Associations Between Age at Menopause, Vascular Risk, and 3-Year Cognitive Change in the Canadian Longitudinal Study on Aging

BACKGROUND AND OBJECTIVES

Mounting evidence supports sex differences in Alzheimer disease (AD) risk. Vascular and hormonal factors may together contribute to AD risk in female adults. We investigated whether age at menopause, vascular risk, and history of hormone therapy (HT) containing estrogens together influence cognition over a 3-year follow-up period. We hypothesized that earlier menopause and elevated vascular risk would have a synergistic association with lower cognitive scores at follow-up and that HT containing estrogens would attenuate this synergistic association to preserve cognition.

METHODS

We used data from postmenopausal female participants and age-matched male participants in the Canadian Longitudinal Study on Aging. Vascular risk was calculated using a summary score of elevated blood pressure, antihypertensive medications, elevated low-density lipoprotein cholesterol, diabetes, smoking, and obesity. Cognition was measured with a global cognitive composite at baseline and 3-year follow-up. Linear models tested independent and interactive associations of age at menopause, vascular risk, and HT history with cognition at 3-year follow-up, adjusting for baseline cognition, baseline age, years of education, and test language (English/French).

RESULTS

We included 8,360 postmenopausal female participants (mean age at baseline = 65.0 ± 8.53 years, mean age at menopause = 50.1 ± 4.62 years) and 8,360 age-matched male participants for comparison. There was an interaction between age at menopause and vascular risk, such that earlier menopause and higher vascular risk were synergistically associated with lower cognitive scores at follow-up (β = 0.013, 95% CI 0.001-0.025, p = 0.03). In stratified analyses, vascular risk was associated with lower cognitive scores in female participants with earlier menopause (menopausal ages 35-48 years; β = -0.044, 95% CI -0.066 to -0.022, p < 0.001), but not average (ages 49-52 years; β = -0.007, 95% CI -0.027 to 0.012, p = 0.46) or later menopause (ages 53-65 years; β = 0.003, 95% CI -0.020 to 0.025, p = 0.82). The negative association of vascular risk with cognition in female participants with earlier menopause was stronger than the equivalent association in age-matched male participants. HT history did not further modify the synergistic association of age at menopause and vascular risk with follow-up cognition (β = -0.005, 95% CI -0.032 to 0.021, p = 0.69).

DISCUSSION

Endocrine and vascular processes may synergistically contribute to increased risk of cognitive decline in female adults. These findings have implications for the development of sex-specific dementia prevention strategies.

Coronary artery calcium as a marker of healthy and unhealthy aging in adults aged 75 and older: The Atherosclerosis Risk in Communities (ARIC) study

BACKGROUND AND AIMS

Coronary artery calcium (CAC) is validated for risk prediction among middle-aged adults, but there is limited research exploring implications of CAC among older adults. We used data from the Atherosclerosis Risk in Communities (ARIC) study to evaluate the association of CAC with domains of healthy and unhealthy aging in adults aged ≥75 years.

METHODS

We included 2,290 participants aged ≥75 years free of known coronary heart disease who underwent CAC scoring at study visit 7. We examined the cross-sectional association of CAC = 0, 1-999 (reference), and ≥1000 with seven domains of aging: cognitive function, hearing, ankle-brachial index (ABI), pulse-wave velocity (PWV), forced vital capacity (FVC), physical functioning, and grip strength.

RESULTS

The mean age was 80.5 ± 4.3 years, 38.6% male, and 77.7% White. 10.3% had CAC = 0 and 19.2% had CAC≥1000. Individuals with CAC = 0 had the lowest while those with CAC≥1000 had the highest proportion with dementia (2% vs 8%), hearing impairment (46% vs 67%), low ABI (3% vs 18%), high PWV (27% vs 41%), reduced FVC (34% vs 42%), impaired grip strength (66% vs 74%), and mean composite abnormal aging score (2.6 vs 3.7). Participants with CAC = 0 were less likely to have abnormal ABI (aOR:0.15, 95%CI:0.07-0.34), high PWV (aOR:0.57, 95%CI:0.41-0.80), and reduced FVC (aOR:0.69, 95%CI:0.50-0.96). Conversely, participants with CAC≥1000 were more likely to have low ABI (aOR:1.74, 95%CI:1.27-2.39), high PWV (aOR:1.52, 95%CI:1.15-2.00), impaired physical functioning (aOR:1.35, 95%CI:1.05-1.73), and impaired grip strength (aOR:1.46, 95%CI:1.08-1.99).

CONCLUSIONS

Our findings highlight CAC as a simple measure broadly associated with biological aging, with clinical and research implications for estimating the physical and physiological aging trajectory of older individuals.

Nonalcoholic Fatty Liver Disease and Longitudinal Change in Imaging and Plasma Biomarkers of Alzheimer Disease and Vascular Pathology

BACKGROUND AND OBJECTIVES

Prospective measures of plasma and cerebral MRI biomarkers of Alzheimer disease (AD) and vascular neuropathology provide an opportunity to investigate possible mechanisms linking liver disease and dementia. We aimed to quantify the association of midlife nonalcoholic fatty liver disease (NAFLD) with change in plasma and brain MRI biomarkers of AD and vascular neuropathology.

METHODS

We included participants from the Atherosclerosis Risk in Communities Study with brain MRI measurements of white matter hyperintensity (WMH) volume and temporal-parietal lobe cortical thickness meta region of interest (ROI) at up to 2 different visits, in 2011-13 and 2016-19, and plasma biomarkers of β-amyloid (Aβ)42:40, phosphorylated tau at threonine 181, and neurofilament light (NfL) were measured up to 3 times in 1993-95, 2011-13, and 2016-19. NAFLD was categorized using the fatty liver index in 1990-92. Multivariate linear regression was performed for associations between midlife NAFLD and change in plasma and brain MRI biomarkers of AD and vascular neuropathology. The primary models adjusted for demographics, Apolipoprotein E, alcohol use, and kidney function.

RESULTS

Among 1,706 participants (mean age 56 years, 62% female, 28% Black), midlife NAFLD vs no NAFLD was associated with greater late-life WMH volume (difference per SD 0.19, 95% CI 0.06-0.31) and faster late-life WMH increase over 6 years (difference in annual change, SD 0.28, 95% CI 0.05-0.51), suggesting accumulating vascular pathology. Midlife NAFLD vs no NAFLD was also associated with AD biomarkers in midlife (lower Aβ42:40 [SD -0.21, 95% CI -0.39 to -0.04] measured in 1993-95) and late life (lower Aβ42:40 [SD -0.13, 95% CI -0.23 to -0.03] and lower temporal-parietal lobe cortical thickness meta ROI [SD -0.16, 95% CI -0.28 to -0.05] measured in 2011-13). Although midlife NfL was lower in individuals with vs without midlife NAFLD, those with NAFLD exhibited a faster rate of NfL increase that accelerated over time.

DISCUSSION

Midlife NAFLD shows associations with AD and accumulating vascular pathology, revealing potential pathways linking liver function to dementia. Plasma biomarkers of neuropathology and neuronal injury may serve as easily measurable and dynamic indicators for monitoring the impacts of impaired liver function on brain health.

Social relationships, amyloid burden, and dementia: The ARIC-PET study

INTRODUCTION

This study aimed to assess whether social relationships in mid-life reduce the risk of dementia related to amyloid burden.

METHODS

Participants in the Atherosclerosis Risk in Communities (ARIC) study were assessed for social support and isolation (visit 2; 1990-1992). A composite measure, "social relationships," was generated. Brain amyloid was evaluated with florbetapir positron emission tomography (PET); (visit 5; 2012-2014). Incident dementia cases were identified following visit 5 through 2019 using ongoing surveillance. Relative contributions of mid-life social relationships and elevated brain amyloid to incident dementia were evaluated with Cox regression models.

RESULTS

Among 310 participants without dementia, strong mid-life social relationships were associated independently with lower dementia risk. Elevated late-life brain amyloid was associated with greater dementia risk.

DISCUSSION

Although mid-life social relationships did not moderate the relationship between amyloid burden and dementia, these findings affirm the importance of strong social relationships as a potentially protective factor against dementia.

Associations Between Prior Head Injury, Physical Functioning, and Frailty in the Atherosclerosis Risk in Communities Study

BACKGROUND

Older adults have the highest rates of head injury and are at the greatest risk for subsequent dysfunction, yet research on subsequent physical decline is limited. We sought to examine cross-sectional and prospective associations of head injury with physical functioning and frailty among older adults.

METHODS

A total of 5 598 Atherosclerosis Risk in Communities Study participants from Visit 5 (2011-13) underwent assessments of physical functioning (Short Physical Performance Battery [SPPB], comprised of gait speed, chair stands, and balance) and frailty (defined using established criteria) were followed through Visit 7 (2018-19). Head injury was self-reported or based on ICD-9 codes. Adjusted linear and multinomial logistic regression models were used to estimate associations. Prospective models incorporated inverse probability of attrition weights to account for death or attrition.

RESULTS

Participants were a mean age of 75 years, 58% were women, 22% were Black, and 27% had a prior head injury. Compared to individuals without head injury, individuals with head injury had worse physical functioning (SPPB total score, β-coefficient = -0.22, 95% CI: -0.35 to -0.09) and were more likely to be pre-frail (OR = 1.19, 95% CI: 1.04 to 1.35) or frail (OR = 1.40, 95% CI: 1.08 to 1.80) compared to robust. Prospectively, head injury was associated with a 0.02 m/s greater decline (95% CI: -0.04 to -0.01) in gait speed over a median of 5 years. Among baseline robust individuals (n = 1 847), head injury was associated with increased odds of becoming pre-frail (OR = 1.32, 95% CI: 1.04 to 1.67) or frail (OR = 1.92, 95% CI: 1.05 to 3.51) compared to robust.

CONCLUSIONS

Older adults with prior head injury had worse physical functioning and greater frailty at baseline and were more likely to become frail and walk slower over time, compared to individuals without head injury.

Liver integrity and the risk of Alzheimer's disease and related dementias

INTRODUCTION

We examined midlife (1990-1992, mean age 57) and late-life (2011-2013, mean age 75) nonalcoholic fatty liver disease (NAFLD) and aminotransferase with incident dementia risk through 2019 in the Atherosclerosis Risk in Communities (ARIC) Study.

METHODS

We characterized NAFLD using the fatty liver index and fibrosis-4, and we categorized aminotransferase using the optimal equal-hazard ratio (HR) approach. We estimated HRs for incident dementia ascertained from multiple data sources.

RESULTS

Adjusted for demographics, alcohol consumption, and kidney function, individuals with low, intermediate, and high liver fibrosis in midlife (HRs: 1.45, 1.40, and 2.25, respectively), but not at older age, had higher dementia risks than individuals without fatty liver. A U-shaped association was observed for alanine aminotransferase with dementia risk, which was more pronounced in late-life assessment.

DISCUSSION

Our findings highlight dementia burden in high-prevalent NAFLD and the important feature of late-life aminotransaminase as a surrogate biomarker linking liver hypometabolism to dementia. Highlights Although evidence of liver involvement in dementia development has been documented in animal studies, the evidence in humans is limited. Midlife NAFLD raised dementia risk proportionate to severity. Late-life NAFLD was not associated with a high risk of dementia. Low alanine aminotransferase was associated with an elevated dementia risk, especially when measured in late life.

