Publications by authors named "David B Hogan"

156 Publications

The Brain in Motion II Study: study protocol for a randomized controlled trial of an aerobic exercise intervention for older adults at increased risk of dementia.

Trials 2021 Jun 14;22(1):394. Epub 2021 Jun 14.

Department of Physiology & Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 4N1, Canada.

Background: There remains no effective intervention capable of reversing most cases of dementia. Current research is focused on prevention by addressing risk factors that are shared between cardiovascular disease and dementia (e.g., hypertension) before the cognitive, functional, and behavioural symptoms of dementia manifest. A promising preventive treatment is exercise. This study describes the methods of a randomized controlled trial (RCT) that assesses the effects of aerobic exercise and behavioural support interventions in older adults at increased risk of dementia due to genetic and/or cardiovascular risk factors. The specific aims are to determine the effect of aerobic exercise on cognitive performance, explore the biological mechanisms that influence cognitive performance after exercise training, and determine if changes in cerebrovascular physiology and function persist 1 year after a 6-month aerobic exercise intervention followed by a 1-year behavioural support programme (at 18 months).

Methods: We will recruit 264 participants (aged 50-80 years) at elevated risk of dementia. Participants will be randomly allocated into one of four treatment arms: (1) aerobic exercise and health behaviour support, (2) aerobic exercise and no health behaviour support, (3) stretching-toning and health behaviour support, and (4) stretching-toning and no health behaviour support. The aerobic exercise intervention will consist of three supervised walking/jogging sessions per week for 6 months, whereas the stretching-toning control intervention will consist of three supervised stretching-toning sessions per week also for 6 months. Following the exercise interventions, participants will receive either 1 year of ongoing telephone behavioural support or no telephone support. The primary aim is to determine the independent effect of aerobic exercise on a cognitive composite score in participants allocated to this intervention compared to participants allocated to the stretching-toning group. The secondary aims are to examine the effects of aerobic exercise on a number of secondary outcomes and determine whether aerobic exercise-related changes persist after a 1-year behavioural support programme (at 18 months).

Discussion: This study will address knowledge gaps regarding the underlying mechanisms of the pro-cognitive effects of exercise by examining the potential mediating factors, including cerebrovascular/physiological, neuroimaging, sleep, and genetic factors that will provide novel biologic evidence on how aerobic exercise can prevent declines in cognition with ageing.

Trial Registration: ClinicalTrials.gov NCT03035851 . Registered on 30 January 2017.
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http://dx.doi.org/10.1186/s13063-021-05336-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8201462PMC
June 2021

Construct and Criterion-Related Validity of the Clinical Frailty Scale in Persons with HIV.

J Acquir Immune Defic Syndr 2021 May 28. Epub 2021 May 28.

Department of Medicine, Section of Geriatric Medicine, University of Calgary, Calgary, Alberta, Canada Southern Alberta Clinic, Calgary, Alberta, Canada Department of Medicine, University of Calgary, Calgary, Alberta, Canada Department of Medicine (Neurology), University of Alberta, Edmonton, Alberta, Canada Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada Department of Psychiatry, University of Alberta, Edmonton, Alberta, Canada Departments of Neurology and Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.

Background: The co-occurrence of frailty and cognitive impairment in older (50+) persons with HIV (PWH) is common and increases the risk of poor outcomes. In HIV clinics, the most commonly used frailty measures are the frailty phenotype (FP), which requires measuring grip strength and gait speed to implement, and the frailty index (FI) based on comprehensive health data collected on patients. We examined construct and criterion-related validity (as it predicts cognition) of the clinical frailty scale (CFS), a less resource-intensive approach for assessing frailty, in relation to these more commonly used frailty assessments (FP, FI).

Setting/methods: 143 older (age 50+) PWH (mean age 57; 88% male) seen at the Southern Alberta Clinic underwent both frailty screening with the FP, CFS, and FI and neuropsychological testing. Mixed effects regressions examined the associations between frailty status and cognition.

Results: Concordance with the FP was slightly superior for the CFS than the FI. The FP and CFS had similar associations with domain-specific cognitive performance with frail PWH performing worse than non-frail individuals on tests requiring manual dexterity (Trail Making-Part A&B; Symbol Digit; Grooved Pegboard; P values <0.05). Neither were associated with executive function, learning, or memory performance. The FI was associated with worse fluency, fine motor skills (Grooved Pegboard), and Trail Making Part A.

Conclusion: The CFS is a simple screening tool with good construct and criterion-related validity. It was associated with a similar pattern of cognitive deficits as the FP. If confirmed and the associations are extended to other clinically significant characteristics and outcomes, the CFS can be considered as an alternative to the FP and FI in assessing frailty in older PWH.
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http://dx.doi.org/10.1097/QAI.0000000000002736DOI Listing
May 2021

New horizons in falls prevention and management for older adults: a global initiative.

Age Ageing 2021 May 26. Epub 2021 May 26.

Centre for Innovation in Medical Engineering (CIME), Faculty of Engineering, University of Malaya, Kuala Lumpur, Malaysia.

Background: falls and fall-related injuries are common in older adults, have negative effects both on quality of life and functional independence and are associated with increased morbidity, mortality and health care costs. Current clinical approaches and advice from falls guidelines vary substantially between countries and settings, warranting a standardised approach. At the first World Congress on Falls and Postural Instability in Kuala Lumpur, Malaysia, in December 2019, a worldwide task force of experts in falls in older adults, committed to achieving a global consensus on updating clinical practice guidelines for falls prevention and management by incorporating current and emerging evidence in falls research. Moreover, the importance of taking a person-centred approach and including perspectives from patients, caregivers and other stakeholders was recognised as important components of this endeavour. Finally, the need to specifically include recent developments in e-health was acknowledged, as well as the importance of addressing differences between settings and including developing countries.

Methods: a steering committee was assembled and 10 working Groups were created to provide preliminary evidence-based recommendations. A cross-cutting theme on patient's perspective was also created. In addition, a worldwide multidisciplinary group of experts and stakeholders, to review the proposed recommendations and to participate in a Delphi process to achieve consensus for the final recommendations, was brought together.

