13). Results showed an increased expression of CD177 in mAD but not in healthy or aMCI patients. IL-8 stimulated increased expression of the CD11b integrin in PMN of healthy subjects in vitro but PMN of aMCI and mAD patients failed to respond. CD14 and CD16 expression was lower in PMN of mAD but not in aMCI individuals relative to controls. Only PMN of aMCI subjects expressed lower levels of CD88. Phagocytosis toward opsonized E. coli was differentially impaired in PMN of aMCI and mAD subjects whereas the capacity to ingest Dextran particles was absent only in mAD subjects. Killing activity was severely impaired in aMCI and mAD subjects whereas free radical production was only impaired in mAD patients. Inflammatory cytokine (TNFα, IL-6, IL-1β, IL-12p70) and chemokine (MIP-1α, MIP-1β, IL-8) production in response to LPS stimulation was very low in aMCI and nearly absent in mAD subjects. TLR2 expression was low only in aMCI. Our data showed a differentially altered capacity of PMN of aMCI and mAD subjects to respond to pathological aggression that may impact impaired responses associated with AD development.

Interactive Effects of Dementia Severity and Comorbidities on Medicare Expenditures

BACKGROUND

Few studies have examined how dementia and comorbidities may interact to affect healthcare expenditures.

OBJECTIVE

To examine whether effects of dementia severity on Medicare expenditures differed for individuals with different levels of comorbidities.

METHODS

Data are drawn from the Washington Heights-Inwood Columbia Aging Project (WHICAP). Comprehensive clinical assessments of dementia severity were systematically carried out at ∼18 month intervals. Dementia severity was measured by Clinical Dementia Rating (CDR). Comorbidities were measured by a modified Elixhauser comorbidities index. Generalized linear models examined effects of dementia severity, comorbidities, and their interactions on Medicare expenditures (1999-2010).

RESULTS

At baseline, 1,280 subjects were dementia free (CDR = 0, 66.4%), 490 had very mild dementia (CDR = 0.5, 25.4%), 108 had mild dementia (CDR = 1, 5.6%), and 49 had moderate/severe dementia (CDR = 2/3, 2.5%). Average annual Medicare expenditures for individuals with moderate/severe dementia were more than twice as high as those who were dementia free (CDR = 0: $9,108, CDR = 0.5/1: $11,664, CDR≥2: $19,604, p < 0.01). Expenditures were approximately 10 times higher among those with≥3 comorbidities than among those with no comorbidities ($2,612 for those with no comorbidities, to $6,109 for those with 1, $10,656 for those with 2, and $30,244 for those with≥3 comorbidities, p < 0.001). Dementia severity was associated with higher expenditures, but comorbidities were the most important predictor of expenditures. We did not find strong interaction effects between number of comorbidities and dementia severity.

CONCLUSIONS

Increasing dementia severity and higher comorbidities are associated with higher Medicare expenditures. Care of individuals with dementia should focus on management of comorbidities.

Diabetes Care and Dementia Among Older Adults: A Nationwide 3-Year Longitudinal Study

OBJECTIVES

To compare diabetes monitoring and the incidence of acute diabetic complications between patients with and without incident Alzheimer's Disease and Related Syndromes (ADRS).

DESIGN

Longitudinal observational study from 2010 to 2014.

SETTING

Data from the French national health system database.

PARTICIPANTS

The France-Démence cohort: individuals aged 65 years or older suffering from incident ADRS, based on long-term disease registry, hospitalization for dementia, or antidementia drug delivery. They were matched (1:1) to a pair free of ADRS on age, sex, residence area, and insurance scheme. This study included France-Démence population with known diabetes for at least 2 years.

MEASUREMENTS

Data related to diabetes control and complications: biological monitoring such as glycated hemoglobin A_1c (HbA_1c, ≥1/y, ≥2/y), lipid profile, microalbuminuria; eye examination; hospitalization for diabetes-related complications such as coma with ketoacidosis; and hospitalization for hypoglycemia were studied between the year prior to ADRS identification (Y_-1) and the 2 following years (Y₀; Y₁). Incidences between the 2 groups (ADRS/non-ADRS) were compared using age-standardized incidence ratios (SIR).

