Association of Proton Pump Inhibitor Use With Incident Dementia and Cognitive Decline in Older Adults: A Prospective Cohort Study

BACKGROUND & AIMS

Prior studies have suggested that proton pump inhibitor (PPI) use is associated with increased risk of dementia; however, these have been limited by incomplete assessment of medication use and failure to account for confounders. Furthermore, prior studies have relied on claims-based diagnoses for dementia, which can lead to misclassification. We investigated the associations of PPI and histamine-2 receptor antagonist (H2RA) use with dementia and cognitive decline.

METHODS

We conducted a post hoc analysis of ASPirin in Reducing Events in the Elderly (ASPREE), a randomized trial of aspirin in the United States and Australia, including 18,934 community-based adults ≥65 years of all races/ethnicities. Baseline and recent PPI and H2RA use were determined according to review of medications during annual in-person study visits. Incident dementia was defined according to Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, criteria. Secondary endpoints include cognitive impairment, no dementia (CIND) and changes in cognition. Associations of medication use with dementia and CIND outcomes were examined using Cox proportional hazards models. Changes in cognitive test scores were examined using linear mixed-effects models.

RESULTS

Baseline PPI use vs nonuse was not associated with incident dementia (multivariable hazard ratio, 0.88; 95% confidence interval, 0.72-1.08), CIND (multivariable hazard ratio, 1.00; 95% confidence interval, 0.92-1.09), or with changes in overall cognitive test scores over time (multivariable B, -0.002; standard error, 0.01; P = .85). Similarly, no associations were observed between H2RA use and all cognitive endpoints.

CONCLUSIONS

In adults ≥65 years of age, PPI and H2RA use were not associated with incident dementia, CIND, or decline in cognition over time. These data provide reassurance about the safety of long-term use of PPIs among older adults.

Health Characteristics and Aspirin Use in Participants at the Baseline of the ASPirin in Reducing Events in the Elderly - eXTension (ASPREE-XT) Observational Study

BACKGROUND

Aspirin as a primary preventative in healthy older adults did not prolong disability-free survival in the ASPREE randomized trial. Observational studies following randomized trials allow assessment of benefits and harms which may not appear during the trial. We describe health characteristics, physical function, and aspirin use in the ASPREE-eXTension (ASPREE-XT) observational study cohort.

METHODS

Descriptive statistics compared health characteristics of those consented to ASPREE-XT at their first post-trial baseline (XT01) to corresponding ASPREE baseline values, and to those not consented. Likelihood of an indication for aspirin was assessed in participants reporting aspirin use at XT01.

RESULTS

16,317 (93%) of the remaining and eligible 17,546 ASPREE participants were consented into ASPREE-XT; 14,894 completed XT01. Mean participant age had increased from 74.9 to 80.6 years. Overall health and physical function declined from the original ASPREE baseline; more participants were living alone, there was higher prevalence of chronic kidney disease, diabetes, and frailty, grip strength was lower and gait speed slower. Those not consented into ASPREE-XT were slightly older, and had lower cognitive scores and higher prevalence of age-related conditions than those who continued. 1015/11,717 (8.7%) participants without an apparent indication for aspirin reported using aspirin at XT01.

CONCLUSIONS

The ASPREE-XT cohort was slightly less healthy at the XT01 visit than at ASPREE trial initiation, and rates of aspirin use without indication were similar to ASPREE baseline. Participants will be followed long-term to investigate aspirin's potential legacy towards dementia and cancer prevention and explore determinants of healthy aging.

Evaluating the impact of Hazelwood mine fire event on students' educational development with Bayesian interrupted time-series hierarchical meta-regression

BACKGROUND

Environmental disasters such as wildfires, floods and droughts can introduce significant interruptions and trauma to impacted communities. Children and young people can be disproportionately affected with additional educational disruptions. However, evaluating the impact of disasters is challenging due to difficulties in establishing studies and recruitment post-disasters.

OBJECTIVES

We aimed to (1) develop a Bayesian model using aggregated school-level data to evaluate the impact of environmental disasters on academic achievement and (2) evaluate the impact of the 2014 Hazelwood mine fire (a six-week fire event in Australia).

