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1.  Multimorbidity and Risk of Mild Cognitive Impairment. 
OBJECTIVES
To determine the association of multiple chronic conditions with risk of incident mild cognitive impairment (MCI)/dementia.
DESIGN
Prospective cohort study
SETTING
Olmsted County, Minnesota.
PARTICIPANTS
Cognitively normal individuals (N=2,176) enrolled in the Mayo Clinic Study of Aging (MCSA).
MEASUREMENTS
Participants were randomly selected from the community and evaluated by a study coordinator, a physician, and underwent neuropsychometric testing at baseline and at 15-month intervals to assess diagnoses of MCI and dementia. We electronically captured information on International Classification of Diseases, ninth revision (ICD-9) codes for chronic conditions in the five years prior to enrollment using the Rochester Epidemiology Project medical records linkage system. We defined multimorbidity as having two or more chronic conditions and examined the association of multimorbidity with MCI/dementia using Cox proportional hazards models.
RESULTS
Among 2,176 cognitively normal participants (mean [±SD] age 78.5 [±5.2] years; 50.6% men), 1,884 (86.6%) had multimorbidity. The risk of MCI/dementia was elevated in persons with multimorbidity (hazard ratio [HR]: 1.38; 95% confidence interval [CI], 1.05–1.82). The HR was stronger in persons with ≥4 conditions (HR: 1.61; 95%CI, 1.21–2.13) compared to persons with only 0 or 1 conditions, and for men (HR: 1.53, 95% CI, 1.01– 2.31) than for women (HR: 1.20, 95% CI, 0.83– 1.74).
CONCLUSION
In older adults, having multiple chronic conditions is associated with an increased risk of MCI/dementia. This is consistent with the hypothesis that multiple etiologies may contribute to MCI and late-life dementia. Preventing chronic diseases may be beneficial in delaying or preventing MCI or dementia.
doi:10.1111/jgs.13612
PMCID: PMC4607039  PMID: 26311270
mild cognitive impairment; dementia; multimorbidity
2.  Association Between Olfactory Dysfunction and Amnestic Mild Cognitive Impairment and Alzheimer Disease Dementia 
JAMA neurology  2016;73(1):93-101.
IMPORTANCE
To increase the opportunity to delay or prevent mild cognitive impairment (MCI) or dementia due to Alzheimer's disease (AD), markers of early detection are essential. Olfactory impairment may be an important clinical marker and predictor of these conditions and may help identify persons at increased risk.
OBJECTIVE
To examine associations of impaired olfaction with incident MCI subtypes, and progression from MCI subtypes to AD dementia.
DESIGN, SETTING, AND PARTICIPANTS
Participants enrolled in the population-based, prospective Mayo Clinic Study of Aging were clinically evaluated at baseline and every 15-months thereafter, and classified as having normal cognition, MCI (amnestic, aMCI and nonamnestic, naMCI), and dementia. We administered the Brief Smell Identification Test (B-SIT) to assess olfactory function.
MAIN OUTCOMES AND MEASURES
Mild cognitive impairment, AD dementia, longitudinal change in cognitive performance measures.
RESULTS
Over a mean 3.5 years of follow-up, there were 250 incident cases of MCI among 1430 cognitively normal participants. We observed an association between decreasing olfactory identification, as measured by decrease in number of correct responses in B-SIT score, and an increased risk of aMCI. Compared to the upper B-SIT quartile (Q4, best scores), hazard ratios (HR) were 1.12; P = 0.68 for Q3; HR, 1.95; P =0.003 for Q2; and HR, 2.18; P = 0.001 (worst scores; p for trend <0.001) after adjustment for sex and education, with age as the time scale. There was no association with naMCI. There were 64 incident dementia cases among 221 prevalent MCI cases. The B-SIT score also predicted progression from aMCI to AD, with a significant dose-response with worsening B-SIT quartiles. Compared to Q4, HR estimates were 3.02, P = 0.038 for Q3; HR, 3.63; P = 0.024 for Q2; and HR, 5.20; P = 0.001 for Q1. After adjusting for key predictors of MCI risk, B-SIT (as a continuous measure) remained a significant predictor of MCI (HR, 1.10; p < 0.001), and improved the model concordance.
CONCLUSIONS AND RELEVANCE
Olfactory impairment predicts incident aMCI and progression from aMCI to AD. These findings are consistent with previous studies that have reported associations of olfactory impairment with cognitive impairment in late life, and suggest that olfactory tests have potential utility for screening for MCI and MCI that is likely to progress.
doi:10.1001/jamaneurol.2015.2952
PMCID: PMC4710557  PMID: 26569387
3.  Duration and Severity of Diabetes Are Associated with Mild Cognitive Impairment 
Archives of neurology  2008;65(8):1066-1073.
Background
It remains unknown whether diabetes mellitus is a risk factor for mild cognitive impairment (MCI).
Objective
To investigate the association of diabetes mellitus with MCI using a population-based case-control design.
Design, Setting, and Participants
Our study was conducted in subjects aged 70 through 89 years on October 1, 2004, who were randomly selected from the Olmsted County, MN, population.
Main Outcome Measure
We administered to all participants the Clinical Dementia Rating Scale, a neurological exam, and a neuropsychological evaluation including 9 tests in 4 cognitive domains to diagnose normal cognition, MCI, or dementia. We assessed history of diabetes, diabetes treatment, and complications by interview and we measured fasting blood glucose. History of diabetes was also confirmed using a medical records-linkage system.
Results
We compared 329 patients with MCI to 1640 subjects free of MCI and of dementia. The frequency of diabetes was similar in subjects with MCI (20.1%) and in subjects without MCI (17.7%; odds ratio [OR], 1.16; 95% confidence interval [CI], 0.85-1.57). However, MCI was associated with onset of diabetes before age 65 years (OR, 2.20; 95% CI, 1.29-3.73), diabetes duration ≥10 years (OR, 1.76; 95% CI, 1.16-2.68), treatment with insulin (OR, 2.01; 95% CI, 1.22-3.31), and presence of complications (OR, 1.80; 95% CI, 1.13-2.89) after adjustment for age, sex, and education. Analyses using alternative definitions of diabetes yielded consistent findings.
