Health Disparities in Dementia

Enhanced associations between subjective cognitive concerns and blood-based AD biomarkers using a novel EMA approach

BACKGROUND

Subjective cognitive concerns (SCC) have emerged as important early indicators of Alzheimer's disease (AD) risk. Traditional measures of SCC rely on recall-based assessments, which may be limited in capturing real-time fluctuations in cognitive concerns. Ecological Momentary Assessment (EMA) offers a promising alternative by providing real-time data. This study aimed to link SCC assessed via EMA and traditional measures with blood-based AD biomarkers in a diverse, dementia-free, community-based sample based in the Bronx, NY.

METHODS

Einstein Aging Study (EAS) participants underwent in-person, recall-based assessments of SCC during an in-clinic visit. Additionally, EMA SCC assessments were collected once per day over two weeks. Linear regressions were conducted to examine the relationships between SCC variables and plasma biomarkers adjusted for demographics and mild cognitive impairment (MCI) status.

RESULTS

In N = 254 participants, EMA-reported SCCs demonstrated significant associations with AD biomarkers, particularly p-tau181 (β = 0.21, p = 0.001). Further, significant associations remain across both cognitive (cognitively unimpaired vs. MCI) and racial groups. In contrast, traditional SCC measures exhibited limited associations with these biomarkers. The findings highlight the added value of EMA in capturing SCCs that could indicate early ADRD risk.

CONCLUSIONS

EMA provides a more dynamic and potentially sensitive method for detecting early AD risk compared to traditional SCC assessments. These real-time measures could enhance early detection and clinical intervention, particularly in diverse and under-resourced populations. This study underscores the potential of EMA for broad applicability and inclusivity in monitoring AD progression and facilitating early therapeutic interventions.

Eating and swallowing care disparities in persons with dementia: A conceptual framework

INTRODUCTION

Eating and swallowing difficulties are prevalent and distressing among persons living with dementia (PLWD). These challenges may be especially burdensome for PLWD in lower-resourced settings, where environmental factors such as social support, health-care infrastructure, and food access are critical for meeting quality standards of eating and swallowing care. However, clinical practices and research methods have not sufficiently focused on the lived environment to promote high-quality, socially and culturally aligned management approaches.

METHODS

To address this gap, we developed a conceptual framework informed by the literature, grounded in ecological systems and fundamental cause theories, and refined through iterative discussion.

RESULTS

Our framework highlights individual-, system-, and community-level factors and resources influencing person-centered eating and swallowing care for PLWD. It identifies areas at risk for inequitable care along the swallowing management continuum.

DISCUSSION

We propose future research areas to help health-care providers reconcile the demands of eating and swallowing care with the lived realities of PLWD.

HIGHLIGHTS

There are eating/swallowing care disparities among persons living with dementia. We introduce a conceptual framework applying social and structural determinants of health to eating/swallowing care. We also recommend areas to address disparities and improve eating/swallowing care.

Dementia Diagnosis Unawareness and Caregiver Burden in a Multi-ethnic Cohort

BACKGROUND

Previous reports suggest patient and caregiver lack of awareness of dementia. Little is known about how this varies by ethnicity and how informal (family) caregiver burden is associated with knowing a dementia diagnosis.

OBJECTIVE

To investigate whether participants with probable dementia were aware of a diagnosis provided by a physician and how this differed among Mexican American and non-Hispanic White participants; whether having a primary care physician was associated with dementia diagnosis unawareness; and the association of dementia diagnosis unawareness with caregiver burden.

METHODS

This was a population-based cohort study in Nueces County, Texas. Participants who scored less than 20 on the Montreal Cognitive Assessment (MoCA) were classified as having probable dementia. Diagnosis unawareness was defined as participants with probable dementia who had not been told that diagnosis by a healthcare provider. Logistic regression models examined the association of ethnicity and dementia diagnosis unawareness. A negative binomial regression was used to assess the association of dementia diagnosis unawareness and caregiver burden.

RESULTS

Eighty-one percent of eligible participants were not aware of a dementia diagnosis. Mexican American participants (MAP) were more likely to be unaware of a diagnosis (85%, 95% CI 81-89%) than non-Hispanic white participants (NHWP) (68%, 95% CI 58-75%). Only 6.6% of the participants with probable dementia had no primary care provider, with no observed association between diagnosis unawareness and lack of primary care. Diagnosis unawareness was not associated with caregiver burden (IRR = 0.93, 95% CI 0.77-1.14) but was associated with lower MoCA score (IRR = 0.98, 95% CI 0.96-1.00) and greater physical impairment (IRR = 1.06, 95% CI 1.03-1.10).