Conclusion: in this New Horizons article, the global challenges in falls prevention are depicted, the goals of the worldwide task force are summarised and the conceptual framework for development of a global falls prevention and management guideline is presented.
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http://dx.doi.org/10.1093/ageing/afab076DOI Listing
May 2021

Sex differences in multimorbidity and polypharmacy trends: A repeated cross-sectional study of older adults in Ontario, Canada.

PLoS One 2021 26;16(4):e0250567. Epub 2021 Apr 26.

ICES, Toronto, Ontario, Canada.

Background: Multimorbidity is increasing among older adults, but the impact of these recent trends on the extent and complexity of polypharmacy and possible variation by sex remains unknown. We examined sex differences in multimorbidity, polypharmacy (5+ medications) and hyper-polypharmacy (10+ medications) in 2003 vs 2016, and the interactive associations between age, multimorbidity level, and time on polypharmacy measures.

Methods And Findings: We employed a repeated cross-sectional study design with linked health administrative databases for all persons aged ≥66 years eligible for health insurance in Ontario, Canada at the two index dates. Descriptive analyses and multivariable logistic regression models were conducted; models included interaction terms between age, multimorbidity level, and time period to estimate polypharmacy and hyper-polypharmacy probabilities, risk differences and risk ratios for 2016 vs 2003. Multimorbidity, polypharmacy and hyper-polypharmacy increased significantly over the 13 years. At both index dates prevalence estimates for all three were higher in women, but a greater absolute increase in polypharmacy over time was observed in men (6.6% [from 55.7% to 62.3%] vs 0.9% [64.2%-65.1%] for women) though absolute increases in multimorbidity were similar for men and women (6.9% [72.5%-79.4%] vs 6.2% [75.9%-82.1%], respectively). Model findings showed that polypharmacy decreased over time among women aged < 90 years (especially for younger ages and those with fewer conditions), whereas it increased among men at all ages and multimorbidity levels (with larger absolute increases typically at older ages and among those with 4 or fewer conditions).

Conclusions: There are sex and age differences in the impact of increasing chronic disease burden on changes in measures of multiple medication use among older adults. Though the drivers and health consequences of these trends warrant further investigation, the findings support the heterogeneity and complexity in the evolving association between multimorbidity and polypharmacy measures in older populations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250567PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075196PMC
April 2021

Trends in Anticoagulant Use at Nursing Home Admission and Variation by Frailty and Chronic Kidney Disease Among Older Adults with Atrial Fibrillation.

Drugs Aging 2021 Jul 21;38(7):611-623. Epub 2021 Apr 21.

ICES, Toronto, ON, Canada.

Background: Atrial fibrillation (AF) is relatively common among nursing home residents, and decisions regarding anticoagulant therapy in this setting may be complicated by resident frailty and other factors.

Objectives: The aim of this study was to examine trends and correlates of oral anticoagulant use among newly admitted nursing home residents with AF following the approval of direct-acting oral anticoagulants (DOACs).

Methods: We conducted a retrospective cohort study of all adults aged > 65 years with AF who were newly admitted to nursing homes in Ontario, Canada, between 2011 and 2018 (N = 36,466). Health administrative databases were linked with comprehensive clinical assessment data captured shortly after admission, to ascertain resident characteristics. Trends in prevalence of anticoagulant use (any, warfarin, DOAC) at admission were captured with prescription claims and examined by frailty and chronic kidney disease (CKD). Log-binomial regression models estimated crude percentage changes in use over time and modified Poisson regression models assessed factors associated with anticoagulant use and type.

Results: The prevalence of anticoagulant use at admission increased from 41.1% in 2011/2012 to 58.0% in 2017/2018 (percentage increase = 41.1%, p < 0.001). Warfarin use declined (- 67.7%, p < 0.001), while DOAC use increased. Anticoagulant use was less likely among residents with a prior hospitalization for hemorrhagic stroke (adjusted risk ratio [aRR] 0.65, 95% confidence interval [CI] 0.60-0.70) or gastrointestinal bleed (aRR 0.80, 95% CI 0.78-0.83), liver disease (aRR 0.78, 95% CI 0.69-0.89), severe cognitive impairment (aRR 0.89, 95% CI 0.85-0.94), and non-steroidal anti-inflammatory drug (aRR 0.76, 95% CI 0.71-0.81) or antiplatelet (aRR 0.25, 95% CI 0.23-0.27) use, but more likely for those with a prior hospitalization for ischemic stroke or thromboembolism (aRR 1.30, 95% CI 1.27-1.33). CKD was associated with a reduced likelihood of DOAC versus warfarin use in both the early (aRR 0.62, 95% CI 0.54-0.71) and later years (aRR 0.79, 95% CI 0.76-0.83) of our study period. Frail residents were significantly less likely to receive an anticoagulant at admission, although this association was modest (aRR 0.95, 95% CI 0.92-0.98). Frailty was not associated with anticoagulant type.

Conclusions: While the proportion of residents with AF receiving oral anticoagulants at admission increased following the approval of DOACs, over 40% remained untreated. Among those treated, use of a DOAC increased, while warfarin use declined. The impact of these recent treatment patterns on the balance between benefit and harm among residents warrant further investigation.
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http://dx.doi.org/10.1007/s40266-021-00859-1DOI Listing
July 2021

Bertrand Russell and Aging.

Authors:
David B Hogan

J Am Geriatr Soc 2021 May 24;69(5):1410-1411. Epub 2021 Feb 24.

Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

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http://dx.doi.org/10.1111/jgs.17079DOI Listing
May 2021

Examining the municipal-level representativeness of the Canadian Longitudinal Study on Aging (CLSA) cohort: an analysis using Calgary participant baseline data.

Health Promot Chronic Dis Prev Can 2021 Feb;41(2):48-56

Brenda Strafford Centre on Aging, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

Introduction: The Canadian Longitudinal Study on Aging (CLSA) is a rich, nationally representative population-based resource that can be used for multiple purposes. Although municipalities may wish to use CLSA data to address local policy needs, how well localized CLSA cohorts reflect municipal populations is unknown. Because Calgary, Alberta, is home to one of 11 CLSA data collection sites, our objective was to explore how well the Calgary CLSA sample represented the general Calgary population on select sociodemographic variables.

