Cardiovascular diseases, risk factors and cognitive decline in the general population

Cognitive function constitutes a critical dimension of the health status of elderly individuals. Age-associated decline in cognitive function may partly be attributed to the negative effects of systemic medical diseases and related factors, including cardiovascular diseases (CVDs) and vascular risk factors. Cognitive decline has been an understudied outcome in cardiovascular epidemiological research. Few reports have comprehensively examined cognitive function in relation to clinical manifestations of systemic atherosclerotic disease in different arterial beds. Inconsistent findings are common in the literature and these arc likely to reflect the vast differences between studies regarding the choice of population under study, the methods applied for measuring and defining CVD, the types and timing of administration of protocols used for assessing cognitive function, and the paths taken in the analysis of data.The principal aim of the present study was to examine the longitudinal change in cognitive test performance in relation to major clinical CVDs and vascular risk factors in a population-based sample of older people. The administration of a battery of neuropsychological tests on two separate occasions facilitated the study of actual change in both general cognition and across different cognitive abilities according to an objectively-determined CVD status. A valid estimation of peak prior cognitive ability allowed the exploration of the impact of CVD and risk factors on the imputed decline from best-ever level of cognitive function to that measured in old age.The analysis is based on a cohort of 809 men and 783 women aged 55-74 years which in 1987/8 was randomly selected from the general population of Edinburgh. A comprehensive assessment of the prevalence of major CVDs and vascular risk factors was held at baseline and during two follow-up examinations. Since baseline, the study sample has been followed up to determine the incidence of angina pectoris, peripheral arterial disease (PAD), myocardial infarction (MI), and stroke. Cognitive testing was first held in 1998/9 when the mean age of the surviving cohort (n=1209) was 73.1 years (SD=5.0) and subsequently about four years later using the same test protocol. The present investigation is based on the 452 study participants who attended follow-up cognitive testing in 2002/3.Both general cognition, as indexed by a general cognitive factor representing the variance common to all the cognitive tests used, and most individual cognitive measures were negatively affected in participants with CVD but no evidence of stroke relative to non-vascular controls. Of the specific CVD manifestations, stroke was significantly associated with a steeper four-year decline in both general cognitive function and verbal memory. When decline was estimated from peak, prior cognitive level, stroke was related to a greater decline in both general cognition and verbal fluency. In the absence of stroke, MI was associated with an accelerated fouryear decline in non-verbal reasoning ability but the presence of angina was not related to cognitive decline in this study. Symptomatic PAD also independently predicted faster decline in both general cognition and verbal memory over the fouryear follow-up. Several potentially modifiable vascular risk factors, including education, body mass index, smoking, diastolic blood pressure, inflammatory markers and blood viscosity were also related to decline in general and specific cognitive abilities, independently of age, sex, prior cognitive ability and vascular disease. The associations with decline in specific cognitive measures principally resulted from the impact of atherosclerotic disease and risk factors on general cognitive ability rather than the individual functions per se.The findings from the present study further add to those of previous investigations demonstrating a relationship between CVDs, vascular risk factors, and cognitive decline in older people. Specifically, they reveal that, even in the absence of overt stroke, clinical CVDs are associated with a greater cognitive decline in the elderly, independently of potential confounding by a wide range of vascular risk factors. Also, the relationships between several vascular risk factors and cognitive decline proved to be independent of overt co-existing vascular pathology. Based on these findings, further study is needed to determine the combined effects of CVDs and multiple risk factors on cognitive outcomes in samples of older people. In addition, what the likely pathological mechanisms are underlying cognitive decline associated with atherosclerotic disease and vascular risk factors needs to be addressed in future studies. From a perspective of preventing or delaying vascular based cognitive decline and impairment, more research is required to assess the effectiveness of both individual and population-based strategies targeting vascular disease and risk factors in older age groups. Finally, further investigation is needed to address the potential impact of subtle cognitive deficits on indicators of the quality of life and the capability of self-maintenance of elderly vascular patients, on adherence to medical treatment and rehabilitation, and further cognitive decrements and survival