RESULTS

The studied population included 87,816 individuals. HbA1c determination was less frequent in ADRS group, no matter the study period and the minimal annual threshold used. Respectively, 82.6% and 88.5% of ADRS and non-ADRS group had at least 1 HbA_1c testing during Y_-1 [SIR = 0.94, 95% confidence interval (CI) 0.93-0.95], 73.4% and 89.0% during Y₀ (SIR = 0.83, 95% CI 0.82-0.84), and 75.4% and 89.3% during Y₁ (SIR = 0.85, 95% CI 0.83‒0.86). Subjects with ADRS were also consistently more hospitalized than non-ADRS peers. The gap was maximal in the year following the diagnosis, as observed for hospitalizations for any cause related to diabetes (SIR Y_-1: 2.04, Y₀: 3.14, Y₁: 1.67), diabetes mellitus with coma (SIR Y_-1: 3.84, Y₀: 9.30, Y₁: 3.06), and hypoglycemia (SIR Y_-1: 4.20, Y₀: 5.25, Y₁: 2.27).

CONCLUSIONS

Incident ADRS is associated with a less frequent diabetes monitoring and an increased risk of diabetes complications compared with older people without ADRS. Our study questions healthcare quality offered to participants with ADRS in comorbidity control. Further investigations are required to explain the mechanisms underlying our results and to propose actions to improve care of patients with ADRS.

Enhanced susceptibility of triple transgenic Alzheimer's disease (3xTg-AD) mice to acute infection

BACKGROUND

Infection is a recognised risk factor for Alzheimer's disease (AD) and can worsen symptoms in established disease. AD patients have higher rates of infection and are more likely to require hospital admissions due to infections than individuals without dementia. Infections have also been found to increase the risk of those over 84 years of age being diagnosed with dementia. However, few studies have investigated immune responses to infection in AD.

METHODS

Here, we investigated the immune responses of the triple transgenic Alzheimer's disease (3xTg-AD) mouse model of AD to infection with the parasites Toxoplasma gondii and Trichuris muris. Cytometric bead array, histology, immunohistochemistry and immunofluorescence were used to evaluate immune responses and the effects on the brain of acute infection.

RESULTS

3xTg-AD mice, despite having comparable parasite loads, were more susceptible to infection with more severe morbidity. A worsened outcome to infection can be linked to an exaggerated immune response. 3xTg-AD mice had an increased pro-inflammatory response characterised by the production of pro-inflammatory mediators such as tumour necrosis TNF-α, IL-6, CCL5 and CXCL-1, as well as an increase in immune cell infiltration to the sites of infection. T cell responses to parasite antigen also showed elevated production of the pro-inflammatory cytokines TNF-α (10 fold) and IL-6 (twofold). We investigated whether 3xTg-AD mice had a propensity for a more Th1-dominated response using the T. muris worm infection and showed that akin to T. gondii, there was an enhanced pro-inflammatory response which was associated with retention of worms in the gut and associated pathology. Irrespective of whether the infection was one that could infect the brain or cause a local gut inflammation, 3xTg-AD mice had increased numbers of activated microglia during infection in both the cortex and the hippocampus.

CONCLUSIONS

Our findings suggest that in AD, responses to infection are exaggerated outside of the CNS. Additionally, the results presented here indicate that both systemic and localised inflammation caused by an infection exacerbate neuroinflammation in AD.

Aerobic exercise improves quality of life, psychological well-being and systemic inflammation in subjects with Alzheimer's disease

BACKGROUND

Alzheimer's disease has a destructive drawbacks on the patient and his/her entire family as this disease badly af fects the behavior, cognition and abilities to do activities of daily living (ADL). The physical and mental benefits of exercise are widely known but seldom available to persons suffering from Alzheimer's disease.

OBJECTIVE

The aim of this study was to measure quality of life, systemic inflammation and psychological well-being response to aerobic exercises in Alzheimer's.