Conclusions
These findings suggest an association between earlier onset, longer duration, and greater severity of diabetes and MCI.
doi:10.1001/archneur.65.8.1066
PMCID: PMC2630223  PMID: 18695056
4.  Diabetes is Associated with Worse Executive Function in both Eastern and Western populations: Shanghai Aging Study and Mayo Clinic Study of Aging 
Background and Objectives
It remains unknown whether the association between diabetes mellitus (DM) and cognitive function differs in Eastern and Western populations. This study aimed to elucidate whether DM is associated with worse cognitive performance in both populations.
Methods
The Shanghai Aging Study (SAS) and the Mayo Clinic Study of Aging (MCSA) are two population-based studies with similar design and methodology in Shanghai, China and Rochester, MN USA. Non-demented participants underwent cognitive testing, and DM was assessed from the medical record. Separate analyses were performed in SAS and MCSA regarding the association between DM and cognitive performance.
Results
A total of 3348 Chinese participants in the SAS and 3734 American subjects in the MCSA were included. Compared with MCSA subjects, SAS participants were younger, less educated, and had lower frequency of vascular disease, APOE ε4 carriers and obesity. Participants with DM (compared to non-DM participants) performed significantly worse on all the cognitive domains in both the SAS and MCSA. After adjustment for age, sex and education, and vascular covariates, DM was associated with worse performance in executive function (β= −0.15, p = 0.001 for SAS, and β= −0.10, p = 0.008 for MCSA) in the total sample and in the cognitively normal sub-sample. Furthermore, DM was associated with poor performance in visuospatial skills, language, and memory in the SAS, but not in the MCSA.
Conclusions
Diabetes is associated with cognitive dysfunction, in particular exerts a negative impact on executive function regardless of race, age and prevalence of vascular risk factors.
doi:10.3233/JAD-150073
PMCID: PMC4617674  PMID: 26402765
cognition; diabetes mellitus; executive function; cross-sectional studies
5.  Predictors of early-onset cognitive impairment 
Brain  2014;137(5):1280-1281.
doi:10.1093/brain/awu089
PMCID: PMC3999725  PMID: 24771400
6.  Mortality in mild cognitive impairment varies by subtype, sex and lifestyle factors. The Mayo Clinic Study of Aging 
Journal of Alzheimer's disease : JAD  2015;45(4):1237-1245.
Background
Etiologic differences in mild cognitive impairment (MCI) subtypes may impact mortality.
Objective
To assess the rate of death in MCI overall, and by subtype, in the population-based Mayo Clinic Study of Aging.
Methods
Participants aged 70–89 years at enrollment were clinically evaluated at baseline and 15-month intervals to assess diagnoses of MCI and dementia. Mortality in MCI cases vs. cognitively normal (CN) individuals was estimated using Cox proportional hazards models.
Results
Over a median follow-up of 5.8 years, 331 of 862 (38.4%) MCI cases and 224 of 1292 (17.3%) cognitively normal participants died. Compared to CN individuals, mortality was elevated in persons with MCI (hazard ratio [HR] = 2.03; 95% CI: 1.61 to 2.55), and was higher for non-amnestic MCI (naMCI; HR = 2.47; 95% CI: 1.80 to 3.39) than for amnestic MCI (aMCI; HR = 1.89; 95% CI: 1.48 to 2.41) after adjusting for confounders. Mortality varied significantly by sex, education, history of heart disease, and engaging in moderate physical exercise (p for interaction <0.05 for all). Mortality rate estimates were highest in MCI cases who were men, did not exercise, had heart disease, and had higher education vs. CN without these factors, and for naMCI cases vs. aMCI cases without these factors.
Conclusions
These findings suggest stronger impact of etiologic factors on naMCI mortality. Prevention of heart disease, exercise vigilance, may reduce MCI mortality. Delayed MCI diagnosis in persons with higher education impacts mortality, and higher mortality in men may explain similar dementia incidence by sex in our cohort.
doi:10.3233/JAD-143078
PMCID: PMC4398642  PMID: 25697699
Mild cognitive impairment; mortality; cohort studies; incidence studies; prognosis; outcomes research
7.  Association of Pancreatic Polypeptide with Mild Cognitive Impairment Varies by APOE ε4 Allele 
We conducted a preliminary case–control investigation of the association of pancreatic polypeptide (PP) with mild cognitive impairment (MCI) in 202 MCI cases (mean age, 81.6 years) and 202 age- and sex-matched cognitively normal controls in the Mayo Clinic Study of Aging. Plasma PP was measured and examined as the natural logarithm (continuous) and dichotomized at the median. The OR (95% CI) of MCI increased with increasing PP [1.46 (1.04–2.05)]. There was a negative interaction of PP with apolipoprotein E (APOE) ε4 allele; compared to the reference group (no APOE ε4 allele and low PP), the OR (95% CI) for combinations of ε4 and PP were: 2.64 (1.39–5.04) for APOE ε4 plus low PP; 2.09 (1.27–3.45) for no APOE ε4 plus high PP; and 1.91 (1.04–3.53) for no APOE ε4 plus high PP (P for interaction = 0.017). There was also a trend toward a negative interaction with type 2 diabetes (P for interaction = 0.058). Compared to no diabetes and low PP, the OR (95% CI) was 3.02 (1.22–7.46) for low PP plus diabetes but 1.80 (1.01–3.22) for high PP plus diabetes. Participants with high PP had a greater mean (SD) weight loss (kilograms per decade) than persons with low PP [−2.27 (4.07) vs. −1.61 (5.24); P = 0.016]. MCI cases had a non-significantly greater weight loss per decade compared to controls. These findings suggest that high PP alone or jointly with APOE ε4 allele or type 2 diabetes is associated with MCI, and that high PP may mitigate some effects of APOE ε4 allele and type 2 diabetes on cognition. Potential mechanisms may involve PP-related weight loss and centrally mediated effects of PP on cognition. These findings remain to be validated in other studies.