Positive and negative well-being of older adults with symptomatic peripheral artery disease: A population-based investigation

Objective We investigated positive and negative subjective well-being in relation to lower-extremity peripheral artery disease (PAD) in a sample of older adults. Method 4760 participants in the English Longitudinal Study of Ageing (ELSA) provided baseline data on symptomatic PAD, sociodemographic characteristics, lifestyle risk factors, and co-morbid conditions. Baseline and two-year follow-up data were available for life satisfaction, quality of life, and depressive symptoms. Results Participants with PAD symptoms had lower baseline levels of life satisfaction (β = −0.03, p < .05) and quality of life (β = −0.04, p < .01), and more depressive symptoms (β = 0.03, p < .05). These associations remained statistically significant in multivariate analyses. Baseline PAD did not, however, influence well-being levels at two-year follow-up. Discussion Greater awareness of the potential for chronic vascular morbidity to disrupt the lives of older adults is needed to inform effective multidisciplinary support and interventions that help maintain the quality of life of those affected

Loneliness and social isolation among older informal caregivers: A review of the evidence from longitudinal investigations

This chapter concerns the psychosocial well-being of informal caregivers who provide personal care in later life for their spouse, other family, friends, or neighbours, in frequent need of care. Specifically, in this chapter, I provide a critical review of longitudinal studies from across the world investigating the development of loneliness and social isolation in both representative and non-probabilistic samples of informal caregivers. The contributions of individual caregiver characteristics and specific strains associated with the caregiving role to feelings of loneliness and social isolation are discussed. Pertinent methodological issues are also considered and potential explanatory mechanisms underpinning the observed associations are highlighted. Finally, directions for future research are provided

Loneliness, social integration, and incident dementia over 6 years: prospective findings from the English longitudinal study of ageing

Objectives: Social relationships are important for the maintenance of cognitive function at older ages, with both objective features of social networks and perceived social connections (loneliness) being relevant. There is limited evidence about how different aspects of social experience predict diagnosed dementia. Methods: The sample comprised 6,677 dementia-free individuals at baseline (2004) from the English Longitudinal Study of Ageing. Baseline information on loneliness, number of close relationships, marital status, and social isolation (contact with family and friends and participation in organizations) was analyzed in relation to incident dementia over an average 6.25 years using Cox regression, controlling for potential confounding factors. Results: Two hundred twenty participants developed dementia during follow-up. In multivariable analyses, dementia risk was positively related to greater loneliness (hazard ratio 1.40, 95% confidence interval 1.09-1.80, p = .008), and inversely associated with number of close relationships (p < .001) and being married (p = .018). Sensitivity analyses testing for reverse causality and different criteria for diagnosing dementia confirmed the robustness of these findings. There was no association with social isolation. Discussion: Dementia risk is associated with loneliness and having fewer close relationships in later life. The underlying mechanisms remain to be elucidated, but efforts to enhance older peoples' relationship quality may be relevant to dementia risk

35 social contact mode and 15-year episodic memory trajectories in older adults with and without hearing loss: the Elsa study

Introduction Frequent social contact benefits cognition in later life although evidence is lacking on the potential importance of the modes chosen by older adults for interacting with others in their social network. Method 11,513 participants in the English Longitudinal Study of Ageing (ELSA) provided baseline information on hearing status and social contact mode and frequency of use. Multilevel growth curve models compared episodic memory (immediate and delayed recall) at baseline and long-term in participants who interacted frequently (offline only or offline and online combined), compared to infrequently, with others in their social network. Results Frequent offline (β = 0.29; p < 0.05) and combined offline and online (β = 0.76; p < 0.001) social interactions predicted better episodic memory after adjustment for multiple confounding factors. We observed positive long-term influences of combined offline and online interactions on memory in participants without hearing loss (β = 0.48, p = 0.001) but not of strictly offline interactions (β = 0.00, p = 0.970). In those with impaired hearing, long-term memory was positively influenced by both modes of engagement (offline only: β = 0.93, p < 0.001; combined online and offline: β = 1.47, p < 0.001). Sensitivity analyses confirmed the robustness of these findings. Conclusion Supplementing conventional social interactions with online communication modes may help older adults, especially those living with hearing loss, sustain, and benefit cognitively from, personal relationships