METHODS

Forty Alzheimer elderly subjects were enrolled in two groups; the first group received treadmill aerobic exercise, while the second group was considered as a control group and received no training intervention for two months. Assessment of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), Rosenberg Self-Esteem Scale (RSES),Beck Depression Inventory (BDI), Profile of Mood States(POMS) and SF-36 health quality of life (SF-36 HRQL) were taken before and at the end of the study.

RESULTS

There was a 25.2%, 19.4%, 23.5%, 21.3%, 17.7% , 11.7%, 12.5% and 10.1 % reduction in mean values of TNF-α, IL-6, BDI, POMS, health transition SF-36 subscale, bodily pain SF-36 subscale, role functioning: emotional SF-36 subscale and mental health SF-36 subscale respectively in addition to 15.7%, 13.1%, 12.6%, 11.1%, 13.2% and 11.2 % increase in mean values of RSES, physical functioning SF-36 subscale, role functioning:physical SF-36 subscale, general health SF-36 subscale, Vitality SF-36 subscale and Social functioning SF-36 subscale respectively in group (A) received aerobic exercise training, so that there was a significant reduction in the mean values of TNF-α, IL-6, BDI & POMS and increase in the mean values of SF-36 HRQL subscale scores, RSES in group (A) as a result of aerobic exercise training, while the results of group (B) who received no training intervention were not significant. Also, there were significant differences between mean levels of the investigated parameters in group (A) and group (B) at the end of the study (P<0.05).

CONCLUSION

Treadmill walking exercise training is an effective treatment policy to improve quality of life, systemic inflammation and psychological wellbeing in Alzheimer's.

Nanobiomaterials' applications in neurodegenerative diseases

The blood-brain barrier is the interface between the blood and brain, impeding the passage of most circulating cells and molecules, protecting the latter from foreign substances, and maintaining central nervous system homeostasis. However, its restrictive nature constitutes an obstacle, preventing therapeutic drugs from entering the brain. Usually, a large systemic dose is required to achieve pharmacological therapeutic levels in the brain, leading to adverse effects in the body. As a consequence, various strategies are being developed to enhance the amount and concentration of therapeutic compounds in the brain. One such tool is nanotechnology, in which nanostructures that are 1-100 nm are designed to deliver drugs to the brain. In this review, we examine many nanotechnology-based approaches to the treatment of neurodegenerative diseases. The review begins with a brief history of nanotechnology, followed by a discussion of its definition, the properties of most reported nanomaterials, their biocompatibility, the mechanisms of cell-material interactions, and the current status of nanotechnology in treating Alzheimer's, Parkinson's diseases, and amyotrophic lateral sclerosis. Of all strategies to deliver drug to the brain that are used in nanotechnology, drug release systems are the most frequently reported.

Cohort Study on Predictors of Need for Nursing Care in Alzheimer's Disease: An Analysis of Healthcare Data

BACKGROUND

The individual and societal burden of Alzheimer's disease (AD) is substantial. Identifying relevant factors deteriorating AD and inducing need for nursing care would be of high relevance for healthcare planning.

OBJECTIVE

The main objective of this study was the identification of predictors of first assignment of a level of long-term care in AD, used as an approximation for disease progression.

METHODS

In a retrospective cohort study using data from a large German statutory health and long-term care insurance (SHI) company, co-morbidities and drug exposure were evaluated with respect to their predictive value for disease progression (first day the amount of daily nursing care exceeded 1.5 hours). Time to disease progression was modeled using COX-proportional hazard regression with stepwise selection of predictor variables.

RESULTS

The risk of nursing care need increased substantially with increasing age. Number of hospitalizations and number of different drugs used were significant indicators for progression, whereas outpatient visits were associated with a reduced need for care. Gender did not indicate significant influence on progression. Malignant neoplasms of ill-defined, secondary, and unspecified sites, malnutrition, renal failure, and injuries increased the risk of need for nursing care most significantly. Among prescribed drugs, significant increased risks were associated with drugs used in diabetes, preparations for treatment of wounds and ulcers, antiseptics and disinfectants, and analgesics.