CONCLUSION

Dementia diagnosis unawareness was very high in this community. MAPs are more likely to be unaware of a diagnosis than NHWPs. Lack of access to primary care and caregiver burden were not associated with dementia diagnosis unawareness.

TRIAL REGISTRATION

Study registered at clinicaltrials.gov NCT03403257.

Racial/Ethnic Differences in Neuropsychological Test Performance in Frontotemporal Degeneration

Racial disparities in neuropsychological test performance are well documented in Alzheimer's Disease (AD) but have received little attention in frontotemporal degeneration (FTD). Identification of potential disparities in neuropsychological performance is critical to identify ways to improve inclusivity in clinical research and care of representative FTD populations. We evaluated disparities in neuropsychological performance among individuals with clinically diagnosed FTD (behavioral variant FTD [bvFTD] or primary progressive aphasia [PPA]) using data from the National Alzheimer's Coordinating Center (NACC) collected between September 2005 and November 2023. Only 10% of NACC FTD cases are from racially/ethnically minoritized groups. Black (n=56), Hispanic (n=77) and White (n=1301) individuals were evaluated in the cognitive domains of episodic memory, working memory, processing speed, cognitive flexibility, attention, category fluency and lexical retrieval, in addition to global cognition across Uniform Data Set versions 1 to 3. Linear regressions examined the association between racial/ethnic group and cognitive scores covarying for disease stage, age, sex, and education. After adjusting for age, sex, and education using NACC established normative correction, binary logistic regression examined group differences in the proportion of participants classified as impaired (<=-1.5 normative z-score) for each cognitive test. Minoritized individuals, on average, had lower scores and/or greater likelihood of impairment (odds ratio; OR) on measures of global cognition (Black: β = -3.63; OR = 2.74; Hispanic: β = -2.50), lexical retrieval (Black: β = -4.31; OR = 3.28; Hispanic: β = -2.90; OR = 3.81), processing speed (Black: β = 26.80; OR = 4.07; Hispanic: β = 21.31; OR = 2.37), cognitive flexibility (Black: β = 46.65; OR = 3.35), attention (Hispanic: β = -0.39), working memory (Black: β = -0.79; Hispanic: β = -0.42), episodic memory (Hispanic: β = -1.67), and category fluency (Hispanic: β = -1.28). We did not identify any neuropsychological tests where White individuals performed worse than minoritized individuals. These findings indicate racial/ethnic differences in neuropsychological test performance on measures of global cognition, executive function, and lexical retrieval. Critically, these tests are used in diagnosis and monitoring of FTD. Future efforts must focus on increasing research participation in underrepresented populations with FTD to support the diverse needs of individuals, and an understanding of social determinants of health in FTD to evaluate potential sources of the observed differences across racial and ethnic groups.

Vascular Cognitive Impairment

OBJECTIVE

Vascular cognitive impairment is a major contributor to age-associated cognitive decline, both independently and as a contributor to mixed dementia syndromes. This article reviews the current understanding of how vascular dysfunction contributes to cognitive impairment and dementia risk in older individuals and includes updated diagnostic criteria and treatment recommendations.

LATEST DEVELOPMENTS

Clinical and research criteria have been evolving to more accurately determine the full prevalence of vascular cognitive impairment. The Boston Criteria version 2.0 for cerebral amyloid angiopathy now includes multiple punctate MRI T2 white matter hyperintensities and MR-visible perivascular spaces in addition to previously described T2* hemorrhagic signatures. MR-visible perivascular spaces are associated with both vascular cognitive impairment and Alzheimer disease, potentially linking cerebrovascular dysfunction to neurodegenerative disorders through its role in brain waste clearance. The American Heart Association's goal for cardiovascular health promotion, "Life's Essential 8," has been updated to include sleep health and acknowledges psychological well-being and social determinants of health as fundamental components necessary to achieve optimal cardiovascular health for all adults.