METHODS

Bayesian hierarchical meta-regression was developed to evaluate the impact of the mine fire using easily accessible aggregated school-level data from the standardised National Assessment Program-Literacy and Numeracy (NAPLAN) test. NAPLAN results and school characteristics (2008-2018) from 69 primary/secondary schools with different levels of mine fire-related smoke exposure were used to estimate the impact of the event. Using an interrupted time series design, the model estimated immediate effects and post-interruption trend differences with full Bayesian statistical inference.

RESULTS

Major academic interruptions across NAPLAN domains were evident in high exposure schools in the year post-mine fire (greatest interruption in Writing: 11.09 [95%CI: 3.16-18.93], lowest interruption in Reading: 8.34 [95%CI: 1.07-15.51]). The interruption was comparable to a four to a five-month delay in educational attainment and had not fully recovered after several years.

CONCLUSION

Considerable academic delays were found as a result of a mine fire, highlighting the need to provide educational and community-based supports in response to future events. Importantly, this work provides a statistical method using readily available aggregated data to assess the educational impacts in response to other environmental disasters.

Association of metformin, aspirin, and cancer incidence with mortality risk in adults with diabetes

BACKGROUND

Metformin and aspirin are commonly co-prescribed to people with diabetes. Metformin may prevent cancer, but in older people (over 70 years), aspirin has been found to increase cancer mortality. This study examined whether metformin reduces cancer mortality and incidence in older people with diabetes; it used randomization to 100 mg aspirin or placebo in the ASPirin in Reducing Events in the Elderly (ASPREE) trial to quantify aspirin's impact on metformin users.

METHODS

Analysis included community-dwelling ASPREE participants (aged ≥70 years, or ≥65 years for members of US minority populations) with diabetes. Diabetes was defined as a fasting blood glucose level greater than 125 mg/dL, self-report of diabetes, or antidiabetic medication use. Cox proportional hazards regression models were used to analyze the association of metformin and a metformin-aspirin interaction with cancer incidence and mortality, with adjustment for confounders.

RESULTS

Of 2045 participants with diabetes at enrollment, 965 were concurrently using metformin. Metformin was associated with a reduced cancer incidence risk (adjusted hazard ratio [HR] = 0.68, 95% confidence interval [CI] = 0.51 to 0.90), but no conclusive benefit for cancer mortality (adjusted HR = 0.72, 95% CI = 0.43 to 1.19). Metformin users randomized to aspirin had greater risk of cancer mortality compared with placebo (HR = 2.53, 95% CI = 1.18 to 5.43), but no effect was seen for cancer incidence (HR = 1.11, 95% CI = 0.75 to 1.64). The possible effect modification of aspirin on cancer mortality, however, was not statistically significant (interaction P = .11).

CONCLUSIONS

In community-dwelling older adults with diabetes, metformin use was associated with reduced cancer incidence. Increased cancer mortality risk in metformin users randomized to aspirin warrants further investigation.

ASPREE TRIAL REGISTRATION

ClinicalTrials.gov ID NCT01038583.

Long-term impact of exposure to coalmine fire emitted PM2.5 on emergency ambulance attendances

BACKGROUND

Little is known about the long-term health effects of coalmine fire smoke exposure. The 2014 Hazelwood coalmine fire event in southeast Australia released smoke into surrounding areas for 6 weeks.

OBJECTIVES

We aimed to investigate whether individual-level exposure to coalmine fire-related PM_2.5 was associated with a long-term increase in ambulance attendances following a coalmine fire event.

METHODS

A total of 2223 residents from the most exposed town of Morwell were assessed for ambulance attendances after the Hazelwood event from April 1, 2014 to December 31, 2017. PM_2.5 exposure was estimated for each individual using participant self-reported location diary data during the event and modelled PM_2.5 concentrations. Recurrent event survival analysis was used to evaluate the relationship between PM_2.5 exposure and ambulance attendances.

