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

Hospitalizations of the older adults with and without dementia during the last two years of life: the impact of comorbidity and changes from 2002 to 2017

BACKGROUND

Multimorbidity creates challenges for care and increases health care utilization and costs. People with dementia often have multiple comorbidities, but little is known about the role of these comorbidities in hospitalizations.

AIMS

This study examines the frequency of hospitalizations during the last two years of life in older adults with and without dementia, the impact of comorbidities on hospitalizations, and their time trends.

METHODS

The data came from national registers and covered all persons 70 and above who died in Finland in 2002-2017. The effect of dementia and comorbidities on hospitalizations in the last two years of life was determined using binary logistic regression and negative binomial regression.

RESULTS

At all levels of comorbidity, people with dementia were less likely to be hospitalized and had a lower number of hospitalizations than people at the same level of comorbidity but no dementia. Hospitalizations were strongly associated with multimorbidity. During the study period, the overall hospitalization rates from home and LTC have declined.

DISCUSSION

The declining trend of hospitalization during the 15-year study period should be interpreted in the context of the health and long-term care system.

CONCLUSION

Among people with dementia, comorbidities were the main driver for hospitalizations. Regardless of the number of comorbidities, people with dementia were hospitalized less often than people without dementia in last two years of life. It remains unclear whether the lower hospitalization rate is due to the improved ability to care for people with dementia outside the hospital or to the lack of sufficient medical care for them.

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.

Multimorbidity in neurodegenerative diseases: a network analysis

The socioeconomic costs of neurodegenerative diseases (NDs) are highly affected by comorbidities. This study aims to enhance our understanding of the prevalent complications of NDs through the lens of network analysis. A multimorbidity network (MN) was constructed based on a longitudinal EHR dataset of 93,647,498 diagnoses of 824,847 patients. The association between the conditions was measured by two metrics, i.e. Phi-correlation and Cosine Index (CI). Based on multiple network centrality measures, a fused ranking list of the prevalent multimorbidities was provided. Finally, class-level networks depicting the prevalence and strength of diseases in different classes were constructed. The general MN included 928 diseases and 337,253 associations. Considering a 99% confidence level, two networks of 575 relationships were constructed based on Phi-correlations (73 diseases) and CI (102 diseases). Five out of 19 ICD-9 categories did not appear in either of the networks. Also, ND's immediate MNs for the top 50% of the significant associations included 42 relationships, whereas the Phi-correlation and CI networks included 36 and 34 diseases, respectively. Thirteen diseases were identified as the most notable multimorbidities based on various centrality measures. The analysis framework helps practitioners toward better resource allocations, more effective preventive screenings, and improved quality of life for ND patients and caregivers.

The Impact on Anxiety Symptoms of an Immersive Virtual Reality Remediation Program in Bipolar Disorders: A Randomized Clinical Trial

Background: The objective of this work is to investigate the effectiveness of a cognitive remediation intervention on anxiety symptoms in people with bipolar disorder and the therapeutic effect on people whose anxiety symptoms were above the threshold for a screener and whose comorbidity could be identified as an anxiety disorder. Methods: The experimental intervention included 24 sessions (around 45 min each), two for each week over three months. The entire program was inspired by user-centered rehabilitation principles in a recovery-oriented perspective and an approach to bipolar disorder in an evolutionary and non-discriminating vision. The primary outcomes measure the score of the Zung Self-Rating Anxiety Scale (SAS), hypothesizing a higher decrease in the experimental group than in the control group. The survey has been conducted per the CONSORT guidelines for feasibility studies. Results: We evaluate a decrease in the overall SAS score from T0 to T1 to be higher in the experimental group compared to the control group, indicating an improvement in anxiety symptoms (p < 0.0001). Conclusions: The study suggests that virtual reality could have a role in treating anxiety symptoms and disorders in young adults with bipolar disorders or anxiety symptoms in people with hyperactivity and novelty-seeking behaviorsunder stress and high risk for bipolar disorder.

Low serum HDL-cholesterol is associated with increased risk of the subcortical small vessel type of dementia

Background

There are conflicting results whether serum lipid pattern is related to the amount of white matter hyperintensities (WMHs) on magnetic resonance imaging. Little is known of the associations between lipid concentrations and the subsequent risk of the subcortical small vessel type of dementia (SSVD), in which WMHs are a prominent manifestation. Here, we determined whether lipid levels are associated with the risk of SSVD, Alzheimer's disease (AD), or mixed dementia (combined AD and SSVD).

Methods

This was a longitudinal, prospective study of 329 patients with subjective or objective mild cognitive impairment at baseline. The statistical analyses included Cox proportional hazards regression with adjustments for age, gender, education, body mass index, current smoking, hypertension, diabetes mellitus, and APOE ε4 genotype.

