The Brodmann Area 39/40 of the Brain in Alzheimer’s, Mild Cognitive Impairment, and No Cognitive Impairment Subjects at Advanced Age Demonstrate Comparable Levels of Blood-Brain Barrier Breach

• Alzheimer’s disease (AD) is one of the most common form of dementia • Mild cognitive impairment (MCI), specifically amnestic subtype, more likely to progress to AD • Pathogenesis Theories: o Accumulation of amyloid-beta peptides and neurofibrillary tangles containing hyperphosphorylated neuronal tau protein o Blood Brain Barrier (BBB) dysfunction is associated with AD pathogenesis • Brodmann area 39/40: regions of parietal cortex are responsible for language, spatial cognition, memory retrieval, attention, phonological processing, and emotional processing • Hypothesis: An increased BBB permeability in Brodmann area 39/40 of AD and age-matched MCI and no cognitive impairment (NCI) subject

Complex mechanisms linking neurocognitive dysfunction to insulin resistance and other metabolic dysfunction

Scientific evidence has established several links between metabolic and neurocognitive dysfunction, and epidemiologic evidence has revealed an increased risk of Alzheimer’s disease and vascular dementia in patients with diabetes. In July 2015, the National Institute of Diabetes, Digestive, and Kidney Diseases gathered experts from multiple clinical and scientific disciplines, in a workshop entitled “The Intersection of Metabolic and Neurocognitive Dysfunction”, to clarify the state-of-the-science on the mechanisms linking metabolic dysfunction, and insulin resistance and diabetes in particular, to neurocognitive impairment and dementia. This perspective is intended to serve as a summary of the opinions expressed at this meeting, which focused on identifying gaps and opportunities to advance research in this emerging area with important public health relevance

Diabetes Is Associated with Cerebrovascular but not Alzheimer\u27s Disease Neuropathology

INTRODUCTION: The relationship of diabetes to specific neuropathologic causes of dementia is incompletely understood. METHODS: We used logistic regression to evaluate the association between diabetes and infarcts, Braak neurofibrillary tangle stage, and neuritic plaque score in 2365 autopsied persons. In a subset of \u3e1300 persons with available cognitive data, we examined the association between diabetes and cognition using Poisson regression. RESULTS: Diabetes increased odds of brain infarcts (odds ratio [OR] = 1.57, P \u3c .0001), specifically lacunes (OR = 1.71, P \u3c .0001), but not Alzheimer\u27s disease neuropathology. Diabetes plus infarcts was associated with lower cognitive scores at end of life than infarcts or diabetes alone, and diabetes plus high level of Alzheimer\u27s neuropathologic changes was associated with lower mini-mental state examination scores than the pathology alone. DISCUSSION: This study supports the conclusions that diabetes increases the risk of cerebrovascular but not Alzheimer\u27s disease pathology, and at least some of diabetes\u27 relationship to cognitive impairment may be modified by neuropathology

Early incident and subsyndromal delirium in older patients undergoing elective surgical procedures: a randomized clinical trial of an avoid delirium protocol

BackgroundPharmacological avoidance guidelines for preventing delirium have been suggested; however, there are limited pragmatic studies of these strategies. Early (<24 h) delirium can be observed in the postoperative care unit and is associated with an increased risk of subsequent delirium. We examined the effectiveness of an avoid delirium protocol (ADP) in older (>65 years) patients undergoing elective surgeries.MethodsThe randomized controlled trial assessed an ADP developed using the American Geriatric Society's Clinical Practice Guidelines for Postoperative Delirium in Older Adults, on early (<24 h) incident or subsyndromal delirium. Delirium was assessed using the confusion assessment method before surgery, in the post-anesthesia care unit, and on postoperative day 1. The primary outcome of early delirium was the combined incidence of incident or subsyndromal delirium.ResultsEarly delirium was identified in 24/235 patients (10.2%) with a risk ratio of 1.27 (95% CI 0.59–2.73, P = 0.667) for patients randomized to the ADP. In cases with protocol adherence and no benzodiazepine use, early delirium was present in 10/73 (13.7%) compared to 14/148 (9.5%) in non-adherent cases [risk ratio 1.45 (95% CI 0.57–3.10, P = 0.362)]. Lower American Society of Anesthesiologists physical class [odds ratio 3.31 (95% CI 1.35–8.92, P = 0.008)] and an inpatient admission [odds ratio 2.67 (95% CI 1.55–4.87, P = 0.0002)] were associated with early delirium.ConclusionsOur findings suggest that pharmacological avoidance protocols limiting or avoiding the use of specific classes of medications are not effective in reducing early incident or subsyndromal delirium in older patients undergoing elective surgery

