Taking balance measurement out of the laboratory and into the home: discriminatory capability of novel centre of pressure measurement in fallers and non-fallers

We investigated three methods for estimating centre of pressure excursions, as measured using a portable pressure sensor matrix, in order to deploy similar technology into the homes of older adults for longitudinal monitoring of postural control and falls risk. We explored the utility of these three methods as markers of falls risk in a cohort of 120 community dwelling older adults with and without a history of falls (65 fallers, 55 non-fallers). A number of standard quantitative balance parameters were derived using each centre of pressure estimation method. Rank sum tests were used to test for significant differences between fallers and non-fallers while intra-class correlation coefficients were also calculated to determine the reliability of each method. A method based on estimating the changes in the magnitude of pressure exerted on the pressure sensor matrix was found to be the most reliable and discriminative. Our future work will implement this method for home-based balance measurement

Circulating ceramide ratios and risk of vascular brain aging and dementia

BACKGROUND: We determined the association between ratios of plasma ceramide species of differing fatty-acyl chain lengths and incident dementia and Alzheimer\u27s disease (AD) dementia in a large, community-based sample. METHODS: We measured plasma ceramide levels in 1892 [54% women, mean age 70.1 (SD 6.9) yr.] dementia-free Framingham Offspring Study cohort participants between 2005 and 2008. We related ratios of very long-chain (C24:0, C22:0) to long-chain (C16:0) ceramides to subsequent risk of incident dementia and AD dementia. Structural MRI brain measures were included as secondary outcomes. RESULTS: During a median 6.5 year follow-up, 81 participants developed dementia, of whom 60 were diagnosed with AD dementia. In multivariable Cox-proportional hazards analyses, each standard deviation (SD) increment in the ratio of ceramides C24:0/C16:0 was associated with a 27% reduction in the risk of dementia (HR 0.73, 95% CI 0.56-0.96) and AD dementia (HR 0.73, 95% CI 0.53-1.00). The ratio of ceramides C22:0/C16:0 was also inversely associated with incident dementia (HR per SD 0.75, 95% CI 0.57-0.98), and approached statistical significance for AD (HR 0.73, 95% CI 0.53-1.01, P = 0.056). Higher ratios of ceramides C24:0/C16:0 and C22:0/C16:0 were also cross-sectionally associated with lower white matter hyperintensity burden on MRI (-0.05 ± 0.02, P = 0.02; -0.06 ± 0.02, P = 0.003; respectively per SD increase), but not with other MRI brain measures. CONCLUSIONS: Higher plasma ratios of very long-chain to long-chain ceramides are associated with a reduced risk of incident dementia and AD dementia in our community-based sample. Circulating ceramide ratios may serve as potential biomarkers for predicting dementia risk in cognitively healthy adults

Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study

Background: Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions. Methods: International experts in cognitive disorders were invited to assess seven illustrative clinical vignettes containing history and bedside characteristics alone. Participants assigned a probable diagnosis and selected the appropriate investigation and treatment. Qualitative, quantitative and inter-rater agreement analyses were undertaken. Results: Eighteen diagnostic terminologies were assigned by 45 cognitive experts from 12 countries with a median of 13 years of experience, across the seven scenarios. Accurate discrimination between FCD and neurodegeneration was observed, independently of background and years of experience: 100% of the neurodegenerative vignettes were correctly classified and 75%–88% of the FCD diagnoses were attributed to non-neurodegenerative causes. There was <50% agreement in the terminology used for FCD, in comparison with 87%–92% agreement for neurodegenerative syndromes. Blood tests and neuropsychological evaluation were the leading diagnostic modalities for FCD. Diagnostic communication, psychotherapy and psychiatry referral were the main suggested management strategies in FCD. Conclusions: Our study demonstrates the feasibility of distinguishing between FCD and neurodegeneration based on relevant patient characteristics and history details. These characteristics need further validation and operationalisation. Heterogeneous labelling and framing pose clinical and research challenges reflecting a lack of agreement in the field. Careful consideration of FCD diagnosis is advised, particularly in the presence of comorbidities. This study informs future research on diagnostic tools and evidence-based interventions

Does lowering blood pressure with antihypertensive therapy preserve independence in activities of daily living? a systematic review