Results

During the follow-up (mean 4.1 years), 80 patients converted to dementia [SSVD, n = 15 (5 %); AD, n = 39 (12 %); and mixed dementia, n = 26 (8 %)]. Serum high-density lipoprotein cholesterol (HDL, per SD increase) was inversely associated with the risk of SSVD, whereas triglycerides (TG), low-density lipoprotein cholesterol (LDL)/HDL ratio, and TG/HDL ratio were positively associated with SSVD risk. Furthermore, the lowest HDL tertile was associated with a sevenfold, and the highest tertile of TG/HDL ratio with a threefold, increase in SSVD risk. There were no associations with the risk of AD or mixed dementia after adjustment for covariates.

Conclusion

In a memory clinic population, low HDL and high TG/HDL ratio were independent risk factors of SSVD, but not of AD or mixed dementia.

Which factors preceding dementia identification impact future healthcare use trajectories: multilevel analyses in administrative data

BACKGROUND

Healthcare use patterns preceding a diagnosis of Alzheimer's Disease and Related Diseases (ADRD) may be associated with the quality of healthcare use trajectories (HUTs) after diagnosis. We aimed to identify determinants of future favorable HUTs, notably healthcare use preceding ADRD identification.

METHODS

This nationwide retrospective observational study was conducted on subjects with incident ADRD identified in 2012 in the French health insurance database. We studied the 12-month healthcare use ranging between 18 and 6 months preceding ADRD identification. The five-year HUTs after ADRD identification were qualified by experts as favorable or not. In order to take into account geographical differences in healthcare supply, we performed mixed random effects multilevel multivariable logistic regression model to identify determinants of future favorable HUTs. Analyses were stratified by age group (65-74, 75-84, ≥ 85).

RESULTS

Being a woman, and preventive and specialist care preceding ADRD identification increased the probability of future favorable HUT, whereas institutionalization, comorbidities, medical transportation and no reimbursed drug during [-18;-6] months decreased it. Besides, some specificities appeared according to age groups. Among the 65-74 years subjects, anxiolytic dispensing preceding ADRD identification decreased the probability of future favorable HUT. In the 75-84 years group, unplanned hospitalization and emergency room visit preceding ADRD identification decreased this probability. Among subjects aged 85 and older, short hospitalization preceding ADRD identification increased the probability of future favorable HUTs.

CONCLUSION

Regular healthcare use with preventive and specialist care preceding ADRD identification increased the probability of future favorable HUTs whereas dependency decreased it.

Health Experiences of Sexual and Gender Minority People Living With Dementia and Their Care Partners: Protocol for a Scoping Review

BACKGROUND

People living with dementia and their care partners who identify as a sexual and gender minority (SGM) often experience specific health inequities and disparities due to discrimination related to age, cognitive impairment, and being SGM.

OBJECTIVE

The purpose of this scoping review is to identify, explore, and synthesize the state of the science regarding the health and health care experiences of SGM people living with dementia and their care partners. This review also aims to identify gaps in research and set forth key recommendations to improve the health and health care experiences of SGM people living with dementia and their care partners by advancing health equity through research, policy, and practice.

METHODS

The protocol follows the guidelines set forth by Joanna Briggs Institute protocol for scoping reviews. Steps of this framework that will be followed include (1) identifying the research question; (2) identifying relevant studies; (3) study selection; (4) charting the data; (5) collating, summarizing, and reporting the results; and (6) consultation. This scoping review will explore several electronic databases, including MEDLINE, Embase, CINAHL, AgeLine, PsychINFO, and Scopus. Health librarians will conduct the initial search for articles that are in English, include people living with dementia who identify as SGM, SGM people living with dementia and their care partners, or SGM care partners caring for people with dementia. Studies must be peer reviewed and focus on the phenomenon of interest, which is the health and health care experiences of participants. Covidence will be used to review abstracts and full-text articles and to screen articles. After the search has been completed, 2 independent reviewers will screen article titles and abstracts to identify eligibility. Discrepancies will be discussed and decided upon by the 2 reviewers. Relevant studies will be collected, and data will be extracted and charted to summarize key findings. Key findings will be presented to a community stakeholder group of SGM care partners and people living with dementia, and a listening session will be convened.

RESULTS

This scoping review will identify the state of the science of health and health care experiences of people living with dementia and their care partners who identify as SGM. We will identify gaps and provide recommendations to inform future research, policy, and practice to improve health and health care experiences of SGM people living with dementia and their care partners.

CONCLUSIONS

Little is known about people living with dementia and their care partners who identify as SGM. This scoping review will be one of the first to identify the health and health care experiences of people living with dementia and their care partners who identify as SGM. The results of this review will be used to guide future interventions and to inform future policy and practice to improve health care and reduce health disparities in this population.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/44918.

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.

Comorbidities in dementia during the last years of life: a register study of patterns and time differences in Finland

BACKGROUND

Comorbidities have major implications for the care of people with dementia.

