Interdisciplinary and Transdisciplinary Perspectives: On the Road to a Holistic Approach to Dementia Prevention and Care.

 Dementia, of which the most frequent form is Alzheimer's disease, is a chronic and terminal condition with multi-factorial causes and numerous consequences on a patient's life. Combining perspectives from different disciplines seems necessary for unraveling dementia's entangled issues. Current dementia management is a multidisciplinary effort; however, integrating different disciplines as a holistic treatment process is often hindered due to different responsibilities, various conceptual approaches, and distinctive research methods. With this paper, we raise some of the challenges that need to be addressed in order to initiate an interdisciplinary or even transdisciplinary research agenda. We also outline recommendations on how to integrate multiple disciplinary perspectives in dementia care and research. We see opportunities for young investigators to draw from different fields of research in dementia as their research focus is still developing. By establishing common objectives with investigators from other fields, we can pursue the goal of improving treatment and care as a team-meaning accomplishing different tasks but sharing a common purpose. It is necessary to address the communication between fields that limits the understanding of connections between cognitive symptoms, biological processes, treatment, lifestyle, and care giving in order to reach the aim of developing a holistic, person-centered, patient-first approach. Associating biomedical research to field experience from care professionals and the study of human science will promote a more independent, social, and sustainable lifestyle for people with dementia.

Effects of psychological eating behaviour domains on the association between socio-economic status and BMI.

OBJECTIVE: The current study investigates potential pathways from socio-economic status (SES) to BMI in the adult population, considering psychological domains of eating behaviour (restrained eating, uncontrolled eating, emotional eating) as potential mediators stratified for sex. DESIGN: Data were derived from the population-based cross-sectional LIFE-Adult-Study. Parallel-mediation models were conducted to obtain the total, direct and indirect effects of psychological eating behaviour domains on the association between SES and BMI for men and for women. SETTING: Leipzig, Germany. SUBJECTS: We studied 5935 participants aged 18 to 79 years. RESULTS: Uncontrolled eating mediated the association between SES and BMI in men only and restrained eating in both men and women. Emotional eating did not act as mediator in this relationship. The total effect of eating behaviour domains on the association between SES and BMI was estimated as ß=-0·03 (se 0·02; 95 % CI -0·062, -0·003) in men and ß=-0·18 (se 0·02; 95 % CI -0·217, -0·138) in women. CONCLUSIONS: Our findings do not indicate a strong overall mediation effect of the eating behaviour domains restrained eating, uncontrolled eating and emotional eating on the association between SES and BMI. Further research on other pathways of this association is strongly recommended. Importantly, our findings indicate that, independent from one's social position, focusing on psychological aspects in weight reduction might be a promising approach.

[The Prevalence of Current Depressive Symptoms in an Urban Adult Population]. / Die Prävalenz aktueller depressiver Symptomatik in einer urbanen Erwachsenenpopulation.

Objective We sought to provide prevalence rates of depressive symptoms in the adult population of the city of Leipzig, Germany (18 - 79 years; N = 8,861). Methods Data were derived from the Leipzig population-based study of adults (LIFE-ADULT-Study). The German version of the Center for Epidemiological Studies Depression Scale (CES-D) was used to assess depressive symptoms using a cut-off score ≥ 23 points. Results The prevalence of current depressive symptoms was 6.4 % (95 %-KI = 5.4 - 7.4). Significantly higher prevalence rates were found in females than in males, in individuals in middle age (40 - 59 years) than in younger and older adults as well as in those individuals with lower socioeconomic status (SES). Conclusion The study findings did not indicate a generally increased risk of depressive symptoms in urban-living adults.

Which types of mental work demands may be associated with reduced risk of dementia?