Positive and negative experiences of social support and risk of dementia in later life: an investigation using the English longitudinal study of ageing

Background: Having a network of close relationships may reduce the risk of developing dementia. However, social exchange theory suggests that social interaction entails both rewards and costs. The effects of quality of close social relationships in later life on the risk of developing dementia are not well understood. Objective: To investigate the effects of positive and negative experiences of social support within key relationships (spouse or partner, children, other immediate family, and friends) on the risk of developing dementia in later life. Methods: We analyzed 10-year follow up data (2003/4 to 2012/13) in a cohort of 10,055 dementia free (at baseline) core participants aged 50 years and over from the English Longitudinal Study of Ageing (ELSA). Incidence of dementia was identified from participant or informant reported physician diagnosed dementia or overall score of informant-completed IQCODE questionnaire. Effects of positive and negative experiences of social support measured at baseline on risk of developing dementia were investigated using proportional hazards regression accommodating interval censoring of time-todementia. Results: There were 340 (3.4%) incident dementia cases during the follow-up. Positive social support from children significantly reduced the risk of dementia (hazard ratio, HR = 0.83, p = 0.042, 95% CI: 0.69 to 0.99). Negative support from other immediate family (HR = 1.26, p = 0.011, CI: 1.05 to 1.50); combined negative scores from spouse and children (HR = 1.23, p = 0.046, CI: 1.004 to 1.51); spouse, children, and other family (HR = 1.27, p = 0.021, CI = 1.04 to 1.56); other family & friends (HR = 1.25, p = 0.033, CI: 1.02 to 1.55); and the overall negative scores (HR = 1.31, p = 0.019, CI: 1.05 to 1.64) all were significantly associated with increased risk of dementia. Conclusion: Positive social support from children is associated with reduced risk of developing dementia whereas experiences of negative social support from children and other immediate family increase the risk. Further research is needed to better understand the causal mechanisms that drive these associations

Prevalence of vitamin B-12 insufficiency during pregnancy and its effect on offspring birth weight:a systematic review and meta-analysis

Background: Vitamin B-12 and folate are micronutrients essential for normal embryogenesis. Vitamin B-12 insufficiency in pregnancy is high in certain parts of the world, such as India, and although this has been linked to low birth weight (LBW) in these populations, the relation between vitamin B-12 and birth weight (BW) elsewhere is unknown. Objectives: We performed a systematic review to assess 1) the worldwide prevalence of vitamin B-12 insufficiency in pregnancy and 2) its association with BW. Design: A search of 5 electronic databases was performed to identify eligible articles. Random-effects meta-analysis was conducted according to geographic regions and pregnancy trimesters for the prevalence subreview and by categorical measures of BW. Results: A total of 57 and 23 articles were included for the prevalence and BW subreviews, respectively. The pooled estimates of vitamin B-12 insufficiency were 21%, 19%, and 29% in the first, second, and third trimesters, respectively, with high rates for the Indian subcontinent and the Eastern Mediterranean. The large heterogeneity between studies was partially addressed by creating a standardized score for each study (mean vitamin B-12 insufficiency ÷ cutoff value), which internally corrected for geographic region, trimester, and assay type. Twelve of the 13 longitudinal studies included showed a decrease in mean or median vitamin B-12 across trimesters. Pooled analysis showed nonsignificantly lower maternal vitamin B-12 concentrations in LBW than in normal-BW infants and higher odds of LBW with lower vitamin B-12 values (adjusted OR: 1.70; 95% CI: 1.16, 2.50), but studies from India largely contributed to the latter. Conclusions: Our review indicates that vitamin B-12 insufficiency during pregnancy is common even in nonvegetarian populations and that concentrations of vitamin B-12 decrease from the first to the third trimester. There is no consistent association between vitamin B-12 insufficiency and LBW. However, given the long-term risks of LBW, this observation warrants further cohort studies and randomized controlled trials