doi:10.3389/fnagi.2015.00172
PMCID: PMC4561818  PMID: 26441635
cognition; mild cognitive impairment; case–control study; pancreatic polypeptide; neuropeptide; type 2 diabetes; apolipoprotein E
8.  Diabetes and Elevated HbA1c levels are Associated with Brain Hypometabolism but not Amyloid Accumulation 
Dysfunctional insulin signaling may affect brain metabolism or amyloid deposition. We investigated the associations of type 2 diabetes with amyloid accumulation measured using 11C-Pittsburgh Compound B (PiB) and brain hypometabolism measured using 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET).
Methods
We studied a sample of non-demented participants from the population-based Mayo Clinic Study of Aging. All subjects underwent MRI, amyloid PET and FDG PET. Alzheimer’s disease (AD) signature and region of interest (ROI) measures for PiB retention ratio and FDG ratio were measured. Diabetes was assessed from the Rochester Epidemiology Project medical records-linkage system.
Results
Among 749 participants (median age 79.0 years; 56.5% male, 81.0% cognitively normal; 20.6% diabetics), FDG hypometabolism (FDG ratio < 1.31) in the AD signature meta-ROI was more common in diabetics (48.1%) than in non-diabetics (28.9%; p <0.001). The median FDG ratio was lower in diabetics vs. non-diabetics in the AD signature meta-ROI (1.32 vs. 1.40, p < 0.001), and in the angular (1.40 vs. 1.48, p < 0.001) and posterior cingulate gyri ROIs (1.63 vs. 1.72, p < 0.001). The odds ratio (OR [95% confidence interval]) for abnormal AD signature FDG hypometabolism was elevated (OR, 2.28 [1.56, 3.33]) in diabetics vs. non-diabetics after adjustment for age, sex, and education, and after additional adjustment for Apolipoprotein ε4 allele, glycemic level, and cognitive status (OR, 1.69 [1.10, 2.60]). However, AD signature PiB retention ratio was similar in diabetics vs. non-diabetics (OR, 1.03 [0.71, 1.51]; p = 0.87). In post-hoc analyses in non-diabetics, a 1% increase in HBA1c was associated with greater AD signature hypometabolism in cognitively normal subjects (OR, 1.93 [1.03, 3.62; p = 0.04]) and in the total cohort (OR 1.59 [0.92, 2.75; p = 0.10).
Conclusion
Diabetes and poor glycemic control in non-diabetics may enhance glucose hypometabolism in AD signature regions. These factors should be investigated in longitudinal studies for their role in detecting onset of symptoms in AD.
doi:10.2967/jnumed.113.132647
PMCID: PMC4011952  PMID: 24652830
Diabetes; cerebral glucose metabolism; FDG- and PiB-PET imaging; hemoglobin A1c; amyloid accumulation
9.  Subtle gait changes in patients with REM Behavior Disorder 
Background
Many people with REM sleep behavior disorder have an underlying synucleinopathy, the most common of which is Lewy body disease. Identifying additional abnormal clinical features may help in identifying those at greater risk of evolving to a more severe syndrome. As gait disorders are common in the synucleinopathies, early abnormalities in gait in those with REM sleep behavior disorder could help in identifying those at increased risk of developing overt parkinsonism and/or cognitive impairment.
Methods
We identified 42 probable REM sleep behavior disorder subjects and 492 controls using the Mayo Sleep Questionnaire and assessed gait velocity, cadence and stride dynamics with an automated gait analysis system.
Results
Cases and controls were similar in age (79.9 ± 4.7 & 80.1 ± 4.7, p= 0.74), UPDRS score (3.3 ± 5.5 & 1.9 ± 4.1, p=0.21) and Mini-Mental State Examination scores (27.2 ± 1.9 & 27.7 ± 1.6, p=0.10). A diagnosis of probable REM sleep behavior disorder was associated with decreased velocity (−7.9 cm/sec, 95%CI −13.8 to −2.0, p<0.01), cadence (−4.4 steps/min, 95%CI −7.6 to −1.3, p<0.01), and significantly increased double limb support variability (30%, 95%CI 6 – 60, p=0.01), greater stride time variability (29%, 95%CI 2 – 63, p=0.03) and swing time variability (46%, 95%CI 15 – 84, p<0.01).
Conclusions
Probable REM sleep behavior disorder is associated with subtle gait changes prior to overt clinical parkinsonism. Diagnosis of probable REM sleep behavior disorder supplemented by gait analysis may help as a screening tool for disorders of α-synuclein.
doi:10.1002/mds.25653
PMCID: PMC3952497  PMID: 24130124
REM Sleep Behavior Disorder; gait; gait variability
10.  Association of Mediterranean diet with Mild Cognitive Impairment and Alzheimer’s disease: A Systematic Review and Meta-Analysis 
Background/Objective
To conduct a systematic review of all studies to determine whether there is an association between the Mediterranean diet (MeDi) and cognitive impairment.
Methods
We conducted a comprehensive search of the major databases and hand-searched proceedings of major neurology, psychiatry, and dementia conferences through November 2012. Prospective cohort studies examining the MeDi with longitudinal follow-up of at least 1 year and reporting cognitive outcomes (mild cognitive impairment [MCI] or Alzheimer’s disease [AD]) were included. The effect size was estimated as hazard-ratio (HR) with 95% confidence intervals (CIs) using the random-effects model. Heterogeneity was assessed using Cochran’s Q-test and I2-statistic.