Mid-Life Vascular Risk and Rate of Physical Function Decline Among Older Adults: The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

Physical function and its decline in older age may be connected to treatable vascular risk factors in mid-life. This study aimed to evaluate whether these factors affect the underlying rate of decline.

METHODS

This prospective cohort included 5 481 older adults aged 67-91 in the Atherosclerosis Risk in Communities Study (mean [standard deviation {SD}] age = 75.8 [5.0], 58% women, 21% Black race) without a history of stroke. The main outcome was the rate of Short Physical Performance Battery (SPPB) decline over a median late-life follow-up of 4.8 years. Primary mid-life (aged 45-64) exposures were Visit 1 hypertension (>140/90 mm Hg or treatment), diabetes (>126 mg/dL or treatment), high cholesterol (>240 mg/dL or treatment), and smoking, and number of decades of vascular risk exposure across Visits 1-4.

RESULTS

The average adjusted rate of SPPB decline (points per 5 years) for older adults was -0.79 (confidence interval [CI]: -0.87, 0.71) and was accelerated by mid-life hypertension (+57% decline vs normotension: additional decline of -0.47, 95% CI: -0.64, -0.30), diabetes (+73% decline vs no diabetes: additional decline of -0.67, 95% CI: -1.09, -0.24), elevated systolic blood pressure (+17% decline per SD: -0.16, 95% CI: -0.23, -0.10), and elevated fasting blood glucose (+16% decline per SD: -0.015, 95% CI: -0.24, -0.06). Each decade greater mid-life exposure to hypertension (+32% decline: -0.93, 95% CI: -1.25, -0.61) and diabetes (+35% decline: -1.03, 95% CI: -1.68, -0.38) was associated with faster SPPB decline.

CONCLUSIONS

Mid-life control of blood pressure and diabetes may offset aging-related functional decline.

Plasma Neuronal Growth Regulator 1 May Link Physical Activity to Reduced Risk of Type 2 Diabetes: A Proteome-Wide Study of ARIC Participants

Habitual physical activity (PA) impacts the plasma proteome and reduces the risk of developing type 2 diabetes (T2D). Using a large-scale proteome-wide approach in Atherosclerosis Risk in Communities study participants, we aimed to identify plasma proteins associated with PA and determine which of these may be causally related to lower T2D risk. PA was associated with 92 plasma proteins in discovery (P < 1.01 × 10-5), and 40 remained significant in replication (P < 5.43 × 10-4). Eighteen of these proteins were independently associated with incident T2D (P < 1.25 × 10-3), including neuronal growth regulator 1 (NeGR1; hazard ratio per SD 0.85; P = 7.5 × 10-11). Two-sample Mendelian randomization (MR) inverse variance weighted analysis indicated that higher NeGR1 reduces T2D risk (odds ratio [OR] per SD 0.92; P = 0.03) and was consistent with MR-Egger, weighted median, and weighted mode sensitivity analyses. A stronger association was observed for the single cis-acting NeGR1 genetic variant (OR per SD 0.80; P = 6.3 × 10-5). Coupled with previous evidence that low circulating NeGR1 levels promote adiposity, its association with PA and potential causal role in T2D shown here suggest that NeGR1 may link PA exposure with metabolic outcomes. Further research is warranted to confirm our findings and examine the interplay of PA, NeGR1, adiposity, and metabolic health.

ARTICLE HIGHLIGHTS

Moving towards the detection of frailty with biomarkers: A population health study

Aging adults experience increased health vulnerability and compromised abilities to cope with stressors, which are the clinical manifestations of frailty. Frailty is complex, and efforts to identify biomarkers to detect frailty and pre-frailty in the clinical setting are rarely reproduced across cohorts. We developed a predictive model incorporating biological and clinical frailty measures to identify robust biomarkers across data sets. Data were from two large cohorts of older adults: "Invecchiare in Chianti (Aging in Chianti, InCHIANTI Study") (n = 1453) from two small towns in Tuscany, Italy, and replicated in the Atherosclerosis Risk in Communities Study (ARIC) (n = 6508) from four U.S. communities. A complex systems approach to biomarker selection with a tree-boosting machine learning (ML) technique for supervised learning analysis was used to examine biomarker population differences across both datasets. Our approach compared predictors with robust, pre-frail, and frail participants and examined the ability to detect frailty status by race. Unique biomarker features identified in the InCHIANTI study allowed us to predict frailty with a model accuracy of 0.72 (95% confidence interval (CI) 0.66-0.80). Replication models in ARIC maintained a model accuracy of 0.64 (95% CI 0.66-0.72). Frail and pre-frail Black participant models maintained a lower model accuracy. The predictive panel of biomarkers identified in this study may improve the ability to detect frailty as a complex aging syndrome in the clinical setting. We propose several concrete next steps to keep research moving toward detecting frailty with biomarker-based detection methods.

Proteomic Indicators of Health Predict Alzheimer's Disease Biomarker Levels and Dementia Risk

OBJECTIVE

Few studies have comprehensively examined how health and disease risk influence Alzheimer's disease (AD) biomarkers. The present study examined the association of 14 protein-based health indicators with plasma and neuroimaging biomarkers of AD and neurodegeneration.

METHODS

In 706 cognitively normal adults, we examined whether 14 protein-based health indices (ie, SomaSignal® tests) were associated with concurrently measured plasma-based biomarkers of AD pathology (amyloid-β [Aβ]42/40 , tau phosphorylated at threonine-181 [pTau-181]), neuronal injury (neurofilament light chain [NfL]), and reactive astrogliosis (glial fibrillary acidic protein [GFAP]), brain volume, and cortical Aβ and tau. In a separate cohort (n = 11,285), we examined whether protein-based health indicators associated with neurodegeneration also predict 25-year dementia risk.

RESULTS

Greater protein-based risk for cardiovascular disease, heart failure mortality, and kidney disease was associated with lower Aβ42/40 and higher pTau-181, NfL, and GFAP levels, even in individuals without cardiovascular or kidney disease. Proteomic indicators of body fat percentage, lean body mass, and visceral fat were associated with pTau-181, NfL, and GFAP, whereas resting energy rate was negatively associated with NfL and GFAP. Together, these health indicators predicted 12, 31, 50, and 33% of plasma Aβ42/40 , pTau-181, NfL, and GFAP levels, respectively. Only protein-based measures of cardiovascular risk were associated with reduced regional brain volumes; these measures predicted 25-year dementia risk, even among those without clinically defined cardiovascular disease.

INTERPRETATION

Subclinical peripheral health may influence AD and neurodegenerative disease processes and relevant biomarker levels, particularly NfL. Cardiovascular health, even in the absence of clinically defined disease, plays a central role in brain aging and dementia. ANN NEUROL 2024;95:260-273.

Rest-Activity Rhythms Are Associated With Prevalent Cardiovascular Disease, Hypertension, Obesity, and Central Adiposity in a Nationally Representative Sample of US Adults

BACKGROUND

Rest-activity rhythms (RARs), a measure of circadian rhythmicity in the free-living setting, are related to mortality risk, but evidence is limited on associations with cardiovascular disease (CVD) and its risk factors.

METHODS AND RESULTS

Participants included 4521 adults from the 2013 to 2014 National Health and Nutrition Examination Survey physical activity monitoring examination. Wrist-worn ActiGraph GT3X+ data were used to estimate RARs. Multivariable logistic models evaluated associations of RARs with prevalent CVD, hypertension, obesity, and central adiposity. Participants (mean age, 49 years) in the highest versus lowest tertile of relative amplitude (greater circadian rhythmicity) had 39% to 62% lower odds of prevalent CVD, hypertension, obesity, and central adiposity. A more active wake period was associated with 19% to 72% lower CVD, hypertension, obesity, and central adiposity odds. Higher interdaily stability (regular sleep-wake and rest-activity patterns) was related to 52% and 23% lower CVD and obesity odds, respectively. In contrast, participants in the highest versus lowest tertile of intradaily variability (fragmented RAR and inefficient sleep) had >3-fold and 24% higher CVD and obesity odds, respectively. A later and less restful sleep period was associated with 36% to 2-fold higher CVD, hypertension, obesity, and central adiposity odds. A statistically significant linear trend was observed for all associations (P-trend<0.05).

CONCLUSIONS

A robust, stable, and less fragmented RAR, an active wake period, and an earlier and more restful sleep period are associated with lower prevalent CVD, hypertension, obesity, and central adiposity, with evidence of a dose-response relationship. The magnitude, timing, and regularity of sleep-wake and rest-activity patterns may be important targets for reducing cardiovascular risk.

Hearing Loss and Physical Activity Among Older Adults in the United States

BACKGROUND

Hearing loss is associated with adverse health outcomes among older adults. Lower physical activity levels may partly explain these observations, yet the association between hearing loss, hearing aid use, and physical activity among older adults is understudied.

METHODS

Cross-sectional analysis of National Health and Aging Trends Study (2021) participants. The better-hearing ear pure-tone average (BPTA) at speech frequencies (0.5-4 kHz) was modeled continuously (10-dB increments) and categorically (no: ≤25 dB, mild: 26-40 dB, moderate or greater: >40 dB hearing loss). Activity measures were wrist accelerometry-derived (Actigraph) total activity counts, daily active minutes, activity fragmentation (using active-to-sedentary transition probability), and self-reported participation in vigorous activities and walking for exercise in the last month. We used multivariable regression adjusted for sociodemographic and health covariates.

RESULTS

Among 504 participants excluding hearing aid users (mean age = 79 years, 57% female, 9% Black), 338 (67%) had hearing loss. Worse hearing (continuously and categorically) was associated with fewer counts and active minutes, more fragmented activity, and greater odds of not reporting recent vigorous activities. Among 472 participants with hearing loss including hearing aid users, nonusers (n = 338) had more fragmented activity and greater odds of not reporting walking for exercise compared to users.

CONCLUSIONS

Older adults with hearing loss are less physically active. This may mediate the association between hearing loss and other adverse outcomes. Recognition of this potential association is essential for providers to better support older adults in maintaining an active lifestyle. Future research is warranted to understand the impact of hearing interventions.

Associations Between Mid-Life Psychosocial Measures and Estimated Late Life Amyloid Burden: The Atherosclerosis Risk in Communities (ARIC)-PET Study

Background

Psychosocial factors are modifiable risk factors for Alzheimer's disease (AD). One mechanism linking psychosocial factors to AD risk may be through biological measures of brain amyloid; however, this association has not been widely studied.

Objective

To determine if mid-life measures of social support and social isolation in the Atherosclerosis Risk in Communities (ARIC) Study cohort are associated with late life brain amyloid burden, measured using florbetapir positron emission tomography (PET).

Methods

Measures of social support and social isolation were assessed in ARIC participants (visit 2: 1990-1992). Brain amyloid was evaluated with florbetapir PET standardized uptake value ratios (SUVRs; visit 5: 2012-2014).

Results

Among 316 participants without dementia, participants with intermediate (odds ratio (OR), 0.47; 95% CI, 0.25-0.88), or low social support (OR, 0.43; 95% CI, 0.22-0.83) in mid-life were less likely to have elevated amyloid SUVRs, relative to participants with high social support. Participants with moderate risk for social isolation in mid-life (OR, 0.32; 95% CI, 0.14-0.74) were less likely to have elevated amyloid burden than participants at low risk for social isolation. These associations were not significantly modified by sex or race.