Methods: Baseline characteristics (i.e. sex, marital status, ethnicity, education, retirement status, income, immigration, internal migration) of CLSA participants who visited the Calgary data collection site between 2011 and 2015 were compared to analogous profiles derived from the 2011 National Household Survey (NHS) and 2016 Census datasets, which spanned the years when data were collected on the CLSA participants.

Results: Calgary CLSA participants were representative of the Calgary population for age, sex and Indigenous identity. Discrepancies of over 5% with the NHS and/or 2016 Census were found for marital status, measures of ethnic diversity (i.e. immigrant status, place of birth, non-official language spoken at home), internal migration, income, retirement status and education.

Conclusion: Voluntary studies face challenges in recruiting fully representative cohorts. Communities opting to use CLSA data at a municipal level, including the 10 other CLSA data collection sites, should exercise caution when interpreting the results of these analyses, as CLSA participants may not be fully representative of the local population on select characteristics of interest.
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http://dx.doi.org/10.24095/hpcdp.41.2.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7923734PMC
February 2021

Evaluating the Real-World Representativeness of Participants with Mild Cognitive Impairment in Canadian Research Protocols: a Comparison of the Characteristics of a Memory Clinic Patients and Research Samples.

Can Geriatr J 2020 Dec 1;23(4):297-328. Epub 2020 Dec 1.

Hotchkiss Brain Institute, Calgary, AB.

Background: Studies of mild cognitive impairment (MCI) employ rigorous eligibility criteria, resulting in sampling that may not be representative of the broader clinical population.

Objective: To compare the characteristics of MCI patients in a Calgary memory clinic to those of MCI participants in published Canadian studies.

Methods: Clinic participants included 555 MCI patients from the PROspective Registry of Persons with Memory SyMPToms (PROMPT) registry in Calgary. Research participants included 4,981 individuals with MCI pooled from a systematic literature review of 112 original, English-language peer-reviewed Canadian studies. Both samples were compared on baseline sociodemographic variables, medical and psychiatric comorbidities, and cognitive performance for MCI due to Alzheimer's disease and Parkinson's disease.

Results: Overall, clinic patients tended to be younger, more often male, and more educated than research participants. Psychiatric disorders, traumatic brain injury, and sensory impairment were commonplace in PROMPT (up to 83% affected) but > 80% studies in the systematic review excluded these conditions. PROMPT patients also performed worse on global cognition measures than did research participants.

Conclusion: Stringent eligibility criteria in Canadian research studies excluded a considerable subset of MCI patients with comorbid medical or psychiatric conditions. This exclusion may contribute to differences in cognitive performance and outcomes compared to real-world clinical samples.
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http://dx.doi.org/10.5770/cgj.23.416DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704078PMC
December 2020

Genetic Risk, Vascular Function, and Subjective Cognitive Complaints Predict Objective Cognitive Function in Healthy Older Adults: Results From the Brain in Motion Study.

Front Integr Neurosci 2020 3;14:571683. Epub 2020 Nov 3.

Department of Physiology & Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

Aging is associated with subjective memory complaints. Approximately half of those with subjective memory complaints have objective cognitive impairment. Previous studies have provided evidence of an association between genetic risk for Alzheimer's disease (AD) and dementia progression. Also, aging is a significant risk factor for vascular pathology that may underlie at least some of the cognitive changes. This study investigates the relative contribution of subjective cognitive complaints (SCC), vascular function, and genetic risk for dementia in predicting objective cognitive performance. Multiple regression and relative importance analysis were used to investigate the relative contribution of vascular function, self-reported SCC, and dementia genetic risk, in predicting objective cognition in a sample of 238 healthy community-dwelling older adults. Age, sex, premorbid cognitive abilities, subjective verbal memory complaints, higher cerebrovascular blood flow during submaximal exercise, and certain dementia risk alleles were significant predictors of worse objective verbal memory performance ( < 0.001, = 35.2-36.4%). Using relative importance analysis, subjective verbal memory complaints, and certain dementia risk alleles contributed more variance than cerebrovascular measures. These results suggest that age-related changes in memory in healthy older adults can be predicted by subjective memory complaints, genetic risk, and to a lesser extent, cerebrovascular function.
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http://dx.doi.org/10.3389/fnint.2020.571683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669615PMC
November 2020

Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD)5: Guidelines for management of vascular cognitive impairment.

Alzheimers Dement (N Y) 2020 11;6(1):e12056. Epub 2020 Nov 11.

Department of Medicine (Neurology) Hurvitz Brain Sciences Research Program LC Campbell Cognitive Neurology Unit Canadian Partnership for Stroke Recovery University of Toronto Toronto Canada.

Introduction: Vascular disease is a common cause of dementia, and often coexists with other brain pathologies such as Alzheimer's disease to cause mixed dementia. Many of the risk factors for vascular disease are treatable. Our objective was to review evidence for diagnosis and treatment of vascular cognitive impairment (VCI) to issue recommendations to clinicians.

Methods: A subcommittee of the Canadian Consensus Conference on Diagnosis and Treatment of Dementia (CCCDTD) reviewed areas of emerging evidence. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assign the quality of the evidence and strength of the recommendations.

Results: Using standardized diagnostic criteria, managing hypertension to conventional blood pressure targets, and reducing risk for stroke are strongly recommended. Intensive blood pressure lowering in middle-aged adults with vascular risk factors, using acetylsalicylic acid in persons with VCI and covert brain infarctions but not if only white matter lesions are present, and using cholinesterase inhibitors are weakly recommended.

Conclusions: The CCCDTD has provided evidence-based recommendations for diagnosis and management of VCI for use nationally in Canada, that may also be of use worldwide.
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http://dx.doi.org/10.1002/trc2.12056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7657196PMC
November 2020

Sex Differences in Antipsychotic and Benzodiazepine Prescribing Patterns: A Cohort Study of Newly Admitted Nursing Home Residents with Dementia in Ontario, Canada.

Drugs Aging 2020 11 26;37(11):817-827. Epub 2020 Sep 26.

ICES, Toronto, ON, M4N 3M5, Canada.

