Epidemiology of Motoric Cognitive Risk Syndrome in the Kerala Einstein Study: Protocol for a Prospective Cohort Study.

BACKGROUND: The southern India state of Kerala has among the highest proportion of older adults in its population in the country. An increase in chronic age-related diseases such as dementia is expected in the older Kerala population. Identifying older individuals early in the course of cognitive decline offers the best hope of introducing preventive measures early and planning management. However, the epidemiology and pathogenesis of predementia syndromes at the early stages of cognitive decline in older adults are not well established in India. OBJECTIVE: The Kerala Einstein Study (KES) is a community-based cohort study that was established in 2008 and is based in the Kozhikode district in Kerala state. KES aims to establish risk factors and brain substrates of motoric cognitive risk syndrome (MCR), a predementia syndrome characterized by the presence of slow gait and subjective cognitive concerns in individuals without dementia or disability. This protocol describes the study design and procedures for this KES project. METHODS: KES is proposing to enroll a sample of 1000 adults ≥60 years old from urban and rural areas in the Kozhikode district of Kerala state: 200 recruited in the previous phase of KES and 800 new participants to be recruited in this project. MCR is the cognitive phenotype of primary interest. The associations between previously established risk factors for dementia as well as novel risk factors (apathy and traumatic brain injury) and MCR will be examined in KES. Risk factor profiles for MCR will be compared between urban and rural residents as well as with individuals who meet the criteria for mild cognitive impairment (MCI). Cognitive and physical function, medical history and medications, sociodemographic characteristics, lifestyle patterns, and activities of daily living will be evaluated. Participants will also undergo magnetic resonance imaging and electrocardiogram investigations. Longitudinal follow-up is planned in a subset of participants as a prelude to future longitudinal studies. RESULTS: KES (2R01AG039330-07) was funded by the US National Institutes of Health in September 2019 and received approval from the Indian Medical Council of Research to start the study in June 2021. We had recruited 433 new participants from urban and rural sites in Kozhikode as of May 2023: 41.1% (178/433) women, 67.7% (293/433) rural residents, and 13.4% (58/433) MCR cases. Enrollment is actively ongoing at all the KES recruitment sites. CONCLUSIONS: KES will provide new insights into risk factors and brain substrates associated with MCR in India and will help guide future development of regionally specific preventive interventions for dementia. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/49933.

Utilizing community engagement studios to inform clinical trial design at a Center of Excellence for Alzheimer's Disease.

Despite the disproportionate burden of Alzheimer's disease in older adults of color, the scientific community continues to grapple with underrepresentation of racial and ethnic minorities in clinical research. Our Center of Excellence for Alzheimer's Disease (CEAD) collaborated with a local community partner to conduct community engagement (CE) studios to effectively involve our community of diverse older adults in the early planning stages of a clinical trial. Given the COVID-19 pandemic, the in-person studio format was adapted to allow for virtual, real-time participation. Our objective is to describe the process and feasibility of conducting virtual CE studios in an older adult population. Ninety percent of participants were non-Hispanic Black community-dwelling woman aged 60 years and older. The overall background and proposed clinical trial design was presented to the participants who then made recommendations regarding potential recruitment strategies, the use of culturally relevant language to describe the study, and logistical recommendations to improve participation and retention among community members. Our CEAD successfully conducted virtual CE studios during the COVID-19 pandemic, by partnering with a community-based organization, to engage community stakeholders about clinical trial design. CEADs are in a unique position to implement CE studios to better support patient access to clinical trials.

Mediation Analyses of the Role of Apathy on Motoric Cognitive Outcomes.

Recent literature indicates that apathy is associated with poor cognitive and functional outcomes in older adults, including motoric cognitive risk syndrome (MCR), a predementia syndrome. However, the underlying biological pathway is unknown. The objectives of this study were to (1) examine the cross-sectional associations between inflammatory cytokines (Interleukin 6 (IL-6) and C-Reactive Protein (CRP)) and apathy and (2) explore the direct and indirect relationships of apathy and motoric cognitive outcomes as it relates to important cognitive risk factors. N = 347 older adults (≥65 years old) enrolled in the Central Control of Mobility in Aging Study (CCMA). Linear and logic regression models showed that IL-6, but not CRP was significantly associated with apathy adjusted for age, gender, and years of education (ß = 0.037, 95% CI: 0.002-0.072, p = 0.04). Apathy was associated with a slower gait velocity (ß = -14.45, 95% CI: -24.89-4.01, p = 0.01). Mediation analyses demonstrated that IL-6 modestly mediates the relationship between apathy and gait velocity, while apathy mediated the relationships between dysphoria and multimorbidity and gait velocity. Overall, our findings indicate that apathy may be an early predictor of motoric cognitive decline. Inflammation plays a modest role, but the underlying biology of apathy warrants further investigation.