Conclusions

Lower social support and moderate risk of social isolation in mid-life were associated with lower odds of elevated amyloid SUVR in late life, compared to participants with greater mid-life psychosocial measures. Future longitudinal studies evaluating mid-life psychosocial factors, in relation to brain amyloid as well as other health outcomes, will strengthen our understanding of the role of these factors throughout the lifetime.

Central arterial stiffening and intracranial atherosclerosis: the atherosclerosis risk in communities neurocognitive study (ARIC-NCS): Aortic stiffness & intracranial atherosclerosis

OBJECTIVES

Previous studies suggest an association between central arterial stiffness (CAS) and intracranial atherosclerotic disease (ICAD) among Asian participants with stroke or hypertension; this association has not been evaluated in United States populations. We assessed the cross-sectional association of CAS with ICAD presence and burden in late-life, and differences in association by age, sex, and race.

MATERIALS AND METHODS

We conducted a cross-sectional analysis of 1,285 Atherosclerosis Risk in Communities Study participants [mean age 75 (standard deviation: 5) years, 38 % male, 20  % Black] at Visit 5 (2011-2013). CAS was measured as carotid-femoral pulse wave velocity (cfPWV) using the Omron VP-1000 Plus. ICAD was assessed using high-resolution vessel wall MRI and MR angiography. We evaluated associations of a 1 standard deviation (SD) cfPWV (3.02 m/s) and high vs. non-high cfPWV (≥ 13.57 m/s vs. < 13.57 m/s) with presence of plaques (yes/no) and plaque number (0, 1-2, and >2) using multivariable logistic and ordinal logistic regression models adjusted for covariates.

RESULTS

Each one SD greater cfPWV was associated with higher odds of plaque presence (odds ratio (OR)=1.32, 95 % confidence interval (CI): 1.22, 1.43), and an incrementally higher odds of number of plaques (OR 1-2 vs. 0 plaques = 1.21, 95 % CI: 1.10, 1.33; OR >2 vs. 0 plaques = 1.51, 95 % CI: 1.33,1.71). Results suggested differences by race, with greater magnitude associations among Black participants.

CONCLUSIONS

CAS was positively associated with ICAD presence and burden; cfPWV may be a useful subclinical vascular measure for identification of individuals who are at high risk for cerebrovascular disease.

The Relationship of Neighborhood Disadvantage, Biological Aging, and Psychosocial Risk and Resilience Factors in Heart Failure Incidence Among Black Persons: A Moderated Mediation Analysis

OBJECTIVES

Deprived living environments contribute to greater heart failure (HF) risk among non-Hispanic Black persons, who disproportionately occupy disadvantaged neighborhoods. The mechanisms for these effects are not fully explicated, partially attributable to an insufficient understanding of the individual factors that contribute additional risk or resilience to the impact of neighborhood disadvantage on health. The objective of this study was, therefore, to clarify the complex pathways over which such exposures act to facilitate more targeted, effective interventions. Given the evidence for a mediating role of biological age and a moderating role of individual psychosocial characteristics in the neighborhood disadvantage-HF link, we tested a moderated mediation mechanism.

METHODS

Using multilevel causal moderated mediation models, we prospectively examined whether the association of neighborhood disadvantage with incident HF mediated through accelerated biological aging, captured by the GrimAge epigenetic clock, is moderated by hypothesized psychosocial risk (negative affect) and resilience (optimism) factors.

RESULTS

Among a sample of 1,448 Black participants in the shared Jackson Heart Study-Atherosclerosis Risk in Communities cohort (mean age 64.3 years), 334 adjudicated incident hospitalized HF events occurred over a median follow-up of 18 years. In models adjusted for age and sex, the indirect (GrimAge-mediated) effect of neighborhood disadvantage was moderated by psychosocial risk such that for every standard deviation increase in negative affect the hazards of HF was 1.18 (95% confidence interval = 1.05, 1.36). No moderated mediation effect was detected for optimism.

DISCUSSION

Findings support the necessity for multilevel interventions simultaneously addressing neighborhood and individual psychosocial risk in the reduction of HF among Black persons.

Biological Age Mediates the Effects of Perceived Neighborhood Problems on Heart Failure Risk Among Black Persons

OBJECTIVE

We assessed whether biological age, measured by the epigenetic clock GrimAge, mediates the association of objective and subjective neighborhood disadvantage with incident HF among Black persons.

METHODS

Participants were 1448 self-reported Black adults (mean age (standard deviation, SD) = 64.3 (5.5)) dually enrolled in two community-based cohorts in Jackson, Mississippi, the ARIC and JHS cohorts, who were free of HF as of January 1, 2000. Incident HF events leading to hospitalization through December 31, 2017, were classified using ICD-9 discharge codes of HF. Multilevel age- and sex-adjusted Cox causal mediation models were used to examine whether biological age (at the person and neighborhood level) mediated the effects of objective (the National Area Deprivation Index, ADI) and subjective (perceived neighborhood problems) neighborhood disadvantage on incident HF.

RESULTS

A total of 334 incident hospitalized HF events occurred over a median follow-up of 18.0 years. The total effect of the ADI and perceived neighborhood problems (SD units) on HF was hazard ration (HR) = 1.26 and 95% confidence interval (CI) 0.98-1.56 and HR = 1.26 and 95% CI 1.10-1.41, respectively. GrimAge mediated a majority of the effect of perceived neighborhood problems on HF (person-level indirect effect HR = 1.07; 95% CI 1.02-1.12 and neighborhood-level indirect effect HR = 1.18; 95% CI 1.03-1.34), with the combined indirect effect explaining 94.8% of the relationship. The combined indirect effect of ADI on incident HF was comparable but not statistically significant.

CONCLUSIONS

Subjective neighborhood disadvantage may confer an increased risk of HF among Black populations.

Distinct moderating pathways for psychosocial risk and resilience in the association of neighborhood disadvantage with incident heart failure among Black persons

Objective

To assess whether psychosocial factors moderate the associations between neighborhood disadvantage and incident heart failure (HF).

Methods

Among 1448 Non-Hispanic (NH) Black persons dually enrolled in two community-based cohorts in Jackson, Mississippi who were free of HF as of January 1, 2000, 336 HF events classified by reviewer panel accrued through December 31, 2017. Multilevel, multivariable Cox regression models were used to examine whether optimism and negative affect moderated the associations of two measures of neighborhood characteristics (the national Area Deprivation Index (ADI) and perceived neighborhood problems) on incident hospitalized HF.

Results

Optimism moderated the association of the ADI with incident HF. Compared to participants reporting the lowest tertile of optimism, those in the highest tertile of optimism had a 29% lower rate of HF associated with increasing ADI in fully adjusted models. We found no evidence for a moderating effect of negative affect.

Conclusions

This study supports optimism as a source of resilience to the detrimental effects of neighborhood disadvantage on HF risk. Population-level strategies to promote sociocultural antecedents to optimism may serve as a viable method of reducing the disproportionate burden of HF among NH Black persons.

Multimorbidity is associated with lower total 24-hour movement activity among US adults

Objective

Having chronic conditions may result in reduced physical and cognitive function but less is known about multimorbidity with daily movement. We examined the association of multimorbidity and device-measured total daily movement in a nationally representative sample of US adults aged ≥ 30 years from the 2011-2014 National Health and Nutrition Examination Surveys.

Methods

Any multimorbidity (≥2 conditions) and complex multimorbidity (≥3 conditions across ≥ 3 body systems) were quantified using 16 chronic conditions via self-report and/or clinical thresholds. Total movement over 24-hours (Monitor-Independent Movement Summary units [MIMS-units]) was measured using a wrist-worn device (ActiGraph GT3X). Multivariable linear regression examined the association of 1) each chronic condition, 2) number of conditions, 3) any multimorbidity, and 4) complex multimorbidity with total movement. Covariates included age, gender, race/ethnicity, educational attainment, and smoking status.

Results

Among US adults (N = 7304, mean age: 53.2 ± 0.34 years, 53.2% female, 69.4% Non-Hispanic White), 62.2% had any multimorbidity with 34.2% having complex multimorbidity. After adjustment, a higher number of chronic conditions was associated with incrementally lower total movement (β MIMS-units [95% CI] compared to those with no chronic conditions; one: -419 [-772, -66], two: -605 [-933, -278], three: -1201 [-1506, -895], four: -1908 [-2351, -1465], 5+: -2972 [-3384, -2560]). Complex multimorbidity presence was associated with -1709 (95% CI: -2062, -1357) and -1269 (-1620, -918) lower total movement compared to those without multimorbidity and multimorbidity but not complex, respectively.

Conclusions

Multimorbidity was associated with lower 24-h movement among US adults and may be helpful for identifying adults at risk for low movement.

Associations Between Head Injury and Subsequent Risk of Falls: Results From the Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND AND OBJECTIVES

Falls are a leading cause of head injury among older adults, but the risk of fall occurring after a head injury is less well-characterized. We sought to examine the association between head injury and subsequent risk of falls requiring hospital care among community-dwelling older adults.

METHODS

This analysis included 13,081 participants in the Atherosclerosis Risk in Communities Study enrolled in 1987-1989 and followed through 2019. The association of head injury (time-varying exposure, self-reported and/or ICD-9/10 code identified) with the risk of subsequent (occurring >1-month after head injury) falls requiring hospital care (ICD-9/10 code defined) was modeled using Cox proportional hazards regression. Secondary analyses included Fine and Gray proportional hazards regression to account for the competing risk of death, analysis of head injury frequency and severity, and formal testing for interaction by age, sex, and race. Models were adjusted for age, sex, race/center, education, military service, alcohol consumption, smoking, diabetes, hypertension, and psychotropic medication use.

RESULTS

The mean age of participants at baseline was 54 years, 58% were female, 28% were Black, and 14% had at least one head injury occurring over the study period. Over a median 23 years of follow-up, 29% of participants had a fall requiring medical care. In adjusted Cox proportional hazards models, individuals with head injury had 2.01 (95% CI 1.85-2.18) times the risk of falls compared with individuals without head injury. Accounting for the competing risk of mortality, individuals with head injury had 1.69 (95% CI 1.57-1.82) times the risk of falls compared with individuals without head injury. We observed stronger associations among men compared with women (men: hazard ratio [HR] = 2.60, 95% CI 2.25-3.00; women: HR = 1.80, 95% CI 1.63-1.99, p-interaction <0.001). We observed evidence of a dose-response association for head injury number and severity with fall risk (1 injury: HR = 1.68, 95% CI 1.53-1.84; 2+ injuries: HR = 2.37, 95% CI 1.92-2.94 and mild: HR = 1.97, 95% CI 1.78-2.18; moderate/severe/penetrating: HR = 2.50, 95% CI 2.06-3.02).

DISCUSSION

Among community-dwelling older adults followed over 30 years, head injury was associated with subsequent falls requiring medical care. We observed stronger associations among men and with increasing number and severity of head injuries. Whether older individuals with head injury might benefit from fall prevention measures should be a focus of future research.

Hearing Loss and Frailty among Older Adults: The Atherosclerosis Risk in Communities Study

OBJECTIVES

Hearing loss may contribute to frailty through cognitive and physical decline, but population-based evidence using validated measures remains scarce. We investigated the association of hearing loss with phenotypic frailty and its individual components and explored the potential protective role of hearing aid use.