RESULTS

For each 10 μg/m³ increase in mean coalmine fire-related PM_2.5 exposure, there was a 10% (adjusted hazard ratio [HR]:1.10, 95%CI:1.03-1.17) increase in the overall risk of ambulance attendances within 3.5 years after the coalmine fire. Exposure to PM_2.5 was also associated with increased risk of respiratory (HR: 1.21, 95%CI: 1.02-1.44) and cardiovascular (HR: 1.13, 95%CI: 1.01-1.28) related ambulance attendances.

CONCLUSION

These results demonstrate that exposure to coalmine fire smoke during the Hazelwood event was associated with a long-term health risk post the fire event, specifically for respiratory and cardiovascular conditions. These findings are important for effective implementation of health care services following future extended coalmine fire PM_2.5 events.

Anticholinergic medication burden and cognitive function in participants of the ASPREE study

STUDY OBJECTIVE

What is the association between anticholinergic burden and specific domains of cognitive function in older adults who are initially without major cognitive impairment?

DESIGN

Post-hoc analysis of longitudinal observational data from the ASPirin in Reducing Events in the Elderly (ASPREE) study.

PATIENTS

19,114 participants from Australia and the United States aged 70 years and older (65 years and older for US minorities) were recruited and followed for a median of 4.7 years. At enrollment, participants were free of known cardiovascular disease, major physical disability, or dementia.

MEASUREMENTS

Cognitive assessments administered at baseline and biennially at follow-up visits included the Modified Mini-Mental State examination (3MS), Hopkins Verbal Learning Test-Revised (HVLT-R) delayed recall, Controlled Oral Word Association Test (COWAT), and Symbol Digit Modalities Test (SDMT). Anticholinergic burden was calculated at baseline using the Anticholinergic Cognitive Burden (ACB) scale and grouped as scores of 0 (no burden), 1-2 (low to moderate), or 3+ (high).

MAIN RESULTS

Linear mixed effects models were used to assess the relationship between ACB score and cognition over time. After adjusting for sex, age, education, minority status, smoking status, hypertension, diabetes, depression, chronic kidney disease, country, and frailty, participants with a high ACB score had worse performance over time for 3MS (Adjusted [Adj] B=-0.092, P=0.034), HVLT-R delayed recall (Adj B=-0.104, P<0.001), COWAT (Adj B=-0.151, P<0.001), and SDMT (Adj B=-0.129, P=0.026), than participants with an ACB score of 0. A low to moderate ACB score was also associated with worse performance over time for HVLT-R delayed recall (Adj B=-0.037, P=0.007) and COWAT (Adj B=-0.065, P=0.003), compared to those with no ACB.

CONCLUSIONS

Anticholinergic burden predicts worse cognitive function over time in initially dementia-free older adults, particularly for executive function (COWAT) and episodic memory (HVLT-R).

Long-term impact of coal mine fire smoke on lung mechanics in exposed adults

BACKGROUND AND OBJECTIVE

In 2014, a 6-week-long fire at the Hazelwood coal mine exposed residents in the adjacent town of Morwell to high concentrations of fine particulate matter with an aerodynamic diameter < 2.5 μm (PM_2.5 ). The long-term health consequences are being evaluated as part of the Hazelwood Health Study.

METHODS

Approximately 3.5-4 years after the mine fire, adults from Morwell (n = 346) and the comparison town Sale (n = 173) participated in the longitudinal Respiratory Stream of the Study. Individual PM_2.5 exposure was retrospectively modelled. Lung mechanics were assessed using the forced oscillation technique (FOT), utilizing pressure waves to measure respiratory system resistance (Rrs) and reactance (Xrs). Multivariate linear regression was used to evaluate associations between PM_2.5 and transformed Rrs at 5 Hz, area under the reactance curve (AX5) and Xrs at 5 Hz controlling for key confounders.

RESULTS

There were clear dose-response relationships between increasing mine fire PM_2.5 and worsening lung mechanics, including a reduction in post-bronchodilator (BD) Xrs5 and an increase in AX5. A 10 μg/m³ increase in mine fire-related PM_2.5 was associated with a 0.015 (95% CI: 0.004, 0.027) reduction in exponential (Xrs5) post-BD, which was comparable to 4.7 years of ageing. Similarly, the effect of exposure was associated with a 0.072 (0.005, 0.138) increase in natural log (lnAX5) post-BD, equivalent to 3.9 years of ageing.