INTRODUCTION: Previous studies have demonstrated that an overall high level of mental work demands decreased dementia risk. In our study, we investigated whether this effect is driven by specific mental work demands and whether it is exposure dependent. METHODS: Patients aged 75+ years were recruited from general practitioners and participated in up to seven assessment waves (every 1.5 years) of the longitudinal AgeCoDe study. Analyses of the impact of specific mental work demands on dementia risk were carried out via multivariate regression modeling (n = 2315). RESULTS: We observed a significantly lower dementia risk in individuals with a higher level of "information processing" (HR, 0.888), "pattern detection" (HR, 0.878), "mathematics" (HR, 0.878), and "creativity" (HR, 0.878). Yet, exposure-dependent effects were only significant for "information processing" and "pattern detection." DISCUSSION: Our longitudinal observations suggest that dementia risk may be reduced by some but not all types of mental work demands.

Prevalence of DSM-5 Mild Neurocognitive Disorder in Dementia-Free Older Adults: Results of the Population-Based LIFE-Adult-Study.

OBJECTIVE: The DSM-5 introduces mild neurocognitive disorder (miNCD) as a syndrome that recognizes the potential clinical importance of acquired cognitive deficits being too mild to qualify for diagnosis of dementia. We provide new empirical data on miNCD including total, age-, and sex-specific prevalence rates; number and types of neurocognitive domains being impaired; and diagnostic overlap with the well-established mild cognitive impairment (MCI) concept. DESIGN: Cross-sectional results of an observational cohort study (LIFE-Adult-Study). SETTING: General population. PARTICIPANTS: A total of 1,080 dementia-free individuals, aged 60-79 years. MEASUREMENTS: We calculated weighted point prevalence rates with confidence intervals (95% CI) for miNCD and analyzed diagnostic overlap between miNCD and MCI by calculating overall percentage agreement and Cohen's kappa coefficient. RESULTS: Weighted total prevalence of miNCD was 20.3% (95% CI: 17.8-23.0). Prevalence was similar in both sexes, but significantly higher in older age. Two-thirds (66.2%) of the individuals with miNCD showed impairment restricted to only one out of six possible neurocognitive domains. Learning and memory was the most frequently (38.3%) impaired domain in all miNCD-cases, followed by social cognition (26.1%). Analysis of diagnostic overlap with MCI yielded an overall agreement of 98.6% and a kappa of 0.959. CONCLUSIONS: By considering all six predefined neurocognitive domains, our study observed a substantial proportion of dementia-free older adults having miNCD. Provision of information on the underlying etiology/ies may be of prime importance in future studies aiming at evaluating the clinical relevance of the miNCD syndrome.

Education as protector against dementia, but what exactly do we mean by education?

OBJECTIVES: even though a great number of research studies have shown that high education has protective effects against dementia, some studies did not observe such a significant effect. In that respect, the aim of our study was to investigate and compare various operationalisation approaches of education and how they impact dementia risk within one sample. METHODS: data were derived from the Leipzig longitudinal study of the aged (LEILA75+). Individuals aged 75 and older underwent six cognitive assessments at an interval of 1.5 years and a final follow-up 15 years after the baseline assessment. We operationalised education according to different approaches used in previous studies and analysed the impact on dementia incidence via multivariate cox regression modelling. RESULTS: the results showed that whether education is identified as significant protector against dementia strongly depends on the operationalisation of education. Whereas the pure number of years of education showed statistically significant protective effects on dementia risk, other more complex categorical classification approaches did not. Moreover, completing >10 years of education or a tertiary level seems to be an important threshold to significantly reduce dementia risk. CONCLUSION: findings suggest a protective effect of more years of education on a lower dementia risk with a particular critical threshold of completing >10 years of education. Further, the findings highlight that, when examining risks and protective factors of dementia, a careful consideration of the underlying definitions and operationalisation approaches is required.

Eating Behaviour in the General Population: An Analysis of the Factor Structure of the German Version of the Three-Factor-Eating-Questionnaire (TFEQ) and Its Association with the Body Mass Index.