BACKGROUND Hypertension is a major risk factor for functional impairment. Dependence is an important related outcome for older adults, but outcomes in hypertension trials appear to focus primarily on major vascular events. This systematic review had 2 objectives: (i) to determine the proportion of randomized controlled trials (RCTs) evaluating antihypertensive therapies that reported a measure of a person\u27s ability to carry out activities of daily living (ADL) and (ii) to evaluate the effect of blood pressure (BP)-lowering therapies on ability to carry out ADL compared with control therapy. METHODS We searched electronic databases, reference lists of relevant meta-analyses, and hypertension guidelines for clinical trials of adults with hypertension/prehypertension that were randomized to antihypertensive therapy or control for &amp;gt;= 1 year. RESULTS Of 2,924 citations screened, there were 93 eligible RCTs. One (1%) reported ADL as a primary outcome measure. Nine (10%) reported ADL as a secondary outcome. Of these, 6 used validated ADL scales, whereas 4 measured ADL within quality-of-life scales. Six trials with duration of &amp;gt; 1 year (n = 12,663) were amenable to meta-analysis, despite use of different ADL scales. The odds of having difficulty with ADL was reduced by BP-lowering therapy compared with control therapy (odds ratio = 0.84; 95% confidence interval = 0.77-0.92; I-2 = 0%). CONCLUSIONS We identified few trials of antihypertensive therapy that reported ADL as an outcome measure, with heterogeneity in scales used. Antihypertensive therapy was associated with a lower risk of ADL impairment compared with control therapy. RCTs evaluating the effect of antihypertensive drugs on ADL in older adults with mild hypertension are required

Antithrombotic therapy after acute ischemic stroke in patients with atrial fibrillation

Background and Purpose-For patients with atrial fibrillation and ischemic stroke (IS), current guidelines recommend oral anticoagulation (OAC) alone for secondary prevention of IS. In a large prospective cohort of patients with acute IS and atrial fibrillation, we determine the association between antithrombotic regimen on discharge and risk of major vascular events. Methods-Prospective cohort of consecutive patients included in the Ontario Stroke Registry. Multivariable Cox proportional hazard models were used to determine the association between antithrombotic regimen on discharge and time to death or admission for recurrent IS, myocardial infarction, or major bleeding. Results-Two thousand one hundred sixty-two patients were hospitalized atrial fibrillation and acute IS. At discharge, 8.0% were prescribed no antithrombotic therapy, 21.6% antiplatelet therapy alone, 39.3% OAC (warfarin) alone, and 31.1% combination OAC and antiplatelet therapy. Compared with OAC alone (hazard ratio [HR], 1.0), no antithrombotic therapy (HR, 1.51; 95% confidence interval, 1.23-1.86) and antiplatelet therapy (HR, 1.31; 95% confidence interval, 1.14-1.50) were associated with an increased risk of the primary composite outcome, whereas combination OAC and antiplatelet therapy was associated with a trend toward a reduced risk (HR, 0.91; 95% confidence interval, 0.80-1.04 overall and HR, 0.79; 95% confidence interval, 0.61-1.02 in those with coronary heart disease). Results were consistent in those with severe stroke: HR 1.58 (95% CI, 1.21-2.06), 1.34 (95% CI, 1.09-1.63), and 0.91 (95% CI, 0.74-1.11), respectively. Conclusions-Contrary to current guidelines, 30% of patients with atrial fibrillation and recent IS are not prescribed any OAC therapy on discharge, whereas a further 30% are prescribed combination OAC and antiplatelet therapy. Combination OAC and antiplatelet therapy in patients at high cardiovascular risk requires evaluation in clinical trials, particularly with the newer OACs, given their more favorable risk-benefit ratio compared with warfarin

Blood pressure from mid‐ to late life and risk of incident dementia

ObjectiveTo determine the association between blood pressure during midlife (40-64 years) to late life (≥65 years) and risk of incident dementia.MethodsThis study included 1,440 (758 women, mean age 69 ± 6 years) Framingham Offspring participants who were free of dementia and attended 5 consecutive examinations at 4-year intervals starting at midlife (1983-1987, mean age 55 years) until late life (1998-2001, mean 69 years) and subsequently were followed up for incident dementia (mean 8 years). We determined the effect of midlife hypertension (≥140/90 mm Hg), late life hypertension, lower late life blood pressure (&lt;100/70 mm Hg), persistence of hypertension during mid- to late life, and steep decline in blood pressure from mid- to late life over an 18-year exposure period.ResultsDuring the follow-up period, 107 participants (71 women) developed dementia. Using multivariable Cox proportional hazards models, we found that midlife systolic hypertension (hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.05-2.35) and persistence of systolic hypertension into late life (HR 1.96, 95% CI 1.25-3.09) were associated with an elevated risk of incident dementia. However, in individuals with low to normal blood pressure (≤140/90 mm Hg) at midlife, a steep decline in systolic blood pressure during mid- to late life was also associated with a &gt;2-fold increase in dementia risk (HR 2.40, 95% CI 1.39-4.15).ConclusionsElevated blood pressure during midlife, persistence of elevated blood pressure into late life, and, among nonhypertensives, a steep decline in blood pressure during mid- to late life were associated with an increased dementia risk in a community-based cohort. Our data highlight the potential sustained cognitive benefits of lower blood pressures in midlife but also suggest that declining blood pressure in older adults with prehypertension or normotension, but not in those with hypertension, may be a risk marker for dementia