CONCLUSION

This is the first study using FOT in adults evaluating long-term respiratory outcomes after medium-term ambient PM_2.5 exposure to coal mine fire smoke. These results should inform public health policies and planning for future events.

A Cohort Study of Anticholinergic Medication Burden and Incident Dementia and Stroke in Older Adults

BACKGROUND

Anticholinergic medications may increase risk of dementia and stroke, but prospective studies in healthy older people are lacking.

OBJECTIVE

Compare risk of incident dementia and stroke by anticholinergic burden among initially healthy older people.

DESIGN

Prospective cohort study.

SETTING

Primary care (Australia and USA).

PARTICIPANTS

19,114 community-dwelling participants recruited for the ASPREE trial, aged 70+ years (65+ if US minorities) without major cardiovascular disease, dementia diagnosis, or Modified Mini-Mental State Examination score below 78/100.

MEASUREMENTS

Baseline anticholinergic exposure was calculated using the Anticholinergic Cognitive Burden (ACB) score. Dementia was adjudicated using Diagnostic and Statistical Manual of Mental Disorders volume IV criteria, and stroke using the World Health Organization definition.

RESULTS

At baseline, 15,000 participants (79%) had an ACB score of zero, 2930 (15%) a score of 1-2, and 1184 (6%) a score of ≥ 3 (indicating higher burden). After a median follow-up of 4.7 years and adjusting for baseline covariates, a baseline ACB score of ≥ 3 was associated with increased risk of ischemic stroke (adjusted HR 1.58, 95% CI 1.06, 2.35), or dementia (adjusted HR 1.36, 95% CI 1.01, 1.82), especially of mixed etiology (adjusted HR 1.53, 95% CI 1.06, 2.21). Results were similar for those exposed to moderate/highly anticholinergic medications.

LIMITATIONS

Residual confounding and reverse causality are possible. Assessment of dose or duration was not possible.

CONCLUSIONS

High anticholinergic burden in initially healthy older people was associated with increased risk of incident dementia and ischemic stroke. A vascular effect may underlie this association. These findings highlight the importance of minimizing anticholinergic exposure in healthy older people.

Gender differences in barriers to participation in after-school physical activities and related factors in Australian schoolchildren: A cross-sectional study

INTRODUCTION

This study investigated the gender differences in reported barriers to participation in after-school physical activity (PA) and related health and socio-behavioural factors in Australian schoolchildren.

METHODS

5001 students aged 10 to 16 years completed the health and well-being survey in 2014 indicating that they would like to participate in after-school PA. Negative binomial regression models, stratified by gender, tested the relationship of age, reported health, junk food, participation in leisure PA, TV watching, weight status and socio-economic index for area score (related factors) with the total number of barriers.

RESULTS

Girls were more likely to report a greater number of barriers to participation in after-school PA than boys (P < .05). Older age was associated with a higher number of barriers in girls (B(95% CI) = 1.061 (1.032, 1.090)) but not in boys. In both boys and girls, being overweight (boys: very overweight (1.367 (1.081, 1.730)); girls: slightly overweight (1.186 (1.100, 1.278)) or very overweight (1.414 (1.197, 1.667))), compared to students who reported "being about the right weight," was associated with a greater number of barriers. Schoolchildren who reported less than excellent health status perceived a greater number of barriers to after-school PA (girls: good (1.141 (1.060, 1.228)), fair (1.189 (1.070, 1.321)) and poor health (1.329 (1.093, 1.614)); boys: good health (1.166 (1.0728, 1.267))).

CONCLUSIONS

There are gender differences in barriers to participation in after-school PA; these should be taken into account when developing programs to increase schoolchildren's after-school PA.