AIM

To investigate the patterns of comorbidities in dementia in the last five years of life and how these patterns differed between three cohorts.

METHODS

The study included people who died at age 70 and above in 2001 (n = 13,717), 2007 (n = 34,750) and 2013 (n = 38,087) in Finland. ICD-10 morbidity data for a five-year period prior to death were extracted from national registers. Principal component analysis was employed to identify patterns for several morbidities. The associations of principal component scores with dementia were analysed using binary logistic regression. Linear regression was used to examine changes in the number of morbidities in patterns over time.

RESULTS

The morbidity patterns identified in the last years of life were (1) cardiometabolic disorders, (2) neurological, (3) cerebrovascular diseases and (4) musculoskeletal, thyroid and psychiatric disorders. Among the patterns, neurological and musculoskeletal, thyroid and psychiatric disorders were associated with dementia. The number of diagnoses in the cerebrovascular pattern increased and those in the musculoskeletal, thyroid and psychiatric pattern decreased over time.

DISCUSSION

Comorbidity patterns identified in this nationwide register study are largely in line with previous evidence. Time difference in these patterns provide crucial information for service planning.

CONCLUSIONS

Comorbidities in dementia in the last years of life occur in patterns and change over time. More systematic monitoring and updated clinical guidelines are needed for the care of comorbidities with dementia.

The aging endothelium

Cellular senescence is now recognized as one of the hallmarks of aging. Herein, we examine current findings on senescence of the vascular endothelium and its impacts on age-related vascular diseases. Endothelial senescence can result in systemic metabolic changes, implicating senescence in chronic diseases such as diabetes, obesity and atherosclerosis. Senolytics, drugs that eliminate senescent cells, afford new therapeutic strategies for control of these chronic diseases.

Prevalence of affective disorders and dementia in inflammatory polyarthropathies

Comorbid disorders are common in psychiatric diseases and understanding the risk of secondary diseases can aid successful clinical treatment. The objective of this study was to compare the frequency of comorbid dementia, affective disorders, and inflammatory polyarthropathies. Healthcare data obtained via the German Hospital Fees Act from two independent databases with more than 7.4 million cases were analyzed to compare the prevalence of comorbid disorders. Comorbid inflammatory polyarthropathy was observed in 2.27% of patients diagnosed with affective disorders and 1.35% of patients with dementia (p < 0.001). Among patients with a primary diagnosis of inflammatory polyarthropathy, 1.27% of patients were diagnosed with dementia, whereas 4.55% of age-matched patients without inflammatory polyarthropathies had comorbid dementia (p < 0.001). The opposite effect was demonstrated for affective disorders, as 5.77% of patients with a primary diagnosis of inflammatory polyarthropathy also had comorbid affective disorders, while 4.87% of age-matched patients without inflammatory polyarthropathy had an accompanying affective disease (p < 0.001). These findings show an association between the occurrence of inflammatory polyarthropathies, dementia, and affective disorders. This correlation might improve diagnosis and treatment for patients with comorbidities. Moreover, further exploration of the molecular pathophysiology underlying these relationships could be relevant for the development of novel treatment options.

Patients with the Subcortical Small Vessel Type of Dementia Have Disturbed Cardiometabolic Risk Profile

BACKGROUND

Population-based studies have shown that cardiometabolic status is associated with the amount of white matter hyperintensities (WMHs) on magnetic resonance imaging (MRI). However, little is known of cardiometabolic risk factors in the subcortical small vessel type of dementia (SSVD), in which WMHs are one of the most prominent manifestations.

OBJECTIVE

To determine whether the profile of cardiometabolic risk factors differed between SSVD, Alzheimer's disease (AD), mixed dementia (combined AD and SSVD), and healthy controls.

METHODS

This was a mono-center, cross-sectional study of SSVD (n = 40), AD (n = 113), mixed dementia (n = 62), and healthy controls (n = 94). In the statistical analyses, we adjusted for covariates using ANCOVA and binary logistic regression.

RESULTS

The prevalence of hypertension was increased in SSVD and mixed dementia (p < 0.001 and p < 0.05 versus controls, respectively). Diabetes was more prevalent in SSVD patients, and body mass index was lower in AD and mixed dementia, compared to the controls (all p < 0.05). Serum total cholesterol (TC) and low-density lipoprotein-cholesterol (LDL-C) were reduced in the SSVD group (both p < 0.05 versus control). These differences remained after adjustment for covariates. In the SSVD group, Trail Making Test A score correlated positively with systolic blood pressure, mean arterial pressure, and pulse pressure.

CONCLUSION

All dementia groups had an altered cardiometabolic risk profile compared to the controls. The SSVD patients showed increased prevalence of hypertension and diabetes, and in line with previous population-based data, TC and LDL-C in serum were reduced.