Artificial Intelligence and Technology Collaboratories: Innovating aging research and Alzheimer's care

This perspective outlines the Artificial Intelligence and Technology Collaboratories (AITC) at Johns Hopkins University, University of Pennsylvania, and University of Massachusetts, highlighting their roles in developing AI-based technologies for older adult care, particularly targeting Alzheimer's disease (AD). These National Institute on Aging (NIA) centers foster collaboration among clinicians, gerontologists, ethicists, business professionals, and engineers to create AI solutions. Key activities include identifying technology needs, stakeholder engagement, training, mentoring, data integration, and navigating ethical challenges. The objective is to apply these innovations effectively in real-world scenarios, including in rural settings. In addition, the AITC focuses on developing best practices for AI application in the care of older adults, facilitating pilot studies, and addressing ethical concerns related to technology development for older adults with cognitive impairment, with the ultimate aim of improving the lives of older adults and their caregivers. HIGHLIGHTS: Addressing the complex needs of older adults with Alzheimer's disease (AD) requires a comprehensive approach, integrating medical and social support. Current gaps in training, techniques, tools, and expertise hinder uniform access across communities and health care settings. Artificial intelligence (AI) and digital technologies hold promise in transforming care for this demographic. Yet, transitioning these innovations from concept to marketable products presents significant challenges, often stalling promising advancements in the developmental phase. The Artificial Intelligence and Technology Collaboratories (AITC) program, funded by the National Institute on Aging (NIA), presents a viable model. These Collaboratories foster the development and implementation of AI methods and technologies through projects aimed at improving care for older Americans, particularly those with AD, and promote the sharing of best practices in AI and technology integration. Why Does This Matter? The National Institute on Aging (NIA) Artificial Intelligence and Technology Collaboratories (AITC) program's mission is to accelerate the adoption of artificial intelligence (AI) and new technologies for the betterment of older adults, especially those with dementia. By bridging scientific and technological expertise, fostering clinical and industry partnerships, and enhancing the sharing of best practices, this program can significantly improve the health and quality of life for older adults with Alzheimer's disease (AD).

The Annual Wellness Visit Health Risk Assessment: Potential of Patient Portal-Based Completion and Patient-Oriented Education and Support

Background and Objectives

Patient portals are secure online platforms that allow patients to perform electronic health management tasks and engage in bidirectional information exchange with their care team. Some health systems administer Medicare Annual Wellness Visit (AWV) health risk assessments through the patient portal. Scalable opportunities from portal-based administration of risk assessments are not well understood. Our objective is 2-fold-to understand who receives vs misses an AWV and health risk assessment and explore who might be missed with portal-based administration.

Research Design and Methods

This is an observational study of electronic medical record and patient portal data (10/03/2021-10/02/2022) for 12 756 primary care patients 66+ years from a large academic health system.

Results

Two-thirds (n = 8420) of older primary care patients incurred an AWV; 81.0% of whom were active portal users. Older adults who were active portal users were more likely to incur AWV than those who were not, though portal use was high in both groups (81.0% with AWV vs 76.8% without; p < .001). Frequently affirmative health risk assessment categories included falls/balance concerns (44.2%), lack of a documented advanced directive (42.3%), sedentary behaviors (39.9%), and incontinence (35.1%). Mean number of portal messages over the 12-month observation period varied from 7.2 among older adults affirmative responses to concerns about safety at home to 13.8 for older adults who reported difficulty completing activities of daily living. Portal messaging varied more than 2-fold across affirmative health risk categories and were marginally higher with greater number affirmative (mean = 13.8 messages/year no risks; 19.6 messages/year 10+ risks).

Discussion and Implications

Most older adults were active portal users-a group more likely to have incurred a billed AWV. Efforts to integrate AWV risk assessments in the patient portal may streamline administration and scalability for dissemination of tailored electronically mediated preventive care but must attend to equity issues.

Dementia and Hearing Aid Use and Cessation: A National Study

PURPOSE

The current standard for management of hearing loss in the United States involves the use of a hearing aid. Anecdotal evidence suggests that the use of a hearing aid may be less effective in the context of dementia, though national data on use and cessation are not described.

METHOD

This longitudinal analysis of the National Health and Aging Trends Study followed participants who self-reported hearing aid use to estimate risk of hearing aid cessation over 9 years. We examine whether hearing aid cessation differs by dementia status using generalized estimating equations logistic regression accounting for loss to follow-up. Supplemental analyses were undertaken to examine the contribution of caregiving and environmental factors on hearing aid cessation.

RESULTS

Of 1,310 older adults who reported hearing loss (25% 80-84 years, 51% women, 74% White), 22% with dementia and 57% baseline hearing aid use. Dementia increased likelihood of ceasing hearing aid use during the first year after adoption (OR = 2.07, 95% CI [1.33, 3.23], p interaction = .11). In later years, older adults with either a previous or recent diagnosis of dementia had a 95% higher odds of hearing aid cessation (OR = 1.95, 95% CI [1.31, 2.90]), a decrease in odds with respect to the first year after adoption, when compared to participants without dementia, after adjusting for demographic, health, and economic factors. Economic and social factors that may influence care demands (more caregivers, income-to-poverty ratio, and additional insurance) increased likelihood for cessation for those with dementia.

CONCLUSIONS

Older adults with (vs. without) dementia are more likely to cease hearing aid use over time, most notably during the first year after adoption. Strategies to support hearing ability, such as self-management or care partner education, may improve communication for those living with co-occurring hearing loss and dementia.

Navigating and diagnosing cognitive frailty in research and clinical domains

While physical frailty has been recognized as a clinical entity for some time, the concept of cognitive frailty (CF) is now gaining increasing attention in the geriatrics research community. CF refers to the co-occurrence of physical frailty and cognitive impairment in older adults, which has been suggested as a potential precursor to both dementia and adverse physical outcomes. However, this condition represents a challenge for researchers and clinicians, as there remains a lack of consensus regarding the definition and diagnostic criteria for CF, which has limited its utility. Here, using insights from both the physical frailty literature and cognitive science research, we describe emerging research on CF. We highlight areas of agreement as well as areas of confusion and remaining knowledge gaps, and provide our perspective on fine-tuning the current construct, aiming to stimulate further discussion in this developing field.