ESSENTIAL POINTS

Vascular cognitive impairment is a common and often underrecognized contributor to cognitive impairment in older individuals, with heterogeneous etiologies requiring individualized treatment strategies. Effective cerebrovascular disease risk factor modification starting in midlife is critical to reducing the risk of Alzheimer disease and related dementias, with the goal of preventing vascular brain injury and maintaining cognitive reserve in the presence of nonvascular age-related brain pathologies.

Implementing New Dementia Care Models in Practice

ABSTRACT

Care for patients with Alzheimer disease and related neurodegenerative causes of dementia is in the midst of a transformation. Recent advancements in diagnostics and therapeutics reflect a rapidly evolving knowledge base and represent positive steps for patients and clinicians facing these progressive diseases; however, the complexities of emerging biomarkers and treatment options present challenges that will require systematic adaptations to routine care to facilitate effective incorporation of these options. This article reviews ongoing updates in the assessment and management of neurodegenerative causes of dementia, focusing on practical models for innovation that practices and health care systems can use to implement these new tools. In particular, sustainable adaptation in the field will benefit from a comprehensive approach implemented at local levels, including (1) education of clinicians and communities to refine perceptions about dementia care, (2) multifaceted stakeholder engagement to optimize infrastructure and workflows to the new era, and (3) investments in personnel to address existing and exacerbated gaps.

Lifestyle, Environment, and Dietary Measures Impacting Cognitive Impairment: The Evidence Base for Cognitive Subtypes

:

Cognition includes all phases of valid functions and processes, e.g., sensitivity, judgment, assessment, and decision-making. Thinking is also a cognitive procedure since it involves considering potential opportunities. There are various types of cognition. Hot cognition involves mental procedures where emotion plays a role, while cold cognition includes mental processes that do not include feelings or emotions. Cognitive memories of various types include sensor memory, sensing touch, smell, and sight; short-term memory allows one to recall, e.g., what one had for lunch a few days ago; working memory includes remembering telephone numbers or directions to a destination; and long-term memory comprises of major milestones in life and recalling one’s childhood events. These are further classified as episodic, e.g., the first day in primary school, and semantic memories, such as recalling the capital city of a country and filling out crossword puzzles. Declarative memories include remembering significant past events, such as global information. Cognition is affected by factors, such as nutrition, aging, addiction, environment, mental health, physical activity, smoking, and keeping the brain active. Consumption of plant- based foods plays a prominent role in the prevention of cognitive memory. Playing games and instruments, reading books, and being socially active make life more satisfying, thus assisting in the preservation of mental function and slowing mental decline.

Association of MIND diet with cognitive decline among Black and White older adults

INTRODUCTION

We examined the Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) diet's association with cognitive decline by race among older adults in the Chicago Health and Aging Project.

METHODS

Five thousand two hundred fifty-nine participants (73.5 [± 6.0] years, 62% Black participants, 62% female) completed a food frequency questionnaire, and two or more cognitive assessments over 7.8 ± 4.6 years.

RESULTS

Overall, higher MIND diet was associated with slower cognitive decline (p for trend = 0.0025). The MIND score (range:0-15) was different between Black and White older adults(6.97 vs. 7.12, p = 0.010). Compared to the lowest tertile, among White participants, the two highest tertiles (MIND score -7: β = 0.0121 [95% confidence interval [CI]: 0.0006, 0.0237]; MIND score -8.5: β = 0.0146 [95% CI: 0.0003, 0.0260]) and among Black participants, only the highest tertile (MIND score -8.5: β = 0.0088 [95% CI: 0.0003, 0.0172]) had association with cognitive decline. Vascular and lifestyle factors attenuated the association only for Black older adults.

DISCUSSION

The MIND diet was associated with slower cognitive decline in Black and White older adults, but this may vary with other lifestyle and vascular factors. Further research is warranted on race-specific cultural diets considering other risk factors for cognitive decline.

HIGHLIGHTS

The intake of Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) diet components varies by race. The MIND diet may slow cognitive decline in both Black and White older adults. This association may vary with other lifestyle and vascular risk factors.