CONCLUSIONS

Physical comorbidities are relevant contributors to an increase in need for nursing care. Some medical predicting conditions may be linked to cognition, while others may be directly linked to demand for care. AD patients with these comorbidities should be monitored with special attention, as they may be under an increased risk of care dependency.

Effect of diabetes on caregiver burden in an observational study of individuals with Alzheimer's disease

Background

The burden on caregivers of patients with Alzheimer’s disease (AD) is associated with the patient’s functional status and may also be influenced by chronic comorbid medical conditions, such as diabetes. This post-hoc exploratory analysis assessed whether comorbid diabetes in patients with AD affects caregiver burden, and whether caregivers with diabetes experience greater burden than caregivers without diabetes. Caregiver and patient healthcare resource use (HCRU) were also assessed.

Methods

Baseline data from the GERAS observational study of patients with AD and their caregivers (both n = 1495) in France, Germany and the UK were analyzed.

Caregiver burden was assessed using the Zarit Burden Interview (ZBI). Caregiver time on activities of daily living (ADL: basic ADL; instrumental ADL, iADL) and supervision (hours/month), and caregiver and patient HCRU (outpatient visits, emergency room visits, nights hospitalized) were assessed using the Resource Utilization in Dementia instrument for the month before the baseline visit. Regression analyses were adjusted for relevant covariates. Time on supervision and basic ADL was analyzed using zero-inflated negative binomial regression.

Results

Caregivers of patients with diabetes (n = 188) were younger and more likely to be female (both p < 0.05), compared with caregivers of patients without diabetes (n = 1307). Analyses showed caregivers of patients with diabetes spent significantly more time on iADL (+16 %; p = 0.03; increases were also observed for basic ADL and total caregiver time but did not reach statistical significance) and had a trend towards increased ZBI score. Patients with diabetes had a 63 % increase in the odds of requiring supervision versus those without diabetes (p = 0.01). Caregiver and patient HCRU did not differ according to patient diabetes.

Caregivers with diabetes (n = 127) did not differ from those without diabetes (n = 1367) regarding burden/time, but caregivers with diabetes had a 91 % increase in the odds of having outpatient visits (p = 0.01).

Conclusions

This cross-sectional analysis found caregiver time on iADL and supervision was higher for caregivers of patients with AD and diabetes versus without diabetes, while HCRU was unaffected by patient diabetes. Longitudinal analyses assessing change in caregiver burden over time by patient diabetes status may help clarify the cumulative impact of diabetes and AD dementia on caregiver burden.

Risk of Unplanned Emergency Department Readmission after an Acute-Care Hospital Discharge among Geriatric Inpatients: Results from the Geriatric EDEN Cohort Study

OBJECTIVES

The study aims 1) to examine whether items of the brief geriatric assessment (BGA) or their combinations predicted the risk of unplanned emergency department readmission after an acute care hospital discharge among geriatric inpatients, and 2) to determine whether BGA could be used as a prognostic tool for unplanned emergency department readmission.

METHODS

A total of 312 older patients (mean age, 84.6 ± 5.4 years; 64.1% female) hospitalized in acute care wards after an emergency department visit were recruited in this observational prospective cohort study and separated into 2 groups based on the occurrence or not of an unplanned emergency department readmission during a 12-month follow-up period after their hospital discharge. A 6-item BGA was performed at emergency department admission before the discharge to acute care wards. Information on incident unplanned emergency department readmission was prospectively collected by phone call and by consulting the hospital registry. Several combinations of items of BGA identifying three levels of risk of unplanned emergency department readmission (i.e., low risk, intermediate risk and high risk) were examined.

RESULTS

The unplanned emergency department readmission was more frequently associated with a temporal disorientation (P=0.004). Area under receiver operating characteristic curves of unplanned emergency department readmission based on BGA items and their combinations ranged from 0.53 to 0.61. The best predictor of unplanned emergency department readmission was the temporal disorientation (hazard ratio>1.65, P<0.035), which defined the high-risk group. Inpatients classified in high-risk group of unplanned emergency department readmission were more frequently readmitted to emergency department than those in intermediate- and low-risk groups (P log Rank <0.004). Prognostic values for unplanned emergency department readmission of items and their combinations were poor with sensitivity below 67%, specificity ranging from 36.4 to 53.7, and positive likelihood ratio below 1.4.