Multiscale architecture for fast optical addressing and control of large-scale qubit arrays

This paper presents a technique for rapid site-selective control of the quantum state of particles in a large array using the combination of a fast deflector (e.g., an acousto-optic deflector) and a relatively slow spatial light modulator (SLM). The use of SLMs for site-selective quantum state manipulation has been limited due to slow transition times that prevent rapid, consecutive quantum gates. By partitioning the SLM into multiple segments and using a fast deflector to transition between them, it is possible to substantially reduce the average time increment between scanner transitions by increasing the number of gates that can be performed for a single SLM full-frame setting. We analyzed the performance of this device in two different configurations: In configuration 1, each SLM segment addresses the full qubit array; in configuration 2, each SLM segment addresses a subarray and an additional fast deflector positions that subarray with respect to the full qubit array. With these hybrid scanners, we calculated qubit addressing rates that are tens to hundreds of times faster than using an SLM alone.

Characterization of Balance Control and Postural Stability in Patients With Alzheimer Disease

Balance in Alzheimer disease (AD) patients is not rigorously understood. In this study, we characterize balance using qualitative [Berg Balance Scale (BBS)] and quantitative measures (posturography) and assess relationships between qualitative and quantitative balance measures in AD. Patients with mild-moderate AD (n=48) were recruited. BBS scores and posturography metrics, including medial-lateral sway range, anterior-posterior sway range, sway area, and sway velocity, were assessed in eyes-open and eyes-closed conditions. Adjusted linear regressions were used to assess relationships between posturography and BBS score. Mean BBS score was 50.4±5.3. In eyes-open conditions, posturography and BBS score were not significantly associated. In eyes-closed conditions, better BBS score was significantly associated with lower sway area (β=-0.91; P =0.006). Better scores of BBS items involving turning and reduced base of support were associated with greater eyes-closed sway area. Posturography in the more challenging eyes-closed condition may predict functional balance deficits in AD patients.

The role of care partners in medical visits of older adults with hearing loss and dementia: A national study

BACKGROUND

Dementia and hearing loss (HL) are conditions, which restrict communication ability and amplify the difficulty of implementing effective care coordination and communication with medical providers. We examined how the presence of HL and dementia influence communication with medical providers, and the role of involved care partners during medical visits.

METHODS

Drawing on responses from 7070 community-dwelling older adults who participated in the 2015 National Health and Aging Trends Study, we used logistic regression to quantify care partner accompaniment to medical visits and the role care partners assume during visits by older adult hearing and dementia status.

RESULTS

Nearly 4 in 10 older adults with dementia also reported HL. Eighty-two percent of older adults with both HL and dementia were accompanied to medical visits by a care partner. Those with HL and dementia were six times more likely to be accompanied by a care partner to medical visits than those with neither condition (OR: 6.04; 95% CI:4.06, 8.99). Care partners of older adults with both (vs neither) HL and dementia were more actively engaged in: (1) facilitating understanding between the older adult and doctor (OR: 4.55, 95% CI:2.68, 7.71); (2) asking or telling the doctor information (OR: 6.13, 95% CI:3.44, 10.9); and (3) reminding the older adult of their questions (OR: 2.52, 95% CI: 1.66, 3.83).

CONCLUSIONS

Care partners have an active role during medical visits of older adults with HL and dementia. Efforts to support care partner engagement and teach advocacy skills may close gaps in care quality for the subgroup of older adults who are living with HL and dementia.

Warming signals in temperate reef communities following more than a decade of ecological stability

Ecosystem structure and function are increasingly threatened by changing climate, with profound effects observed globally in recent decades. Based on standardized visual censuses of reef biodiversity, we describe 27 years of community-level change for fishes, mobile macroinvertebrates and macroalgae in the Tasmanian ocean-warming hotspot. Significant ecological change was observed across 94 reef sites (5-10 m depth range) spanning four coastal regions between three periods (1992-95, 2006-07, 2017-19), which occurred against a background of pronounced sea temperature rise (+0.80°C on average). Overall, fish biomass increased, macroinvertebrate species richness and abundance decreased and macroalgal cover decreased, particularly during the most recent decade. While reef communities were relatively stable and warming was slight between the 1990s and mid-2000s (+0.12°C mean temperature rise), increased abundances of warm affinity fishes and invertebrates accompanied warming during the most recent decade (+0.68°C rise). However, significant rises in the community temperature index (CTI) were only found for fishes, invertebrates and macroalgae in some regions. Coastal warming was associated with increased fish biomass of non-targeted species in fished zones but had little effect on reef communities within marine reserves. Higher abundances of larger fishes and lobsters inside reserves appeared to negate impacts of 'thermophilization'.

HEARING LOSS, HEARING AID USE, AND NEUROPSYCHIATRIC SYMPTOMS IN DEMENTIA: FINDINGS FROM NACC

Hearing loss is highly prevalent among persons living with dementia (PWD) and associated with an increased risk of neuropsychiatric symptoms (NPS), while hearing aid use may be protective. We analyzed data from the National Alzheimer’s Coordinating Center’s (NACC) uniform data set. We estimated the association between hearing loss and number or severity of NPS in a negative binomial regression adjusting for demographic and clinical characteristics. In the subsample with hearing loss, we estimated the association between hearing aid use and number or severity of NPS.10,054 participants were included with a mean age of 75 years. 2,416 (24%) self-reported hearing loss with 71% reporting 2+ NPS. In PWD and hearing loss, 1,325 (54.8%) reported hearing aid use. After a well-balanced matching, in adjusted models, hearing aid use was associated with fewer (IRR=0.82; 95%CI=0.77,0.87) and less severe NPS (IRR=0.74; 95%CI=0.69,0.80). Hearing aid use may represent an underutilized, non-pharmacological intervention to address NPS.

Vestibular therapy to reduce falls in people with Alzheimer's disease: study protocol for a pilot randomized controlled trial

BACKGROUND

Falls are highly common in patients with Alzheimer's disease (AD); around two-thirds of AD patients fall annually. Fall events are major drivers of injury, early institutionalization, and shorter survival. Balance and mobility impairment are among the most important fall risk factors in AD patients. Vestibular therapy (VT) is an effective rehabilitation intervention in improving balance and fall risk through vestibular function, but not often used in AD. We want to evaluate the feasibility of using VT to reduce falls and improve balance function in patients with AD and drive use of an existing, potentially beneficial therapy in a patient population whose high level of vestibular deficits is currently unaddressed.