Background: In nursing homes, residents with dementia frequently receive potentially inappropriate medications that are associated with an increased risk of adverse events. Despite known sex differences in clinical presentation and sociodemographic characteristics among persons with dementia, few studies have examined sex differences in patterns and predictors of potentially inappropriate medication use.

Objectives: The objectives of this study were to examine sex differences in the patterns of antipsychotic and benzodiazepine use in the 180 days following admission to a nursing home, estimate clinical and sociodemographic predictors of antipsychotic and benzodiazepine use in male and female residents, and explore the effects of modification by sex on the predictors of using these drug therapies.

Methods: We conducted a retrospective cohort study of 35,169 adults aged 66 years and older with dementia who were newly admitted to nursing homes in Ontario, Canada between 2011 and 2014. Health administrative databases were linked to detailed clinical assessment data collected using the Resident Assessment Instrument (RAI-MDS 2.0). Cox proportional hazards models were adjusted for clinical and sociodemographic covariates to estimate the rate of antipsychotic and benzodiazepine initiation and discontinuation in the 180 days following nursing home admission in the total sample and stratified by sex. Sex-covariate interaction terms were used to assess whether sex modified the association between covariates and the rate of drug therapy initiation or discontinuation following nursing home entry.

Results: Across 638 nursing homes, our analytical sample included 22,847 females and 12,322 males. At admission, male residents were more likely to be prevalent antipsychotic users than female residents (33.8% vs 28.3%; p < 0.001), and female residents were more likely to be prevalent benzodiazepine users than male residents (17.2% vs 15.3%, p < 0.001). In adjusted models, female residents were less likely to initiate an antipsychotic after admission (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.73-0.86); however, no sex difference was observed in the rate of benzodiazepine initiation (HR 1.04, 95% CI 0.96-1.12). Female residents were less likely than males to discontinue antipsychotics (HR 0.89, 95% CI 0.81-0.98) and benzodiazepines (HR 0.82, 95% CI 0.75-0.89). Sex modified the association between some covariates and the rate of changes in drug use (e.g., widowed males exhibited an increased rate of antipsychotic discontinuation (p-interaction = 0.03) compared with married males), but these associations were not statistically significant among females. Sex did not modify the effect of frailty on the rates of initiation and discontinuation.

Conclusions: Males and females with dementia differed in their exposure to antipsychotics and benzodiazepines at nursing home admission and their patterns of use following admission. A greater understanding of factors driving sex differences in potentially inappropriate medication use may help tailor interventions to reduce exposure in this vulnerable population.
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http://dx.doi.org/10.1007/s40266-020-00799-2DOI Listing
November 2020

A Debatable Top Ten Papers in Geriatric Medicine List.

Authors:
David B Hogan

Can Geriatr J 2020 Sep 1;23(3):228-234. Epub 2020 Sep 1.

Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB.

A personal top ten list of literature about aging and the practice of geriatrics is offered. This is primarily directed at those completing their training in the care of older patients. While acknowledging the limitations of any such exercise, it is hoped that it will engender interest in prior work by and about older persons and their care. Those at the start of their careers in geriatrics are encouraged to read these and other primary contributions, make their own list of essential literature, and incorporate the lessons learned and the examples of prior practitioners into their professional practice.
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http://dx.doi.org/10.5770/cgj.23.440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458603PMC
September 2020

Comorbidities in Older Persons with Controlled HIV Infection: Correlations with Frailty Index Subtypes.

AIDS Patient Care STDS 2020 07;34(7):284-294

Department of Neurology and Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Frailty is prevalent in persons with human immunodeficiency virus (PWH), but factors predisposing older PWH to frailty remain uncertain. We examined factors associated with frailty and determined whether there were multiple frailty subtypes in older adults with controlled HIV infection. This was a cross-sectional outpatient study in an urban HIV clinic. Twenty-nine clinical indicators were extracted from medical records to compute a Frailty Index (FI) for 389 older (age 50+) PWH (range = 50-93; mean = 61.1, standard deviation = 7.2; 85% men) receiving HIV treatment in Calgary, Canada. We used regressions to identify factors associated with FI values. Latent class analysis was used to identify FI subtypes. Age, employment status, and duration of known HIV infection were the strongest predictors of FI (s < 0.05). Four FI subtypes were identified. Subtype 1 (severe metabolic dysfunction+polypharmacy) had the highest mean FI (0.30). Subtype 2 (less severe metabolic dysfunction+polypharmacy) and Subtype 3 (lung and liver dysfunction+polypharmacy) had lower but equivalent mean FIs (0.20 for each). Subtype 4 (least severe metabolic dysfunction) had the lowest mean FI (0.13; s < 0.001). Sociodemographic and behavioral characteristics differed among the subtypes. Individuals with Subtype 1 were older and more frequently unemployed/retired, whereas those with Subtype 3 were more likely to smoke, use crack/cocaine, have heavy alcohol use, and live in temporary/unstable housing. The clinical presentation of frailty in older PWH is heterogeneous. The metabolic syndrome, hepatitis C virus coinfection, cirrhosis, lung disease, and polypharmacy were associated with frailty as were unemployment/retirement, unstable housing, and substance use.
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http://dx.doi.org/10.1089/apc.2020.0051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8106245PMC
July 2020

Age Alone is not Adequate to Determine Health-care Resource Allocation During the COVID-19 Pandemic.

Can Geriatr J 2020 Mar 1;23(1):152-154. Epub 2020 Mar 1.

Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS.

Background: The Canadian Geriatrics Society (CGS) fosters the health and well-being of older Canadians and older adults worldwide. Although severe COVID-19 illness and significant mortality occur across the lifespan, the fatality rate increases with age, especially for people over 65 years of age. The dichotomization of COVID-19 patients by age has been proposed as a way to decide who will receive intensive care admission when critical care unit beds or ventilators are limited. We provide perspectives and evidence why alternative approaches should be used.

Methods: Practitioners and researchers in geriatric medicine and gerontology have led in the development of alternative approaches to using chronological age as the sole criterion for allocating medical resources. Evidence and ethical based recommendations are provided.