CONCLUSIONS

The items of BGA and their combinations were significant risk factors for unplanned emergency department readmission, but their prognostic value was poor.

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Background

Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.

Objectives

To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.

Design

We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.

Participants

The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.

Results

The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.

Conclusions

Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Potential drug-drug interactions in Alzheimer patients with behavioral symptoms

The use of multi drug regimens among the elderly population has increased tremendously over the last decade although the benefits of medications are always accompanied by potential harm, even when prescribed at recommended doses. The elderly populations are particularly at an increased risk of adverse drug reactions considering comorbidity, poly-therapy, physiological changes affecting the pharmacokinetics and pharmacodynamics of many drugs and, in some cases, poor compliance due to cognitive impairment and/or depression. In this setting, drug–drug interaction may represent a serious and even life-threatening clinical condition. Moreover, the inability to distinguish drug-induced symptoms from a definitive medical diagnosis often results in addition of yet another drug to treat the symptoms, which in turn increases drug–drug interactions. Cognitive enhancers, including acetylcholinesterase inhibitors and memantine, are the most widely prescribed agents for Alzheimer’s disease (AD) patients. Behavioral and psychological symptoms of dementia, including psychotic symptoms and behavioral disorders, represent noncognitive disturbances frequently observed in AD patients. Antipsychotic drugs are at high risk of adverse events, even at modest doses, and may interfere with the progression of cognitive impairment and interact with several drugs including anti-arrhythmics and acetylcholinesterase inhibitors. Other medications often used in AD patients are represented by anxiolytic, like benzodiazepine, or antidepressant agents. These agents also might interfere with other concomitant drugs through both pharmacokinetic and pharmacodynamic mechanisms. In this review we focus on the most frequent drug–drug interactions, potentially harmful, in AD patients with behavioral symptoms considering both physiological and pathological changes in AD patients, and potential pharmacodynamic/pharmacokinetic drug interaction mechanisms.

Risk factors for mortality in Down syndrome

BACKGROUND

Down syndrome is a genetic condition that contributes to a significantly shorter life expectancy compared with the general population. We investigated the most common comorbidities in a population of acute hospital patients with Down syndrome and further explored what the most common risk factors for mortality are within this population.

METHOD

From our database of one million patients admitted to National Health Service (NHS) Trusts in northern England, we identified 558 people who had Down syndrome. We compared this group with an age- and gender-matched control group of 5580 people.

RESULTS

The most prevalent comorbid diseases within the Down's population were hypothyroidism (22.9%) and epilepsy (20.3%). However, the conditions that had the highest relative risks (RRs) in the Down's population were septal defects and dementia. Respiratory failure, dementia and pneumonia were the most significantly related comorbidities to mortality in the Down syndrome population. In the control population, respiratory failure, dementia and renal failure were the most significant disease contributors. When these contributors were analysed using multivariate analysis, heart failure, respiratory failure, pneumonia and epilepsy were the identified risk factors for in-hospital mortality in the Down syndrome population. Respiratory failure was the sole risk factor for mortality in the Down syndrome population [RR = 9.791 (1.6-59.9) P ≤ 0.05], when compared with the risk factors for mortality in the control population.

CONCLUSIONS

There is significant medical morbidity in Down syndrome. This morbidity contributes to the lower life expectancy. Respiratory failure is a risk factor for mortality in Down syndrome. We need to thoroughly investigate people with Down syndrome to ensure any treatable illnesses are well managed.