The Three-Factor-Eating-Questionnaire (TFEQ) is an established instrument to assess eating behaviour. Analysis of the TFEQ-factor structure was based on selected, convenient and clinical samples so far. Aims of this study were (I) to analyse the factor structure of the German version of the TFEQ and (II)--based on the refined factor structure--to examine the association between eating behaviour and the body mass index (BMI) in a general population sample of 3,144 middle-aged and older participants (40-79 years) of the ongoing population based cohort study of the Leipzig Research Center for Civilization Diseases (LIFE Health Study). The factor structure was examined in a split-half analysis with both explorative and confirmatory factor analysis. Associations between TFEQ-scores and BMI values were tested with multiple regression analyses controlled for age, gender, and education. We found a three factor solution for the TFEQ with an 'uncontrolled eating', a 'cognitive restraint' and an 'emotional eating' domain including 29 of the original 51 TFEQ-items. Scores of the 'uncontrolled eating domain' showed the strongest correlation with BMI values (partial r = 0.26). Subjects with scores above the median in both 'uncontrolled eating' and 'emotional eating' showed the highest BMI values (mean = 29.41 kg/m²), subjects with scores below the median in all three domains showed the lowest BMI values (mean = 25.68 kg/m²; F = 72.074, p<0.001). Our findings suggest that the TFEQ is suitable to identify subjects with specific patterns of eating behaviour that are associated with higher BMI values. Such information may help health care professionals to develop and implement more tailored interventions for overweight and obese individuals.

The LIFE-Adult-Study: objectives and design of a population-based cohort study with 10,000 deeply phenotyped adults in Germany.

BACKGROUND: The LIFE-Adult-Study is a population-based cohort study, which has recently completed the baseline examination of 10,000 randomly selected participants from Leipzig, a major city with 550,000 inhabitants in the east of Germany. It is the first study of this kind and size in an urban population in the eastern part of Germany. The study is conducted by the Leipzig Research Centre for Civilization Diseases (LIFE). Our objective is to investigate prevalences, early onset markers, genetic predispositions, and the role of lifestyle factors of major civilization diseases, with primary focus on metabolic and vascular diseases, heart function, cognitive impairment, brain function, depression, sleep disorders and vigilance dysregulation, retinal and optic nerve degeneration, and allergies. METHODS/DESIGN: The study covers a main age range from 40-79 years with particular deep phenotyping in elderly participants above the age of 60. The baseline examination was conducted from August 2011 to November 2014. All participants underwent an extensive core assessment programme (5-6 h) including structured interviews, questionnaires, physical examinations, and biospecimen collection. Participants over 60 underwent two additional assessment programmes (3-4 h each) on two separate visits including deeper cognitive testing, brain magnetic resonance imaging, diagnostic interviews for depression, and electroencephalography. DISCUSSION: The participation rate was 33 %. The assessment programme was accepted well and completely passed by almost all participants. Biomarker analyses have already been performed in all participants. Genotype, transcriptome and metabolome analyses have been conducted in subgroups. The first follow-up examination will commence in 2016.

Differential effects of enriched environment at work on cognitive decline in old age.

OBJECTIVES: The aim of the present study was to investigate how different mentally demanding work conditions during the professional life-i.e., enriched environments at work-might influence the rate of cognitive decline in old age. METHODS: Individuals (n = 1,054) of the Leipzig Longitudinal Study of the Aged, a representative population-based cohort study of individuals aged 75 years and older, underwent cognitive testing via the Mini-Mental State Examination (MMSE) in up to 6 measurement waves. Type and level of mentally demanding work conditions in the participants' former professional life were classified based on the O*NET job descriptor database. RESULTS: In multivariate mixed-model analyses (controlling for sociodemographic and health-related factors), a high level of mentally demanding work tasks stimulating verbal intelligence was significantly associated with a better cognitive functioning at baseline (on average 5 MMSE points higher) as well as a lower rate of cognitive decline (on average 2 MMSE points less) over the 8-year follow-up period compared with a low level. The rate of cognitive decline in old age was also significantly lower (on average 3 MMSE points less) in individuals who had a high level of mentally demanding work tasks stimulating executive functions than those who had a low level. CONCLUSIONS: The results suggest that a professional life enriched with work tasks stimulating verbal intelligence and executive functions may help to sustain a good cognitive functioning in old age (75+ years). The findings thus emphasize that today's challenging work conditions may also promote positive health effects.

Age- and gender-specific norms for the German version of the Three-Factor Eating-Questionnaire (TFEQ).