Results: Age alone should not drive decisions for health-care resource allocation during the COVID-19 pandemic. Decisions on health-care resource allocation should take into consideration the preferences of the patient and their goals of care, as well as patient factors like the Clinical Frailty Scale score based on their status two weeks before the onset of symptoms.

Conclusions: Age alone does not accurately capture the variability of functional capacities and physiological reserve seen in older adults. A threshold of 5 or greater on the Clinical Frailty Scale is recommended if this scale is utilized in helping to decide on access to limited health-care resources such as admission to a critical care unit and/or intubation during the COVID-19 pandemic.
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http://dx.doi.org/10.5770/cgj.23.452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279701PMC
March 2020

Blood Pressure Targets for Older Patients-Do Advanced Age and Frailty Really Not Matter?

Can Geriatr J 2020 Jun 1;23(2):205-209. Epub 2020 May 1.

Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

In 2017, Hypertension Canada removed advanced age and frailty as considerations for caution when deciding on intensive therapy in their guidelines for the diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Dementia is not mentioned. In this commentary, we review why advanced age and frailty were removed, and examine what is currently known about the relationship between hypertension and both incident and prevalent dementia. We make the case that the presence of frailty (especially when severe) and dementia should be considered when deciding on intensive therapy in future iterations of Hypertension Canada guidelines.
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http://dx.doi.org/10.5770/cgj.23.429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7259922PMC
June 2020

Outcomes with Biological Disease-Modifying Anti-Rheumatic Drugs (bDMARDs) in Older Patients Treated for Rheumatoid Arthritis.

Can Geriatr J 2020 Jun 1;23(2):184-189. Epub 2020 May 1.

Geriatrics, Internal Medicine, Division of Geriatric Medicine, University of Ottawa, Ottawa, ON, Canada.

Background: Biological disease-modifying antirheumatic drugs (bDMARDs) are recommended for rheumatoid arthritis (RA), but older patients reportedly experience more adverse events (AEs) and show variable treatment response. The objective of this study was to evaluate AEs and effectiveness of bDMARDs in a cohort of older patients.

Methods: AE and treatment effectiveness (based on DAS28 scores) data from a prospective provincial pharmacovigilance program for the years 2006-2009 in patients 55-64, 65-74, and 75+ years of age were compared. An intention to treat analysis with chi-square and unpaired -testing for significance was performed.

Results: There were a total of 333 patients (156 were aged 55-64, 125 were 65-74, 52 were 75+). Those 75+ had higher disease activity and worse functional status at baseline. Among those 75+, AEs with bDMARDs were more common and likely to lead to discontinuation of therapy, be graded as severe, and classified as infectious ( < .05). Remission rate among those 75+ was significantly higher than patients 65-74. Etanercept was the most commonly used drug in all age groups.

Conclusion: Patients 75+ treated with bDMARDs are at a significantly greater risk of AEs, including infectious ones. The higher remission found in the oldest age group warrants further study.
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http://dx.doi.org/10.5770/cgj.23.393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7259924PMC
June 2020

Evaluation of a balance and mobility program for older adults at risk of falling: a mixed methods study.

J Eval Clin Pract 2021 Apr 25;27(2):307-315. Epub 2020 May 25.

Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada.

Rational, Aims, And Objectives: The FallProof Balance and Mobility Program is a multifactorial fall prevention intervention that targets intrinsic risk factors such as muscle strength, balance, gait, and posture. Using mixed methods, we evaluated the implementation of the program for older adults at high risk of falling in the community.

Methods: A pre-post program evaluation and semi-structured interviews were used to evaluate FallProof Balance and Mobility Program offered to older adults who were recurrent fallers. Over a 1-year period, the 12-week program was offered five times. Feasibility, acceptability, and outcome evaluation along with semi-structured interviews were done. Over the course of the evaluation, participants were evaluated three times (baseline, 12, and 16 weeks).

Results: Of the 19 participants, who enrolled in the program, 16 completed the program and 12 attended at least 80% of the classes. Fourteen participants had mildly impaired cognition (Montreal Cognitive Assessment <26). Large gains (effect size 0.90) were seen with self-management (Partner-in-Health Scale). Participants were very satisfied with the program. Three themes emerged from the semi-structured interviews: (a) fall-related benefits, (b) variety of activities and motivating instructors, and (c) deterrents to participation.

Conclusion: Findings provided insights into pragmatic issues of implementing a balance and mobility program for older adults at risk of falling. The FallProof program was found to be feasible and acceptable in a small cohort of older adults from the community.
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http://dx.doi.org/10.1111/jep.13413DOI Listing
April 2021

Aerobic exercise improves cognition and cerebrovascular regulation in older adults.

Neurology 2020 05 13;94(21):e2245-e2257. Epub 2020 May 13.

From the Department of Physiology and Pharmacology (V.G., L.L.D., A.V.T., G.A.E., M.J.P.), Hotchkiss Brain Institute (V.G., L.L.D., A.V.T., R.S.L., M.D.H., D.B.H., M.J.P.), Division of Geriatric Medicine (D.B.H.), Department of Medicine, Department of Clinical Neurosciences (V.G., L.L.D., A.V.T., M.D.H., D.B.H., M.J.P.), Libin Cardiovascular Institute of Alberta (T.J.A., M.J.P.), O'Brien Institute for Public Health (V.G., D.B.H., M.J.P.), Department of Cardiac Sciences (T.J.A.), Libin Cardiovascular Institute of Alberta, and Department of Community Health Sciences (M.D.H.), Cumming School of Medicine, Faculty of Kinesiology (M.J.P.), and Department of Psychology (R.S.L.), University of Calgary; Psychology Service (R.S.L.), Alberta Health Service, Foothills Medical Centre, Calgary; Department of Psychiatry (G.A.E.), Faculty of Medicine, and Department of Psychology and Neuroscience (G.A.E.), Faculty of Science, Dalhousie University, Halifax, Nova Scotia; and Program for Pregnancy and Postpartum Health, Physical Activity and Diabetes Laboratory (M.H.D.), Faculty of Kinesiology, Sport, and Recreation, Women and Children's Health Research Institute, Alberta Diabetes Institute, University of Alberta, Edmonton, Canada.