Results
Out of the 664 studies screened, five studies met eligibility criteria. Higher adherence to the MeDi was associated with reduced risk of MCI and AD. The subjects in the highest MeDi tertile had 33% less risk (adjusted HR=0.67; 95% CI, 0.55–0.81; P<0.0001) of cognitive impairment (MCI or AD) as compared to the lowest MeDi score tertile. Among cognitively normal individuals, higher adherence to the MeDi was associated with a reduced risk of MCI (HR=0.73; 95% CI, 0.56–0.96; P=0.02) and AD (HR=0.64; 95% CI, 0.46–0.89; P=0.007). There was no significant heterogeneity in the analyses.
Conclusions
While the overall number of studies is small, pooled results suggest that a higher adherence to the MeDi is associated with a reduced risk of developing MCI and AD, and a reduced risk of progressing from MCI to AD. Further prospective-cohort studies with longer follow-up and randomized controlled trials are warranted to consolidate the evidence.
doi:10.3233/JAD-130830
PMCID: PMC3946820  PMID: 24164735
Mediterranean diet; MCI; Mild Cognitive Impairment; Alzheimer’s disease; systematic review; meta-analysis
11.  Frailty and Mortality Outcomes in Cognitively Normal Older People: Sex Differences in a Population-Based Study 
OBJECTIVES
To characterize frailty in cognitively normal older adults at baseline and to investigate the relationship of frailty with mortality.
DESIGN
A population-based, prospective, cohort study; the Mayo Clinic Study of Aging.
SETTING
Olmsted County, Minnesota.
PARTICIPANTS
Cognitively normal older persons aged 70 years and older (n = 2,356).
MEASUREMENTS
Frailty was assessed at baseline using a 36-item Frailty Index. Four frailty subgroups were identified: Frailty Index ≤0.10 (fit); 0.100.30 (frailest). All participants underwent comprehensive clinical and cognitive assessments. The association of frailty with mortality was assessed using Cox proportional hazards models.
RESULTS
The mean age (standard deviation) was 78.8 (±5.2) years, 50.2% were male, and the median (interquartile range) Frailty Index was 0.17 (0.11–0.22). Frailty increased with age and was more common in older men. Over a median follow-up of 6.5 years (range 7 days to 8.9 years), 500 of the 2,356 participants died, including 292 men. Compared to fit participants, the frailest participants had the greatest risk of death across the whole cohort (hazard ratio, HR= 3.91; 95% confidence interval, CI = 2.69–5.68). The association was stronger in women (HR= 5.26, 95% CI = 2.88–9.61) than men (HR= 3.15, 95% CI = 1.98–5.02).
CONCLUSION
Baseline frailty was common, especially in older men, and increased with age across our cohort. Frailty was associated with a significantly increased risk of death, particularly in women. These gender differences should be considered when designing a geriatric care plan.
doi:10.1111/jgs.13821
PMCID: PMC4721254  PMID: 26782862
frailty; Frailty Index; mortality; aging; sex-differences
12.  Rates of transition between amyloid and neurodegeneration biomarker states and to dementia among non-demented individuals: a population-based cohort study 
The Lancet. Neurology  2015;15(1):56-64.
Summary
Background
We previously observed in a cross-sectional analysis that frequencies of amyloid and neurodegeneration biomarker states varied greatly by age among cognitively non-impaired participants, suggesting dynamic within-person processes. Our objective in this longitudinal study was to estimate rates of transitioning from a less- to a more-abnormal biomarker state by age among non-demented individuals, as well as rates of transitioning to dementia by biomarker state.
Methods
All participants (n=4049) were non-demented at baseline. A subset of 1541 underwent multi-modality imaging. Amyloid PET was used to classify individuals as amyloid positive (A+) or negative (A−). FDG PET and MRI were used to classify individuals as neurodegeneration positive (N+) or negative (N−). All observations from the 4049 individuals were used in a multi-state model to estimate four different age-specific biomarker state transition rates among non-demented individuals: A−N− to A+N−; A−N− to A−N+ (suspected non-Alzheimer pathology, SNAP); A+N− to A+N+; A−N+ (SNAP) to A+N+. We also estimated two age-specific rates to dementia: A+N+ to dementia; and A−N+ (SNAP) to dementia. Using these state-to-state transition rates, we estimated biomarker state frequencies by age.
Findings
All transition rates were low at age 50 and (with one exception) were well-characterized by an exponential increase with age. The rates per 100-person years at ages 65 versus 85 were 1.6 versus 17.2 for A−N− to A−N+, 6.1 versus 20.8 for A+N− to A+N+, 2.6 versus 13.2 for A−N+ to A+N+, 0.8 versus 7.0 for A+N+ to dementia, and 0.6 versus 1.7 for A−N+ to dementia. The one exception to an exponential increase with age was the transition rate from A−N− to A+N− which increased from 4.0 transitions per 100 person-years at age 65 to approximately 7 transitions per 100 person-years in the 70s and then plateaued beyond that age. Estimated biomarker frequencies by age from the multistate model were similar to cross-sectional biomarker frequencies.
Interpretation
Dynamic state-to-state transition rates illustrate important measurable aspects of the changing biology underlying brain aging. The biomarker states we describe relate to both AD and non-AD processes. Our transition rates suggest that brain aging can be conceptualized as a nearly inevitable acceleration toward worse biomarker and clinical states. The one exception was that transition to amyloidosis without neurodegeneration was most dynamic from age 60 to 70 and then plateaued beyond that age. We found that simple transition rates can explain complex, highly interdependent biomarker state frequencies in our sample.
doi:10.1016/S1474-4422(15)00323-3
PMCID: PMC4784263  PMID: 26597325
Cognitive aging; Brain aging; Amyloid imaging; Alzheimer disease; Brain atrophy and Alzheimer disease; FDG PET and Alzheimer disease
13.  Association of Elevated Amyloid Levels With Cognition and Biomarkers in Cognitively Normal People From the Community 
JAMA neurology  2016;73(1):85-92.