The 'Fragebogen zum Essverhalten' (FEV) is the German version of the Three-factor-Eating-Questionnaire (TFEQ). This questionnaire covers three domains of eating behaviour ('cognitive restraint', 'disinhibition' and 'hunger') as well as common problems (e.g. craving for sweets). So far, there is a lack of normative data of the FEV especially for the middle-aged and older population. Aim of this study therefore was to provide age- and gender-specific norms of the FEV for the general population aged 40-79 years. We studied 3144 participants of the ongoing large community-based Leipzig Research Center for Civilization Diseases (LIFE) Health Care Study. We provided age- (four age groups: 40-49, 50-59, 60-69, and 70-79 years) and gender-specific percentile ranks and T-scores for the three domains of the FEV as well as age- and gender-specific frequencies of the common problems in eating behaviour. Females scored significantly higher than males in all three domains of the FEV (p < 0.001). Older individuals showed significantly higher mean scores than the younger ones in the domain of cognitive restraint, but lower mean scores in disinhibition and hunger (p < 0.001). 45.1% of the males and 69.9% of the females reported specific problems in eating. The main problem in both genders was craving for sweets (38.6%). Eating in response to stress was mostly reported in younger individuals. The present study offers current normative data for the FEV in the middle-aged and older general population that can be applied in clinical and non-clinical settings. Information on eating behaviour can be helpful in understanding body weight modulation, and thus, may help to improve interventive and preventive programmes for overweight, obesity, and eating disorders.

Association of the apolipoprotein E genotype with memory performance and executive functioning in cognitively intact elderly.

OBJECTIVE: To test for a possible effect of the apolipoprotein E epsilon 4 (APOE ε4) allele on memory performance and executive functioning (EF) in cognitively intact elderly. METHOD: The authors studied 202 randomly selected and cognitively intact older adults (65+ years) of the Leipzig Research Center for Civilization Diseases Health Care Study. Intact global cognitive functioning was defined using a Mini-Mental Status Examination (MMSE) score ≥ 28. Performance in memory was assessed with the CERAD Word List and Constructional Praxis Recall, performance in EF with the Trail Making Test Part B (TMT-B). Multivariable linear regressions were used to evaluate the association between cognitive performance and APOE status, controlled for covariates. RESULTS: Among the cognitively intact older adults, 21.3% (n = 43) were carriers of the APOE ε4 allele. Carriers did not differ significantly from noncarriers in terms of age, gender, intelligence level, or performance in memory but showed a significantly lower TMT-B performance as a measure of EF (TMT-B M time/SD = 105.6/36.2 vs. 91.9/32.7 s; Mann-Whitney U = 4,313.000; p = .009). The association between lower TMT-B performance and APOE ε4 genotype remained significant in multivariable linear regression analysis. Similar findings were found for the subsample of those 78 elderly, who reached a perfect MMSE-score of 30. CONCLUSIONS: A lower EF performance in cognitively intact older APOE ε4 allele carriers might be related to an early Alzheimer's dementia (AD) prodrome. In this case, a stronger focus on first subtle changes in EF may help to improve early AD detection in those being at genetic risk.

Association between mental demands at work and cognitive functioning in the general population - results of the health study of the Leipzig research center for civilization diseases (LIFE).

BACKGROUND: The level of mental demands in the workplace is rising. The present study investigated whether and how mental demands at work are associated with cognitive functioning in the general population. METHODS: The analysis is based on data of the Health Study of the Leipzig Research Centre for Civilization Disease (LIFE). 2,725 participants aged 40-80 years underwent cognitive testing (Trail-Making Test, Verbal Fluency Test) and provided information on their occupational situation. Participants over the age of 65 years additionally completed the Mini-Mental State Examination. Mental demands at work were rated by a standardized classification system (O*NET). The association between mental demands and cognitive functioning was analyzed using Generalized Linear Modeling (GENLIN) adjusted for age, gender, self-regulation, working hour status, education, and health-related factors. RESULTS: Univariate as well as multivariate analyses demonstrated significant and highly consistent effects of higher mental demands on better performance in cognitive testing. The results also indicated that the effects are independent of education and intelligence. Moreover, analyses of retired individuals implied a significant association between high mental demands at work of the job they once held and a better cognitive functioning in old age. CONCLUSIONS: In sum, our findings suggest a significant association between high mental demands at work and better cognitive functioning. In this sense, higher levels of mental demands - as brought about by technological changes in the working environment - may also have beneficial effects for the society as they could increase cognitive capacity levels and might even delay cognitive decline in old age.