Feasibility of Problem Adaption Therapy in a Diverse, Frail Older Adult Population (PATH-MHS).

The purpose of the Problem Adaptation Therapy - Montefiore Health System (PATH-MHS) pilot program was to demonstrate the feasibility and effectiveness of PATH across a culturally, educationally, and functionally diverse cohort of older adults. METHODS: Clinicians referred 145 participants with depression and cognitive impairment to PATH-MHS. We completed analyses of the change in depression, disability and the association between baseline characteristics and remission of depression. RESULTS: Most participants were Hispanic or Non-Hispanic Black and 54.7% (76) were primary Spanish speakers. Overall, there were significant decreases in the mean PHQ-9 and WHODAS 2.0 scores. In logistic regression models, neither age, education, gender, race/ethnicity, language nor long-term care status was significantly associated with remission of depression. CONCLUSIONS: This study demonstrates that we were able to engage a diverse, cognitively impaired, and frail cohort of older adults in PATH-MHS with significant reductions in depression and disability.

Review of Grief Therapies for Older Adults.

PURPOSE OF REVIEW: The objective of this review is to provide background on common theories of grief, describe the impact of grief on older adults and to introduce various modalities that are currently used and/or being researched for treatment. The objective is also to condense information and identify what has been found beneficial versus what has been found lacking. A brief examination of overlap of other disorders is done. It also will suggest what further research is necessary on this subject, and highlight what research is being done during the COVID-19 Pandemic. FINDINGS: The latest research of grief primarily involves refining the definitions of grief. More concrete definitions of grief will help for better screening tools, and thus target interventions more appropriately. There is considerable need for applying it to the unique and real-world COVID-19 pandemic. SUMMARY: Grief disorders are relatively common and the symptoms overlap other disorders. Since the treatments differ, identifying grief disorders is important, especially in the elderly who are more susceptible to grief disorders. Therapy improves grief better than medications, but medications will help with any co-occurring disorders. No clear superior therapy has been identified but research continues. The pandemic has highlighted the need to refine the definitions of grief disorders and to treat them effectively.

Telehealth for the cognitively impaired older adult and their caregivers: lessons from a coordinated approach.

The Covid-19 pandemic forced providers to alter their delivery of care to special populations, including older adults with cognitive impairment. The Montefiore-Einstein Center for the Aging Brain, a specialty multidisciplinary center for the evaluation and management of patients with neurodegenerative disorders, developed a coordinated approach (Coordinated Care At Risk/Remote Elderly program [CCARRE]) to reach our diverse population during the initial Covid-19 crisis in New York City, USA. In the tele-evaluation of the first 85 patients seen with CCARRE, we recognized unique factors that could improve patient care, lessen burden and optimize access to community resources. Lessons learned from the experience are shared.

Apathy and the Risk of Predementia Syndromes in Community-Dwelling Older Adults.

OBJECTIVES: Apathy is a potential predictor of dementia in older adults, but this investigation has been limited to older adults with a preexisting neurological illness like mild cognitive impairment (MCI), stroke or Parkinson's disease. The objective of this study was to investigate the association between apathy at baseline and incident predementia syndromes, including MCI and motoric cognitive risk syndrome (MCR), subjective cognitive complaints and slow gait, in community-dwelling older adults. METHOD: We prospectively studied the association between apathy (using the 3-item subscale of the Geriatric Depression Scale [GDS3A]) and incident cognitive disorders in 542 community-dwelling older adults enrolled in the Central Control of Mobility in Aging study using Cox proportional hazard models. Associations were reported as hazard ratio (HR) with 95% confidence intervals (CIs), adjusting for age, education, baseline cognitive performance, and depressive symptoms. RESULTS: Apathy was associated with incident MCR (HR 2.39, 95% CI: 1.10-5.20), but not predementia syndromes overall nor MCI. In sensitivity analyses of MCI subtypes, apathy was associated with nonamnestic MCI (HR 2.44, 95% CI: 1.14-5.22), but not amnestic MCI. Our study was limited by a short follow-up time (median 13.6 months; interquartile range 29.8) and a brief subscale measurement of apathy, GDS3A. DISCUSSION: In our study, apathy predicted MCR but not MCI in community-dwelling older adults. These results and the current literature suggest that apathy is an early risk factor for dementia. Additionally, apathy may be a novel treatment target that could forestall the disability of dementia.

Walking While Talking and Risk of Incident Dementia.