IMPORTANCE
The role of amyloid in the progression of Alzheimer disease (AD) pathophysiology is of central interest to the design of randomized clinical trials. The presence of amyloid has become a prerequisite for enrollment in several secondary prevention trials for AD, yet the precise effect of elevated amyloid levels on subsequent clinical and biomarker events is less certain.
OBJECTIVE
To explore the effect of elevated amyloid levels on subsequent changes in cognition and biomarkers.
DESIGN, SETTING, AND PARTICIPANTS
A total of 564 cognitively normal individuals (median age, 78 years) from the Mayo Clinic Study of Aging, a population-based longitudinal study in Olmsted County, Minnesota, with serial cognitive data were selected for this study. The data used in this study were collected from January 12, 2006, to January 9, 2014. Individuals included in this study had undergone magnetic resonance imaging, fluorodeoxyglucose positron emission tomography (FDG-PET), and Pittsburgh Compound B (PiB) PET at baseline were not cognitively impaired at baseline and had at least 1 clinical follow-up. A subset of 286 individuals also underwent serial imaging. Elevated amyloid level was defined as a standardized uptake value ratio of greater than 1.5 on PiB PET. Associations with baseline amyloid status and baseline and longitudinal change in clinical and imaging measures were evaluated after adjusting for age and hippocampal volume. APOE4 effects were also evaluated.
MAIN OUTCOMES AND MEASURES
Cognitive measures of memory, language, attention/executive function, visuospatial skills, PiB levels, hippocampal and ventricular volumes, and FDG-PET measures.
RESULTS
At baseline, 179 (31.7%) individuals with elevated amyloid levels had poorer cognition in all domains measured, reduced hippocampal volume, and greater FDG-PET hypometabolism. Elevated amyloid levels at baseline were associated with a greater rate of cognitive decline in all domains (0.04 to 0.09 z score units per year) except language and a greater rate of amyloid accumulation (1.6% per year), hippocampal atrophy (30 mm3 per year), and ventricular enlargement (565 mm3 per year). Elevated amyloid levels were also associated with an increased risk of mild cognitive impairment (hazard ratio, 2.9; 95% CI, 1.7–5.0, and hazard ratio, 1.6; 95% CI, 0.9–2.8, for PiB+ APOE4 carriers and PiB+ noncarriers, respectively, compared with PiB− noncarriers). These associations were largely independent of APOE4.
CONCLUSIONS AND RELEVANCE
In persons selected from a population-based study, elevated amyloid levels at baseline were associated with worse cognition and imaging biomarkers at baseline and with greater clinical decline and neurodegeneration. These results have implications for the design of randomized clinical trials for AD.
doi:10.1001/jamaneurol.2015.3098
PMCID: PMC4710552  PMID: 26595683
14.  Cardiac Disease Increases Risk of Non-amnestic Mild Cognitive Impairment: Stronger impact in women 
JAMA neurology  2013;70(3):374-382.
Objective
Non-amnestic mild cognitive impairment (naMCI), a putative precursor of vascular and other non-Alzheimer’s disease dementias, is hypothesized to have a vascular etiology. We investigated the association of cardiac disease with amnestic (aMCI) and non-amnestic (naMCI) MCI.
Design
A prospective, population-based, cohort study with a median 4.0 years of follow-up.
Setting
Olmsted County, Minnesota.
Participants
Participants were evaluated at baseline and every 15 months using the Clinical Dementia Rating scale, a neurological evaluation, and neuropsychological testing. A diagnosis of normal cognition, MCI, or dementia was made by consensus. Cardiac disease at baseline was assessed from the participant’s medical records.
Main outcome measures
Incident MCI, aMCI, naMCI.
Results
Among 1,450 subjects free of MCI or dementia at baseline, 366 developed MCI. Cardiac disease was associated with an increased risk of naMCI (hazard ratio [HR] 95% confidence interval; 1.77 [1.16–2.72]). However, the association varied by sex (P for interaction = .02). Cardiac disease was associated with an increased risk of naMCI (HR, 3.07 [1.58–5.99]) in women, but not in men (HR, 1.16 [0.68–1.99]. Cardiac disease was not associated with any MCI or aMCI.
Conclusion
Cardiac disease is an independent risk factor for naMCI, within sex comparisons showed a stronger association in women. Prevention and management of cardiac disease and vascular risk factors may reduce the risk of naMCI.
doi:10.1001/jamaneurol.2013.607
PMCID: PMC3734560  PMID: 23358884
15.  Role of β-amyloidosis and Neurodegeneration in Subsequent Imaging Changes in Mild Cognitive Impairment 
JAMA neurology  2015;72(12):1475-1483.
Importance
To understand how a model of Alzheimer disease pathophysiology based on β-amyloidosis and neurodegeneration predicts the regional anatomic expansion of hypometabolism and atrophy in persons with mild cognitive impairment (MCI).
Objective
To define the role of β-amyloidosis and neurodegeneration in the subsequent progression of topographic cortical structural and metabolic changes in MCI.
Design
Longitudinal, observational study with serial brain imaging.
Setting
Population-based cohort.
Participants
Ninety six MCI participants (all >70 years) with serial imaging biomarkers from the Mayo Clinic Study of Aging or Mayo Alzheimer Disease Research Center. Participants were characterized initially as having elevated or not elevated brain β-amyloidosis (“A+” or “A−“) based on 11C-Pittsburgh compound B positron emission tomography (PET). They were further characterized initially by the presence or absence of neurodegeneration (“N+” or “N−“), where presence of neurodegeneration was defined by abnormally low hippocampal volume or hypometabolism in an Alzheimer Disease (AD)-like pattern on 18fluoro-deoxyglucose (FDG) PET.
Main Outcome Measures
Regional FDG Standardized Uptake Value ratio (SUVR) and grey matter volumes in medial temporal, lateral temporal, lateral parietal and medial parietal regions.