METHODS

The proposed pilot clinical trial will be a parallel-group randomized controlled trial. Patients with a diagnosis of mild-moderate AD, age ≥ 60, and the presence of a caregiver will be recruited from the Johns Hopkins Memory and Alzheimer's Treatment Center. Eligible patients will be offered vestibular testing. Patients with vestibular loss will be offered participation in the VT trial. One-hundred AD patients with vestibular loss will be enrolled and randomized 1:1 into the control and intervention arms of the trial. All patients will undergo baseline balance and cognitive assessment, followed by 8 weeks of active control therapy or VT, consisting of ~25-min office sessions with a vestibular therapist. Patients will be tracked for falls and undergo follow-up balance and cognitive assessment at 8 and 52 weeks (1 year) to assess the potential short-term and longer-term effects, respectively, of VT on balance and cognition. The main outcomes of this trial are falls, balance (using the Berg Balance Scale and the Timed Up and Go test), and cognition (using the clock drawing test, the Card Rotations test, the Money Road Map test, and the triangle completion task).

DISCUSSION

As the population ages and the number of individuals with AD in the US grows to a projected 14 million in 2050, managing falls in AD will continue to grow as a critical public health concern; this trial assesses feasibility of a potential solution.

TRIAL REGISTRATION

ClinicalTrial.Gov identifier - NCT03799991 . Registered 01 August 2019.

Perceptions of and Experiences with Consumer Sleep Technologies That Use Artificial Intelligence

This study aims to assess the perspectives and usability of different consumer sleep technologies (CSTs) that leverage artificial intelligence (AI). We answer the following research questions: (1) what are user perceptions and ideations of CSTs (phase 1), (2) what are the users' actual experiences with CSTs (phase 2), (3) and what are the design recommendations from participants (phases 1 and 2)? In this two-phase qualitative study, we conducted focus groups and usability testing to describe user ideations of desires and experiences with different AI sleep technologies and identify ways to improve the technologies. Results showed that focus group participants prioritized comfort, actionable feedback, and ease of use. Participants desired customized suggestions about their habitual sleeping environments and were interested in CSTs+AI that could integrate with tools and CSTs they already use. Usability study participants felt CSTs+AI provided an accurate picture of the quantity and quality of sleep. Participants identified room for improvement in usability, accuracy, and design of the technologies. We conclude that CSTs can be a valuable, affordable, and convenient tool for people who have issues or concerns with sleep and want more information. They provide objective data that can be discussed with clinicians.

Vestibular Function Predicts Balance and Fall Risk in Patients with Alzheimer's Disease

BACKGROUND

Patients with Alzheimer's disease (AD) are at high risk for falls. Vestibular dysfunction predicts balance impairment in healthy adults; however, its contribution to falls in patients with AD is not well known.

OBJECTIVE

The objective of this study was to assess whether vestibular function contributes to balance and fall risk in patients with AD.

METHODS

In this prospective observational study, we assessed vestibular function using measures of semicircular canal (vestibulo-ocular reflex (VOR) gain) and saccular function (cervical vestibular-evoked myogenic (cVEMP) response), and we assessed balance function using the Berg Balance Scale and quantitative posturography. We evaluated falls incidence for a mean 1-year follow-up period (range 3-21 months) in 48 patients with mild-moderate AD.

RESULTS

Relative to matched controls, AD patients exhibited increased medio-lateral (ML) sway in eyes-open (0.89 cm versus 0.69 cm; p = 0.033) and eyes-closed (0.86 cm versus 0.65 cm; p = 0.042) conditions. Among AD patients, better semicircular canal function was associated with lower ML sway and antero-posterior (AP) sway in the eyes-closed condition (β= -2.42, 95% CI (-3.89, -0.95), p = 0.002; β= -2.38, 95% CI (-4.43, -0.32), p = 0.025, respectively). Additionally, better saccular function was associated with lower sway velocity (β= -0.18, 95% CI (-0.28, -0.08); p = 0.001). Finally, we observed that better semicircular canal function was significantly associated with lower likelihood of falls when adjusted for age, sex, and MMSE score (HR = 0.65; p = 0.009).

CONCLUSION

These results support the vestibular system as an important contributor to balance and fall risk in AD patients and suggest a role for vestibular therapy.

Domains of delirium severity in Alzheimer's disease and related dementias

BACKGROUND

The ability to rate delirium severity is key to providing optimal care for persons with Alzheimer's Disease and Related Dementias (ADRD). Such ratings would allow clinicians to assess response to treatment, recovery time and prognosis, nursing burden and staffing needs, and to provide nuanced, appropriate patient-centered care. Given the lack of existing tools, we defined content domains for a new delirium severity instrument for use in individuals with mild to moderate ADRD, the DEL-S-AD.

METHODS

We built upon our previous study in which we created a content domain framework to inform development of a general delirium severity instrument, the DEL-S. We engaged a new expert panel to discuss issues of measurement in delirium and dementia and to determine which content domains from the prior framework were useful in characterizing delirium severity in ADRD. We also asked panelists to identify new domains. Our panel included eight interdisciplinary members with expertise in delirium and dementia. Panelists participated in two rounds of review followed by two surveys over 2 months.

RESULTS

Panelists endorsed the same content domains as for general delirium severity, including Cognitive, Level of Consciousness, Inattention, Psychiatric-Behavioral, Emotional Dysregulation, Psychomotor Features, and Functional; however, they excluded six of the original subdomains which they considered unhelpful in the context of ADRD: cognitive impairment; anxiety; fear/sense of unease; depression; gait/walking; and incontinence. Debated measurement challenges included assessment at one point in time versus over time, accounting for differences in clinical settings, and accurate assessment of symptoms related to delirium versus dementia.

CONCLUSIONS

By capturing a range of characteristics of delirium severity potentially present in patients with ADRD, a population that may already have attention, functional, and emotional changes at baseline, the DEL-S-AD provides a novel rating tool that will be useful for clinical and research purposes to improve patient care.

