Matthew Prina

Frailty and the prediction of dependence and mortality in low- and middle-income countries: a 10/66 population-based cohort study

BackgroundIn countries with high incomes, frailty indicators predict adverse outcomes in older people, despite a lack of consensus on definition or measurement. We tested the predictive validity of physical and multidimensional frailty phenotypes in settings in Latin America, India, and China.MethodsPopulation-based cohort studies were conducted in catchment area sites in Cuba, Dominican Republic, Venezuela, Mexico, Peru, India, and China. Seven frailty indicators, namely gait speed, self-reported exhaustion, weight loss, low energy expenditure, undernutrition, cognitive, and sensory impairment were assessed to estimate frailty phenotypes. Mortality and onset of dependence were ascertained after a median of 3.9 years.ResultsOverall, 13,924 older people were assessed at baseline, with 47,438 person-years follow-up for mortality and 30,689 for dependence. Both frailty phenotypes predicted the onset of dependence and mortality, even adjusting for chronic diseases and disability, with little heterogeneity of effect among sites. However, population attributable fractions (PAF) summarising etiologic force were highest for the aggregate effect of the individual indicators, as opposed to either the number of indicators or the dichotomised frailty phenotypes. The aggregate of all seven indicators provided the best overall prediction (weighted mean PAF 41.8 % for dependence and 38.3 % for mortality). While weight loss, underactivity, slow walking speed, and cognitive impairment predicted both outcomes, whereas undernutrition predicted only mortality and sensory impairment only dependence. Exhaustion predicted neither outcome.ConclusionsSimply assessed frailty indicators identify older people at risk of dependence and mortality, beyond information provided by chronic disease diagnoses and disability. Frailty is likely to be multidimensional. A better understanding of the construct and pathways to adverse outcomes could inform multidimensional assessment and intervention to prevent or manage dependence in frail older people, with potential to add life to years, and years to life.

Late-life depression symptom dimensions and cognitive functioning in the Longitudinal Aging Study Amsterdam (LASA)

Background Depression often co-occurs in late-life in the context of declining cognitive functions, but it is not clear whether specific depression symptom dimensions are differentially associated with cognitive abilities. Methods The study sample comprised 3107 community-dwelling older adults from the Longitudinal Aging Study Amsterdam (LASA). We applied a Multiple Indicators Multiple Causes (MIMIC) model to examine the association between cognitive abilities and latent dimensions of the Center for Epidemiologic Studies Depression Scale (CES-D), while accounting for differential item functioning (DIF) due to age, gender and cognitive function levels. Results A factor structure consisting of somatic symptoms, positive affect, depressed affect, and interpersonal difficulties fitted the data well. Higher levels of inductive reasoning were significantly associated with lower levels of depressed affect and somatic symptoms, whereas faster processing speed was significantly associated with lower levels of somatic symptoms. DIF due to age and gender was found, but the magnitude of the effects was small and did not alter substantive conclusions. Limitations Due to the cross-sectional context of this investigation, the direction of influence between depression symptom levels and cognitive function levels cannot be established. Furthermore, findings are relevant to non-clinical populations, and they do not clarify whether certain DIF effects may be found only at high or low levels of depression. Conclusions Our findings suggest differential associations between late-life depression dimensions and cognitive abilities in old age, and point towards potential etiological mechanisms that may underline these associations. These findings carry implications for the prognosis of cognitive outcomes in depressed older adults.

A multiple indicators multiple causes model of late-life depression in Latin American countries

Background The Euro-D depression scale consists of symptom clusters that may be differentially related to demographic and cognitive characteristics in older adults. This hypothesis needs further investigation and the role of measurement bias on substantive conclusions remains to be established. Method The study sample comprised 10,405 community-dwelling older adults from six Latin American countries. We applied a Multiple Indicators Multiple Causes (MIMIC) model for a concurrent investigation of measurement bias and of the association between Euro-D symptom clusters and background variables. Results The factorial validity of Euro-D, with a two-dimensional structure – affective suffering and motivation disturbance, was consistently supported in all countries. Although complete measurement invariance could not be assumed across countries, measurement bias was minor. Both Euro-D factors were unrelated to age, but related to gender, as well as to impairment in memory and verbal fluency. Gender differences were larger for affective suffering than for motivation disturbance, whereas differences in verbal fluency impairment were more strongly related to motivation disturbance. Limitations Our analytic strategies could only examine invariance at the level of indicator thresholds. The generalisability of current findings needs to be examined in clinical populations. A wider set of cognitive tests is needed. We did not examine the compositional factors that could have accounted for the variation in Euro-D scores across countries, as this was beyond the aims of the paper. Conclusion The current study adds evidence for the construct validity of Euro-D and for the possible differential association of depression symptom-clusters with gender and verbal fluency in older adults. An understanding of the heterogeneity of late-life depression may carry clinical implications for the diagnosis and treatment of depression in old age.