A Mindfulness-Based Lifestyle Intervention for Dementia Risk Reduction: Protocol for the My Healthy Brain Feasibility Randomized Controlled Trial

BACKGROUND

Lifestyle behavior change and mindfulness have direct and synergistic effects on cognitive functioning and may prevent Alzheimer disease and Alzheimer disease-related dementias (AD/ADRD). We are iteratively developing and testing My Healthy Brain (MHB), the first mindfulness-based lifestyle group program targeting AD/ADRD risk factors in older adults with subjective cognitive decline. Our pilot studies (National Institutes of Health [NIH] stage 1A) have shown that MHB is feasible, acceptable, and associated with improvement in lifestyle behavior and cognitive outcomes.

OBJECTIVE

We will compare the feasibility of MHB versus an education control (health enhancement program [HEP]) in 50 older adults (aged ≥60 y) with subjective cognitive decline and AD/ADRD risk factors. In an NIH stage 1B randomized controlled trial (RCT), we will evaluate feasibility benchmarks, improvements in cognitive and lifestyle outcomes, and engagement of hypothesized mechanisms.

METHODS

We are recruiting through clinics, flyers, web-based research platforms, and community partnerships. Participants are randomized to MHB or the HEP, both delivered in telehealth groups over 8 weeks. MHB participants learn behavior modification and mindfulness skills to achieve individualized lifestyle goals. HEP participants receive lifestyle education and group support. Assessments are repeated after the intervention and at a 6-month follow-up. Our primary outcomes are feasibility, acceptability, appropriateness, credibility, satisfaction, and fidelity benchmarks. The secondary outcomes are cognitive function and lifestyle (physical activity, sleep, nutrition, alcohol and tobacco use, and mental and social activity) behaviors. Data analyses will include the proportion of MHB and HEP participants who meet each benchmark (primary outcome) and paired samples 2-tailed t tests, Cohen d effect sizes, and the minimal clinically important difference for each measure (secondary outcomes).

RESULTS

Recruitment began in January 2024. We received 225 inquiries. Of these 225 individuals, 40 (17.8%) were eligible. Of the 40 eligible participants, 21 (52.5%) were enrolled in 2 group cohorts, 17 (42.5%) were on hold for future group cohorts, and 2 (5%) withdrew before enrollment. All participants have completed before the intervention assessments. All cohort 1 participants (9/21, 43%) have completed either MHB or the HEP (≥6 of 8 sessions) and after the intervention assessments. The intervention for cohort 2 (12/21, 57%) is ongoing. Adherence rates for the Garmin Vivosmart 5 (128/147, 87.1% weeks) and daily surveys (105/122, 86.1% weeks) are high. No enrolled participants have dropped out. Enrollment is projected to be completed by December 2024.

CONCLUSIONS

The RCT will inform the development of a larger efficacy RCT (NIH stage 2) of MHB versus the HEP in a more diverse sample of older adults, testing mechanisms of improvements through theoretically driven mediators and moderators. The integration of mindfulness with lifestyle behavior change in MHB has the potential to be an effective and sustainable approach for increasing the uptake of AD/ADRD risk reduction strategies among older adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05934136; https://www.clinicaltrials.gov/study/NCT05934136.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/64149.

Dignity in people with dementia: A concept analysis

Background: Dignity, an abstract and complex concept, is an essential part of humanity and an underlying guiding principle in healthcare. Previous literature indicates dignity is compromised in people with dementia (PwD), but those PwD maintain the capacity to live with dignity with appropriate external support. Alzheimer's disease and related dementias (ADRDs) lead to progressive functional decline and increased vulnerability and dependence, leading to heightened risks of PwD receiving inappropriate or insufficient care that diminishes dignity. Considering the increased disease prevalence and the continuously escalating costs of dementia care, establishing a productive value-based guideline may prevent suffering, maximize dignity, and thus promote quality of life (QoL).Aim: The goal of this project is to identify actionable targets for integrating dignity harmoniously and practically into care planning and management for PwD.Research Design: We conducted a concept analysis using Walker and Avant's eight-step process. A comprehensive literature search was conducted (PubMed and CINAHL) with the keywords "dignity," "dementia," "Alzheimer's disease," and "dementia care."Results: A total of 42 out of 4910 publications were included. The concept of dignity in PwD is operationalized as the promotion of worthiness and the accordance of respect that allows the presence and expression of a person's sense of self, regardless of physical, mental, or cognitive health. The concept has two subdimensions: absolute dignity which encompasses the inherent self and relative dignity characterized by its dynamic reflective nature. Worthiness and respect are the two main attributes, while autonomy is an underlying component of dignity. Specific antecedents of dignity in PwD are empowerment, non-maleficence, and adaptive environmental scaffolding. As a consequence of facilitating dignity in PwD, QoL may be enhanced.Conclusion: As a foundational and necessary humanistic value, incorporating dignity into dementia care can lead to efficient and effective care that optimizes QoL in PwD throughout their disease progression.