Considering the Technological and Sensory Needs of Patients With Cognitive Impairment in the Era of Telehealth

During the COVID-19 pandemic, telehealth has become an important means of delivering memory care. Telehealth that is responsive to the technological abilities and preferences as well as the sensory needs of persons living with dementia is critical to advancing access to care. We conducted a systematic review to investigate the use of telehealth among older adults with cognitive impairment. The search yielded 3,551 titles and abstracts that led to 17 full-text articles. Studies showed that telehealth can be used for routine care, cognitive assessment and telerehabilitation with good efficacy and satisfaction. Three studies investigated telemedicine delivery in the home and 16/17 studies relied on support staff and care partners to navigate technology. No studies reported adaptations to account for sensory impairments and 5/17 studies excluded individuals with sensory impairments. This talk will review barriers and facilitators totelehealth for older adults with cognitive impairment and adaptations to address sensory needs.

Angiotensin Receptor Blockers Upregulate Angiotensin Type 4 Receptor in Brains of Cognitively Intact Individuals

The primary dementia-protective benefits of Angiotensin receptor type 1 (AT1R) blockers (ARBs) are believed to arise from systemic effects on blood pressure. However, there is a brain-specific renin-angiotensin system (b-RAS) that acts mainly through three receptor subtypes: AT1R, AT2R, and AT4R. AT1R promotes inflammation and oxidative stress (OS). AT2R increases nitric oxide. AT4R is essential for dopamine release and mediates memory consolidation. Here, we aimed to investigate the effects of ARBs on b-RAS, OS, inflammation, PHF-tau, and beta-amyloid load. Postmortem frontal-cortex brains of age- and sex-matched cognitively intact (CI) individuals using (n=30) and not using ARBs (n=30) and Alzheimer's disease (AD) patients using (n=30) and not using ARBs (n=30) were studied. Protein levels of receptors were measured by Western blot. Protein carbonyl (PC) and cytokine levels were measured by ELISA. Tangle and amyloid-β scores were used as outcomes. In CI individuals, our data shows that ARB treatment was associated with higher protein levels of AT4R (median(range) 0.69(1.92) vs 0.17(1.18) CI+ARBs vs CI, p=0.02), lower level of OS marker PC (10.60(8.32) vs 11.26(7.44), CI+ARBs vs CI, p=0.03) and lower hippocampal and overall amyloid scores (0(5.45) vs 1.15(4.21) p=0.03, 0.79(12.75) vs 3.41(13.36) p=0.04, CI+ARBs vs CI, respectively). In AD group, ARB treatment was associated with lower AT1R protein levels (0.47(1.15) vs 0.59(1.99), AD+ARBs vs AD, p=0.02). No significant changes were observed in OS, inflammation, or PHF-tau and amyloid load in AD brains treated with ARBs. Our results highlight the impact of ARBs on the brains of cognitively intact and AD older individuals.

Neuropsychiatric Symptoms and Hearing Loss in Dementia: Unmet Need and Opportunity for Intervention

Hearing loss is one of the most common comorbidities among persons with dementia, with prevalence of 60-&gt;90%. Most go untreated and disparities exist. However, sensory impairment may influence the health of individuals and care partners. We will share findings from a clinic-based cohort of persons with dementia (n=101). Controlling for demographic and clinical factors, we found that every 10 decibel increase in hearing loss was associated with nearly an additional neuropsychiatric symptom (b = 0.7 per 10 dB; p = 0.01) and 1.3-point increase in severity (b = 1.3 per 10 dB; p = 0.04). These findings provide the first estimates that utilize objective audiometry. Furthermore, hearing aid use appeared to be protective. Hearing care may represent an additional, but underutilized, non-pharmacological intervention. We will discuss these findings in the context of the epidemiology of hearing loss in dementia and highlight new opportunities for managing hearing loss through community-based approaches.

278 Understanding Perspectives on Artificial Intelligence Technologies for Sleep Self-Management

Introduction

Until recently, understanding one’s sleep activity relied on technology only available in sleep labs with data analyzed by experts. Transitioning this technology from the lab to natural environments results in noisy data. Fortunately, advances in signal processing through Artificial Intelligence (AI) have made these technologies accessible to consumers. This study seeks to provide recommendations that address user preferences and concerns related to sleep self-management devices and software that leverage AI, as they have the potential to increase both the quantity and quality of sleep data available to researchers.

Methods

We assigned adult participants (N=25) with Pittsburgh Sleep Quality Index scores ≥ 5 (indicating low sleep quality) to one of four focus group sessions based on their self-reported prior use of sleep technologies. After a short demonstration, the moderator solicited participant feedback on devices and software in each of the following four categories: • headbands (Beddr, Dreem 2, Muse S) • sleep tracking mats (Withings) • snoring detectors (Smart Nora) • mobile applications (Sleep Cycle Alarm Clock, Sleep Score, Do I Snore, Sleep Rate)

Results

Participants anticipated discomfort from wearing headbands and placing snoring detectors under their pillow, although a subset of participants indicated that they would be willing to sacrifice comfort in exchange for improved accuracy. Conversely, participants were interested in sleep tracking pads since they could passively collect sleep data without additional burden. Similarly, participants viewed mobile applications positively due to their ability to collect sleep data from a nightstand rather than being attached to the participant; however, there were concerns about remembering to activate these applications.

Conclusion

Based on these results, we recommend using sleep tracking mats to collect patient-generated sleep data due to their ease of use and relative comfort, the main concerns related to lab-based sleep study participation. As a passive sensor, these require the least setup and support consistent data collection. Other devices run the risk of participants forgetting to use the device or becoming removed during the night resulting in missing data. By leveraging these existing technologies for remote sleep studies, researchers can increase recruitment and accessibility to promote sleep research participant diversity.

Support (if any):

Hearing Care Disparities in Dementia: Access and Usability in the Coming Era of OTC Hearing Aids

Age-related hearing loss is highly prevalent among persons with dementia (PwDs) and is associated with an increased risk of neuropsychiatric symptoms. However, few use hearing aids and disparities exist. PwDs and, in particular, minority older adults, have some of the lowest rates of hearing aid use. Recent federal legislation created the designation of over-the-counter hearing aids, which will debut by 2020-2021, and represents an opportunity to advance accessibility. This presentation will share estimates of hearing aid use among community-dwelling PwDs from two cohorts, where hearing aid use ranges from 7-11% among African Americans versus 33-45% among whites. To explore this gap, the presentation will share findings from semi-structured interviews with care partners of PwDs and hearing loss around barriers and facilitators of hearing care, including device usability. With growing understanding of sensory health, a changing hearing care landscape represents a critical opening to increase access to hearing care for PwDs. Part of a symposium sponsored by the Alzheimer’s Disease Research Interest Group.

