Céline Meillon

Compensatory mechanisms in higher-educated subjects with Alzheimer’s disease: a study of 20 years of cognitive decline

A better knowledge of long-term trajectories of cognitive decline is a central feature of the study of the process leading to Alzheimers dementia. Several factors may mitigate such decline, among which is education, a major risk factor for Alzheimers disease. The aim of our work was to compare the pattern and duration of clinical trajectories before Alzheimers dementia in individuals with low and high education within the PAQUID cohort involving 20 years of follow-up. The sample comprises 442 participants with incident Alzheimers disease (27.2% were male)--171 with low education (mean age=86.2 years; standard deviation=5.3 years) and 271 with higher education (mean age=86.5; standard deviation=5.4)--and 442 control subjects matched according to age, sex and education. At each visit and up to the 20-year follow-up visit, several cognitive and clinical measures were collected and incident cases of Alzheimers disease clinically diagnosed. The evolution of clinical measures in pre-demented subjects and matched controls was analysed with a semi-parametric extension of the mixed effects linear model. The results show that the first signs of cognitive decline occurred 15 to 16 years before achieving dementia threshold in higher-educated subjects whereas signs occurred at 7 years before dementia in low-educated subjects. There seemed to be two successive periods of decline in higher-educated subjects. Decline started ∼15 to 16 years before dementia with subtle impairment restricted to some cognitive tests and with no impact during the first 7 to 8 years on global cognition, cognitive complaints, or activities of daily living scales. Then, ∼7 years before dementia, global cognitive abilities begin to deteriorate, along with difficulties dealing with complex activities of daily living, the increase in self-perceived difficulties and depressive symptoms. By contrast, lower-educated subjects presented a single period of decline lasting ∼7 years, characterized by decline concomitantly affecting specific and more global cognitive function along with alteration in functional abilities. This study demonstrates how early cognitive symptoms may emerge preceding Alzheimers dementia particularly in higher-educated individuals, for whom decline occurred up to 16 years before dementia. It also demonstrates the protective role of education in the clinical trajectory preceding Alzheimers dementia. We suggest that the initial decline in cognition occurs at the onset of comparable Alzheimers disease pathology in both groups, and is associated with immediate decline to dementia in the lower education group. In contrast, higher education protects against further cognitive decline for ∼7 years until pathology becomes more severe.

Self‐Reported Hearing Loss, Hearing Aids, and Cognitive Decline in Elderly Adults: A 25‐Year Study

To investigate the association between hearing loss, hearing aid use, and cognitive decline.

Cognitive Decline After Entering a Nursing Home: A 22-Year Follow-Up Study of Institutionalized and Noninstitutionalized Elderly People

OBJECTIVE The objective of this study is to compare cognitive decline of elderly people after entering an institution with that of elders living in the community with similar clinical conditions. DESIGN The Personnes Agées QUID (PAQUID) cohort is a prospective population-based study which included, at baseline, 3777 community-dwelling people aged 65 years and older. Participants were followed-up for 22 years. Among those who were nondemented and living at home at baseline, 2 groups were compared: participants who entered a nursing home during study follow-up (n = 558) and those who remained living at home (n = 3117). Cognitive decline was assessed with Mini-Mental State Examination (MMSE), Benton visual retention test, and verbal fluency Isaacs Set Test. RESULTS After controlling for numerous potential confounders, including baseline MMSE and instrumental activities of daily living scores, incident dementia, depressive symptoms, and chronic diseases, nursing home placement was significantly associated with a lower score on MMSE between the last visit before and after institutionalization (difference of 2.8 points, P < .0001) and greater further cognitive decline after institutionalization (difference of 0.7 point per year, P < .0001). Similar results were found for the Benton memory test. In a second series of analysis in which the persons who became demented over the study follow-up were excluded, the results remained unchanged. CONCLUSIONS The present study suggests that institutionalized elderly people present a greater cognitive decline than persons remaining in the community. The reasons of that decline remain unclear and may be related to physical and psychological effects of institutionalization in elderly people.

Norms and associated factors of the STAI-Y State anxiety inventory in older adults: results from the PAQUID study.