Anxiety disorders and physical comorbidity: increased prevalence but reduced relevance of specific risk factors for hospital-based mortality during a 12.5-year observation period in general hospital admissions

Anxiety disorders (AD) are associated with an increase in physical comorbidities, but the effects of these diseases on hospital-based mortality are unclear. Consequently, we investigated whether the burden of physical comorbidity and its relevance on hospital-based mortality differed between individuals with and without AD during a 12.5-year observation period in general hospital admissions. During 1 January 2000 and 30 June 2012, 11,481 AD individuals were admitted to seven General Manchester Hospitals. All comorbidities with a prevalence ≥ 1 % were compared with those of 114,810 randomly selected and group-matched hospital controls of the same age and gender, regardless of priority of diagnoses or specialized treatments. Comorbidities that increased the risk of hospital-based mortality (but not mortality outside of the hospital) were identified using multivariate logistic regression analyses. AD individuals compared to controls had a substantial excess comorbidity, but a reduced hospital-based mortality rate. Twenty-two physical comorbidities were increased in AD individuals compared with controls, which included cardiovascular diseases and their risk factors. The most frequent physical comorbidities in AD individuals were hypertension, asthma, cataract, and ischaemic heart disease. Risk factors for hospital-based mortality in AD individuals were lung cancer, alcoholic liver disease, respiratory failure, heart failure, pneumonia, bronchitis, non-specific dementia, breast cancer, COPD, gallbladder calculus, atrial fibrillation, and angina. The impact of atrial fibrillation, angina, and gallbladder calculus on hospital-based mortality was higher in AD individuals than in controls. In contrast, other mortality risk factors had an equal or lower impact on hospital-based mortality in sample comparisons. Therefore AD individuals have a higher burden of physical comorbidity that is associated with a reduced risk of general hospital-based mortality. Atrial fibrillation, angina, and gallbladder calculus are major risk factors for general hospital-based mortality in AD individuals.

Dementia Increases Severe Sepsis and Mortality in Hospitalized Patients With Chronic Obstructive Pulmonary Disease

Dementia increases the risk of morbidity and mortality in hospitalized patients. However, information on the potential effects of dementia on the risks of acute organ dysfunction, severe sepsis and in-hospital mortality, specifically among inpatients with chronic obstructive pulmonary disease (COPD), is limited. The observational analytic study was inpatient claims during the period from 2000 to 2010 for 1 million people who were randomly selected from all of the beneficiaries of the Taiwan National Health Insurance in 2000. In total, 1406 patients with COPD and dementia were admitted during the study period. Hospitalized patients with COPD and free from a history of dementia were randomly selected and served as control subjects (n = 5334). The patient groups were matched according to age (±3 years), gender, and the year of admission, with a control/dementia ratio of 4. Only the first-time hospitalization data for each subject was analyzed. Logistic regression models were used to calculate the odds ratio (OR) of outcome measures (acute organ dysfunction, severe sepsis, and mortality), controlling for confounding factors (age, sex, comorbidity, infection site, hospital level, and length of stay). In COPD patients with dementia, the incidence rate of severe sepsis and hospital mortality was 17.1% and 4.8%, respectively, which were higher than the controls (10.6% and 2.3%). After controlling for potential confounding factors, dementia was found to significantly increase the odds of severe sepsis and hospital mortality with an adjusted OR (OR) of 1.38 (95% confidence interval [CI] 1.10-1.72) and 1.69 (95% CI 1.18-2.43), respectively. Dementia was also significantly associated with an increased OR of acute respiratory dysfunction (adjusted OR 1.39, 95% CI 1.09-1.77). In hospitalized COPD patients, the presence of dementia may increase the risks of acute respiratory dysfunction, severe sepsis, and hospital mortality, which warrants the attention of health care professionals.

Bipolar disorder and comorbidity: increased prevalence and increased relevance of comorbidity for hospital-based mortality during a 12.5-year observation period in general hospital admissions

BACKGROUND

Bipolar disorder (BD) is associated with an increase of psychiatric and physical comorbidities, but the effects of these disorders on general hospital-based mortality are unclear. Consequently, we investigated whether the burden of comorbidity and its relevance on hospital-based mortality differed between individuals with and without BD during a 12.5-year observation period in general hospital admissions.