DESIGN

Cross-sectional study of community-dwelling older adults at visit 6 (2016-2017) of the Atherosclerosis Risk in Communities (ARIC) study, a cohort study of older adults from 4 U.S. communities (Washington County, MD; Forsyth County, NC; Jackson, MS; and Minneapolis, MN).

SETTING AND PARTICIPANTS

Population-based study of 3179 participants (mean age = 79.2 years, 58.9% female).

METHODS

Pure-tone audiometry at 0.5-4 kHz was used to assess unaided hearing, and the better-hearing ear's pure-tone average was categorized as follows: no [≤25 dB hearing level (HL)], mild (26-40 dB HL), and moderate or greater (>40 dB HL) hearing loss. Hearing aid use was self-reported. The Fried/physical frailty phenotype was used to categorize frailty status (robust, pre-frail, or frail). Multivariable multinomial and logistic regression models were used to study the association of hearing loss/hearing aid use with frailty status and individual frailty components, respectively.

RESULTS

In our sample, 40% had mild and 27% had moderate or greater hearing loss (12% and 55% reported hearing aid use, respectively). Moderate or greater hearing loss was associated with greater odds of being pre-frail [odds ratio (OR), 1.25; 95% CI, 1.01-1.57] and frail (OR, 1.62; 95% CI, 1.06-2.47) vs robust, and greater odds of having slow gait, low physical activity, and exhaustion, compared with no hearing loss. Among those with hearing loss (>25 dB HL), compared with hearing aid users, nonusers had greater odds of being frail vs robust, and having unintentional weight loss, slow gait, and low physical activity.

CONCLUSIONS AND IMPLICATIONS

Hearing loss is associated with pre-frailty and frailty. Longitudinal studies are warranted to establish if hearing aid use may prevent or delay frailty onset.

Heart rate variability and risk of agitation in Alzheimer's disease: the Atherosclerosis Risk in Communities Study

Agitation in Alzheimer's disease is common and may be related to impaired emotion regulation capacity. Heart rate variability, a proposed index of autonomic and emotion regulation neural network integrity, could be associated with agitation propensity in Alzheimer's disease. We used the Atherosclerosis Risk in Communities Study cohort data, collected over seven visits spanning over two decades, to investigate whether heart rate variability (change) was associated with agitation risk in individuals clinically diagnosed with dementia due to Alzheimer's disease. Agitation (absence/presence) at Visit 5, the primary outcome, was based on the Neuropsychiatric Inventory agitation/aggression subscale, or a composite score comprising the total number of agitation/aggression, irritability, disinhibition and aberrant motor behaviour subscales present. Visit 1-5 heart rate variability measures were the log-transformed root mean square of successive differences in R-R intervals and standard deviation of normal-to-normal R-R intervals obtained from resting, supine, standard 12-lead ECGs. To aid interpretability, heart rate variability data were scaled such that model outputs were expressed for each 0.05 log-unit change in heart rate variability (which approximated to the observed difference in heart rate variability with every 5 years of age). Among 456 participants who had dementia, 120 were clinically classified to have dementia solely attributable to Alzheimer's disease. This group showed a positive relationship between heart rate variability and agitation risk in regression models, which was strongest for measures of (potentially vagally mediated) heart rate variability change over the preceding two decades. Here, a 0.05 log-unit of heart rate variability change was associated with an up to 10-fold increase in the odds of agitation and around a half-unit increase in the composite agitation score. Associations persisted after controlling for participants' cognitive status, heart rate (change), sociodemographic factors, co-morbidities and medications with autonomic effects. Further confirmatory studies, incorporating measures of emotion regulation, are needed to support heart rate variability indices as potential agitation propensity markers in Alzheimer's disease and to explore underlying mechanisms as targets for treatment development.

Spousal Cognitive Status and Risk for Declining Cognitive Function and Dementia: The Atherosclerosis Risk in Communities Study

Objectives: We investigated the relationship between the cognitive status of participants' spouses and participants' own cognitive outcomes, controlling for mid-life factors. Methods: Participants (n = 1845; baseline age 66-90 years) from the prospective Atherosclerosis Risk in Communities Study were followed from 2011 to 2019. We used linear regression and Cox proportional hazard models to estimate whether spouses of people with MCI/dementia had lower cognitive functioning and elevated risk of incident dementia. Results: Having a spouse with MCI/dementia was associated with a deficit in cognitive function (b = -0.09 standard deviations; 95% CI = -0.18, 0.00). Adjustment for mid-life risk factors attenuated this association (b = -0.02 standard deviations; 95% CI = -0.10, 0.06). We observed no significant relationship between spousal MCI/dementia status and incident dementia (hazard ratio = 0.97; 95% CI = 0.69, 1.38). Discussion: Spousal cognitive status is not associated with poor cognitive outcomes independent of mid-life factors.

The association of perceived discrimination with dementia risk in Black older adults

INTRODUCTION

Non-Hispanic Black, compared to non-Hispanic White, older adults are at increased risk for dementia. This may be due partly to greater exposure to psychosocial stressors, such as discrimination; however, few studies have examined this association.

METHODS

We examined the association of perceived discrimination (e.g., everyday, lifetime, and discrimination burden) with dementia risk in 1583 Black adults co-enrolled in the Atherosclerosis Risk in Communities (ARIC) Study and the Jackson Heart Study (JHS). Perceived discrimination (defined continuously and using tertiles) was assessed at JHS Exam 1 (2000-2004; mean age ± SD:66.2 ± 5.5) and related to dementia risk through ARIC visit 6 (2017) using covariate-adjusted Cox proportional hazards models.

RESULTS

Associations of perceived everyday, lifetime, and burden of discrimination with dementia risk were not supported in age-adjusted models or demographic- and cardiovascular health-adjusted models. Results were similar across sex, income, and education.

DISCUSSION

In this sample, associations between perceived discrimination and dementia risk were not supported.

HIGHLIGHTS

In Black older adults perceived discrimination not associated with dementia risk. Younger age and greater education linked to greater perceived discrimination. Older age and less education among factors associated with dementia risk. Factors increasing exposure to discrimination (education) are also neuroprotective.

Sex differences in associations between APOE ε2 and longitudinal cognitive decline

INTRODUCTION

We examined whether sex modifies the association between APOE ε2 and cognitive decline in two independent samples.

METHODS

We used observational data from cognitively unimpaired non-Hispanic White (NHW) and non-Hispanic Black (NHB) adults. Linear mixed models examined interactive associations of APOE genotype (ε2 or ε4 carrier vs. ε3/ε3) and sex on cognitive decline in NHW and NHB participants separately.

RESULTS

In both Sample 1 (N = 9766) and Sample 2 (N = 915), sex modified the association between APOE ε2 and cognitive decline in NHW participants. Specifically, relative to APOE ε3/ε3, APOE ε2 protected against cognitive decline in men but not women. Among APOE ε2 carriers, men had slower decline than women. Among APOE ε3/ε3 carriers, cognitive trajectories did not differ between sexes. There were no sex-specific associations of APOE ε2 with cognition in NHB participants (N = 2010).

DISCUSSION

In NHW adults, APOE ε2 may protect men but not women against cognitive decline.

HIGHLIGHTS

We studied sex-specific apolipoprotein E (APOE) ε2 effects on cognitive decline. In non-Hispanic White (NHW) adults, APOE ε2 selectively protects men against decline. Among men, APOE ε2 was more protective than APOE ε3/ε3. In women, APOE ε2 was no more protective than APOE ε3/ε3. Among APOE ε2 carriers, men had slower decline than women. There were no sex-specific APOE ε2 effects in non-Hispanic Black (NHB) adults.

Association of Olfaction and Microstructural Integrity of Brain Tissue in Community-Dwelling Adults: Atherosclerosis Risk in Communities Neurocognitive Study

BACKGROUND AND OBJECTIVES

Research on olfaction and brain neuropathology may help understand brain regions associated with normal olfaction and dementia pathophysiology. To identify early regional brain structures affected in poor olfaction, we examined cross-sectional associations of microstructural integrity of the brain with olfaction in the Atherosclerosis Risk in Communities Neurocognitive Study.

METHODS

Participants were selected from a prospective cohort study of community-dwelling adults; selection criteria included the following: evidence of cognitive impairment, participation in a previous MRI study, and a random sample of cognitively normal participants. Microstructural integrity was measured by 2 diffusion tensor imaging (DTI) measures, fractional anisotropy (FA) and mean diffusivity (MD), and olfaction by a 12-item odor identification test at the same visit. Higher FA and MD values indicate better and worse microstructural integrity, respectively, and higher odor identification scores indicate better olfaction. We used brain region-specific linear regression models to examine associations between DTI measures and olfaction, adjusting for potential confounders.

RESULTS

Among 1,418 participants (mean age 76 ± 5 years, 41% male, 21% Black race, 59% with normal cognition), the mean olfaction score was 9 ± 2.3. Relevant to olfaction, higher MD in the medial temporal lobe (MTL) regions, namely the hippocampus (β -0.79 [95% CI -0.94 to -0.65] units lower olfaction score per 1 SD higher MD), amygdala, entorhinal area, and some white matter (WM) tracts connecting to these regions, was associated with olfaction. We also observed associations with MD and WM FA in multiple atlas regions that were not previously implicated in olfaction. The associations between MD and olfaction were particularly stronger in the MTL regions among individuals with mild cognitive impairment (MCI) compared with those with normal cognition (e.g., βhippocampus -0.75 [95% CI -1.02 to -0.49] and -0.44 [95% CI -0.63 to -0.26] for MCI and normal cognition, respectively, p interaction = 0.004).

DISCUSSION

Neuronal microstructural integrity in multiple brain regions, particularly the MTL (the regions known to be affected in early Alzheimer disease), is associated with odor identification ability. Differential associations in the MTL regions among cognitively normal individuals compared with those with MCI may reflect the earlier vs later effects of the dementia pathogenesis. It is likely that some of the associated regions may not have any functional relevance to olfaction.

Factors Associated with Poor Olfaction and Olfactory Decline in Older Adults in the ARIC Neurocognitive Study

Olfactory function has significant implications for human health, but few risk factors for olfactory decline have been identified. We examined the factors associated with olfactory status and decline over five years in the Atherosclerosis Risk in Communities (ARIC) Neurocognitive Study. A 12-item odor identification test was used to assess olfaction in 6053 participants in 2011-2013 (ARIC visit 5, mean age: 75.6, 41% male, 23% Black race) and in 3235 participants in 2016-2017 (visit 6). We used Poisson regression models to examine cross-sectional associations of a range of potential factors with the total odor identification errors (mean errors: 2.8 ± 2.4) in visit 5 participants. We used mixed-effect Poisson regression to examine associations with olfactory decline between visits 5 and 6. We also examined associations with visit 5 anosmia prevalence (847 cases, 14%) and incident anosmia between the two visits (510 cases, 16%) using Poisson models. Older age, male sex, lower education, Black race, APOE ε4 alleles, and diabetes were associated with higher odor identification errors and higher anosmia prevalence, and greater physical activity and hypertension with better olfaction. Age, male sex, lower education, Black race, APOE ε4 allele, and vitamin B12 levels were associated with incident anosmia over 5 years. Older age was associated with faster olfactory decline. Future studies with longer follow-ups are warranted.