SO WHAT

The prevalence of physical inactivity in Australian adolescents is staggering. We observed that girls reported a greater number of barriers to participation in after-school PA than boys; and being overweight and reporting poorer overall health were associated with a greater number of barriers. Affordable, gender- and age-specific after-school PA programs suitable for schoolchildren of all body shapes and sizes and all abilities are needed.

The factors associated with distress following exposure to smoke from an extended coal mine fire

In February 2014, the coalmine adjacent to the Hazelwood Power Station in the Latrobe Valley of Victoria, Australia, caught fire, with residents from the nearby town of Morwell and the wider area exposed to smoke for six weeks. Although there was evidence linking the mine-fire event with psychological distress, no studies have evaluated the degree of distress in relation to the level of smoke exposure. We aimed to investigate the exposure-response relationship between particulate matter 2.5 μm or less in diameter (PM_2.5) released during the Hazelwood mine fire event and long-term symptoms of posttraumatic distress in the affected community, including the consideration of other key factors. A total of 3096 Morwell residents, and 960 residents from the largely unexposed comparison community of Sale, were assessed for symptoms of posttraumatic distress 2.5 years after the Hazelwood incident using the Impact of Events Scale-Revised (IES-R). Individual-level PM_2.5 exposure was estimated by mapping participants' self-reported location data on modelled PM_2.5 concentrations related to the mine fire. Multivariate linear regression was used to evaluate the exposure-response relationship. Both mean and peak exposure to mine fire-related PM_2.5 were found to be associated with participant IES-R scores with an interaction effect between age and mean PM_2.5 exposure also identified. Each 10 μg/m³ increase in mean PM_2.5 exposure corresponded to a 0.98 increase in IES-R score (95% CI: 0.36 to 1.61), and each 100 μg/m³ increase in peak PM_2.5 exposure corresponded to a 0.36 increase (95% CI: 0.06 to 0.67). An age-effect was observed, with the exposure-response association found to be stronger for younger adults. The results suggest that increased exposure to PM_2.5 emissions from the Hazelwood mine fire event was associated with higher levels of psychological distress associated with the mine fire and the most pronounced effect was on younger adults living in the affected community.

Prescription Medication Use in Older Adults Without Major Cardiovascular Disease Enrolled in the Aspirin in Reducing Events in the Elderly (ASPREE) Clinical Trial

BACKGROUND

Efforts to minimize medication risks among older adults include avoidance of potentially inappropriate medications. Contemporary analysis of medication use in community-dwelling older people compared with the general population is lacking.

PARTICIPANTS

A total of 19,114 community-dwelling adults in Australia and the United States aged 70 years or older (65 years or older for U.S. minorities) without histories of major cardiovascular disease, cognitive impairment, or disability participated in a randomized, placebo-controlled trial of aspirin: ASPirin in Reducing Events in the Elderly study. Measurements Prescribed baseline medications obtained by self-report and medical record review were grouped by World Health Organization Anatomic and Therapeutic Chemical category. Potentially inappropriate medications were defined using a modified American Geriatrics Society Beers Criteria. Polypharmacy was defined as 5 or more medications, and hyperpolypharmacy defined as 10 or more medications. Cross-sectional descriptive statistics and adjusted odds ratios were computed.

RESULTS

The median number of prescription medications per participant was three, regardless of age. Women had a higher medication prevalence. Cardiovascular drugs (primarily antihypertensives) were the most commonly reported (64%). Overall, 39% of the cohort reported taking at least one potentially inappropriate medication, with proton-pump inhibitors being the most commonly reported (21.2% of cohort). Of the cohort, 27% had polypharmacy, and 2% hyperpolypharmacy. Age 75 years or older, less than 12 years of education, hypertension, diabetes mellitus, chronic kidney disease, frailty, gastrointestinal complaint, and depressive symptoms were associated with an increased likelihood of potentially inappropriate medications and polypharmacy. For almost all medication classes, prevalence was equivalent or lower than the general older population.

CONCLUSION

Overall medication burden and polypharmacy are low in older adults free of major cardiovascular disease, disability, and cognitive impairment. The prevalence of potentially inappropriate medications is higher than previously reported and similar to more vulnerable populations as a result of the introduction of proton-pump inhibitors to the American Geriatrics Society Beers Criteria. Longitudinal follow-up is required to further understand the balance of benefits and risks for potentially inappropriate medications and polypharmacy in community-dwelling older people.