BACKGROUND The latest version of the State-Trait Anxiety Inventory (STAI-Y) is commonly used in older adults, even though this anxiety scale was developed in and for young adults. Norms and associated factors of the STAI-Y are lacking for older adults in the general population. The objectives of the present study were to produce norms on the STAI-Y State scale for older adults using a large sample of older adults selected from a general population and to examine the sociodemographic and health-related factors associated with the STAI-Y State score. METHODS 993 community-dwelling individuals aged 66 years and over from the PAQUID study were evaluated at home by a psychologist for the following variables: age, education, marital status, proximity of relatives, self-assessment of income sufficiency, occupation during active life, depressive symptomatology, objective and subjective health, objective and subjective cognitive functioning, adverse life events, activities of daily living, drug use, and cigarette consumption. RESULTS Norms were stratified for age, sex, and education and were produced separately for older adults with and without depressive symptomatology. Multivariate analyses revealed that younger age (66-79 years), female sex, lower education, perception of income insufficiency, depressive symptomatology, poor subjective health, subjective cognitive complaints, psychotropic drugs use, and recent adverse life events were independently associated with higher STAI-Y State score. CONCLUSIONS This study provides norms for the STAI-Y State anxiety inventory in a general population of older adults and indicates the specific factors linked with state anxiety. Such factors should be taken into account by clinicians in order to better understand state anxiety in older adults.

State Anxiety and Cognitive Functioning in Older Adults

OBJECTIVE To assess the relationship between state anxiety and performance on neuropsychological tests in older adults. METHODS Nine hundred fifty-five community-dwelling individuals without dementia age 66 and over were evaluated at home by a psychologist. State anxiety was measured by the State-Trait Anxiety Inventory Y. Cognitive assessment included general cognitive functioning (Mini-Mental State Examination), verbal fluency (Isaacs Set Test), short-term visual memory (Bentons Visual Retention Test), speed of information processing/visuomotor coordination (Digit Symbol Coding), conceptual knowledge (Similarities), episodic memory (Verbal Paired Associates), and working memory (Digit Span forward/backward). Covariates included age, education, sex, depressive symptoms (Center for Epidemiologic Studies-Depression Scale), subjective health, subjective cognitive complaint, chronic diseases, functional abilities in basic and instrumental activities of daily living, and use of medication. RESULTS Adjustments for confounders substantially modified the relationship between state anxiety and cognitive performance. Multivariate analyses revealed positive effects of mild and moderate state anxiety for verbal fluency and general cognitive functioning, respectively. High and moderate anxiety also had beneficial influence on short-term visual memory performance in participants with low education level and on the speed of information/visuomotor coordination processing in participants using medications. CONCLUSIONS These results suggest that when confounders are taken into account, state anxiety in older adults is not necessarily deleterious for cognitive performance and has no appreciable negative effect on many cognitive domains or can even be beneficial. Relationships between state anxiety and cognitive performances are complex because they are influenced by many factors and differ according to anxiety severity and cognitive domains.

Group and individual cognitive therapies in Alzheimer's disease: the ETNA3 randomized trial.

BACKGROUND Although non-drug interventions are widely used in patients with Alzheimers disease, few large scale randomized trials involving a long-term intervention and several cognitive-oriented approaches have been carried out. ETNA3 trial compares the effect of cognitive training, reminiscence therapy, and an individualized cognitive rehabilitation program in Alzheimers disease to usual care. METHODS This is a multicenter (40 French clinical sites) randomized, parallel-group trial, with a two-year follow-up comparing groups receiving standardized programs of cognitive training (group sessions), reminiscence therapy (group sessions), individualized cognitive rehabilitation program (individual sessions), and usual care (reference group). Six hundred fifty-three outpatients with Alzheimers disease were recruited. The primary efficacy outcome was the rate of survival without moderately severe to severe dementia at two years. Secondary outcomes were cognitive impairment, functional disability, behavioral disturbance, apathy, quality of life, depression, caregivers burden, and resource utilization. RESULTS No impact on the primary efficacy measure was evidenced. For the two group interventions (i.e. cognitive training and reminiscence), none of the secondary outcomes differed from usual care. The larger effect was seen with individualized cognitive rehabilitation in which significantly lower functional disability and a six-month delay in institutionalization at two years were evidenced. CONCLUSIONS These findings challenge current management practices of Alzheimers patients. While cognitive-oriented group therapies have gained popularity, this trial does not show improvement for the patients. The individualized cognitive rehabilitation intervention provided clinically significant results. Individual interventions should be considered to delay institutionalization in Alzheimers disease.