Aging-Related Multisystem Dysregulation Over the Adult Life Span and Physical Function in Later Life: The Atherosclerosis Risk in Communities (ARIC) Study

BACKGROUND

Multisystem dysregulation (Dm) shows promise as a metric of aging and predicts mortality. However, Dm needs to be studied with less severe endpoints indicating modifiable aging stages. Physical function, reflecting healthy longevity rather than just longevity, is more relevant to the goals of geroscience but has not been well investigated.

METHODS

We tested the association of midlife Dm and its change over ~20 years with physical function in later life in 5 583 the Atherosclerosis Risk in Communities Study cohort participants (baseline mean age 54.7). Dm quantifies the multivariate statistical deviation of 17 physiologically motivated biomarkers relative to their distribution in a young healthy sample at baseline. Physical function was assessed from grip strength and the Short Physical Performance Battery (SPPB). Associations were quantified using linear regression and ordinal logistic regression adjusting for age, sex, race, and education.

RESULTS

Each unit increment in midlife Dm was associated with 1.71 times the odds of having a lower SPPB score. Compared to the first quartile of midlife Dm, the odds ratios of having a lower SPPB score were 1.25, 1.56, and 2.45, respectively, for the second-fourth quartiles. Similar graded association patterns were observed for each SPPB component test and grip strength. An inverse monotonic relationship also was observed between the annual growth rate of Dm and physical function.

CONCLUSION

Greater Dm and progression in midlife were associated with lower physical function in later life. Future studies on the factors that lead to the progression of Dm may highlight opportunities to preserve physical function.

Bidirectional Association Between Frailty and Cardiac Structure and Function: The Atherosclerosis Risk in Communities Study

Background Frailty and heart failure frequently coexist in late life. Limited data exist regarding the longitudinal associations of frailty and subclinical cardiac dysfunction. We aim to quantify the association of frailty with longitudinal changes in cardiac function and of cardiac function with progression in frailty status in older adults. Methods and Results Participants in the Atherosclerosis Risk in Communities cohort underwent frailty assessments at Visit 5 (V5; 2011-2013), V6 (2016-2017), and V7 (2018-2019), and echocardiographic assessments at V5 and V7. We assessed the association between frailty status at V5 and changes in frailty status from V5 to V7 and changes in cardiac function over 6 years. We then evaluated the association of cardiac function measured at Visit 5 with progression in frailty status over 4 years. Multivariable regression models adjusted for demographics and comorbidities. Among 2574 participants free of heart failure at V5 and V7 (age 74±4 years at V5 and 81±4 years at V7), 3% (n=83) were frail. Frailty at V5 was associated with greater left atrial volume index and E/e' ratio at V5 and 7. Participants who transitioned from robust at V5 to frail at V7 demonstrated greater increases in left ventricular mass index, left atrial volume index, and E/e' over the same period. Among 1648 robust participants at Visit 5, greater left ventricular mass index and mean wall thickness, lower tissue Doppler imaging e', and higher E/e' ratio at Visit 5 were associated with progression in frailty status. Conclusions Among robust, older adults free of heart failure, progression in frailty and subclinical left ventricular remodeling and diastolic dysfunction are interrelated.

Dementia occurring over a 32-year follow-up attributable to hypertension observed at different ages: Implications for dementia prevention

INTRODUCTION

The fraction of dementia attributable to hypertension might vary depending on the age of the population considered and the age through which dementia occurs.

METHODS

In the Atherosclerosis Risk in Communities study, we quantified population attributable fractions (PAF) of dementia by age 80 and 90 from hypertension assessed at ages of 45-54 (n = 7572), 55-64 (n = 12,033), 65-74 (n = 6561), and 75-84 (n = 2086).

RESULTS

The PAF for dementia by age 80 from all non-normal blood pressure at ages 45-54 was 15.3% (95% confidence interval [CI] = 6.9%-22.3%), 19.1% (95% CI = 9.9%-26.9%) at ages 55-64, and 19.9% (95% CI = -4.4%-38.5%) at ages 65-74. The strongest PAFs were from stage 2 hypertension (11.9%-21.3%). For dementia by age 90, PAFs from non-normal blood pressure up through age 75 were smaller (10.9%-13.8%), and non-significant by age 75-84.

DISCUSSION

Interventions targeting hypertension even in early late life might reduce a sizeable proportion of dementia.

HIGHLIGHTS

We estimated prospective population attributable risks of dementia for hypertension. 15%-20% of dementia cases by age 80 are from non-normal blood pressure (BP). Associations between hypertension and dementia persisted through age 75. Midlife to early late-life BP control might reduce a large proportion of dementia.

Association of Childhood and Midlife Neighborhood Socioeconomic Position With Cognitive Decline

Importance

Early-life socioeconomic adversity may be associated with poor cognitive health over the life course.

Objective

To examine the association of childhood and midlife neighborhood socioeconomic position (nSEP) with cognitive decline.

Design, Setting, and Participants

This cohort study included 5711 men and women enrolled in the community-based Atherosclerosis Risk in Communities (ARIC) Study with repeated cognitive data measured over a median 27.0 years (IQR, 26.0-27.9 years) (1990-2019). Statistical analysis was performed from December 2022 through March 2023.

Exposure

Residence addresses for ARIC Study cohort participants were obtained at midlife (1990-1993) and as recalled addresses at 10 years of age (childhood). A composite nSEP z score was created as a sum of z scores for US Census-based measures of median household income; median value of owner-occupied housing units; percentage of households receiving interest, dividend, or net rental income; percentage of adults with a high school degree; percentage of adults with a college degree; and percentage of adults in professional, managerial, or executive occupations. Childhood nSEP and midlife nSEP were modeled as continuous measures and discretized into tertiles.

Main Outcomes and Measures

A factor score for global cognition was derived from a battery of cognitive tests administered at 5 in-person visits from baseline to 2019. The rate of cognitive decline from 50 to 90 years of age was calculated by fitting mixed-effects linear regression models with age as the time scale and adjusted for race, sex, birth decade, educational level, and presence of the apolipoprotein E ε4 allele.

Results

Among 5711 ARIC Study participants (mean [SD] baseline age, 55.1 [4.7] years; 3372 women [59.0%]; and 1313 Black participants [23.0%]), the median rate of cognitive decline was -0.33 SDs (IQR, -0.49 to -0.20 SDs) per decade. In adjusted analyses, each 1-SD-higher childhood nSEP score was associated with a slower (β, -9.2%; 95% CI, -12.1% to -6.4%) rate of cognitive decline relative to the sample median. A comparable association was observed when comparing the highest tertile with the lowest tertile of childhood nSEP (β, -17.7%; 95% CI, -24.1% to -11.3%). Midlife nSEP was not associated with the rate of cognitive decline.

Conclusions and Relevance

In this cohort study of contextual factors associated with cognitive decline, childhood nSEP was inversely associated with trajectories of cognitive function throughout adulthood.

The Association Between Midlife Leisure-Time Physical Activity and Hearing Loss in Late Life in the Atherosclerosis Risk in Communities Study

BACKGROUND

Hearing loss is highly prevalent in older ages and has several health consequences. Some cardiovascular risk factors are associated with worse hearing at older ages. Still, the role of midlife leisure-time physical activity (PA) as a risk factor for hearing loss is yet to be investigated.

METHODS

Among 3 198 participants of the Atherosclerosis Risk in Communities study, we investigated the associations of midlife and change from mid- to late-life PA (assessed via modified Baecke questionnaire) with hearing loss (audiometric battery [worse-ear pure-tone average, and speech-in-noise test]) at older ages. We used regression analyses, adjusted for demographics, medical conditions, and noise exposure, to estimate differences in hearing between those who met and did not meet PA recommendations at midlife and at late life.

RESULTS

A total of 1 386 (43.3%) participants met PA recommendations at midlife. These participants, compared to those who did not meet recommendations, had lower (better) pure-tone average by 1.51 (0.46, 2.55) decibels, identified 0.37 (0.01, 0.74) more words (better score) in the speech-in-noise test, and had a lower relative risk of having hearing loss at older ages (eg, relative risk ratio for severe hearing loss vs normal hearing = 0.70 [0.52, 0.95]). Similarly, those who persistently met PA recommendations from mid- to late life had, compared with those who did not, a better hearing at older ages.

CONCLUSIONS

Meeting PA public health recommendations in midlife and mid- to late life was associated with better hearing at older ages and reduced risk of hearing loss. Promoting adequate levels of PA may be an essential component of hearing care.

AD and non-AD mediators of the pathway between the APOE genotype and cognition

INTRODUCTION

The apolipoprotein E (APOE) genotype is a driver of cognitive decline and dementia. We used causal mediation methods to characterize pathways linking the APOE genotype to late-life cognition through Alzheimer's disease (AD) and non-AD neuropathologies.

METHODS

We analyzed autopsy data from 1671 individuals from the Religious Orders Study, Memory and Aging Project, and Minority Aging Research Study (ROS/MAP/MARS) studies with cognitive assessment within 5 years of death and autopsy measures of AD (amyloid beta (Aβ), neurofibrillary tangles), vascular (athero/arteriolo-sclerosis, micro-infarcts/macro-infarcts), and non-AD neurodegenerative neuropathologies (TAR DNA protein 43 [TDP-43], Lewy bodies, amyloid angiopathy, hippocampal sclerosis).

RESULTS

The detrimental effect of APOE ε4 on cognition was mediated by summary measures of AD and non-AD neurodegenerative neuropathologies but not vascular neuropathologies; effects were strongest in individuals with dementia. The protective effect of APOE ε2 was partly mediated by AD neuropathology and stronger in women than in men.

DISCUSSION

The APOE genotype influences cognition and dementia through multiple neuropathological pathways, with implications for different therapeutic strategies targeting people at increased risk for dementia.

HIGHLIGHTS

Both apolipoprotein E (APOE) ε2 and APOE ε4 effects on late-life cognition are mediated by AD neuropathology. The estimated mediated effects of most measures of AD neuropathology were similar. Non-Alzheimer's disease (AD) neurodegenerative pathologies mediate the effect of ε4 independently from AD. Non-AD vascular pathologies did not mediate the effect of the APOE genotype on cognition. The protective effect of APOE ε2 on cognition was stronger in women.

Association of leisure-time physical activity and sedentary behavior with carotid atherosclerosis morphology: The ARIC carotid-MRI study

Objective

We evaluated the prospective association of midlife leisure-time physical activity (LTPA) and sedentary behavior (SB), and their temporal patterns, with MRI-measured carotid atherosclerotic morphology.

Methods

Participants enrolled in the Carotid MRI substudy (2004-2006) of the Atherosclerosis Risk in Communities (ARIC) Study and with self-reported assessments of LTPA and SB at visits 1 (1987-1989) and 3 (1993-1995) were included in this study. LTPA was ascertained using the ARIC/Baecke physical activity questionnaire and categorized according to the American Heart Association's metric of poor, intermediate, or ideal physical activity. SB, measured as TV viewing frequency, was categorized as high, medium, and low. We used multivariable adjusted linear and logistic regression models to examine the associations between midlife (visit 3 only) and persistent (visit 1 to 3) LTPA and TV viewing with carotid artery plaque burden and components.