METHODS

During 1 January 2000 and 30 June 2012, 621 individuals with BD were admitted to three General Manchester Hospitals. All comorbidities with a prevalence ≥1% were compared with those of 6210 randomly selected and group-matched hospital controls of the same age and gender, regardless of priority of diagnoses. Comorbidities that increased the risk for hospital-based mortality (but not mortality outside of the hospitals) were identified using multivariate logistic regression analyses.

RESULTS

Individuals with BD had a more severe course of disease than controls that was associated with a higher total number of in-hospital deaths. Individuals with BD compared to controls had a substantial higher burden of comorbidities, the most frequent comorbidities included asthma, type-2 diabetes mellitus (T2DM), and alcohol dependence. 18 other diseases with a surplus of diabetes related complications were also increased. Fourteen comorbidities contributed to the prediction of hospital-based mortality in univariate analyses. Risk factors for hospital-based mortality in multivariate analyses were ischemic stroke, pneumonia, bronchitis, chronic obstructive pulmonary disease, T2DM, and hypertension. The impact of T2DM on hospital-based mortality was higher in individuals with BD than in controls.

LIMITATIONS

The study design was not assigned to assess the type of BD, the current bipolar status, and if individuals with BD were treated with medication. It was neither possible to compare drug effects, nor to compare the adherence to treatment between samples.

CONCLUSION

In one of the largest samples of individuals with BD in general hospitals, the excess comorbity in individuals with BD compared to controls is in particular caused by asthma and T2DM. T2DM and its complications cause significant excess hospital-based mortality in individuals with BD.

Comorbidity and dementia: a scoping review of the literature

BACKGROUND

Evidence suggests that amongst people with dementia there is a high prevalence of comorbid medical conditions and related complaints. The presence of dementia may complicate clinical care for other conditions and undermine a patient's ability to manage a chronic condition. The aim of this study was to scope the extent, range and nature of research activity around dementia and comorbidity.

METHODS

We undertook a scoping review including all types of research relating to the prevalence of comorbidities in people with dementia; current systems, structures and other issues relating to service organisation and delivery; patient and carer experiences; and the experiences and attitudes of service providers. We searched AMED, Cochrane Library, CINAHL, PubMed, NHS Evidence, Scopus, Google Scholar (searched 2012, Pubmed updated 2013), checked reference lists and performed citation searches on PubMed and Google Scholar (ongoing to February 2014).

RESULTS

We included 54 primary studies, eight reviews and three guidelines. Much of the available literature relates to the prevalence of comorbidities in people with dementia or issues around quality of care. Less is known about service organisation and delivery or the views and experiences of people with dementia and their family carers. There is some evidence that people with dementia did not have the same access to treatment and monitoring for conditions such as visual impairment and diabetes as those with similar comorbidities but without dementia.

CONCLUSIONS

The prevalence of comorbid conditions in people with dementia is high. Whilst current evidence suggests that people with dementia may have poorer access to services the reasons for this are not clear. There is a need for more research looking at the ways in which having dementia impacts on clinical care for other conditions and how the process of care and different services are adapting to the needs of people with dementia and comorbidity. People with dementia should be included in the debate about the management of comorbidities in older populations and there needs to be greater consideration given to including them in studies that focus on age-related healthcare issues.

3.0 T MRI arterial spin labeling and magnetic resonance spectroscopy technology in the application of Alzheimer's disease