Objective: To test the hypothesis that aerobic exercise is associated with improvements in cognition and cerebrovascular regulation, we enrolled 206 healthy low-active middle-aged and older adults (mean ± SD age 65.9 ± 6.4 years) in a supervised 6-month aerobic exercise intervention and assessed them before and after the intervention.

Methods: The study is a quasi-experimental single group pre/postintervention study. Neuropsychological tests were used to assess cognition before and after the intervention. Transcranial Doppler ultrasound was used to measure cerebral blood flow velocity. Cerebrovascular regulation was assessed at rest, during euoxic hypercapnia, and in response to submaximal exercise. Multiple linear regression was used to examine the association between changes in cognition and changes in cerebrovascular function.

Results: The intervention was associated with improvements in some cognitive domains, cardiorespiratory fitness, and cerebrovascular regulation. Changes in executive functions were negatively associated with changes in cerebrovascular resistance index (CVRi) during submaximal exercise (β = -0.205, = 0.013), while fluency improvements were positively associated with changes in CVRi during hypercapnia (β = 0.106, 0.03).

Conclusion: The 6-month aerobic exercise intervention was associated with improvements in some cognitive domains and cerebrovascular regulation. Secondary analyses showed a novel association between changes in cognition and changes in cerebrovascular regulation during euoxic hypercapnia and in response to submaximal exercise.
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http://dx.doi.org/10.1212/WNL.0000000000009478DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7357295PMC
May 2020

Canadian Geriatrics in the Time of COVID-19.

J Am Geriatr Soc 2020 Jun 11;68(6):1173-1174. Epub 2020 May 11.

Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1111/jgs.16518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267568PMC
June 2020

Association of sleep spindle characteristics with executive functioning in healthy sedentary middle-aged and older adults.

J Sleep Res 2021 04 12;30(2):e13037. Epub 2020 Apr 12.

Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

To determine the relationship between sleep spindle characteristics (density, power and frequency), executive functioning and cognitive decline in older adults, we studied a convenience subsample of healthy middle-aged and older participants of the Brain in Motion study. Participants underwent a single night of unattended in-home polysomnography with neurocognitive testing carried out shortly afterwards. Spectral analysis of the EEG was performed to derive spindle characteristics in both central and frontal derivations during non-rapid eye movement (NREM) Stage 2 and 3. Multiple linear regressions were used to examine associations between spindle characteristics and cognitive outcomes, with age, body mass index (BMI), periodic limb movements index (PLMI) and apnea hypopnea index (AHI) as covariates. NREM Stage 2 total spindle density was significantly associated with executive functioning (central: β = .363, p = .016; frontal: β = .408, p = .004). NREM Stage 2 fast spindle density was associated with executive functioning (central: β = .351, p = .022; frontal: β = .380, p = .009) and Montreal Cognitive Assessment score (MoCA, central: β = .285, p = .037; frontal: β = .279, p = .032). NREM Stage 2 spindle frequency was also associated with MoCA score (central: β = .337, p = .013). Greater spindle density and fast spindle density were associated with better executive functioning and less cognitive decline in our study population. Our cross-sectional design cannot infer causality. Longitudinal studies will be required to assess the ability of spindle characteristics to predict future cognitive status.
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http://dx.doi.org/10.1111/jsr.13037DOI Listing
April 2021

Resident-Level Predictors of Dementia Pharmacotherapy at Long-Term Care Admission: The Impact of Different Drug Reimbursement Policies in Ontario and Saskatchewan: Prédicteurs de la pharmacothérapie de la démence au niveau des résidents lors de l'hospitalisation dans des soins de longue durée : l'impact de différentes politiques de remboursement des médicaments en Ontario et en Saskatchewan.

Can J Psychiatry 2020 11 10;65(11):790-801. Epub 2020 Apr 10.

50010ICES, Toronto, Ontario, Canada.

Objectives: Cholinesterase inhibitors (ChEIs) and memantine are approved for Alzheimer disease in Canada. Regional drug reimbursement policies are associated with cross-provincial variation in ChEI use, but it is unclear how these policies influence predictors of use. Using standardized data from two provinces with differing policies, we compared resident-level characteristics associated with dementia pharmacotherapy at long-term care (LTC) admission.

Methods: Using linked clinical and administrative databases, we examined characteristics associated with dementia pharmacotherapy use among residents with dementia and/or significant cognitive impairment admitted to LTC facilities in Saskatchewan (more restrictive reimbursement policies; = 10,599) and Ontario (less restrictive; = 93,331) between April 1, 2009, and March 31, 2015. Multivariable logistic regression models were utilized to assess resident demographic, functional, and clinical characteristics associated with dementia pharmacotherapy.

Results: On admission, 8.1% of Saskatchewan residents were receiving dementia pharmacotherapy compared to 33.2% in Ontario. In both provinces, residents with severe cognitive impairment, aggressive behaviors, and recent antipsychotic use were more likely to receive dementia pharmacotherapy; while those who were unmarried, admitted in later years, had a greater degree of frailty, and recent hospitalizations were less likely. The direction of the association for older age, rural residency, medication number, and anticholinergic therapy differed between provinces.

Conclusions: While more restrictive criteria for dementia pharmacotherapy coverage in Saskatchewan resulted in fewer residents entering LTC on dementia pharmacotherapy, there were relatively few differences in the factors associated with use across provinces. Longitudinal studies are needed to assess how differences in prevalence and characteristics associated with use impact patient outcomes.
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http://dx.doi.org/10.1177/0706743720909293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564697PMC
November 2020

Canadian Guidelines on Benzodiazepine Receptor Agonist Use Disorder Among Older Adults Title.

Can Geriatr J 2020 Mar 30;23(1):116-122. Epub 2020 Mar 30.

Department of Psychiatry, University of Montreal, Montreal, QC.

Background: Benzodiazepine receptor agonist (BZRA) use disorder among older adults is a relatively common and challenging clinical condition.

Method: The Canadian Coalition for Seniors' Mental Health, with financial support from Health Canada, has produced evidence-based guidelines on the prevention, identification, assessment, and management of this form of substance use disorder.