INTRODUCTION: Walking while talking (WWT) is a performance-based test of divided attention that examines cognitive-motor interactions. The purpose of this study is to examine the predictive validity of WWT for dementia and dementia subtypes. METHODS: We prospectively studied the associations of WWT performance at baseline with risk of developing incident dementia in 1,156 older adults (mean age: 78.28 ± 5.27 years, 60.7% female) enrolled in the Einstein Aging Study using Cox proportional hazard models. Associations were reported as hazard ratio (HR) with 95% confidence intervals (CI). RESULTS: Over a median follow-up of 1.90 years (interquartile range: 4.70 years), 85 participants developed incident dementia (53 Alzheimer dementia [AD] and 26 vascular dementia [VaD]). Three gait domains were derived using principal component analysis. Only variability, which loaded heavily for swing time standard deviation (SD) and step time SD, was associated with an increased risk of incident dementia per 1 point increase (HR: 1.24, 95% CI: 1.02-1.54) and VaD (HR: 1.50, 95% CI: 1.06-2.12) after adjusting for demographics, disease burden, mental status, and normal walking velocity. Among eight individual gait variables, only swing time variability SD was associated with increased risk for both incident dementia (HR: 1.35, 95% CI: 1.03-1.77) and VaD (HR: 1.78, 95% CI: 1.12-2.83). Variability and swing time SD were not significantly associated with risk of incident AD. CONCLUSIONS: Complex walking as assessed by the WWT task is a simple and pragmatic tool for assessing risk of developing dementia, especially VaD, in older adults.

Screening Older Adults for Mental Disorders.

Avoidable disability associated with depression, anxiety, and impaired cognition among older adults is pervasive. Incentives for detection of mental disorders in late life include increased reimbursement, reduced cost, and less burden for patients and families. However, screening not aligned with diagnosis, intervention, and outcome assessment has questionable utility. The link between screening, treatment, and outcomes is well established for depression, less so for anxiety and impaired cognition. This article details the use of common instruments to screen and assess depression, anxiety, and cognitive impairment.

Effect of Maladaptive Beliefs and Attitudes about Sleep among Community-dwelling African American Men at Risk for Obstructive Sleep Apnea.

This study compared differences in both maladaptive beliefs and attitudes about sleep between African American (heareafter referred to as black) men at risk for obstructive sleep apnea (OSA) and those without OSA risk. METHODS: A convenience sample of 120 community-dwelling men provided sociodemographic, health and sleep data. A validated questionnaire was used to identify men at high risk for OSA and the Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16) scale was used to measure endorsed attitudes and beliefs about sleep. RESULTS: The mean age of the sample was 42 ± 15 years. Men reported difficulty falling asleep (23%), difficulty maintaining sleep (23%), early morning awakening (35%), and use of sleep medicine (6%). 27% were at high risk for OSA. Men at high OSA risk had greater DBAS scores [F1, 92=13.68, p<0.001]; OSA risk was related to greater rate of sleep dissatisfaction overall [46% vs. 13%, Χ2=24.52, p<0.001]. CONCLUSION: The findings suggest that maladaptive beliefs and attitudes about sleep are important characteristics of black men at risk for OSA, and potential screenings around sleep difficulties should also consider these factors.

Obstructive sleep apnea risk and psychological health among non-Hispanic blacks in the Metabolic Syndrome Outcome (MetSO) cohort study.

INTRODUCTION: This study assessed associations of depression and anxiety with risk of obstructive sleep apnea (OSA) among non-Hispanic blacks in the Metabolic Syndrome Outcome (MetSO) study. METHOD: A total of 1,035 patients participated. ARES™ score ≥6 defined high OSA risk. Moderate depression was defined by a CES-D score ≥16. Moderate anxiety was measured by a BAI score ≥16. RESULTS: The mean age was 62 ± 14 years; 70% were female. A total of 93% were diagnosed with hypertension; 61%, diabetes; and 72%, dyslipidemia; 90% were overweight/obese; 33% had a history of heart disease; and 10% had a stroke. Logistic regression analysis, adjusting for age and gender, showed that patients with depression had nearly two-fold increased odds of being at risk for OSA (OR 1.75, 95% CI 1.02-2.98, p < 0.05). Patients with anxiety had three-fold increased odds of being at risk for OSA (OR 3.30, 95% CI 2.11-5.15, p < 0.01). After adjusting for marital status and income, patients with anxiety had a 6% increase in OSA risk (OR 1.06, 95% CI 1.04-1.09, p < 0.05), but depression was no longer significant. CONCLUSION: Our results suggest that non-Hispanic blacks with metabolic syndrome who experience anxiety and/or depression should be screened for OSA.