Results
In the primary regions of interest, the A+N+ group had lower FDG SUVR and grey matter volumes at baseline, and showed large declines in FDG SUVR and grey matter volumes compared to the A−N+ and A−N−, but not the A+N− group. The A+N− group exhibited declines in FDG SUVR over time, which were not significantly different from the A−N+ or A−N− groups. The A−N+ group did not show declines in FDG SUVR or grey matter volume compared to A+N− or A−N− groups.
Conclusions and Relevance
Persons with MCI who were A+N+ demonstrated volumetric and metabolic worsening in temporal and parietal association areas, consistent with the expectation that the MCI stage in the Alzheimer pathway heralds incipient isocortical involvement. The A−N+ group, those with suspected non-Alzheimer pathophysiology, lacked a distinctive longitudinal volumetric or metabolic profile.
doi:10.1001/jamaneurol.2015.2323
PMCID: PMC4735877  PMID: 26437123
16.  Probable REM Sleep Behavior Disorder Increases Risk for Mild Cognitive Impairment and Parkinson’s Disease: A Population-Based Study 
Annals of Neurology  2012;71(1):49-56.
Objective
REM sleep behavior disorder (RBD) is associated with neurodegenerative disease and particularly with the synucleinopathies. Convenience samples involving subjects with idiopathic RBD have suggested an increased risk of incident mild cognitive impairment (MCI), dementia (usually dementia with Lewy bodies) or Parkinson’s disease (PD). There is no data on such risk in a population-based sample.
Methods
Cognitively normal subjects aged 70–89 in a population-based study of aging who screened positive for probable RBD using the Mayo Sleep Questionnaire were followed at 15 month intervals. In a Cox Proportional Hazards Model, we measured the risk of developing MCI, dementia, PD among the exposed (pRBD+) and unexposed (pRBD−) cohorts.
Results
Forty-four subjects with pRBD+ at enrollment (median duration of pRBD features was 7.5 years), and 607 pRBD− subjects, were followed prospectively for a median of 3.8 years. Fourteen of the pRBD+ subjects developed MCI and one developed PD (15/44=34% developed MCI / PD); none developed dementia. After adjustment for age, sex, education, and medical comorbidity, pRBD+ subjects were at increased risk of MCI / PD [Hazard Ratio (HR) 2.2, 95% Confidence Interval (95%CI) 1.3 – 3.9; p=0.005]. Inclusion of subjects who withdrew from the study produced similar results, as did exclusion of subjects with medication-associated RBD. Duration of pRBD symptoms did not predict the development of MCI / PD (HR 1.05 per 10 years, 95%CI 0.84 – 1.3; p=0.68).
Interpretation
In this population-based cohort study, we observed that pRBD confers a 2.2-fold increased risk of developing MCI / PD over four years.
doi:10.1002/ana.22655
PMCID: PMC3270692  PMID: 22275251
sleep disorders; parasomnias; dementia; Alzheimer’s disease; dementia with Lewy bodies; parkinsonism; synuclein
17.  Relative Intake of Macronutrients Impacts Risk of Mild Cognitive Impairment or dementia 
High caloric intake has been associated with an increased risk of cognitive impairment. Total caloric intake is determined by the calories derived from macronutrients. The objective of the study was to investigate the association between percent of daily energy (calories) from macronutrients and incident mild cognitive impairment (MCI) or dementia. Participants were a population-based prospective cohort of elderly persons who were followed over a median 3.7 years (interquartile range, 2.5–3.9) of follow-up. At baseline and every 15 months, participants (median age, 79.5 years) were evaluated using the Clinical Dementia Rating scale, a neurological evaluation, and neuropsychological testing for a diagnosis of MCI, normal cognition, or dementia. Participants also completed a 128-item food-frequency questionnaire at baseline; total daily caloric and macronutrient intakes were calculated using an established database. The percent of total daily energy from protein (% protein), carbohydrate (% carbohydrate), and total fat (% fat) was computed. Among 937 subjects who were cognitively normal at baseline, 200 developed incident MCI or dementia. The risk of MCI or dementia (hazard ratio [HR], [95% confidence interval]) was elevated in subjects with high % carbohydrate (upper quartile: 1.89 [1.17–3.06]; P for trend=0.004), but was reduced in subjects with high % fat (upper quartile: 0.56 [0.34–0.91]; P for trend=0.03), and high % protein (upper quartile 0.79 [0.52 – 1.20]; P for trend=0.03) in the fully adjusted models. A dietary pattern with relatively high caloric intake from carbohydrates and low caloric intake from fat and proteins may increase the risk of MCI or dementia in elderly persons.
doi:10.3233/JAD-2012-120862
PMCID: PMC3494735  PMID: 22810099
Mild cognitive impairment; dementia; dietary proteins; dietary fats; dietary carbohydrates; caloric intake; energy intake; prospective studies; community-based
18.  Untreated Type 2 Diabetes and Its Complications Are Associated With Subcortical Infarctions 
Diabetes Care  2010;34(1):184-186.
OBJECTIVE
To investigate the association of type 2 diabetes with subcortical infarctions.
RESEARCH DESIGN AND METHODS
We investigated this association in subjects with type 2 diabetes (case subjects; n = 93) and without type 2 diabetes (control subjects; n = 186), matched by age, sex, and years of education. Participants were a subset of the Mayo Clinic Study of Aging (median age 79 years) who had undergone magnetic resonance imaging.
RESULTS
The frequency of subcortical infarctions was 39% in case subjects and 29% in control subjects (odds ratio 1.59 [95% CI 0.91–2.75]). The association was stronger in case subjects without treatment (2.60 [1.11–6.08]) and in case subjects with diabetes-related complications (1.96 [1.02–3.74]) compared with control subjects.