Results: Inappropriate use of BZRAs should be avoided by considering non-pharmacological approaches to the management of late life insomnia, anxiety, and other common indications for the use of BZRA. Older persons should only be prescribed BZRAs after they are fully informed of alternatives, benefits, and risks associated with their use. Clinicians should have a high index of suspicion for the presence of BZRA use disorders. The full version of these guidelines can be accessed at www.ccsmh.ca.

Conclusions: A person-centred, stepped care approach utilizing gradual dose reductions should be used in the management of BZRA use disorder.
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http://dx.doi.org/10.5770/cgj.23.419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7067147PMC
March 2020

Impact of aerobic exercise, sex, and metabolic syndrome on markers of oxidative stress: results from the study.

J Appl Physiol (1985) 2020 04 27;128(4):748-756. Epub 2020 Feb 27.

Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

Oxidative stress may be involved in disease pathology and dependent on both modifiable and nonmodifiable factors. This study aimed to assess exercise-induced changes in markers of oxidative stress among older, sedentary adults and to determine the effects of metabolic syndrome (MetS) status, aerobic capacity, age, sex, and weight on these biomarkers. Two hundred and six participants (means ± SE; 66.8 ± 6.4 yr, 104 women) of the study underwent a 6-mo aerobic exercise intervention. At three time points, venous blood samples were collected and analyzed for markers of oxidative stress [advanced oxidation protein products (AOPP), malondialdehyde (MDA), 3-nitrotyrosine (3-NT) and antioxidant status: catalase, uric acid (UA), superoxide dismutase (SOD), and ferric-reducing ability of plasma (FRAP)]. AOPP levels significantly decreased after 6 mo of aerobic exercise ( = 0.003). This decrease was not modified by MetS status ( = 0.183). Subjects with MetS possessed significantly higher levels of AOPP ( < 0.001), MDA ( = 0.004), and FRAP ( = 0.049) across the intervention (). Men possessed significantly higher levels of FRAP ( < 0.001), catalase ( = 0.023), and UA ( = 0.037) across the intervention (). Sex-MetS status interaction analyses revealed that the effect of MetS is highly sex dependent. These findings are multifaceted because the effect of MetS status seems distinctly different between sexes, pointing to the importance of acknowledging modifiable and nonmodifiable factor differences in individuals who possess conditions where oxidative stress may be part of the etiology. Oxidative stress is implicated in a myriad of conditions, namely cardiovascular disease risk factors. This article details the effect of aerobic exercise, sex, and metabolic syndrome on markers of oxidative stress. We conclude that 6 mo of aerobic exercise significantly decreased oxidative stress, and further, that there is an effect of metabolic syndrome status on oxidative stress and antioxidant status levels, which are highly dependent on the sex of the individual.
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http://dx.doi.org/10.1152/japplphysiol.00667.2019DOI Listing
April 2020

An Emerging Concern-High Rates of Frailty among Middle-aged and Older Individuals Living with HIV.

Can Geriatr J 2019 Dec 30;22(4):190-198. Epub 2019 Dec 30.

Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.

Background: The aim of the present study was to calculate a frailty index (FI) in older adults (≥50) living with HIV, search for cross-sectional associations with the FI, and investigate the association between the FI score and two-year mortality.

Methods: Cross-sectional study with a short-term prospective component for the determination of two-year mortality was performed. The study took place in an HIV outpatient clinic in Calgary, Canada between November 1, 2016 and December 31, 2018. Over 700 patients 50 years of age or older took part. We calculated a FI for each patient, examined associations between FI and select patient characteristics, and evaluated the association between FI value and two-year mortality.

Results: The mean FI was 0.303 (± 0.128). Mean FI did not differ between males and females, nor was it associated with either nadir or current CD4 cell count. It did increase with age, duration of ART, and duration of diagnosed HIV infection. Mean FI was higher among those who died compared to survivors (0.351 vs. 0.301; =.033).

Conclusions: Frailty is highly prevalent in persons living with HIV and associated with a higher mortality rate. Health-care providers should be aware of the earlier occurrence of frailty in adults living with HIV.
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http://dx.doi.org/10.5770/cgj.22.387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887139PMC
December 2019

Investigation of antihypertensive class, dementia, and cognitive decline: A meta-analysis.

Neurology 2020 01 11;94(3):e267-e281. Epub 2019 Dec 11.

From Neuroscience Research Australia (R.P., K.J.A.); University of New South Wales (R.P., C.A., H.B., J.C., P.S.S., K.J.A.), Sydney, Australia; Johns Hopkins University (S.Y., M.C.C.), Baltimore, MD; The George Institute for Global Health (C.A., J.C.), Sydney, Australia; The George Institute China at Peking University Health Sciences Center (C.A.), Beijing, China; Icahn School of Medicine at Mount Sinai (S.A.), New York, NY; Center for Life Course Health Research/Geriatrics (R.A., S.K.-K., S.S., E.V.), University of Oulu; Medical Research Center Oulu (R.A.), Oulu University Hospital; Oulu City Hospital (R.A.), Finland; Department of Preventive Medicine and Public Health (H.A.), Fukuoka University, Japan; Guys and St Thomas' NHS Foundation Trust (N.B.), London, UK; University of Pittsburgh (J.C.B., M.G.), PA; Leiden University Medical Centre (A.S.B., S.T.), the Netherlands; University of Sheffield (A.B., J.P.), UK; School for Mental Health and Neuroscience, Department of Psychiatry and Neuropsychology (M.v.B., S.K.), Maastricht University, the Netherlands; University of Cambridge (C.B.), UK; University of California (M.C., C.K.), Irvine; University of Florida (S.D.), Gainesville; Albert Einstein College of Medicine (C.D., M.K.), New York, NY; University of Alberta (R.A.D., G.P.M.), Edmonton, Canada; International Longevity Centre (F.F.), Paris, France; University of Amsterdam (W.A.v.G., E.P.M.v.C.), the Netherlands; Golgi Cenci Foundation (A.G., R.V.), Milan, Italy; Trinity College Dublin (A.H., R.A.K.), Ireland; University of Calgary (D.B.H.), Canada; Newcastle University (C.J., B.C.M.S.), Newcastle upon Tyne; University of Bristol (P.G.K., S.K.K.), UK; University of Eastern Finland (J.L.), Kuopio; Faculty of Sport and Health Sciences, University of Jyväskylä (J.L.), Finland; School of Pharmacy, University of Waterloo (C.M.), Ontario, Canada; Academic Medical Center (T.v.M., E.R.), Amsterdam; Donders Institute for Brain, Cognition and Behaviour (T.v.M., E.R.), Radboud University Medical Center, Nijmegen, the Netherlands; National University of Singapore (T.-P.N.); Sengkang General Hospital (I.R.), Singhealth Duke-NUS Academic Medical Centre, Singapore; Dalhousie University (K.R.), Halifax, Canada; Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy (L.R., I.S.), and Department of Psychology (J.S.), Centre for Ageing and Health (AgeCap) at the University of Gothenburg, Sweden; University of Leuven (J.A.S., L.T.), Belgium; Bordeaux Population Health Research Center (P.J.T., C.T.), UMR 1219, CHU Bordeaux, University of Bordeaux, Inserm, France; University of Adelaide (P.J.T.); Australian National University (E.W.), Canberra, Australia; and University of Warwick (J.W.), Coventry, UK.