Results

Among the 1,582 (mean age: 59 years, 43% male, 18% Black) participants, 45.7%, 21.7%, and 32.6% reported ideal, intermediate, or poor LTPA, respectively. High TV viewing was reported in 33.8% of participants, with 46.4% and 19.8% reporting medium or low TV viewing, respectively. Compared to poor LTPA, ideal LTPA in midlife was not associated with total wall volume (ß=0.01, 95% CI: -0.01, 0.03), maximum carotid wall thickness (ß=0.06, 95% CI: -0.08, 0.21), normalized wall index (ß=-0.01, 95% CI: -0.03, 0.01), or maximum stenosis (ß=-0.11, 95% CI: -1.98, 1.76). Low or middle, compared to high, TV viewing was also not associated with carotid artery measures of plaque burden. Compared to poor LTPA or high TV viewing, ideal LTPA (odds ratio (OR): 0.82, 95% CI: 0.55, 1.23) and low TV viewing (OR=0.90, 95% CI: 0.56, 1.44) was not associated with odds of lipid core presence, respectively.

Conclusion

Overall, this study does not provide strong evidence for an association between LTPA and SB with carotid plaque measures.

Association of Carotid Atherosclerosis With Hearing Loss: A Cross-sectional Analysis of the Atherosclerosis Risk in Communities Study

Objective

To describe the association between midlife carotid atherosclerosis and late-life hearing loss among participants in the Atherosclerosis Risk in Communities (ARIC) study.

Design, Setting, and Participants

For this cross-sectional study and temporal analysis of a cohort within the ongoing ARIC prospective cohort study, participants were recruited from 4 communities in the US. The analysis evaluated information on mean carotid intima-media thickness (cIMT), from visit 1 (1987-1989) to visit 4 (1994-1996), carotid plaque presence at visit 4, and audiometric data from visit 6 (2016-2017). The cIMT measures were calculated from ultrasonography recordings by trained readers at the ARIC Ultrasound Reading Center. At each visit, cIMT was computed as the average of 3 segments: the distal common carotid, the carotid artery bifurcation, and the proximal internal carotid arteries. Presence of carotid plaque was determined based on an abnormal wall thickness, shape, or wall texture. Audiometric 4-frequency pure tone average (PTA) was measured and calculated for the better-hearing ear and modeled as a continuous variable. Linear regression estimated the association between cIMT and carotid plaque with hearing, adjusting for age, sex, race and study center, education level, body mass index (calculated as weight in kilograms divided by height in meters squared), smoking status, hypertension, cholesterol levels, diabetes, and exposure to occupational noise. Missing data (exposure and covariates) were imputed with multiple imputation by chained equations. Data analyses were performed from April 6 to July 13, 2022.

Main Outcomes and Measures

Hearing loss assessed using 4-frequency (0.5, 1.0, 2.0, and 4.0 kilohertz) PTA for both ears and carotid plaque at visit 4 and mean cIMT from visit 1 to visit 4.

Results

Among a total of 3594 participants (mean [SD] age at visit 4, 59.4 [4.6] years; 2146 [59.7%] female; 819 [22.8%] Black and 2775 [77.2%] White individuals), fully adjusted models indicated that an additional 0.1 mm higher mean cIMT was associated with 0.59 dB (95% CI, 0.17 to 1.02 dB) higher PTA. Compared with participants without carotid plaque, plaque presence was associated with 0.63 dB (95% CI, -0.57 to 1.84 dB) higher PTA.

Conclusion and Relevance

The findings of this cross-sectional study with temporal analyses of a cohort with the ongoing ARIC study found that subclinical atherosclerosis in midlife was associated with worse hearing in older adulthood. Prevention and control of carotid atherosclerosis during middle age may positively affect the hearing health of older adults.

Associations of Late-Life Sleep Medication Use With Incident Dementia in the Atherosclerosis Risk in Communities Study

BACKGROUND

Sleep medications may contribute to dementia development or indicate sleep disturbances that are markers of or contributors to neurologic disease. The objective of this study was to examine the use of sleep medications and incident dementia in a community-based cohort of older adults. We hypothesize late-life sleep medication use is associated with a greater risk of dementia.

METHODS

The Atherosclerosis Risk in Communities (ARIC) study is an ongoing community-based cohort study. ARIC participants taking barbiturates, benzodiazepines, antidepressants, non-benzodiazepine receptor agonists (Z-drugs), or other hypnotics in 2011-2013 were categorized as sleep medication users. Participants were followed through 2019 for incident dementia. Logistic regression propensity scores were used to match sleep medication users with nonusers (1:2). Cox proportional hazards regression models were used to estimate hazard ratios (HR) for time to dementia diagnosis with adjustment for demographics, lifestyle characteristics, and cardiovascular risk factors.

RESULTS

One-quarter of the eligible ARIC participants used sleep medications. In the matched sample (N = 4 197; 69% female; mean age 75.3 + 5.0 years), 632 dementia cases were ascertained over a median follow-up of 6.5 years. In the fully adjusted model, sleep medication use compared to nonuse was associated with a 48% greater risk of dementia (HR: 1.48; 95% confidence interval (CI): 1.26-1.74).

CONCLUSION

To expand on these findings, studies with longer follow-up and earlier assessment of sleep medication use are needed. Furthermore investigation of the potential dose-response association of multiple sleep medications and the potential causal role of sleep medications in the development of dementia may be clinically meaningful.

Abstract P228: Accelerometer-Derived Daily Steps, Cognition, and Cognitive Impairment in U.S. Community-Dwelling Older Adults: The Atherosclerosis Risk in Communities Study

Introduction: Higher physical activity levels have been shown to preserve cognitive function and prevent cognitive impairment (CI). Whether daily steps, an easily interpretable physical activity metric, is associated with measures of brain health has not been widely studied.

Hypothesis: Higher daily step count is associated with better cognitive function and lower odds of CI.

Methods: Cross-sectional analysis of ARIC participants (mean age: 78 years, 41% male, 19% Black) who wore an accelerometer (ActiGraph GT3X) on the waist for ≥10 hours on ≥3 days between 2016-17. Daily steps were derived and examined continuously and by quartiles. Global and domain-specific (memory, language, executive function) factor scores were estimated from a battery of cognitive tests. Participants were classified as having CI if they had an adjudicated diagnosis of mild CI or dementia. Hypotheses were tested using linear and logistic regression models, adjusted for age, sex, race, education, and accelerometer wear time.

Results: Among 454 participants, 88 (19.4%) had CI. The mean number of daily steps was 3,501 (SD=1,974). In adjusted models, a higher daily step count was associated with better global cognition and executive function factor scores (e.g., those in the 4 th daily-step quartile [≥4,499 steps] vs. 1 st [<2074 steps] had a 0.43 [95% confidence interval: 0.24 to 0.61] higher executive function score). Associations of step count with memory or language scores were not supported. The odds of CI were lower for participants who had a higher daily steps count (e.g., those in the 4 th daily-step quartile vs. 1 st had 62% [odds ratio (OR)=0.38, 95% confidence interval: 0.16 to 0.90] lower odds of CI. The OR of CI for continuous daily steps shown in the Figure.

Conclusions: Higher daily steps were associated with better cognitive function and may be a helpful marker in identifying participants with CI. Prospective studies of accelerometer-measured physical activity and cognitive outcomes are needed to understand the direction of these associations.

Abstract P500: Age-Specific Population Attributable Fractions for the Impact of Hypertension on Dementia Risk

Introduction: Hypertension in midlife, but not late life, is a robust predictor of subsequent dementia. However, the fraction of dementia attributable to hypertension might vary depending on the age of the population considered, and the age through which dementia onset occurs. Here, we investigated associations of hypertension assessed at various ages with incident dementia by age 80 or 90, then estimated population attributable fractions (PAF) for dementia from hypertension categories at each of these age groups.

Hypothesis: Given hypertension prevalence increases with age but its relative risk for dementia tends to decrease, we had no prior expectation of the age at which the PAF’s would be highest. We hypothesized, however, that PAFs for incident dementia would be higher when hypertension is measured in midlife age groups versus late-life age groups.

Methods: We leveraged 32 years of follow-up data from the Atherosclerosis Risk in Communities study (ARIC), a prospective, community-based cohort that enrolled participants aged 45-64 years from four US communities (Washington County, MD; Forsyth County, NC; Jackson, MS; and selected suburbs of Minneapolis, MI) at ARIC visit 1 (1987-1989). Participants were followed through 2018-2019. We used Cox proportional hazards models to estimate hazard ratios, then quantified PAFs, of dementia by age 80 and 90 from hypertension assessed at ages of 45-54 (ARIC visit 1), 55-64 (ARIC visits 1 and 4), 65-74 (ARIC visits 4 and 5), and 75-84 (ARIC visit 5).

Results: Hypertension was assessed among 7,572 participants aged 45-54; 12,033 aged 55-64; and 6,561 aged 65-74. By age 80 the number identified as having incident dementia was 711, 910, and 372, respectively. Relative to normotension, hypertension in each age category was associated with hazard ratios (HRs) greater than 1.0 for dementia from hypertension by age 80. The PAF for dementia by age 80 from hypertension measured at age 45-54 was 15.3% (95% CI = 6.9, 22.3%), 19.1% (95% CI = 9.9, 26.9%) at ages 55-64, and 19.9% (95% CI = -4.4, 38.5%) at ages 65-74. By age 90, the number of incident dementia cases were 958; 2,302; and 1,327, respectively; and, among the 2,086 participants aged 75-84, 400 incident dementia cases. HRs were slightly smaller than those by age 80, while hypertension assessed in the 75-84 age group was not significant. The PAFs for dementia by age 90 from hypertension at age 45-54 was 13.8% (95% CI = 6.6, 20.0%), 12.9% (95% CI = 7.0, 18.2%) at ages 55-64, 10.9% (95% CI = 0.02, 21.0%) at ages 65-74, and non-significant at ages 75-84.

Conclusions: Public health interventions targeting hypertension in midlife through early late-life might reduce a sizeable proportion of dementia cases.

Abstract P469: Risk of Long-Term All-Cause Mortality After Incident Ischemic Stroke of Different Severity in the Atherosclerosis Risk in Communities Study

Background: Stroke is associated with increased risk of mortality. However, studies on the association between stroke severity and mortality using prospective cohort data with details on cardiovascular risk factors at midlife have not been published in recent years in the US. We studied the association between stroke severity and subsequent all-cause mortality in the Atherosclerosis Risk in Communities Study (ARIC) study.

Hypothesis: Risk of all-cause mortality increases after incident ischemic strokes with greater risk at higher stroke severity.

Methods: Severity of incident ischemic strokes in ARIC from 1987 to 2018 was assessed through review of hospital records using the National Institutes of Health Stroke Scale (NIHSS) and categorized as minor, (NIHSS ≤5), mild (6-10), moderate (11-15), and severe (≥16). Deaths were ascertained through linkage with the National Death Index. We used Cox proportional hazard models adjusted for demographic variables and baseline risk factors to determine the hazard ratios (HRs) for all-cause mortality associated with each category of stroke severity, in participants after incident ischemic stroke compared to those who remained stroke-free throughout the study period.

Results: Among 15661 participants free of stroke at baseline (1987-1989), 1036 developed incident ischemic stroke. There were 757 deaths among participants with incident ischemic stroke during the follow-up after stroke (median=16.1 years). Mean baseline age was 54.16 years, 55.2% women and 26.8% black participants. Cox proportional HRs of mortality after incident ischemic stroke controlling for demographics (Model 1) and further adjusted for risk factors at midlife (age 45-64) are displayed in Table 1.