New2Neuropsychology (N2N): An organization to promote diversity, equity, and inclusion in neuropsychology

OBJECTIVE

To introduce New2Neuropsychology (N2N), an organization that seeks to increase recruitment of historically underrepresented minoritized (URM) students, and to examine preliminary data on N2N's impact and effectiveness in increasing knowledge about neuropsychology for URM students.

METHOD

This paper reviews relevant literature on factors informing the development of N2N. We also present descriptive data on N2N's impact to date, and results of pre- and post- surveys for presentations about neuropsychology delivered to 90 college students (mean age = 24.23, 64.4% juniors or seniors) between November 2021 - March 2023.

RESULTS

N2N has reached >500 students in events across 27 schools and, with the American Academy of Clinical Neuropsychology, disseminated $84,000 in scholarships to URM students. N2N presentation attendees reported increased understanding of neuropsychology and the training pathway (ps < .001, Cohen's ds = 0.94 - 1.73) and increased confidence in their ability to become neuropsychologists (p < .001, d = 0.41). There were no overall pre-post differences for interest in pursuing a career in neuropsychology (p > .05); however, a subset of students who reported low interest at baseline (n = 57) reported a statistically significant increase in their interest post-presentation (p < .01, d = 0.36).

CONCLUSIONS

To date, N2N has progressed toward its goal, showing preliminary success increasing knowledge about neuropsychology for URM students. With continued development and support, N2N seeks to transform the pathway to neuropsychology for URM students, expanding accessibility of N2N resources across diverse groups and connecting URM students to neuropsychology research and clinical experiences.

Modeling the Population Equity of Alzheimer Disease Treatments in the US

Importance

The arrival of new medications for Alzheimer disease (AD) has prompted efforts to measure their value using conventional cost-effectiveness analyses; however, these analyses focus on how much health improvement new medications generate per dollar spent. As AD disproportionately affects older adults, women, racial and ethnic minority individuals, and individuals with lower socioeconomic and educational levels, it is critical to also examine the health equity outcomes of treatment.

Objective

To estimate the health equity impact of a hypothetical disease-modifying treatment for early AD in the US and to examine targeted policies to mitigate health care disparities.

Design, Setting, and Participants

This economic evaluation, which used a distributional cost-effectiveness analysis, was conducted from June 16, 2022, to January 11, 2024. The study included subgroups defined by race and ethnicity and by social vulnerability quintiles in the US.

Exposures

A hypothetical disease-modifying treatment compared with best supportive care.

Main Outcomes and Measures

The main outcomes were population-level quality-adjusted life-years (QALYs), lifetime costs, and net health benefits. The social welfare impact and change in health inequality were estimated using the Atkinson index.

Results

The distributional cost-effectiveness analysis simulated 316 037 100 individuals from the US population, including 25 subgroups defined by 5 categories of race and ethnicity and population quintiles of social vulnerability, with the fifth quintile representing the most socially vulnerable group. At an opportunity cost benchmark of $150 000 per QALY, treatment was associated with improved population health, adding 28 197 QALYs per year to the US population. Accounting for health inequality preferences (using an aversion level of 11, based on an Atkinson inequality aversion parameter that can range from 0 to infinity, with higher values assigning greater weight to health gains that accrue to the population with the lowest lifetime quality-adjusted life expectancy), treatment was associated with a 0.009% reduction in existing population health inequalities annually. Scenario analyses examining earlier and expanded treatment access suggested a population health improvement of up to 221 358 QALYs.

Conclusions and Relevance

The findings of this economic evaluation suggest that treatment for AD could improve population health and health equity. Policies to enable earlier diagnosis and treatment initiation, as well as expanded access to treatment, may further improve treatment and health equity impacts.

Visual Impairment, Eye Conditions, and Diagnoses of Neurodegeneration and Dementia

Importance

Vision and eye conditions are associated with increased risk for Alzheimer disease and related dementias (ADRDs), but the nature of the association and the underlying biological pathways remain unclear. If causal, vision would be an important modifiable risk factor with viable population-level interventions.