Systematic review of the effect of the psychosocial working environment on cognition and dementia.

The high incidence of cognitive impairment in the ageing population, together with the challenges it imposes to health systems, raises the question of what affect working life has on cognitive abilities. The study, therefore, reviews recent work on the longitudinal impact of psychosocial work conditions on cognitive functioning and on dementia. Relevant articles were identified by a systematic literature search in PubMed and PsycINFO using a standardised search string and specific inclusion and exclusion criteria. We included articles reporting longitudinal effects that were investigated in cohort studies, case-control studies or randomised controlled trials in the working population. Two independent reviewers evaluated the studies in three subsequent phases: (i) title-abstract screening, (ii) full-text screening and (iii) checklist-based quality assessment.Methodical evaluation of the identified articles resulted in 17 studies of adequate quality. We found evidence for a protective effect of high job control and high work complexity with people and data on the risk of cognitive decline and dementia. Moreover, cognitively demanding work conditions seem to be associated with a decreased risk of cognitive deterioration in old age.Psychosocial work conditions can have an impact on cognitive functioning and even on the risk of dementia. As the world of work is undergoing fundamental changes, such as accelerated technological advances and an ageing working population, optimising work conditions is essential in order to promote and maintain cognitive abilities into old age.

Enriched environment at work and the incidence of dementia: results of the Leipzig longitudinal study of the aged (LEILA 75+).

BACKGROUND: The high incidence of cognitive impairments in the aging population together with the challenges it imposes on health systems raise the question of what effect working life has on cognitive abilities. Animal models have demonstrated that so called enriched environments protect against neurodegenerative diseases, such as dementia. The aim was to investigate the impact of enriched environment at work on the incidence of dementia. METHODS: The Leipzig Longitudinal Study of the Aged (LEILA 75+) is an ongoing representative population cohort study that examines cognitive functioning and dementia in individuals aged 75 years and older. The participants' occupational information was matched to O*NET SOC codes and the relevant job descriptors were used to create occupational context indices describing enriched environment at work. RESULTS: Results of logistic regression modeling suggest that a higher level of the index Executive was associated with a lower risk of incident dementia (odds ratio  = 0.61, 95% confidence interval  = 0.47-0.79, p<0.001). Adjustment for various confounders did not alter the association. The cognitive stimulation indices were only significant in univariate analysis. The Novelty-index remained non-significant. CONCLUSIONS: The results suggest that occupational contexts enriched with independent planning/performance of work tasks might decrease the risk of developing dementia. A protective effect of enriched environment at work in general, namely high cognitive stimulation or confrontation with new tasks, could not be confirmed by the results.

[Assessment of mild cognitive impairment and dementia in epidemiologic studies. An overview on the current state of research in Germany]. / Erfassung leichter kognitiver Störungen und demenzieller Erkrankungen in epidemiologischen Studien. Ein Überblick über den aktuellen Forschungsstand in Deutschland.

OBJECTIVE: We sought to provide an overview on the assessment of mild cognitive impairment and dementia in epidemiological studies from Germany. METHODS: We conducted a literature search in the databases Pubmed and PsycInfo. RESULTS: Literature search identified 31 relevant studies using a broad spectrum of methods and neuropsychological instruments. CONCLUSION: Further efforts are necessary to establish a generally accepted core set of instruments enabling a harmonized assessment of mild cognitive impairment and dementia in epidemiological studies. Such a core set should comprise neuropsychological tests but also standardized questionnaires on subjective cognitive impairment and impairment in activities of daily living. If possible, third-party information (proxy interviews) should be included.