Conclusion: Compared to participants free from ischemic stroke, after adjustment for cardiovascular risk factors at midlife, risk of all-cause mortality was 2 to 12-folds higher in ARIC participants after incident ischemic stroke, with a greater risk of mortality observed in those with higher stroke severity.

Abstract P256: Psychosocial Risk Factors Are Associated With Lower Cardiovascular Health, Measured by Life’s Essential 8, in the Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Psychosocial factors (social isolation, social support, trait anger, and depressive symptoms) are associated with cardiovascular disease risk factors and incidence; few studies investigate whether they are associated with cardiovascular health (CVH), and none with a new definition of CVH, Life’s Essential 8 (LE8) published by the American Heart Association (AHA).

Hypothesis: Cross-sectional associations of psychosocial factors and CVH will be inverse, and will be modified by sex and race.

Methods: We included 11,674 ARIC cohort participants (58% women; 23% Black; mean age 57 (standard deviation (SD): 6) years) who attended Visit 2 (1990-1992) and had complete data. All psychosocial factors and the following LE8 components were measured at Visit 2: nicotine exposure, sleep, body mass index, blood lipids, blood glucose, and blood pressure. Physical activity and diet were measured at Visit 1 (1987-1989). Psychosocial factors were categorized per standard convention or by tertiles. LE8 was scored per the AHA definition (0-100 range). Associations of each psychosocial factor with continuous LE8 score were assessed using multivariable linear regressions.

Results: Mean LE8 score was 61 (SD: 15). Poorer scores on psychosocial factor assessments were associated with lower LE8 scores, with the largest magnitude of association for depressive symptoms (Figure). Participants with high levels of depressive symptoms had an LE8 score 8 points lower than those with low levels of depressive symptoms. Stratum-specific estimates and p-values for interaction terms suggested no modification by sex; however psychosocial factors were associated with approximately a 1 point lower LE8 score in White participants than in Black participants.

Conclusion: Poorer psychosocial health factors were associated with lower CVH among middle-aged men and women in ARIC. Future work could investigate whether psychosocial factors modify the relationship between CVH and incident cardiovascular disease.

Abstract P501: Midlife and Late-Life Non-Alcoholic Fatty Liver Disease and Incident Dementia: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Associations of nonalcoholic fatty liver disease (NAFLD) with dementia are controversial. The full spectrum of NAFLD from simple steatosis to fibrosis has been less investigated.

Hypothesis: The severity of NAFLD, especially with the stage of liver fibrosis, is associated with dementia.

Methods: The associations between midlife (1990-92, N=9283, mean age 57, female 55%) and late-life (2011-13, N=5138, mean age 75, female 58%) NAFLD and all cause dementia were quantified by Cox regression. NAFLD was characterized using the fatty liver index and liver fibrosis assessment model (FIB-4). Dementia was adjudicated and ascertained through Dec. 31, 2019 from neuropsychological assessments, annual participant or informant contact, and medical record surveillance. We used Cox models with adjustment for demographics, APOE ε4, alcohol, and kidney function. Additional adjustments were made for metabolic factors to explore the independent contribution of NAFLD to dementia.

Results: During a median follow-up of 24.5 years after midlife NAFLD assessment, 1854 participants developed dementia. During a median of 6.3 years in late-life, there were 893 dementia cases. A graded increase in dementia risk across the spectrum of NAFLD was observed at midlife (p-trend <0.001), but not at older age ( Figure ). In fact, NAFLD in late-life tended to be protective against dementia. After adjusting for the metabolic factors, the associations remained statistically significant in some categories.

Conclusions: Remodeling of hepatic architecture and dysregulation in hepatocellular function in NAFLD at midlife plausibly induce peripheral promoters of neurodegeneration and may expose a large segment of the population to increased risk of dementia. The inverse association of NAFLD with dementia at late-life requires further investigation, possibly reflecting the depletion of susceptibles, the reversibility of NAFLD due to weight loss, and the lack of accuracy in identifying NAFLD using clinical prediction models at older age.

Abstract P151: Late-Life Prediabetes, Diabetes, and Diabetes Duration With Risks of Frailty and Mortality: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Diabetes is a risk factor for frailty and mortality. Longer diabetes duration is associated with higher mortality in older adults, whereas prediabetes is not. Little has been characterized on associations of prediabetes and diabetes duration with frailty risk. Characterizing frailty and mortality risk in older adults with prediabetes and diabetes is useful for planning healthcare resource utilization.

Hypothesis: Longer diabetes duration, but not prediabetes, is associated with higher risks of frailty and mortality in older adults.

Methods: We conducted a prospective analysis of 4119 ARIC Study participants (mean age 75, 56% women, 22% Black adults) who attended visit 5 (2011-3) without prevalent frailty and who attended visit 6 (2016-7) or died without attending visit 6. We used the Fried phenotype to classify frailty based on ≥3 components: unintentional weight loss, exhaustion, grip strength, slow walking speed, low physical activity. We used multinomial logistic regression to estimate relative risk ratios (RRR) for baseline categories of normoglycemia (HbA1c<5.7%), prediabetes (HbA1c 5.7-<6.5%), or diabetes duration <5, 5-<10, or ≥10 years with incident frailty and death.

Results: Over 5 years of follow-up, there were 851 deaths and 229 frailty cases detected at visit 6. The 5-year cumulative incidence of frailty was 3% in older adults without diabetes and 5% in those with diabetes, and the 5-year mortality risk was 15% in older adults without diabetes and 25% in those with diabetes. Compared to those with normoglycemia, older adults with diabetes ≥10 years had higher risk of frailty or mortality after multivariable adjustment ( Table ). Older adults with prediabetes did not have higher risk of frailty or death.

Conclusion: In older adults, longer diabetes duration was associated with high risks of frailty and mortality, whereas prediabetes was not associated with frailty and mortality. Older adults with long-standing diabetes should be targeted for frailty screening and preventive interventions.

Abstract 47: Mid-Life Vascular Risk and Rate of Physical Function Decline Among Older Adults: The Atherosclerosis Risk in Communities Study

Introduction: Physical function decline is associated with poor outcomes, including disability and death. Late-life vascular risk burden is associated with faster physical decline, but earlier life course influence is still unknown. We hypothesized that higher mid-life vascular risk is associated with faster late-life physical function decline.

Methods: We studied 5,481 adults at visit 5 (mean [SD] age=75.8 [5.0], range=67-91 years, 58% women, 21% Black) without stroke or Parkinson disease. Mid-life hypertension (≥140/90 mm Hg or treatment), diabetes (≥126 mg/dL or treatment), high cholesterol (≥240 mg/dL or treatment), and current smoking were assessed at visit 1 (age=45-64 years) and across visits 1-4. Late-life physical function in the Short Physical Performance Battery (SPPB) was assessed at visits 5-7 (median follow-up: 4.8 years). Random-slope, random-intercept linear mixed models tested interactions between rate of SPPB decline and mid-life risk factors, adjusted for visit 5 age, sex, race-site, education, BMI, coronary heart disease, and heart failure.

Results: Mid-life hypertension (+57% decline: 0.47 per 5 years, 95% CI: 0.30-0.64, p<0.001) and diabetes (+73% decline: 0.67 per 5 years, 95% CI: 0.24-1.09, p=0.002) were associated with faster SPPB decline compared to midlife low risk (Figure 1), as were higher systolic blood pressure (+17% per SD: 0.16 per 5 years, 95% CI: 0.10-0.23, p<0.001) and fasting blood glucose (+16% per SD: 0.015 per 5 years, 95% CI: 0.06-0.24, p=0.002). Greater cumulative years of exposure to hypertension and diabetes were associated with faster rates of SPPB decline (+32% decline: 0.93 per 5 years, 95% CI: 0.61-1.25, p<0.001) and diabetes (+35% decline: 1.03 per 5 years, 95% CI: 0.38-1.68, p=0.002).

Conclusions: Older adults with mid-life hypertension and diabetes had faster rates of late-life physical function decline. Midlife control of blood pressure and diabetes may ameliorate late-life functional decline.

Abstract P236: Neighborhood Socioeconomic Status and Functional Status Impairment in Late-Life: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Neighborhood characteristics and physical activity levels may impact physical function. The present study examined the relationship between neighborhood socioeconomic status (NSES) and functional status impairment among older men and women and examined whether this relationship differed by physical activity.

Hypothesis: Compared to those with high levels of NSES, participants with low NSES will have higher odds of functional impairment in late life. This association will be modified by physical activity.

Methods: We constructed an aggregate measure of NSES using census-based indicators of wealth, education, and occupation and quantified distribution-based tertiles of low, middle, and high NSES among ARIC cohort participants in Visit 5 (2011-2013). We used the Rosow-Breslau scale to ascertain functional status (range 0-4; functional impairment defined as a score<4) during the 2016 annual telephone interview. Multivariable logistic regression was used to examine the association between NSES tertiles and functional status impairment adjusting for age, race, ARIC center, and sex. We tested for effect modification by AHA-defined physical activity (categorized as poor, intermediate, ideal based on weekly minutes of moderate-to-vigorous physical activity). We also tested for effect modification by sex, race, and age.

Results: Among 4,439 participants (mean age: 75 (SD 5) years, 22% Black, 55% female), 1,788 (40%) had functional status impairment. In analyses adjusted for sex, race, and age, the odds of functional impairment among participants with low NSES were 1.86 (95% CI: 1.60, 2.16) times the odds of functional impairment among those with high NSES. There was evidence of effect measure modification by race (p=0.06) and age (p=0.07). In White participants, the odds of functional status impairment among participants with low NSES was 1.99 (95% CI: 1.69, 2.35) times the odds of functional impairment among those with high NSES. This association was attenuated in Black participants (OR: 1.38, 95% CI: 0.96, 2.00). In participants less than 74 years, the odds of functional status impairment among participants with low NSES was 2.17 (95% CI: 1.73, 2.72) times the odds of functional impairment among those with high NSES. This association was attenuated in participants 74 years and older (OR: 1.64, 95% CI: 1.34, 1.99). There was no evidence of effect modification by physical activity (p=0.20) nor sex (p=0.65).

Conclusions: Low NSES is modestly associated with functional status impairment in older adulthood. This association appeared stronger in Whites compared to Blacks, and in those younger than 74 years.

Abstract P260: The Association of Changes in Area Deprivation Index With Cardiometabolic Risk Factors: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Higher Area Deprivation Index (ADI) is associated with greater cardiometabolic risk. The impact of changes in ADI on the likelihood of cardiometabolic risk factors is currently unknown.

Methods: Among 12,044 White and Black participants at ARIC Visit 1 (1987-89), we examined the association of cross-categories of ADI quartiles at Visit 1 and at the last visit attended up to Visit 4 (1996-98) with cardiometabolic risk factors at the time of the second ADI measurement. Cross-categories were grouped as stable low ADI (remaining in ADI quartile 1 or 2), increasing ADI (moving from ADI quartile 1 or 2 at Visit 1 to quartile 3 or 4 at follow-up), decreasing ADI (moving from ADI quartile 3 or 4 at Visit 1 to quartile 1 or 2 at follow-up) or stable high ADI (remaining in ADI quartile 3 or 4).We assessed the prevalence of hypertension, diabetes, and obesity in each group at the follow-up time point and used logistic regression to evaluate associations of changes in ADI over the 9-year period with the odds of cardiometabolic risk factors.