Leg length, skull circumference, and the incidence of dementia in Latin America and China: A 10/66 population-based cohort study

Background Adult leg length is influenced by nutrition in the first few years of life. Adult head circumference is an indicator of brain growth. Cross-sectional studies indicate inverse associations with dementia risk, but there have been few prospective studies. Methods Population-based cohort studies in urban sites in Cuba, Dominican Republic Puerto Rico and Venezuela, and rural and urban sites in Peru, Mexico and China. Sociodemographic and risk factor questionnaires were administered to all participants, and anthropometric measures taken, with ascertainment of incident dementia, and mortality, three to five years later. Results Of the original at risk cohort of 13,587 persons aged 65 years and over, 2,443 (18.0%) were lost to follow-up; 10,540 persons with skull circumference assessments were followed up for 40,466 person years, and 10,400 with leg length assessments were followed up for 39,954 person years. There were 1,009 cases of incident dementia, and 1,605 dementia free deaths. The fixed effect pooled meta-analysed adjusted subhazard ratio (ASHR) for leg length (highest vs. lowest quarter) was 0.80 (95% CI, 0.66–0.97) and for skull circumference was 1.02 (95% CI, 0.84–1.25), with no heterogeneity of effect between sites (I2 = 0%). Leg length measurements tended to be shorter at follow-up, particularly for those with baseline cognitive impairment and dementia. However, leg length change was not associated with dementia incidence (ASHR, per cm 1.006, 95% CI 0.992–1.020), and the effect of leg length was little altered after adjusting for baseline frailty (ASHR 0.82, 95% CI 0.67–0.99). A priori hypotheses regarding effect modification by gender or educational level were not supported. However, the effect of skull circumference was modified by gender (M vs F ASHR 0.86, 95% CI 0.75–0.98), but in the opposite direction to that hypothesized with a greater protective effect of larger skull dimensions in men. Conclusions Consistent findings across settings provide quite strong support for an association between adult leg length and dementia incidence in late-life. Leg length is a relatively stable marker of early life nutritional programming, which may confer brain reserve and protect against neurodegeneration in later life through mitigation of cardiometabolic risk. Further clarification of these associations could inform predictive models for future dementia incidence in the context of secular trends in adult height, and invigorate global efforts to improve childhood nutrition, growth and development.

Neurological signs as early determinants of dementia and predictors of mortality among older adults in Latin America: a 10/66 study using the NEUROEX assessment.

BackgroundNeurodegenerative processes in the elderly damage the brain, leading to progressive, incapacitating cognitive, behavioral, and motor dysfunctions which culminate in dementia. Fully manifest dementia is likely to be preceded by the presence of neurological signs, which could serve as early determinants of dementia and predictors of mortality. The aims of this study were to assess the construct validity of a neurological battery assessed among older adults living in Latin America, and to test the association of groups of neurological signs with dementia cross-sectionally, and mortality longitudinally.MethodsThe 10/66 Dementia Research Group collected information on neurological symptoms via the NEUROEX assessment in population based surveys of older adults living in low and middle-income countries. Data from 10,856 adults participating in the baseline assessment of the 10/66 study and living in Cuba, Dominican Republic, Peru, Venezuela and Mexico were analysed. Exploratory and confirmatory analysis were used to explore dimensionality of neurological symptoms. Poisson regression analyses were used to link groups of neurological signs with dementia at baseline. Cox hazard regression models were used to explore the predictive validity of neurological signs with mortality at follow up.ResultsExploratory and confirmatory factor analyses revealed four dimensions of neurological signs, which are associated with lesions of specific brain regions. The identified factors showed consistency with groups of neurological signs such as frontal, cerebellar, extrapyramidal, and more generalized gait disturbance signs. Regression analyses revealed that all groups of neurological signs were positively associated with dementia at baseline and predicted mortality at follow up.ConclusionsOur findings support the construct and predictive validity of the NEUROEX assessment, linking neurological and gait impairments with dementia at baseline, and with mortality at follow up among older adults living in five Latin American countries.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), DEMENTIA RISK, AND MORTALITY: AN EPIDEMIOLOGICAL INVESTIGATION IN LOW TO MIDDLE INCOME COUNTRIES

ever), (2) total tobacco exposure (pack-years), and (3) tobacco (smoking) cessation. Results:Cigarette Smoking Status: Smoking status and risk for incident dementia/nursing home placement was nonsignificant. Level of tobacco exposure (pack-years): Those with normal cognition at baseline and a 30-60 pack-year history had an increased risk of incident dementia/nursing home placement compared to those with a <30 pack-year history (HR 1.46; 95% CI 1.12-1.90; p1⁄40.005). When adding death as an additional event, the pattern of greater risk with increased exposure remained. Models including individuals with MCI at baseline were nonsignificant. Smoking cessation: In those with MCI at baseline, current smokers had a higher rate of incident dementia/nursing home placement than those who had quit smoking (HR 1.70; 95% CI 1.302.22; p1⁄40.000). Similar findings were obtained in individuals with normal cognition at baseline; current smokers had a higher rate of incident dementia/nursing home placement than those who quit smoking (Figure 1; HR 2.23; 95% CI 1.54-3.22; p1⁄40.000). Conclusions: Within cognitively healthy current and former smokers, those with greater tobacco exposure had an increased risk of incident dementia and nursing home placement. Compared to current smokers those who quit smoking showed a reduced risk for incident dementia and nursing home placement.