CONCLUSIONS
These findings suggest that untreated type 2 diabetes and type 2 diabetes with complications are associated with subcortical infarctions.
doi:10.2337/dc10-0602
PMCID: PMC3005470  PMID: 20980413
19.  Spectrum of cognition short of dementia 
Neurology  2015;85(19):1712-1721.
Objective:
To understand the neuropsychological basis of dementia risk among persons in the spectrum including cognitive normality and mild cognitive impairment.
Methods:
We quantitated risk of progression to dementia in elderly persons without dementia from 2 population-based studies, the Framingham Heart Study (FHS) and Mayo Clinic Study of Aging (MCSA), aged 70 to 89 years at enrollment. Baseline cognitive status was defined by performance in 4 domains derived from batteries of neuropsychological tests (that were similar but not identical for FHS and MCSA) at cut scores corresponding to SDs of ≤−0.5, −1, −1.5, and −2 from normative means. Participants were characterized as having no cognitive impairment (reference group), or single or multiple amnestic or nonamnestic profiles at each cut score. Incident dementia over the following 6 years was determined by consensus committee at each study separately.
Results:
The pattern of hazard ratios for incident dementia, rates of incident dementia and positive predictive values across cognitive test cut scores, and number of affected domains was similar although not identical across the FHS and MCSA. Dementia risks were higher for amnestic profiles than for nonamnestic profiles, and for multidomain compared with single-domain profiles.
Conclusions:
Cognitive domain subtypes, defined by neuropsychologically derived cut scores and number of low-performing domains, differ substantially in prognosis in a conceptually logical manner that was consistent between FHS and MCSA. Neuropsychological characterization of elderly persons without dementia provides valuable information about prognosis. The heterogeneity of risk of dementia cannot be captured concisely with one test or a single definition or cutpoint.
doi:10.1212/WNL.0000000000002100
PMCID: PMC4653114  PMID: 26453643
20.  Vegetables, Unsaturated Fats, Moderate Alcohol Intake, and Mild Cognitive Impairment 
Background/Aims
To investigate associations of the Mediterranean diet (MeDi) components and the MeDi score with mild cognitive impairment (MCI).
Methods
Participants (aged 70–89 years) were clinically evaluated to assess MCI and dementia, and completed a 128-item food frequency questionnaire.
Results
163 of 1,233 nondemented persons had MCI. The odds ratio of MCI was reduced for high vegetable intake [0.66 (95% CI = 0.44–0.99), p = 0.05] and for high mono-plus polyunsaturated fatty acid to saturated fatty acid ratio [0.52 (95% CI = 0.33–0.81), p = 0.007], adjusted for confounders. The risk of incident MCI or dementia was reduced in subjects with a high MeDi score [hazard ratio = 0.75 (95% CI = 0.46–1.21), p = 0.24].
Conclusion
Vegetables, unsaturated fats, and a high MeDi score may be beneficial to cognitive function.
doi:10.1159/000305099
PMCID: PMC2889256  PMID: 20502015
Mild cognitive impairment; Dietary intake; Moderate alcohol intake; Unsaturated fatty acids; Mediterranean diet; Longitudinal; Prevalence studies; Incidence studies; Population-based
21.  Performance of the CogState computerized battery in the Mayo Clinic Study on Aging 
Background
The feasibility and validity of brief computerized cognitive batteries at the population-level are unknown.
Methods
Non-demented participants (n = 1660, age 50–97) in the Mayo Clinic Study on Aging completed the computerized CogState battery and standard neuropsychological battery. The correlation between tests was examined and comparisons between CogState performance on the personal computer (PC) and iPad (n = 331), and in the Clinic vs. at home (n = 194), were assessed.
Results
We obtained valid data on >97% of participants on each test. Correlations between the CogState and neuropsychological tests ranged from −0.462 to 0.531. While absolute differences between the PC and iPad were small and participants preferred the iPad, performance on the PC was faster. Participants performed faster on Detection, One Card Learning, and One Back at home compared to the Clinic.
Conclusions
The computerized CogState battery, especially the iPad, was feasible, acceptable, and valid in the population.
doi:10.1016/j.jalz.2015.01.008
PMCID: PMC4595161  PMID: 25858683
Computerized cognitive battery; Epidemiology; Neuropsychology; Cognitively normal; Mild cognitive impairment; Population-based cohort study
22.  Metabolic Syndrome, Inflammation, and Non-Amnestic Mild Cognitive Impairment in Older Persons: A Population-Based Study 
The metabolic syndrome (MetS) is more strongly associated with cognitive impairment in the presence of inflammation. This suggests that the association of MetS with mild cognitive impairment (MCI) may vary with the etiology and the subtype of MCI. This study investigated the association between MetS with or without inflammation and MCI (amnestic [a-MCI] and non-amnestic [na-MCI]). We studied a randomly selected sample of 1969 subjects (ages 70 to 89 years) from Olmsted County, MN, using the Clinical Dementia Rating Scale, a neurological evaluation, and neuropsychological testing. Data for participants were reviewed for a diagnosis of normal cognition, MCI, or dementia. Clinical components of MetS were ascertained by interview and confirmed from the medical records; biochemical measurements were assayed from a blood draw. We compared 88 na-MCI cases and 241 a-MCI cases with 1640 cognitively normal subjects. MetS was not associated with either na-MCI or a-MCI. High C-reactive protein (CRP highest tertile vs lowest tertile) was associated with na-MCI (odds ratio [OR] = 1.85; 95% confidence interval [CI] = 1.05, 3.24) but not with a-MCI, after adjusting for sex, age, and years of education. The combination of MetS and high CRP (compared to no Mets and lowest CRP tertile) was associated with na-MCI (OR = 2.31; 95% CI = 1.07, 5.00), but not with a-MCI (OR = 0.96; 95% CI = 0.59, 1.54). The combined presence of MetS and high levels of inflammation is associated with na-MCI in this elderly cohort, and suggests etiologic differences in MCI subtypes.