Objective

To evaluate potentially causal associations between visual acuity, eye conditions (specifically cataracts and myopia), neuroimaging outcomes, and ADRDs.

Design, Setting, and Participants

A cohort and 2-sample bidirectional mendelian randomization (MR) study was conducted using UK Biobank participants and summary statistics from previously published genome-wide association studies on cataract, myopia, and AD. The participants included in the analysis were aged 55 to 70 years without dementia at baseline (calendar years 2006 to 2010), underwent genotyping, and reported on eye conditions; a subset completed visual acuity examinations (n = 69 852-71 429) or brain imaging (n = 36 591-36 855). Data were analyzed from August 15, 2022, through November 28, 2023.

Exposure

Self-reported cataracts, visual acuity, and myopia measured by refraction error.

Main Outcomes and Measures

ADRD, AD, and vascular dementia were identified from electronic medical records. Total and regional brain volumes were determined using magnetic resonance imaging.

Results

The sample included 304 953 participants (mean [SD] age, 62.1 (4.1) years; 163 825 women [53.72%]); 14 295 (4.69%) had cataracts and 2754 (3.86%) had worse than 20/40 vision. Cataracts (hazard ratio [HR], 1.18; 95% CI, 1.07-1.29) and myopia (HR, 1.35; 95% CI, 1.06-1.70) were associated with a higher hazard of ADRD. In MR analyses to estimate potential causal effects, cataracts were associated with increased risk of vascular dementia (inverse variance-weighted odds ratio [OR], 1.92; 95% CI, 1.26-2.92) but were not associated with increased dementia (OR, 1.21; 95% CI, 0.98-1.50). There were no associations between myopia and dementia. In MR for potential reverse causality, AD was not associated with cataracts (inverse variance-weighted OR, 0.99; 95% CI, 0.96-1.01). Genetic risk for cataracts was associated with smaller total brain (β = -597.43 mm3; 95% CI, -1077.87 to -117.00 mm3) and gray matter (β = -375.17 mm3; 95% CI, -680.10 to -70.24 mm3) volumes, but not other brain regions.

Conclusions and Relevance

In this cohort and MR study of UK Biobank participants, cataracts were associated with increased risk of dementia, especially vascular dementia, and reduced total brain volumes. These findings lend further support to the hypothesis that cataract extraction may reduce the risk for dementia.

Differentiating Prodromal Dementia with Lewy Bodies from Prodromal Alzheimer's Disease: A Pragmatic Review for Clinicians

This pragmatic review synthesises the current understanding of prodromal dementia with Lewy bodies (pDLB) and prodromal Alzheimer's disease (pAD), including clinical presentations, neuropsychological profiles, neuropsychiatric symptoms, biomarkers, and indications for disease management. The core clinical features of dementia with Lewy bodies (DLB)-parkinsonism, complex visual hallucinations, cognitive fluctuations, and REM sleep behaviour disorder are common prodromal symptoms. Supportive clinical features of pDLB include severe neuroleptic sensitivity, as well as autonomic and neuropsychiatric symptoms. The neuropsychological profile in mild cognitive impairment attributable to Lewy body pathology (MCI-LB) tends to include impairment in visuospatial skills and executive functioning, distinguishing it from MCI due to AD, which typically presents with impairment in memory. pDLB may present with cognitive impairment, psychiatric symptoms, and/or recurrent episodes of delirium, indicating that it is not necessarily synonymous with MCI-LB. Imaging, fluid and other biomarkers may play a crucial role in differentiating pDLB from pAD. The current MCI-LB criteria recognise low dopamine transporter uptake using positron emission tomography or single photon emission computed tomography (SPECT), loss of REM atonia on polysomnography, and sympathetic cardiac denervation using meta-iodobenzylguanidine SPECT as indicative biomarkers with slowing of dominant frequency on EEG among others as supportive biomarkers. This review also highlights the emergence of fluid and skin-based biomarkers. There is little research evidence for the treatment of pDLB, but pharmacological and non-pharmacological treatments for DLB may be discussed with patients. Non-pharmacological interventions such as diet, exercise, and cognitive stimulation may provide benefit, while evaluation and management of contributing factors like medications and sleep disturbances are vital. There is a need to expand research across diverse patient populations to address existing disparities in clinical trial participation. In conclusion, an early and accurate diagnosis of pDLB or pAD presents an opportunity for tailored interventions, improved healthcare outcomes, and enhanced quality of life for patients and care partners.

Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review

INTRODUCTION

We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers.

METHODS

We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings.

RESULTS

Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life.

DISCUSSION

Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.

The iceberg of dementia risk: empirical and conceptual arguments in favor of structural interventions for brain health

While pharmacological interventions for dementia struggle to demonstrate improved outcomes for patients and at-risk populations, non-pharmacological lifestyle interventions have been proposed as a tool to achieve dementia risk reduction. In this review, it is argued that lifestyle modification alone is a surface-level intervention from the point of view of fair and far-reaching dementia prevention. Below the tip of this "iceberg of dementia risk," there are living conditions and social structures that represent deeper contributions to risk in the population. It is argued that alongside lifestyle modification, activist research and structural interventions are needed to make our society fairer and more dementia-resilient.

The neuropathological landscape of Hispanic and non-Hispanic White decedents with Alzheimer disease

Despite the increasing demographic diversity of the United States' aging population, there remain significant gaps in post-mortem research investigating the ethnoracial heterogeneity in the neuropathological landscape of Alzheimer Disease (AD). Most autopsy-based studies have focused on cohorts of non-Hispanic White decedents (NHWD), with few studies including Hispanic decedents (HD). We aimed to characterize the neuropathologic landscape of AD in NHWD (n = 185) and HD (n = 92) evaluated in research programs across three institutions: University of California San Diego, University of California Davis, and Columbia University. Only persons with a neuropathologic diagnosis of intermediate/high AD determined by NIA Reagan and/or NIA-AA criteria were included. A frequency-balanced random sample without replacement was drawn from the NHWD group using a 2:1 age and sex matching scheme with HD. Four brain areas were evaluated: posterior hippocampus, frontal, temporal, and parietal cortices. Sections were stained with antibodies against Aβ (4G8) and phosphorylated tau (AT8). We compared the distribution and semi-quantitative densities for neurofibrillary tangles (NFTs), neuropil threads, core, diffuse, and neuritic plaques. All evaluations were conducted by an expert blinded to demographics and group status. Wilcoxon's two-sample test revealed higher levels of neuritic plaques in the frontal cortex (p = 0.02) and neuropil threads (p = 0.02) in HD, and higher levels of cored plaques in the temporal cortex in NHWD (p = 0.02). Results from ordinal logistic regression controlling for age, sex, and site of origin were similar. In other evaluated brain regions, semi-quantitative scores of plaques, tangles, and threads did not differ statistically between groups. Our results demonstrate HD may be disproportionately burdened by AD-related pathologies in select anatomic regions, particularly tau deposits. Further research is warranted to understand the contributions of demographic, genetic, and environmental factors to heterogeneous pathological presentations.

iCare4Me for FTD: A pilot randomized study to improve self-care in caregivers of persons with frontotemporal degeneration

Introduction

A tremendous burden is placed on frontotemporal degeneration (FTD) caregivers who sacrifice their own self-care to manage the functional impairments of their loved one, contributing to high levels of stress and depression. Health coaching provides support for coping with stress while fostering self-care behaviors. We report on preliminary evidence for efficacy of a virtual health coach intervention aimed at increasing self-care.

Methods

Thirty-one caregivers of persons with behavioral variant FTD (bvFTD) were assigned randomly to an intervention group, which included 10 coaching sessions over 6 months plus targeted health information or the control group receiving standard care augmented with the health information. Caregiver self-care (primary outcome), stress, depression, coping, and patient behavioral symptoms were collected at enrollment and 3 and 6 months. Change over time was evaluated between the intervention and control groups using linear mixed-effects models.

Results

There was a significant group-by-time interaction for self-care monitoring (t58 = 2.37, p = 0.02 and self-care confidence (t58 = 2.32, p = 0.02) on the Self-Care Inventory, demonstrating that caregivers who received the intervention improved their self-care over time. Behavioral symptoms were reduced in bvFTD patients whose caregivers received the intervention (t54 = -2.15, p = 0.03).

Discussion

This randomized controlled trial (RCT) shows promise for health coaching as a way to increase support that is urgently needed to reduce poor outcomes in FTD caregivers.