Physical activity pre- and post-dementia: English Longitudinal Study of Ageing

Background: To inform public health interventions, further investigation is needed to identify: (1) frequency/intensity of everyday physical activity (PA) needed to reduce dementia risk; (2) whether post-diagnosis reduction in PA is associated with cognitive outcomes. Methods: Data from 11,391 men and women (aged ≥50) were obtained in the English Longitudinal Study of Ageing. Assessments were at baseline (2002-2003) and biannual follow-ups (2004-2013). Results: Older adults who carried out moderate to vigorous activity at least once per week had a 34%-50% lower risk for cognitive decline and dementia over an 8-10 year follow-up period. From pre- to post-diagnosis, those that decreased PA levels had a larger decrease in immediate recall score, compared to those that maintained or increased PA levels (adjusted for changes in physical function). Conclusion: These findings provide a guideline for everyday PA levels needed to reduce risk for dementia. Reduction in PA after diagnosis was also associated with accelerated cognitive decline

Mortality from circulatory diseases by specific country of birth across six European countries: test of concept

Background: Important differences in cardiovascular disease (CVD) mortality by country of birth have been shown within European countries. We now focus on CVD mortality by specific country of birth across European countries. Methods: For Denmark, England and Wales, France, The Netherlands, Scotland and Sweden mortality information on circulatory disease, and the subcategories of ischaemic heart disease, and cerebrovascular disease, was analysed by country of birth. Information on population was obtained from census data or population registers. Directly age-standardized rates per 100 000 were estimated by sex for each country of birth group using the WHO World Standard population 2000-25 structure. For differences in the results, at least one of the two 95% confidence intervals did not overlap. Results: Circulatory mortality was similar across countries for men born in India (355.7 in England and Wales, 372.8 in Scotland and 244.5 in Sweden). For other country of birth groups-China, Pakistan, Poland, Turkey and Yugoslavia-there were substantial between-country differences. For example, men born in Poland had a rate of 630.0 in Denmark and 499.3 in England and Wales and 153.5 in France; and men born in Turkey had a rate of 439.4 in Denmark and 231.4 in The Netherlands. A similar pattern was seen in women, e.g. Poland born women had a rate of 264.9 in Denmark, 126.4 in England and Wales and 54.4 in France. The patterns were similar for ischaemic heart disease mortality and cerebrovascular disease mortality. Conclusion: Cross-country comparisons are feasible and the resulting findings are interesting. They merit public health consideratio

Association of Adherence to a Healthy Diet with Cognitive Decline in European and American Older Adults

Aim: To examine the association between a healthy diet, assessed by the Healthy Diet Indicator (HDI), and cognitive decline in older adults. Methods: Data from 21,837 participants aged ≥ 55 years from 3 cohorts (Survey in Europe on Nutrition and the Elderly, a Concerted Action[SENECA], Rotterdam Study [RS], Nurses’ Health Study [NHS]) were analyzed. HDI scores were based on intakes of saturated fatty acids, polyunsaturated fatty acids, mono- and disaccharides, protein, cholesterol, fruits and vegetables, and fiber. The Telephone Interview for Cognitive Status in NHS and Mini-Mental State Examination in RS and SENECA were used to assess cognitive function from multiple repeated measures. Using multivariable-adjusted, mixed linear regression, mean differences in annual rates of cognitive decline by HDI quintiles were estimated. Results: Multivariable-adjusted differences in rates in the highest versus the lowest HDI quintile were 0.01 (95% CI –0.01, 0.02) in NHS, 0.00 (95% CI –0.02, 0.01) in RS, and 0.00 (95% CI –0.05, 0.05) in SENECA with a pooled estimate of 0.00 (95% CI –0.01, 0.01), I 2 = 0%. Conclusions: A higher HDI score was not related to reduced rates of cognitive decline in European and American older adults