ANXIETY AND 10‐YEAR RISK OF INCIDENT AND RECURRENT DEPRESSIVE SYMPTOMATOLOGY IN OLDER ADULTS

Anxiety has been shown to often precede depression in children and young adults. Only a small number of investigations have examined this form of comorbidity in older adults and the temporal relationship of these syndromes remains unclear. The objective was to verify whether trait anxiety predicts incident/recurrent depressive symptomatology in older adults independently of variables susceptible to explain this relationship in this population, such as cognitive complaints, subjective health, and baseline depressive symptoms.

Feelings of Loneliness and Living Alone as Predictors of Mortality in the Elderly: The PAQUID Study.

Objective The aim of this work was to determine the predictive value of 2 indicators of psychosocial isolation (living alone and feelings of loneliness) in elderly people. Methods Twenty-two-year follow-up cohort study of 3,620 community-dwelling elderly people enrolled in the PAQUID study, a French prospective population-based study. Participants completed a battery of tests including the Centre for Epidemiological Studies Depression scale and a question regarding living conditions (living alone or living with another person). Feelings of loneliness were measured using the Item 14 (“I felt lonely”) of the French version of the Centre for Epidemiological Studies Depression scale. Mortality rate was measured over a 22-year follow-up period after the baseline assessment visit. The risk of death was estimated using Cox proportional hazards models, adjusted for age, sex, and educational level. Results At baseline, 1,535 participants (42.4%) were living alone, and a total of 498 persons (13.8%) reported frequent feelings of loneliness (FoL). The participants reporting FoL were more frequently women (82.7%), and the mean (SD) age was 76.5 (7.1) years. At the end of the follow-up, 3,116 deaths (86.6%) occurred. Living alone and FoL were both independent predictors of death after 22 years of follow-up (hazard ratio, 1.14; 95% confidence of interval, 1.05–1.23; p = .001) and (hazard ratio, 1.20; 95% confidence of interval, 1.08–1.33; p = .001), respectively. No significant interaction was found between feelings of loneliness and living alone, suggesting that a joint exposure has only an additive effect (&bgr; = 0.08; relative risk = (0.85; 1.40); p = .48). The associations of both measures persisted after adjusting for health status. Adjusting for depression attenuated the predictive value of FoL. Conclusions Living alone and FoL were independently associated with higher risk of mortality. These factors may be useful as readily available psychosocial measures to identify vulnerability in community-dwelling older adults.

Association of low serum 25-hydroxyvitamin D levels with the frailty syndrome in Mexican community-dwelling elderly

Abstract Objective: Since vitamin D is an important regulator of muscle function, the effect of vitamin D deficiency on frailty syndrome has been recently studied. This cross-sectional study aimed to determine the association between 25(OH)-vitamin D levels and frailty status in Mexican community-dwelling elderly. Methods: Sample of 331 community-dwelling elderly aged 70 or older, a subset of those included in the “Coyoacán cohort” were included. 25(OH)-vitamin D assay and frailty status were measured. Results: Mean age was 79.3 years and 54.1% were women. Those classified as frail were more likely to have lower Mini-Mental State Examination score (p = 0.015), more disability for instrumental activities of daily living (p < 0.001) and for activities of daily living (p < 0.001). Serum 25(OH)-vitamin D levels were lower in the frail subgroup when compared with the non-frail one (p < 0.001). Multivariate logistic regression analyses showed a significant association between intermediate tertile [odds ratios (OR) = 4.13; 95% confidence intervals (CI) 2.00–8.56] or insufficient tertile (OR = 8.95; 95% CI 2.41–33.30) of vitamin D levels and frailty even after adjusting for potential confounders. Conclusion: These results suggest that older adults with low 25(OH)-vitamin D levels are associated with the probability to being frail compared with those with sufficient vitamin D levels.

Association Between Frailty and Carotid Central Structure Changes: The Three‐City Study

To demonstrate the association between carotid central structure changes and frailty.