The purpose of this study was to investigate the changes in the cerebral blood flow (CBF) and spectrum variables in the posterior cingulate region of patients with AD under the detection of arterial spin labeling (ASL) and magnetic resonance spectroscopy (MRS). A total of 20 AD patients (8 males and 12 females; mean age, 64.84±8.82 years) and 20 healthy controls (9 males and 11 females; mean age, 64.94±7.93 years) were included in this study for analysis. All images were obtained using a 3.0-T MR imager and an 8-channel head array receiving coil. MRS measurements were conducted exploring variables of metabolite ratios. Statistical analyses were conducted with the SPSS 11.0 statistical software package. Findings in the present study revealed a significant difference in the mean MMSE scores between the AD group and the healthy control group (16.21±4.01 vs. 27.35±1.01, P<0.01). Compared with the healthy control group, CBF in the bilateral frontal region showed a significant decrease in the AD group (right frontal: 83.5±7.2 vs. 110±11.5, P<0.05; left frontal: 85.6±8.1 vs. 108.7±12.2, P<0.05, respectively), and a similar association was also observed in the TL, TPJ, parietal, and hippocampal regions (all P<0.05). MRS imaging in the posterior cingulate region showed a significant reduction in the NAA/Cr ratio in the AD group (1.43±0.1 vs. 1.49±0.0, P<0.05). Additionally, we found that the MI/Cr and Cho/Cr ratios were higher than normal controls in patients with AD (all P<0.05). Our results suggested that 3D ASL detection combined with MRS in studying AD could show the regional hypo-perfusion with the decrease of CBF and the abnormal metabolic changes of the posterior cingulate cortex.

The role of angioplasty in patients with acute coronary syndrome and previous coronary artery bypass grafting

INTRODUCTION

Angioplasty has changed the management of acute coronary syndrome (ACS). However, in patients with previous coronary artery bypass grafting (CABG), the role of angioplasty in the management of ACS is widely debated. Lack of clear guidelines leads to subjective and often stereotypical assessments based on clinician preferences. We sought to investigate if angioplasty affected all cause mortality in ACS patients with previous CABG.

METHODS

Completely anonymous information on patients with ACS with a background of previous CABG, co-morbidities and procedures attending three multi-ethnic general hospitals in the North West of England, United Kingdom in the period 2000-2012 was traced using the ACALM (Algorithm for Comorbidities, Associations, Length of stay and Mortality) study protocol using ICD-10 and OPCS-4 coding systems. Predictors of mortality and survival analyses were performed using SPSS version 20.0.

RESULTS

Out of 12,227 patients with ACS, there were 1172 (19.0%) cases of ACS in patients with previous coronary artery bypass grafting. Of these 83 (7.1%) patients underwent angioplasty. Multi-nominal logistic regression, accounting for differences in age and co-morbidities, revealed that having angioplasty conferred a 7.96 times improvement in mortality (2.36-26.83 95% CI) compared to not having angioplasty in this patient group.

CONCLUSIONS

We have shown that angioplasty confers significantly improved all cause mortality in the management of ACS in patients with previous CABG. The findings of this study highlight the need for clinicians to conscientiously think about the individual benefits and risks of angioplasty for every patient rather than confining to age related stereotypes.

Comorbidity and its relevance on general hospital based mortality in major depressive disorder: a naturalistic 12-year follow-up in general hospital admissions

Major depressive disorder (MDD) is associated with physical comorbidity, but the risk factors of general hospital-based mortality are unclear. Consequently, we investigated whether the burden of comorbidity and its relevance on in-hospital death differs between patients with and without MDD in a 12-year follow-up in general hospital admissions. During 1 January 2000 and 30 June 2012, 9604 MDD patients were admitted to three General Manchester Hospitals. All comorbidities with a prevalence ≥1% were compared with those of 96,040 age-gender matched hospital controls. Risk factors of in-hospital death were identified using multivariate logistic regression analyses. Crude hospital-based mortality rates within the period under observation were 997/9604 (10.4%) in MDD patients and 8495/96,040 (8.8%) in controls. MDD patients compared to controls had a substantial higher burden of comorbidity. The highest comorbidities included hypertension, asthma, and anxiety disorders. Subsequently, twenty-six other diseases were disproportionally increased, many of them linked to chronic lung diseases and to diabetes. In deceased MDD patients, chronic obstructive pulmonary disease and type-2 diabetes mellitus were the most common comorbidities, contributing to 18.6% and 17.1% of deaths. Furthermore, fifteen physical diseases contributed to in-hospital death in the MDD population. However, there were no significant differences in their impact on mortality compared to controls in multivariate logistic regression analyses. Thus in one of the largest samples of MDD patients in general hospitals, MDD patients have a substantial higher burden of comorbidity compared to controls, but they succumb to the same physical diseases as their age-gender matched peers without MDD.