doi:10.1097/WAD.0b013e3181a4485c
PMCID: PMC2837096  PMID: 19568151
metabolic syndrome; insulin resistance; mild cognitive impairment; C-reactive protein; inflammation; cross-sectional study
23.  Polyunsaturated Fatty Acids and Reduced Odds of MCI: The Mayo Clinic Study of Aging 
Mono- and polyunsaturated fatty acids (MUFA, PUFA) have been associated with a reduced risk of dementia. The association of these fatty acids with mild cognitive impairment (MCI) is not fully established. The objective of the study was to investigate the cross-sectional association of dietary fatty acids with MCI in a population-based sample. Participants aged ≥ 70 years on October 1, 2004, were evaluated using the Clinical Dementia Rating Scale (participant and informant), a neurological evaluation, and neuropsychological testing. A panel of nurses, physicians, and neuropsychologists reviewed the data for each participant in order to establish a diagnosis of MCI, normal cognition, or dementia by consensus. Participants also completed a 128-item food-frequency questionnaire. Among 1,233 non-demented subjects, 163 (13.2%) had MCI. The odds ratio (OR) of MCI decreased with increasing PUFA and MUFA intake. Compared to the lowest tertile, the OR (95% confidence interval) for the upper tertiles were 0.44 (0.29–0.66; p for trend = 0.0004) for total PUFA; 0.44 (0.30–0.67; p for trend = 0.0004) for omega-6 fatty acids; 0.62 (0.42–0.91; p for trend = 0.012) for omega-3 fatty acids; and 0.56 (0.38–0.83; p for trend = 0.01) for (MUFA+PUFA):saturated fatty acid ratio after adjustment for age, sex, number of years of education, and caloric intake. In this study, higher intake of PUFA and MUFA was associated with a reduced likelihood of MCI among elderly persons in the population-based setting.
doi:10.3233/JAD-2010-091597
PMCID: PMC2940991  PMID: 20634591
Cross-sectional studies; dietary fats; polyunsaturated fatty acids; monounsaturated fatty acids; population-based; mild cognitive impairment
24.  The Mayo Clinic Study of Aging: Design and Sampling, Participation, Baseline Measures and Sample Characteristics 
Neuroepidemiology  2008;30(1):58-69.
Background
The objective of this study was to establish a prospective population-based cohort to investigate the prevalence, incidence and risk factors for mild cognitive impairment (MCI) and dementia.
Methods
The Olmsted County, Minn., population, aged 70–89 years on October 1, 2004, was enumerated using the Rochester Epidemiology Project. Eligible subjects were randomly selected and invited to participate. Participants underwent a comprehensive in-person evaluation including the Clinical Dementia Rating Scale, a neurological evaluation and neuropsychological testing. A consensus diagnosis of normal cognition, MCI or dementia was made by a panel using previously published criteria. A subsample of subjects was studied via telephone interview.
Results
Four hundred and two subjects with dementia were identified from a detailed review of their medical records but were not contacted. At baseline, we successfully evaluated 703 women aged 70–79 years, 769 women aged 80–89 years, 730 men aged 70–79 years and 517 men aged 80–89 years (total n = 2,719). Among the participants, 2,050 subjects were evaluated in person and 669 via telephone.
Conclusions
Strengths of the study are that the subjects were randomly selected from a defined population, the majority of the subjects were examined in person, and MCI was defined using published criteria. Here, we report the design and sampling, participation, baseline measures and sample characteristics.
doi:10.1159/000115751
PMCID: PMC2821441  PMID: 18259084
Cognitive impairment; Prevalence; Incidence; Risk factors; Cohort studies; Data collection instruments
25.  Direct medical costs and source of cost differences across the spectrum of cognitive decline: A population-based study 
BACKGROUND
Objective cost estimates and source of cost differences are needed across the spectrum of cognition, including cognitively normal (CN), mild-cognitive-impairment (MCI), newly-discovered dementia, and prevalent dementia.
METHODS
Subjects were a subset of the Mayo Clinic Study of Aging stratified-random sampling of Olmsted County, MN, residents aged 70-89 years. A neurologist reviewed provider-linked medical records to identify prevalent-dementia (review date=index). Remaining subjects were invited to participate in prospective clinical/neuropsychological assessments; participants were categorized as CN, MCI, or newly-discovered-dementia (assessment date=index). Costs for medical services/procedures 1-year pre-index (excluding indirect and long-term care costs) were estimated using line-item provider-linked administrative data. We estimated contributions of care-delivery site and comorbid conditions (including and excluding neuropsychiatric diagnoses) to between-category cost differences.
RESULTS
Annual mean medical costs for CN, MCI, newly-discovered-dementia, and prevalent-dementia were $6,042, $6,784, $9,431, $11,678 respectively. Hospital inpatient costs contributed 70% of total costs for prevalent dementia and accounted for differences between CN and both prevalent and newly-discovered dementia. Ambulatory costs accounted for differences between CN and MCI. Age-, sex-, education-adjusted differences reached significance for CN versus newly-discovered and prevalent-dementia and for MCI versus prevalent-dementia. After considering all comorbid diagnoses, between-category differences were reduced (e.g., prevalent-dementia minus MCI (from $4,842 to $3,575); newly-discovered-dementia minus CN (from $3,578 to$711). Following exclusion of neuropsychiatric diagnoses from comorbidity adjustment, between-category differences tended to revert to greater differences.
CONCLUSIONS
Cost estimates did not differ significantly between CN and MCI. Substantial differences between MCI and prevalent dementia reflected high inpatient costs for dementia and appear partly related to co-occurring Mental Disorders. Such comparisons can help inform models aimed at identifying where, when, and for which individuals proposed interventions might be cost-effective.
doi:10.1016/j.jalz.2015.01.007
PMCID: PMC4543557  PMID: 25858682
Dementia; Cognitive status; Mild cognitive impairment; Economics; Utilization; Cost

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