Circulating Cell-Free DNA Is Associated With Cognitive Outcomes

Cell death is a mechanism by which aging tissues are able to maintain homeostasis. DNA of nuclear and mitochondrial origin is released into circulation following apoptosis or necroptosis and can be quantified in the blood as circulating cell-free DNA (ccf-DNA). We hypothesized that higher levels of ccf-DNA would be associated with worse cognitive function. Ultra-sensitive digital PCR was used to measure ccf-DNA in participants from the Rush Alzheimer’s Disease Center Religious Orders Study/Memory and Aging Project. Global cognitive function was derived from a composite of 19 tests on a neuropsychiatric battery. A total of 885 ccf-DNA samples were analyzed from N=624 participants. Generalized estimating equations were used to estimate the cross-sectional association between ccf-DNA and global cognition scores, while latent growth models were used to estimate the longitudinal association between ccf-DNA and global cognition scores. Multinomial logistic regression was used to estimate the odds of having mild cognitive impairment (MCI) or dementia at last study visit relative to normal cognition, based on levels of ccf-DNA. Higher ccf-DNA levels were associated with lower global cognition score (-0.10, [-0.18, -0.02]) cross-sectionally. Each 1-standard deviation increase in ccf-DNA was associated with more rapidly declining global cognitive function over time (-0.11, [-0.19, -0.03]). A dose-response relationship was observed between increasing levels of ccf-DNA and odds of MCI (odds ratio [OR] = 1.08, [0.83, 1.41]) and dementia (OR = 1.29, [1.06, 1.57]). Our results suggest that ccf-DNA may serve as a biomarker of global cognitive decline and dementia risk.

Generation and characterization of a novel human iPSC line from a resilient Alzheimer's disease patient

Alzheimer's disease (AD) is a progressive neurodegenerative disease that is the major cause of dementia in older people. Here, we report the derivation of human induced pluripotent stem cells (iPSCs) from an AD patient at age of 80 who has the APOE ε4/ε4 genotype and is resilient to cognitive decline for 10 years. The iPSCs reprogrammed from the blood cells of this patient by transient expression of pluripotency genes maintain the ε4/ε4 genotype, are karyotypically normal and display typical iPSC characteristics. Upon differentiation, the iPSCs are able to differentiate into cells of the three germ layers, confirming their pluripotency.

Combined effects of sous-vide cooking conditions on meat and sensory quality characteristics of chicken breast meat

This study investigated the combined effects of cooking temperature and time on the meat and eating quality characteristics of the sous-vide chicken breast. For the control group, chicken breast samples were cooked in a convection oven until the internal temperature reached 71°C. Each sample for sous-vide cooking was vacuum packaged and then cooked under continuous thermocontrolled conditions in a water bath at 6 combinations of cooking temperature (60 and 70°C) and time (1, 2, and 3 h). Sous-vide cooked chicken meat at 60°C for 1 h (SV60-1h) showed lower cooking loss (6.58 vs. 26.5%, P < 0.05), Warner-Bratzler shear force (21.7 vs. 29.1 N, P < 0.05), and hardness (9.40 vs. 17.3 N, P < 0.05) than meat cooked by conventional oven. Similar to the objective tenderness parameters, cooked chicken meat from the SV60 treatments for all cooking times showed higher scores in all the tenderness attributes than the control group (P < 0.05). However, a higher flavor intensity was observed in the SV70-3h and control groups than in the SV60 treatments (P < 0.05). Owing to a lesser developed flavor in chicken meat from the SV60-1h treatment, the SV60-2h and 3h treatments were assigned a higher acceptability rating for overall impression (P < 0.05). Therefore, cooking temperature and time of sous-vide significantly influenced the physicochemical and palatability characteristics of chicken breast. In this study, the optimum conditions for the sous-vide chicken breast are to continuously cook at 60°C for 2 to 3 h to improve sensory quality characteristics without reducing the water-holding capacity.

The origin and nature of the complex autoantibody profile in cerebrospinal fluid

The present study demonstrates, using human protein microarrays and plasma and cerebrospinal fluid samples obtained pre-surgically and simultaneously from 46 hip fracture repair patients, that CSF exhibits an extraordinarily complex IgG autoantibody profile composed of thousands of autoantibodies. We show that the pattern of expression levels of individual autoantibodies in CSF closely mimics that in the blood, regardless of age, gender or the presence or absence of disease, indicative of a blood-based origin for CSF autoantibodies. In addition, using five longitudinal serum samples obtained from one healthy individual over a span of nine years, we found that blood autoantibody profiles are remarkably stable over a long period of time, and that autoantibody profiles in both blood and CSF show features that are common among different individuals as well as individual-specific. Lastly, we demonstrate that an elevated CSF/plasma autoantibody ratio is more common in elderly hip fracture repair patients that experienced post-operative delirium than in non-delirium subjects, thus highlighting the crucial role that blood-brain and/or blood-CSF barrier compromise may play in the development of post-operative delirium.

Synthetic chimeric nucleases function for efficient genome editing

CRISPR-Cas systems have revolutionized genome editing across a broad range of biotechnological endeavors. Many CRISPR-Cas nucleases have been identified and engineered for improved capabilities. Given the modular structure of such enzymes, we hypothesized that engineering chimeric sequences would generate non-natural variants that span the kinetic parameter landscape, and thus provide for the rapid selection of nucleases fit for a particular editing system. Here, we design a chimeric Cas12a-type library with approximately 560 synthetic chimeras, and select several functional variants. We demonstrate that certain nuclease domains can be recombined across distantly related nuclease templates to produce variants that function in bacteria, yeast, and human cell lines. We further characterize selected chimeric nucleases and find that they have different protospacer adjacent motif (PAM) preferences and the M44 chimera has higher specificity relative to wild-type (WT) sequences. This demonstration opens up the possibility of generating nuclease sequences with implications across biotechnology.