Results: The study population had a mean age of 63 years, with 55% female and 22% Black adults. Persons with decreasing ADI had a lower prevalence of hypertension, diabetes and obesity at follow-up than those with stable high ADI, while those with increasing ADI had a higher prevalence of hypertension and obesity at follow-up than those with stable low ADI (Figure). In regression models adjusted for age and sex, decreasing ADI was linked to lower odds of hypertension, diabetes and obesity compared to stable high ADI (Table), with stronger associations for hypertension among Black adults (p interaction = 0.03). Increasing ADI was linked to modestly increased odds of obesity compared to stable low ADI. Associations were attenuated after adjustment for lifestyle measures, comorbidities and other social determinants.

Conclusion: ADI changes are associated with the prevalence of cardiometabolic risk factors. Interventional studies should assess the cardiometabolic impact of targeting the built environment.

Abstract 34: A Quarter of a Mile More Steps Are Incrementally Associated With Lower Risk of Proximal CVD Events Among Older Adults: Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Steps are an easily interpretable metric that could be used in patient-clinician communication regarding the health benefits of physical activity for cardiovascular disease (CVD). However, most studies are conducted in younger populations with daily steps goals (e.g., 10,000 steps) that may be unsuitable for older adults.

Hypothesis: We tested the hypothesis that more daily steps are associated with lower risk of proximal CVD events (within 3.5 years) among older adults (≥70 years).

Methods: We analyzed a subsample of participants from the ARIC study visit 6 (2016-17) who wore an accelerometer (ActiGraph GT3X) on the waist ≥3 days for ≥10 hr/day. Daily steps were analyzed continuously and by quartiles. Adjudicated outcomes, through December 2019, included fatal and non-fatal CVD events (coronary heart disease, stroke, and heart failure). Multivariable adjusted Cox proportional hazard models were used to estimate the hazard ratio of CVD events across step measures, adjusted for age, sex, race, education, body mass index (BMI), and accelerometer wear time.

Results: Among the 452 adults with step data (mean age = 78.4; 59% women; 20% Black), 7.5% (34/452) had a CVD event over 1,269 person-years of follow-up. Mean (SD) step count was 3447 (1796) steps/day. CVD cumulative incidence was highest among those in the least active step quartile (Q1: <2077 steps/day) (11.5%) compared to the most active quartile (Q4: ≥4453 steps/day) (3.5%). Every 500 steps/day (about 1/4 mile) was associated with a 14% reduced risk of a CVD event (HR = 0.86, 95% CI: 0.76, 0.98). Further, compared to participants in Q1, participants in Q4 had a 77% reduced risk of a proximal CVD event (HR = 0.23, 95% CI: 0.07, 0.83). Cubic spline HR are presented (figure).

Conclusions: In this community-based cohort of older adults, every 500 steps (~1/4 of a mile) was associated with a 14% lower risk of a CVD event over 3.5 years of follow-up. Additional follow-up is needed to determine if higher steps prevent or delay CVD or if low steps serve as a biomarker of underlying disease.

Abstract P507: Pre-Statistical Harmonization of Cognitive Measures Across Eight Population-Based NIH Cohorts in the Collaborative Cohort of Cohorts for COVID-19 Research (C4R)

Introduction: Long-term neurological consequences (eg, stroke, impaired cognition) have been linked to SARS-CoV-2 infection and severity. There are limited data from studies with racial, ethnic, socioeconomic, and geographic diversity. C4R is a prospective study of adults from 14 cohorts that aims to link pre-COVID phenotyping, including cognition (8 studies), to COVID related illness and sequelae. We aimed to conduct pre-statistical harmonization of cognitive tests administered in English and Spanish from 8 cohorts: ARIC, CARDIA, FHS, HCHS/SOL-INCA, MESA, NOMAS, REGARDS, and SHS (Table).

Methods: We conducted extensive item-level review of administration, scoring, and coding procedures and score distributions for 84 tests administered in English (all studies) and Spanish (NOMAS, MESA, HCHS/SOL-INCA).

Results: Orientation to time and 3-word registration and recall spanned all studies and both languages. Word list recall and verbal fluency (animal; letter) spanned 7 studies (Table). There was variability in the structure, content, administration, scoring, and data coding procedures for items across cohorts and between Spanish and English. Word lists varied by number of words (9-16) and learning trials (3-5). Animal naming varied by time (30 vs. 60 seconds), animal type (4-legged vs. any animal), and scoring (allowing mythical/imaginary animals). Letter fluency varied by whether both Spanish and English words were permitted. Other tests differed by version, study-specific adaptations, prompts/cues, and specificity of scoring rules across cohorts.

Conclusions: Cognitive test harmonization requires detailed review of administration, scoring, coding, translation, and procedural differences. Accounting for this variability is essential to cognitive data interpretation. Our pre-statistical harmonization will inform data augmentation and formal harmonization to yield harmonized measures of cognition to clarify population-level differences in cognitive outcomes linked to SARS-CoV-2 infection.

Abstract MP05: Prospective Associations of Midlife Physical Activity and Sedentary Behavior With Brain Structure: The Cardia Study

Introduction: Strong evidence suggests physical activity may prevent cognitive decline. Less research has explored potential associations of physical activity with brain structure. This is an important research gap given that age related alterations in brain structure are thought to occur prior to signs of cognitive decline.

Objective: To determine if accelerometer measured sedentary time (SED), light-intensity physical activity (LPA), and moderate-to-vigorous intensity physical activity (MVPA) at ages 38-50 years are prospectively associated with brain structure.

Methods: We studied 562 Black and White men and women enrolled in CARDIA who participated in the 2005-06 exam (baseline) and exams 5 (2010-11) and/or 10 years later (2015-16). SED, LPA, and MVPA were measured by the ActiGraph 7164 accelerometer at baseline. Magnetic resonance imaging (MRI) was used to quantify whole brain, white matter, gray matter, and abnormal tissue volume of white matter at the 5- and/or 10-year follow-up. Compositional isotemporal substitution analysis examined associations of SED, LPA, and MVPA at baseline with repeated measures (unstructured covariance) of MRI measures at follow-up after accounting for intracranial volume and adjusting for confounders ( Table ).

Results: Consistent with our hypothesis, substituting 30 minutes of SED to LPA was associated with 0.044% greater total white matter volume (95% CI: 0.001, 0.086). The effect size was larger when substituting SED to MVPA, but this association was not statistically significant. There were no associations observed between accelerometer measures and total brain, total gray matter, or abnormal white matter tissue volumes. Associations did not differ by sex or age.

Conclusions: Statistical substitution of time from SED to higher intensity physical activity (LPA or MVPA) was associated with greater total white matter volume. It is unclear why this association was observed in white matter only. Additional research with longer follow-up is needed to confirm these findings.

Physical Frailty and Brain White Matter Abnormalities: The Atherosclerosis Risk in Communities Study

BACKGROUND

Physical frailty is associated with increased risk for dementia and other neurologic sequelae. However, the neurobiological changes underlying frailty and frailty risk remain unknown. We examined the association of cerebral white matter structure with current and future frailty.

METHODS

Atherosclerosis Risk in Communities Study Neurocognitive Study participants who underwent 3T brain MRI were included. Frailty status was classified according to the Fried criteria. Cerebral white matter integrity was defined using white matter hyperintensity (WMH) volume and microstructure, measured using diffusion tensor imaging fractional anisotropy (FA) and mean diffusivity (MD). Multivariable linear regression was used to relate baseline frailty to white matter structure; multivariable logistic regression was used to relate baseline white matter to frailty risk among participants nonfrail at baseline.

RESULTS

In the cross-sectional analysis (N = 1 754; mean age: 76 years), frailty was associated with greater WMH volume, lower FA, and greater MD. These associations remained consistent after excluding participants with a history of stroke or dementia. Among participants nonfrail at baseline who completed follow-up frailty assessment (N = 1 379; 6.6-year follow-up period), each standard deviation increase in WMH volume was associated with 1.46 higher odds of frailty at follow-up. Composite FA and MD measures were not associated with future frailty; however, secondary analyses found several significant white matter tract-specific associations with frailty risk.

CONCLUSION

The current study demonstrates a robust association of WMH volume with current and future frailty. Although measures of white matter microstructure were altered in frail individuals, these measures were not generally associated with progression from nonfrail to frail status.

Is an MRI-derived anatomical measure of dementia risk also a measure of brain aging?

Machine learning methods have been applied to estimate measures of brain aging from neuroimages. However, only rarely have these measures been examined in the context of biologic age. Here, we investigated associations of an MRI-based measure of dementia risk, the Alzheimer's disease pattern similarity (AD-PS) scores, with measures used to calculate biological age. Participants were those from visit 5 of the Atherosclerosis Risk in Communities Study with cognitive status adjudication, proteomic data, and AD-PS scores available. The AD-PS score estimation is based on previously reported machine learning methods. We evaluated associations of the AD-PS score with all-cause mortality. Sensitivity analyses using only cognitively normal (CN) individuals were performed treating CNS-related causes of death as competing risk. AD-PS score was examined in association with 32 proteins measured, using a Somalogic platform, previously reported to be associated with age. Finally, associations with a deficit accumulation index (DAI) based on a count of 38 health conditions were investigated. All analyses were adjusted for age, race, sex, education, smoking, hypertension, and diabetes. The AD-PS score was significantly associated with all-cause mortality and with levels of 9 of the 32 proteins. Growth/differentiation factor 15 (GDF-15) and pleiotrophin remained significant after accounting for multiple-testing and when restricting the analysis to CN participants. A linear regression model showed a significant association between DAI and AD-PS scores overall. While the AD-PS scores were created as a measure of dementia risk, our analyses suggest that they could also be capturing brain aging.

Changes in physical activity and risk of ischemic stroke: The ARIC study

BACKGROUND

Limited data exist regarding the impact of changes in physical activity (PA) over time on ischemic stroke risk. Exploring this understudied area could help improve stroke prevention strategies and promote PA during the lifespan.

METHODS

We evaluated 11,089 Atherosclerosis Risk in Communities (ARIC) participants recruited in 1987-1989 who completed Visit 3 (1993-1995). We classified PA as meeting recommendations, not meeting recommendations, or no PA. Categories of increased, decreased, stable high, and stable low PA and a continuous PA variable were also evaluated. Crude and adjusted Cox regression models were used to characterize the association of 6-year changes in PA and ischemic stroke risk.

RESULTS

Participants had a mean age of 60 years. During a median of 21 years, 762 ischemic stroke events occurred. Compared to the participants with recommended PA at both visits, those with no PA had 46% higher hazards of ischemic stroke (hazard ratio (HR) = 1.46 (95% confidence interval (CI) = 1.17, 1.82)), and those with recommended PA at Visit 1 and no PA at Visit 3 also had 37% higher hazards (HR = 1.37 (95% CI = 1.02, 1.83)). Participants who increased their PA from Visit 1 to Visit 3 had 23% lower hazard than those with stable low PA at both visits (HR = 0.77 (95% CI = 0.63, 0.94)), while those who decreased their PA had 25% higher hazards compared to those with stable high PA at both visits (HR = 1.25 (95% CI = 1.01, 1.54)).

CONCLUSION

Physical inactivity during midlife increases ischemic stroke risk, while meeting PA recommendations reduces it.