Tracey Holsinger

Systematic Review: Factors Associated With Risk for and Possible Prevention of Cognitive Decline in Later Life

BACKGROUND Many biological, behavioral, social, and environmental factors may contribute to the delay or prevention of cognitive decline. PURPOSE To summarize evidence about putative risk and protective factors for cognitive decline in older adults and the effects of interventions for preserving cognition. DATA SOURCES English-language publications in MEDLINE, HuGEpedia, AlzGene, and the Cochrane Database of Systematic Reviews from 1984 through 27 October 2009. STUDY SELECTION Observational studies with 300 or more participants and randomized, controlled trials (RCTs) with 50 or more adult participants who were 50 years or older, drawn from general populations, and followed for at least 1 year were included. Relevant, good-quality systematic reviews were also eligible. DATA EXTRACTION Information on study design, outcomes, and quality were extracted by one researcher and verified by another. An overall rating of the quality of evidence was assigned by using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) criteria. DATA SYNTHESIS 127 observational studies, 22 RCTs, and 16 systematic reviews were reviewed in the areas of nutritional factors; medical factors and medications; social, economic, or behavioral factors; toxic environmental exposures; and genetics. Few of the factors had sufficient evidence to support an association with cognitive decline. On the basis of observational studies, evidence that supported the benefits of selected nutritional factors or cognitive, physical, or other leisure activities was limited. Current tobacco use, the apolipoprotein E epsilon4 genotype, and certain medical conditions were associated with increased risk. One RCT found a small, sustained benefit from cognitive training (high quality of evidence) and a small RCT reported that physical exercise helps to maintain cognitive function. LIMITATIONS The categorization and definition of exposures were heterogeneous. Few studies were designed a priori to assess associations between specific exposures and cognitive decline. The review included only English-language studies, prioritized categorical outcomes, and excluded small studies. CONCLUSION Few potentially beneficial factors were identified from the evidence on risk or protective factors associated with cognitive decline, but the overall quality of the evidence was low. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality and the National Institute on Aging, through the Office of Medical Applications of Research, National Institutes of Health.

Screening for cognitive impairment: comparing the performance of four instruments in primary care.

To determine whether brief cognitive screening tests perform as well as a longer screening test in diagnosis of cognitive impairment, no dementia (CIND) or dementia.

Prediction of the utility of a switch from unilateral to bilateral ECT in the elderly using treatment 2 ictal EEG indices.

Background The choice of whether to administer nondominant unilateral (UL) or bilateral (BL) ECT remains controversial. Methods A study in which moderately suprathreshold UL nonresponders at treatment 6 were randomized to UL or BL ECT offered the opportunity to explore whether ictal EEG indices at treatment 2 might predict response to UL ECT, and also which UL ECT nonresponders are likely to respond to BL ECT. Results We found that less postictal suppression in response to the second UL ECT stimulus was predictive of a poorer subsequent therapeutic response to UL ECT, but of a better therapeutic response if switched to BL ECT. A multivariate ictal EEG model was developed that had a significant capacity to differentiate those who will respond to UL ECT versus those who will not respond to UL ECT, but who will be therapeutic responders when switched to BL ECT. Conclusions This study raises the possibility that ictal EEG indices at treatment 2 may identify situations when UL ECT is physiologically and therapeutically inadequate, and when BL ECT is likely to be more effective. The determination of whether such predictive physiologic models are of clinical utility for the prediction of outcome awaits further study.

Cognitive impairment and outcomes in older adult survivors of acute myocardial infarction: Findings from the Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health Status registry

BACKGROUND Cognitive impairment without dementia (CIND) and acute myocardial infarction (AMI) are prevalent in older adults; however, the association of CIND with outcomes after AMI is unknown. METHODS We used a multicenter registry to study 772 patients ≥65 years with AMI, enrolled between April 2005 and December 2008, who underwent cognitive function assessment with the Telephone Interview for Cognitive Status-modified (TICS-m) 1 month after AMI. Patients were categorized by cognitive status to describe characteristics and in-hospital treatment, including quality of life and survival 1 year after AMI. RESULTS Mean age was 73.2 ± 6.3 years; 58.5% were men, and 78.2% were white. Normal cognitive function (TICS-m >22) was present in 44.4%; mild CIND (TICS-m 19-22) in 29.8%; and moderate/severe CIND (TICS-m <19) in 25.8% of patients. Rates of hypertension (72.6%, 77.4%, and 81.9%), cerebrovascular accidents (3.5%, 7.0%, and 9.0%), and myocardial infarction (20.1%, 22.2%, and 29.6%) were higher in those with lower TICS-m scores (P < .05 for comparisons). AMI medications were similar by cognitive status; however, CIND was associated with lower cardiac catheterization rates (P = .002) and cardiac rehabilitation referrals (P < .001). Patients with moderate/severe CIND had higher risk-adjusted 1-year mortality that was nonstatistically significant (adjusted hazard ratio 1.97, 95% CI 0.99-3.94, P = .054; referent normal, TICS-m >22). Quality of life across cognitive status was similar at 1 year. CONCLUSIONS Most older patients surviving AMI have measurable CIND. Cognitive impairment without dementia was associated with less invasive care, less referral and participation in cardiac rehabilitation, and worse risk-adjusted 1-year survival in those with moderate/severe CIND, making it an important condition to consider in optimizing AMI care.

Acceptability of dementia screening in primary care patients.

To determine the acceptability of dementia screening in two populations of older adults in different primary care settings.

St John's for depression, worts and all

Your patients are using it, but does it work? D epressive disorders are serious illnesses that cause enormous personal suffering and a high economic burden. The World Health Organization projects that major depression will be the second leading cause of disability worldwide by the year 2020. Most depressed patients are treated in primary care and the most common treatment is antidepressant medication. Despite rapid growth in antidepressant prescribing, outcomes are often poor and patients are increasingly using complementary and alternative medicine such as St Johns wort (SJW). In 2002, 12% of US adults reported using SJW within the past 12 months.1 Should we encourage our patients to try St Johns wort for depression? > Szegedi et al conducted a methodologically sophisticated study to determine whether SJW was about as good as and no worse than paroxetine in patients with moderate to severe major depression. The study produced surprising results. Szegedi et al conducted a methodologically sophisticated study (p 160) designed to determine whether SJW was about as good as and no worse than paroxetine in patients with moderate to severe major depression. An active control, non-inferiority trial is appropriate when there are …

Stability of Diagnoses of Cognitive Impairment, Not Dementia in a Veterans Affairs Primary Care Population

To describe the stability of cognitive impairment, not dementia (CIND) in a longitudinal cohort of primary care veterans. To examine the association between baseline brief cognitive screening tests, demographic and clinical characteristics, and cognitive decline.