The association between neighbourhood walkability and after-school physical activity in Australian schoolchildren

INTRODUCTION

Physical inactivity is a risk factor for many noncommunicable diseases. As reported by the World Health Organisation, 81% of children worldwide are physically inactive. Environmental factors, such as neighbourhood walkability, can shape people's physical activity (PA) behaviour. This study explored the association between neighbourhood walkability and after-school PA among Australian schoolchildren.

METHODS

The Department for Education and Child Development (DECD) distributed the survey to 189 schools across South Australia to assess the health and well-being of schoolchildren aged between 8 and 14 years. Neighbourhood was defined as an area corresponding to a four digit postcode, and its walkability was measured using Walk Score^® . The association between neighbourhood walkability and after-school PA was analysed using multinomial logistic regression adjusted for age, gender, SEIFA score, number of days of TV watching, number of times of eating junk food, neighbourhood safety and children's weight status.

RESULTS

Children residing in highly walkable areas (walker's paradise) compared to car-dependent areas had higher odds (OR(95%CI)) of engaging in after-school PA three (1.216 (1.029, 1.436), P = .021), four (1.287 (1.064, 1.557), P = .009) and five times a week (1.230 (1.030, 1.133), P = .022) compared to children never participating in PA.

CONCLUSION

Living in highly walkable areas (walker's paradise), compared to living in car-dependent areas was associated with higher levels of after-school PA. So what? Creating walkable neighbourhoods with greater access to amenities, services and public transportation may help increase after-school PA among schoolchildren.

High-Level Mobility Assessment Tool Normative Values for Children

BACKGROUND

Physical therapists need to be able to evaluate high-level gross motor skills of children to determine their capacity to engage in activities such as running, jumping, hopping, and stair climbing. The High-Level Mobility Assessment Tool (HiMAT) has excellent interrater and retest reliability and is less susceptible to a ceiling effect than existing mobility scales in children who are 6 to 17 years old and have traumatic brain injury.

OBJECTIVE

The purposes of this study were to develop normative HiMAT score ranges for Australian children and to investigate the relationship between children's HiMAT scores and their age, height, weight, and body mass index (BMI).

DESIGN

This study used a cross-sectional design.

METHODS

Children included in this study were 5 to 12 years old, had no condition affecting their mobility, could follow 2-stage instructions, and had written informed consent from their parent or guardian. A total 1091 children were assessed at their local school, where their height, weight, and HiMAT score were recorded. The relationships between children's age, height, weight, and BMI were summarized using Spearman rank correlations. Truncated regression models were used to determine the most appropriate predictor variable for developing sex-specific normative ranges.

RESULTS

There was a positive correlation between children's HiMAT scores and their age, height, weight, and BMI. Age explained the most variability in HiMAT scores for both boys and girls.

LIMITATIONS

The reliability, validity, and responsiveness of the HiMAT have not been tested across a broad range of children with mobility limitations. Normative data reported in this study are for Australian children only.

CONCLUSIONS

HiMAT scores for children in this study increased with age, height, weight, and BMI. Age was the most appropriate variable for developing a normative dataset of HiMAT scores for children of primary school age.

Permeabilizing millions of cells with single pulses of an excimer laser

Poration of millions of cells with single laser pulses of an argon fluoride excimer laser is developed and demonstrated on plant cells. The essence of the technique is to use the large beam size (10 x 25 mm) of the excimer laser and to split it using an appropriate mask into millions of micron- or submicron-sized beams of 193-nm radiation with enough energy to perforate cell membranes and walls. The extremely small depth of penetration of the 193-nm radiation in biological tissue (< 1 microns) is used to great advantage in this technique to provide for a gentle method that does not lead to cell death. This is the first laser-based method that has enough throughput to make it viable for biotechnological applications. Of considerable significance is that the method is applicable not only in the case of the single cells in suspension, but also for cells growing on the leaves of living plants.