PREVALENCE AND INCIDENCE OF MILD COGNITIVE IMPAIRMENT AND DEMENTIA IN FRAIL ELDERS IN LATIN AMERICA, CHINA AND INDIA: A 10/66 POPULATION–BASED SURVEY

Background:Both type 2 diabetes (T2D) and obesity in mid-life are associated with increased risk for cognitive decline as individuals age. However, it is unknown whether this results in a different prevalence of cognitive impairment for women and men. It is important to understand the nature of any differences because this may provide clues for the prevention of cognitive decline and dementia. Methods:The Action for Health in Diabetes study was a randomized controlled clinical trial of a ten-year intensive lifestyle intervention targeting weight loss compared with a control group in overweight and obese adults with T2D. At enrollment, when clinical, behavioral, and demographic risk factors for cognitive decline were assessed, participants were aged 45-76 years. Cases of cognitive impairment (mild cognitive impairment or dementia) were adjudicated following this intervention, an average [range] of 11.4 [9.5,13.5] years after enrollment. We examined whether the prevalence of cognitive impairment at this time varied by sex and, if so, whether differences were attributable to risk factor profiles or responses to the intervention and whether these varied across risk factor subgroups. Results:Cognitive assessments were conducted for 3,802 individuals (61% women). The prevalence of cognitive impairment was 8.3% in women and 14.8% in men (adjusted odds ratio 0.55, 95% confidence interval [0.43,0.71], p<0.001). The odds ratio for women compared with men was fairly constant across the age range of the cohort (p1⁄40.669). Risk factor profiles varied between women and men, but did not account for the difference in prevalence. The sex-related difference in prevalence was limited to individuals without APOE-ε4 alleles (p1⁄40.034) and could not be accounted for by differing responses to the lifestyle intervention – markers related to weight control (e.g. changes in weight and physical activity) and diabetes control (e.g. HbA1c or medication use) that were altered by the intervention – or differential follow-up. Conclusions: Among overweight and obese older adults with T2D whowere enrolled in a clinical trial of a behavioral intervention, women had a lower prevalence of cognitive impairment than men, which was not explained by traditional risk factors.

A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE PREVALENCE OF DEMENTIA IN MAINLAND CHINA, HONG KONG AND TAIWAN: 2017 UPDATE: 2017 Abstract Supplement

Background: Substantial studies have reported the prevalence and affecting factors of SCD and complainants screening scale has also been used for probing. However, little is known about SCD due to AD in the the eastern countries, especially in China where subjective cognitive complainant screening scale has not yet been applied. Methods:Stratified cluster random sampling was conducted, and 2688 residents of 60-80 years completed the questionnaire 1 and 814 residents were eventually included for clinical and neuropsychological evaluations. Two standards were used to make the diagnosis of MCI and SCD, and a preliminary screening rate comparison was carried further. Finally, we assessed the risk factors of SCD using multiple logistic regression and correlation between SCD Q and Auditory Verbal Learning Test Long Delay Recall (AVLT LR) . Results: (1) Standard 1(ADNI 2): the prevalence of SCD was 18.8% .(2) Standard 2 (Jak/Bondi) : the prevalence of SCD was 14.4%. (3) Cross-tabulation analysis showed that: standard 1 has a relatively higher‘false’ positive rate, whereas standard 2 has higher‘false’ negative rate. (4) Analysis showed that : aging, low education, less close friends and daily drinking were independent risk factors for SCD progressing to MCI. (5) Total points of SCD Q was negatively correlated to the number of AVLT LR. Conclusions:The prevalence of SCD is higher in Shunyi district of China, and many factors leading to SCD progressing. Brief SCD-Q can be used as a reference.

THE ASSOCIATION BETWEEN DEPRESSION AND NON-PSYCHIATRIC HOSPITALISATION AMONGST OLDER PEOPLE

Globalization is challenging social gerontologists’ notions of who older migrants are and how to cater to their needs. This presentation aims to show that there are specific risks for social exclus ...Narrative foreclosure is a new sensitizing concept for studying stagnation of identity development in later life. It is defined as the conviction that no new interpretations of one’s past, nor new commitments and experiences in one’s future are possible that can substantially change one’s life story. The Narrative Foreclosure Scale (NFS) was developed to study this concept empirically. The NFS comprises two subscales: Past and Future. The psychometric properties were studied in two samples of older adults (n=247 and n = 220). Confirmatory factor analyses confirm that the scale consists of two distinct factors. Internal consistencies are sufficient to good. The validity is further confirmed by the relationship with demographics and other psychological constructs, such as personality, hope, reminiscence, ego-integrity, balanced time perspective, wisdom, depression, and positive mental health. It is discussed that diminishing narrative foreclosure may be an important process factor in life-review and narrative therapy with older adults.