Associations of Short Sleep and Shift Work Status with Hypertension among Black and White Americans.

Objective. The purpose of this study was to investigate whether short sleepers (<6 hrs) who worked the non-day-shift were at greater likelihood of reporting hypertension and if these associations varied by individuals' ethnicity. Methods. Analysis was based on the 2010 National Health Interview Survey (NHIS). A total of 59,199 American adults provided valid data for the present analyses (mean age = 46.2 ± 17.7 years; 51.5% were female). Respondents provided work schedule and estimated habitual sleep durations as well as self-report of chronic conditions. Results. Of the sample, 30.8% reported a diagnosis of hypertension, 79.1% reported daytime shift work, 11.0% reported rotating shift work, and 4.0% reported night shift work. Logistic regression analysis showed that shift work was significantly associated with hypertension among Blacks [OR = 1.35, CI: 1.06-1.72. P < 0.05], but not among Whites [OR = 1.01, CI: 0.85-1.20, NS]. Black shift workers sleeping less than 6 hours had significantly increased odds of reporting hypertension [OR = 1.81, CI: 1.29-2.54, P < 0.01], while their White counterparts did not [OR = 1.17, CI: 0.90-1.52, NS]. Conclusions. Findings suggest that Black Americans working the non-day-shift especially with short sleep duration have increased odds of reporting hypertension.

Sleep duration and reported functional capacity among black and white US adults.

OBJECTIVE: Evidence suggests that individuals reporting sleeping below or above the population's modal sleep duration are at risk for diabetes, hypertension, and other cardiovascular diseases. Evidence also indicates that individuals with these conditions have reduced functional capacity. We assessed whether reported sleep duration and functional capacity are independently associated and whether individuals' race/ethnicity has an effect on this association. METHOD: Data were obtained from 29,818 black and white Americans (age range: 18-85 years) who participated in the 2005 National Health Interview Survey (NHIS). The NHIS uses a multistage area probability design sampling of non-institutionalized representatives of the US civilian population. Of the sample, 85% were white and 56% were women. RESULTS: Univariate logistic regression analysis showed that individuals sleeping < 6 h were 3.55 times more likely than those sleeping 6-8 h to be functionally impaired (34% vs 13%; p < 0.001). Likewise, those sleeping > 8 h were 3.77 times more likely to be functionally impaired (36% vs 13%; p < 0.001). Individuals of the black race/ethnicity were more likely to be functionally impaired than their white counterparts (23% vs 19%; p < 0.001). Multivariate-adjusted regression analyses showed significant interactions between individuals' race/ethnicity and short sleep with respect to functional capacity (black: OR = 2.78, p < 0.0001; white: OR = 2.30, p < 0.0001). Significant interactions between race/ethnicity and long sleep were also observed (black: OR = 2.43, p < 0.001; white: OR = 2.63, p < 0.001). CONCLUSION: Our findings suggest that individuals' habitual sleep duration and their race/ethnicity are significant predictors of their functional capacity.

Sleep Duration, Insomnia Symptoms, and Emotion Regulation among Black Women.

INTRODUCTION: This study explored the associations between sleep duration and emotion regulation among urban black women (mean age=59 ± 7 yrs). METHOD: Eligible women (n=523) provided sociodemographic data during face-to-face interviews. We used the Comprehensive Assessment and Referral Examination Physical to measure health status; women also estimated their habitual sleep duration. We utilized a modified version of Weinberger's conceptual model of repression, the Index of Self-Regulation (ISE) to measure emotion regulation. ISE scores were derived by amalgamating the defensive subscale from the Social Desirability Scale and the anxiety subscale from the State-Trait Anxiety Inventory. RESULTS: The median habitual sleep duration was 7 hours; 20% of the women were short sleepers (<6 hours) and 6% were long sleepers (>8 hours). Short sleepers, rather than long sleepers, had a greater likelihood of reporting insomnia symptoms than those sleeping 6-8 hours [63.4% vs. 28.1%; Χ2 = 41.87, p<0.001]. In the first logistic regression model, the odds of being a short sleeper for low regulators were 3 times greater than for high regulators [OR = 3.22 95% CI: 2.05-5.06; p<0.0001]. In multivariate-adjusted analysis, OR was reduced to 2.06, but remained significant. In the second logistic model, the likelihood of being a long sleeper among low regulators were 37% greater than for high regulators, but results were not significant [OR=1.37, 95% CI: 0.62-3.01; NS]. DISCUSSION: Short and long sleep duration are associated with reduced ability for emotion regulation. Women sleeping 6-8 hrs might be more adept at regulating emotions in their daily lives. Insomnia symptoms might mediate associations between emotion regulations and sleep durations.