Detection of early-stage Alzheimer's pathology using blood-based autoantibody biomarkers in elderly hip fracture repair patients

Post-operative delirium (POD) is the most common complication following major surgery in non-demented older (>65 y/o) patients. Patients experiencing POD show increased risk for future cognitive decline, including mild cognitive impairment (MCI) and Alzheimer’s disease (AD) and, conversely, patients with cognitive decline at surgery show increased risk for POD. Here, we demonstrate that a previously established panel of AD-driven MCI (ADMCI) autoantibody (aAB) biomarkers can be used to detect prodromal AD pre-surgically in individuals admitted into the hospital for hip fracture repair (HFR) surgery. Plasma from 39 STRIDE (STRIDE: A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients) HFR patients and sera from 25 age- and sex-matched non-demented and non-surgical controls were screened using human protein microarrays to measure expression of a panel of 44 previously identified MCI aAB biomarkers. The predictive classification accuracy of the aAB biomarker panel was evaluated using Random Forest (RF). The ADMCI aAB biomarkers successfully distinguished 21 STRIDE HFR patients (CDR = 0.5) from 25 matched non-surgical controls with an overall accuracy of 91.3% (sensitivity = 95.2%; specificity = 88.0%). The ADMCI aAB panel also correctly identified six patients with preoperative CDR = 0 who later converted to CDR = 0.5 or >1 at one-year follow-up. Lastly, the majority of cognitively normal (CDR = 0) STRIDE HFR subjects that were positive for CSF AD biomarkers based on the A/T/N classification system were likewise classified as ADMCI aAB-positive using the biomarker panel. Results suggest that pre-surgical detection of ADMCI aAB biomarkers can readily identify HFR patients with likely early-stage AD pathology using pre-surgery blood samples, opening up the potential for early, blood-based AD detection and improvements in peri- and postoperative patient management.

P4580The effect of anesthetic techniques on cardiac troponin-T after non-cardiac surgery

Background

The effects of anesthetics on cardiac protection and clinical outcomes have shown conflicting results in patients undergoing non-cardiac surgery. Unlike cardiac surgeries in which cardio-protective effects of anesthetic techniques have been reported, it lacks evidence and reproducibility in non-cardiac surgery. A current generation high-sensitivity cardiac troponin (hs-cTnI) is known to detect perioperative myocardial injury in non-cardiac surgery which is closely related to clinical outcomes. In this study, we hypothesized that balanced anesthesia using both remifentanil and volatile agents is the most effective in reducing postoperative myocardial injury, and compared the incidence of postoperative myocardial injury among different types of general anesthesia.

Methods

We analyzed the data of 3555 patients who underwent general anesthesia for non-cardiac surgery in our hospital between February 2010 and December 2016. In all patients, hs-cTnI was detected in preoperative period and postoperative period within 48 hours. Major exclusion criteria was troponin elevation before surgery. Patients were stratified into three groups; 661 patients who were received propofol-remifentanil total intravenous anesthesia (TIVA group), 1279 patients who were received volatile anesthesia without remifentanil (Volatile group) and 1622 patients who were received volatile anesthesia with remifentanil (Balanced group). The Primary outcome was troponin elevation [hs-cTnI≥0.04 ng/mL] within post-operative within 48 hours, and the incidence of postoperative complications such as postoperative acute kidney injury, new-onset atrial fibrillation and in-hospital mortality were also compared.

Results

The occurrence of myocaridial injury were significant difference between three groups. The occurrence of myocardial injury was significantly lower in the Balanced group than in Volatile group after adjustment (Odds ratio (OR) = 0.727; 95% confidence interval (CI) = 0.59–0.89; P-value = 0.002). Balanced group and TIVA group showed comparable results in risk of postoperative troponin elevation after adjustment (OR 1.131; 95% CI 0.96–1.33; P-value = 0.133). The incidence of troponin elevation was significantly higher in Volatile group than TIVA group after adjustment (OR 1.6; 95% CI 0.52–0.96; P-value = 0.005). The incidence of AKI was significantly lower in Balanced group than Volatile group after adjustment (OR 0.637; 95% CI 0.49–0.81; P-value <0.001).

Conclusion

The remifentanil combination during general anesthesia may be associated with myocardial protection effect in patients undergoing non-cardiac surgery. Whether this impact leads to adverse long-term outcome remains unclear, and requires further investigation.

Presbyvestibulopathy: Diagnostic criteria Consensus document of the classification committee of the Bárány Society

This paper describes the diagnostic criteria for presbyvestibulopathy (PVP) by the Classification Committee of the Bárány Society. PVP is defined as a chronic vestibular syndrome characterized by unsteadiness, gait disturbance, and/or recurrent falls in the presence of mild bilateral vestibular deficits, with findings on laboratory tests that are between normal values and thresholds established for bilateral vestibulopathy.

The diagnosis of PVP is based on the patient history, bedside examination and laboratory evaluation. The diagnosis of PVP requires bilaterally reduced function of the vestibulo-ocular reflex (VOR). This can be diagnosed for the high frequency range of the VOR with the video-HIT (vHIT); for the middle frequency range with rotary chair testing; and for the low frequency range with caloric testing.

For the diagnosis of PVP, the horizontal angular VOR gain on both sides should be < 0.8 and > 0.6, and/or the sum of the maximal peak velocities of the slow phase caloric-induced nystagmus for stimulation with warm and cold water on each side should be < 25°/s and > 6°/s, and/or the horizontal angular VOR gain should be > 0.1 and < 0.3 upon sinusoidal stimulation on a rotatory chair.

PVP typically occurs along with other age-related deficits of vision, proprioception, and/or cortical, cerebellar and extrapyramidal function which also contribute and might even be required for the manifestation of the symptoms of unsteadiness, gait disturbance, and falls. These criteria simply consider the presence of these symptoms, along with documented impairment of vestibular function, in older adults.

A Precision Medicine Model for Targeted NSAID Therapy in Alzheimer's Disease

BACKGROUND

To date, the therapeutic paradigm for Alzheimer's disease (AD) has focused on a single intervention for all patients. However, a large literature in oncology supports the therapeutic benefits of a precision medicine approach to therapy. Here we test a precision-medicine approach to AD therapy.

OBJECTIVE

To determine if a baseline, blood-based proteomic companion diagnostic predicts response to NSAID therapy.

METHODS

Proteomic assays of plasma from a multicenter, randomized, double-blind, placebo-controlled, parallel group trial, with 1-year exposure to rofecoxib (25 mg once daily), naproxen (220 mg twice-daily) or placebo.