Applying Customer Discovery Method to a Chronic Disease Self-Management Mobile App: Qualitative Study

BackgroundA significant health challenge is evident in the United States, with 6 in 10 adults having a chronic disease and 4 in 10 adults having 2 or more. Chronic disease self-management aims to prevent or delay disease progression and disability and reduce mortality risk. The evidence to support the use of information technology tools, including mobile apps, web-based portals, and web-based educational interventions, that support disease self-management and improve clinical outcomes is growing. Customer discovery and value proposition design methodology is a form of stakeholder engagement and is based on marketing and lean start-up business methods. As applied in health care, customer discovery and value proposition methodology can be used to understand the clinical problem and articulate the product’s hypothesized unique value proposition relative to alternative options that are available to end users. ObjectiveThis study aims to describe the experience and findings of academic researchers applying the customer discovery and value proposition methodology to identify stakeholders, needs, adaptability, and sustainability of a chronic disease self-management mobile app (CDapp). The motivation of the work is to make mobile health app interventions accessible and acceptable for all segments of patients’ chronic diseases. MethodsData were obtained through key informant interviews and analyzed using rapid qualitative analysis techniques. The value proposition framework was used to build the interview guide. The aim was to identify the needs, challenges (pains), and potential benefits (gains) of the CDapp for our stakeholders. ResultsOur results showed that the primary consumers (end users) of a CDapp were the patients. The app adopters (decision makers) can be medical center leaders including population health department managers or insurance providers, while the consumer adoption influencers (influencers or saboteurs) are clinicians and patient caregivers. We developed an ecosystem map to visualize the clinical practice workflow and how an app for chronic disease management might integrate within an academic health care center or system. A value proposition for the identified customer segments was generated. Each stakeholder segment was working within a different framework to improve patient self-management. Patients needed help to adhere to self-care activities and they needed tailored health education. Health care leaders aim to improve the quality of care while reducing costs and workload. Clinicians wanted to improve patient education and care while reducing the time burden. Our results also showed that within academic medical centers, there were variations regarding patients’ self-reported abilities to manage their diseases. ConclusionsCustomer discovery is a useful form of stakeholder engagement when designing studies that seek to implement, adapt, and sustain an intervention. The customer discovery and value proposition methodology can be used as an alternative or complementary approach to formative research to generate valuable information in a brief period

Derivation and validation of the Rapid Assessment of Dementia Risk (RADaR) for older adults.

BackgroundThere is no practical dementia risk score in the clinical setting.ObjectiveTo derive and validate a score obtained by a rapid and simple assessment, which guides primary care providers in predicting the risk of dementia among older adults.DesignA total of 4178 participants from three longitudinal cohorts (mean age at baseline = 76.8 [SD = 7.6] years), without baseline dementia, followed annually for a median of 10 years (IQR: 5 to16 years, Reverse Kaplan-Meier).ParticipantsTo derive the score, we used data from 1,780 participants from the Rush Memory and Aging Project (93% White). To validate the score, we used data from 1,299 participants from the Religious Order Study (92% White), and to assess generalizability, 679 participants from the Minority Aging Research Study (100% Black).MeasurementsClinician-based dementia diagnosis at any time after baseline and predictive variables associated with dementia risk that can be collected in a primary care setting: demographics, clinical indicators, medical history, memory complaints, cognitive and motor tests, and questions to assess functional disability, depressive symptoms, sleep, social isolation, and genetics (APOE e4 and AD polygenic risk score).ResultsAt baseline, age, memory complaint, the ability to handle finances, the recall of the month, recall of the room, and recall of three words, were associated with the cumulative incidence of dementia, in the derivation cohort. The discrimination of the RADaR (Rapid Risk Assessment of Dementia) was good for the derivation and external-validation cohorts (AUC3 years = 0.82-0.86), compared to the overall discrimination of age alone (AUC3 years = 0.73), a major risk factor for dementia. Adding genetic data did not increase discrimination.LimitationsParticipants were volunteers, may not represent the general population.ConclusionsThe RADaR, derived from community-dwelling older persons, is a brief and valid tool to predict dementia risk at 3 years in older White and Black persons