RESULTS

474 participants with mild-to-moderate AD were screened with 351 enrolled into the trial. Using support vector machine (SVM) analyses, 89% of the subjects randomized to either NSAID treatment arms were correctly classified using a general NSAID companion diagnostic. Drug-specific companion diagnostics yielded 98% theragnostic accuracy in the rofecoxib arm and 97% accuracy in the naproxen arm.

CONCLUSION

Inflammatory-based companion diagnostics have significant potential to identify select patients with AD who have a high likelihood of responding to NSAID therapy. This work provides empirical support for a precision medicine model approach to treating AD.

Before Hospice: Symptom Burden, Dementia, and Social Participation in the Last Year of Life

Background: Little is known about clinical symptom burden, dementia, and social isolation in the last year of life among older adults. Objective: To describe and contrast the type and severity of symptom burden for older decedents with and without dementia, and whether specific symptoms and presence of dementia are associated with limitations in social participation in the last year of life. Design: Cross-sectional logistic regression analysis of a population-based study. Setting/Subjects: A total of 1270 community-dwelling adults of age ≥65 years in the United States participated in the 2011 National Health and Aging Trends Study and died by 2015. Measurements: Dementia status, 13 clinical symptoms, and limitations in 6 social activities were drawn from the interview preceding death. Severity of sensory, physical, and psychiatric symptom burden was examined in tertiles. Results: Decedents with dementia (37.3%) had higher prevalence of all symptoms (p's < 0.05), except insomnia and breathing problems. Dementia was associated with greater likelihood of high versus low burden of sensory (odds ratio [OR] 4.52 [95% confidence interval {CI} 3.08-6.63]), physical (OR 3.49 [95% CI 2.48-4.91]), and psychiatric (OR 2.80 [95% CI 1.98-3.95]) symptoms. Dementia and physical symptoms (problems with speaking, leg strength/movement, and balance) were independently associated with limitations in at least three social activities (p's < 0.05 for adjusted ORs). Conclusion: Symptom burden is higher in patients with dementia. Dementia and physical symptoms are associated with social activity limitations. Older patients with dementia or physical symptoms may benefit from earlier emphasis on palliative care and quality of life.

Bayesian Model Averaging for Selection of a Risk Prediction Model for Death within Thirty Days of Discharge: The SILVER-AMI Study

We describe a selection process for a multivariable risk prediction model of death within 30 days of hospital discharge in the SILVER-AMI study. This large, multi-site observational study included observational data from 2000 persons 75 years and older hospitalized for acute myocardial infarction (AMI) from 94 community and academic hospitals across the United States and featured a large number of candidate variables from demographic, cardiac, and geriatric domains, whose missing values were multiply imputed prior to model selection. Our objective was to demonstrate that Bayesian Model Averaging (BMA) represents a viable model selection approach in this context. BMA was compared to three other backward-selection approaches: Akaike information criterion, Bayesian information criterion, and traditional p-value. Traditional backward-selection was used to choose 20 candidate variables from the initial, larger pool of five imputations. Models were subsequently chosen from those candidates using the four approaches on each of 10 imputations. With average posterior effect probability ≥ 50% as the selection criterion, BMA chose the most parsimonious model with four variables, with average C statistic of 78%, good calibration, optimism of 1.3%, and heuristic shrinkage of 0.93. These findings illustrate the utility and flexibility of using BMA for selecting a multivariable risk prediction model from many candidates over multiply imputed datasets.

A Practice Improvement Project to Increase Advance Care Planning in a Dementia Specialty Practice

This study was conducted to enhance the rate of advance care planning (ACP) conversations and documentation in a dementia specialty practice by increasing physician knowledge, attitudes, and skills. We used a pre- and postintervention paired design for physicians and 2 independent groups for patients. The ACP dementia educational program encompassed 3 objectives: (1) to understand the relevance of ACP to the dementia specialty practice, (2) to provide a framework to discuss ACP with patients and caregivers, and (3) to discuss ways to improve ACP documentation and billing in the electronic medical record. A 10-item survey was utilized pre- and posteducational intervention to assess knowledge, attitudes, and skill. The prevalence of ACP documentation was assessed through chart review 3 months pre- and postintervention. The educational intervention was associated with increased confidence in ability to discuss ACP ( P = .033), belief that ACP improves outcomes in dementia ( P = .035), knowledge about ACP Medicare billing codes and requirements ( P = .002), and belief that they have support from other personnel to implement ACP ( P = .017). In 2 independent groups of patients with dementia, documentation rates of an advance directive increased from 13.6% to 19.7% ( P = .045) and the Medical Order for Life-Sustaining Treatment (MOLST) increased from 11.0% to 19.0% ( P = .006). The MOLST documentation in 2 independent groups of patients with nondementia increased from 7.3% to 10.7% ( P = .046). Continuing efforts to initiate educational interventions are warranted to increase the effectiveness ACP documentation and future care of persons with dementia.

Assessment of Instruments for Measurement of Delirium Severity: A Systematic Review

Importance

Measurement of delirium severity has been recognized as highly important for tracking prognosis, monitoring response to treatment, and estimating burden of care for patients both during and after hospitalization. Rather than simply rating delirium as present or absent, the ability to quantify its severity would enable development and monitoring of more effective treatment approaches for the condition.

Objectives

To present a comprehensive review of delirium severity instruments, conduct a methodologic quality rating of the original validation study of the most commonly used instruments, and select a group of top-rated instruments.

Evidence Review

This systematic review was conducted using literature from Embase, PsycINFO, PubMed, Web of Science, and Cumulative Index to Nursing and Allied Health Literature, from January 1, 1974, through March 31, 2017, with the key words delirium, severity, tests, measures, and intensity. Inclusion criteria were original articles assessing delirium severity and using a delirium-specific severity instrument. Final listings of articles were supplemented with hand searches of reference listings to ensure completeness. At least 2 reviewers independently completed each step of the review process: article selection, data extraction, and methodologic quality assessment of relevant articles using a validated rating scale. All discrepancies between raters were resolved by consensus.

Findings

Of 9409 articles identified, 228 underwent full text review, and we identified 42 different instruments of delirium severity. Eleven of the 42 tools were multidomain, delirium-specific instruments providing a quantitative rating of delirium severity; these instruments underwent a methodologic quality review. Applying prespecified criteria related to frequency of use, methodologic quality, construct or predictive validity, and broad domain coverage, an expert panel used an iterative modified Delphi process to select 6 final high-quality instruments meeting these criteria: the Confusion Assessment Method-Severity Score, Confusional State Examination, Delirium-O-Meter, Delirium Observation Scale, Delirium Rating Scale, and Memorial Delirium Assessment Scale.

Conclusions and Relevance

The 6 instruments identified may enable accurate measurement of delirium severity to improve clinical care for patients with this condition. This work may stimulate increased usage and head-to-head comparison of these instruments.

A Review of Diagnostic Impact of Amyloid Positron Emission Tomography Imaging in Clinical Practice

BACKGROUND

Molecular imaging of brain amyloid for the diagnosis of Alzheimer's disease (AD) using positron emission tomography (PET) has been approved for use in clinical practice by the Food and Drug Administration (FDA) since 2012. However, the clinical utility and diagnostic impact of amyloid PET imaging remain controversial. We conducted a review of the recent studies investigating clinical utility of amyloid PET imaging with focus on changes in diagnosis, diagnostic confidence, and patient management.

SUMMARY

A total of 16 studies were included in the final analysis. Overall rate of changes in diagnosis after amyloid PET ranged from 9 to 68% (pooled estimate of 31%, 95% CI 23-39%). All studies reported overall increase in diagnostic confidence or diagnostic certainty after amyloid PET. Changes in patient management ranged from 37 to 87%; the most common type of change in management reported was either the initiation or discontinuation of planned AD medications. Key Messages: Amyloid PET imaging led to moderate to significant changes in diagnosis, diagnostic confidence, and subsequent patient management. It may be most useful in patients with high level of diagnostic uncertainty even after the completing the standard workup.

Utility of the laryngeal handshake method for identifying the cricothyroid membrane

BACKGROUND

The cricothyroid membrane is the most commonly accessed location for invasive surgical airway. Although the laryngeal handshake method is recommended for identifying the cricothyroid membrane, there is no clinical data regarding the utility of the laryngeal handshake method in cricothyroid membrane identification. The objective of this study was to compare the accuracy of cricothyroid membrane identification between the laryngeal handshake method and simple palpation.

METHODS

After anaesthesia induction, the otorhinolaryngology resident and anaesthesia resident identified and marked the needle insertion point for cricothyroidotomy using simple palpation and the laryngeal handshake method, respectively. The cricothyroid membrane was confirmed with ultrasonography. Identification was determined successful if the marked point was placed within the longitudinal area of the cricothyroid membrane and within 5 mm from midline transversely. The accuracy of cricothyroid membrane identification using the laryngeal handshake method and simple palpation was compared.

RESULTS

A total of 123 patients were enrolled. The cricothyroid membrane was correctly identified in 87 (70.7%, 95% confidence interval 61.8-78.6%) patients using the laryngeal handshake method compared to 78 (63.4%, 95% confidence interval 54.3-71.9%) patients using simple palpation (P = .188). The time required to identify the cricothyroid membrane was longer when using the laryngeal handshake method (15 [3-48] seconds vs 10.9 [3-55] seconds, P = .003).

CONCLUSION

The success rate of identifying the cricothyroid membrane was similar among the anesthesiologists who performed the laryngeal handshake method and also among otorhinolaryngologists who used simple palpation.

Characterization of 3 Novel Tau Radiopharmaceuticals, 11C-RO-963, 11C-RO-643, and 18F-RO-948, in Healthy Controls and in Alzheimer Subjects

¹¹C-RO-963, ¹¹C-RO-643, and ¹⁸F-RO-948 (previously referred to as ¹¹C-RO6924963, ¹¹C-RO6931643, and ¹⁸F-RO6958948, respectively) have been reported as promising PET tracers for tau imaging based on in vitro and preclinical PET data. Here we describe the first, to our knowledge, human evaluation of these novel radiotracers. Methods: Amyloid PET-positive Alzheimer disease (AD) subjects and younger controls each received 2 different tau tracers. Dynamic 90-min scans were obtained after bolus injection of ¹¹C-RO-963, ¹¹C-RO-643, or ¹⁸F-RO-948. Arterial blood sampling was performed on 11 healthy controls and 11 AD subjects. Regions were defined on MR images, and PET data were quantified by plasma reference graphical analysis (for total distribution volume) and target cerebellum ratio (SUV ratios of 60- to 90-min frames). SUV ratio images were also analyzed voxelwise. Five older controls each underwent 2 scans with ¹⁸F-RO-948 for evaluation of test-retest variability. Four AD subjects underwent a repeated ¹⁸F-RO-948 scan 6-22 mo after the first scan. Six additional healthy controls (3 men and 3 women; age range, 41-67 y) each underwent 1 whole-body dosimetry scan with ¹⁸F-RO-948. Results: In younger controls, SUV_peak was observed in the temporal lobe with values of approximately 3.0 for ¹¹C-RO-963, 1.5 for ¹¹C-RO-643, and 3.5 for ¹⁸F-RO-948. Over all brain regions and subjects, the trend was for ¹⁸F-RO-948 to have the highest SUV_peak, followed by ¹¹C-RO-963 and then ¹¹C-RO-643. Regional analysis of SUV ratio and total distribution volume for ¹¹C-RO-643 and ¹⁸F-RO-948 clearly discriminated the AD group from the healthy control groups. Compartmental modeling confirmed that ¹¹C-RO-643 had lower brain entry than either ¹¹C-RO-963 or ¹⁸F-RO-948 and that ¹⁸F-RO-948 showed better contrast between (predicted) areas of high versus low tau accumulation. Thus, our subsequent analysis focused on ¹⁸F-RO-948. Both voxelwise and region-based analysis of ¹⁸F-RO-948 binding in healthy controls versus AD subjects revealed multiple areas where AD subjects significantly differed from healthy controls. Of 22 high-binding regions, 13 showed a significant group difference (after ANOVA, F _(1,21) = 45, P < 10^-5). Voxelwise analysis also revealed a set of symmetric clusters where AD subjects had higher binding than healthy controls (threshold of P < 0.001, cluster size > 50). Conclusion: ¹⁸F-RO-948 demonstrates characteristics superior to ¹¹C-RO-643 and ¹¹C-RO-963 for characterization of tau pathology in AD. Regional binding data and kinetic properties of ¹⁸F-RO-948 compare favorably with other existing tau PET tracers.