Objective: High blood pressure is one of the main modifiable risk factors for dementia. However, there is conflicting evidence regarding the best antihypertensive class for optimizing cognition. Our objective was to determine whether any particular antihypertensive class was associated with a reduced risk of cognitive decline or dementia using comprehensive meta-analysis including reanalysis of original participant data.

Methods: To identify suitable studies, MEDLINE, Embase, and PsycINFO and preexisting study consortia were searched from inception to December 2017. Authors of prospective longitudinal human studies or trials of antihypertensives were contacted for data sharing and collaboration. Outcome measures were incident dementia or incident cognitive decline (classified using the reliable change index method). Data were separated into mid and late-life (>65 years) and each antihypertensive class was compared to no treatment and to treatment with other antihypertensives. Meta-analysis was used to synthesize data.

Results: Over 50,000 participants from 27 studies were included. Among those aged >65 years, with the exception of diuretics, we found no relationship by class with incident cognitive decline or dementia. Diuretic use was suggestive of benefit in some analyses but results were not consistent across follow-up time, comparator group, and outcome. Limited data precluded meaningful analyses in those ≤65 years of age.

Conclusion: Our findings, drawn from the current evidence base, support clinical freedom in the selection of antihypertensive regimens to achieve blood pressure goals.

Clinical Trials Registration: The review was registered with the international prospective register of systematic reviews (PROSPERO), registration number CRD42016045454.
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http://dx.doi.org/10.1212/WNL.0000000000008732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7108807PMC
January 2020

The Comprehensive Assessment of Neurodegeneration and Dementia: Canadian Cohort Study.

Can J Neurol Sci 2019 09 16;46(5):499-511. Epub 2019 Jul 16.

Toronto Rehabilitation Institute, Toronto, Ontario, Canada.

Background: The Comprehensive Assessment of Neurodegeneration and Dementia (COMPASS-ND) cohort study of the Canadian Consortium on Neurodegeneration in Aging (CCNA) is a national initiative to catalyze research on dementia, set up to support the research agendas of CCNA teams. This cross-country longitudinal cohort of 2310 deeply phenotyped subjects with various forms of dementia and mild memory loss or concerns, along with cognitively intact elderly subjects, will test hypotheses generated by these teams.

Methods: The COMPASS-ND protocol, initial grant proposal for funding, fifth semi-annual CCNA Progress Report submitted to the Canadian Institutes of Health Research December 2017, and other documents supplemented by modifications made and lessons learned after implementation were used by the authors to create the description of the study provided here.

Results: The CCNA COMPASS-ND cohort includes participants from across Canada with various cognitive conditions associated with or at risk of neurodegenerative diseases. They will undergo a wide range of experimental, clinical, imaging, and genetic investigation to specifically address the causes, diagnosis, treatment, and prevention of these conditions in the aging population. Data derived from clinical and cognitive assessments, biospecimens, brain imaging, genetics, and brain donations will be used to test hypotheses generated by CCNA research teams and other Canadian researchers. The study is the most comprehensive and ambitious Canadian study of dementia. Initial data posting occurred in 2018, with the full cohort to be accrued by 2020.

Conclusion: Availability of data from the COMPASS-ND study will provide a major stimulus for dementia research in Canada in the coming years.
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http://dx.doi.org/10.1017/cjn.2019.27DOI Listing
September 2019

Effect of aerobic exercise on white matter microstructure in the aging brain.

Behav Brain Res 2019 11 4;373:112042. Epub 2019 Jul 4.

Department of Physiology and Pharmacology, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada. Electronic address:

Aging is associated with decline in white matter (WM) microstructure, decreased cognitive functioning, and increased risk of Alzheimer's disease and related dementias. Recent research has identified aerobic physical exercise as a promising intervention for increasing white matter microstructure in aging, with the aim of increasing cognitive abilities, and protecting against neurodegenerative processes. However, the degree to which white matter microstructure can be protected or improved with exercise remains incompletely understood. Here, a sub-group of 25 healthy, sedentary participants (aged 57 to 86 years; M = 67.1; SD = 7.9; 11 female, 14 male) from the larger Brain in Motion Study (Tyndall et al., 2013) underwent diffusion tensor imaging (DTI) before and after a six-month aerobic exercise intervention. DTI data were analysed with FSL's Tract-Based Spatial Statistics (TBSS) to determine whether WM microstructure improved, as defined by increased fractional anisotropy (FA) and/or decreased mean diffusivity (MD), after the aerobic exercise intervention. Neither FA nor MD of the cerebral WM were significantly correlated with either age or cardiovascular fitness at baseline. Whole-brain WM mean FA decreased over the intervention while mean MD showed no significant change. Longitudinal TBSS analyses revealed decreased FA in the left uncinate fasciculus, left anterior corona radiata, left inferior fronto-occipital fasciculus, and left anterior thalamic radiation. MD increased in the left forceps major, left inferior longitudinal fasciculus, and left superior longitudinal fasciculus. Results indicate that six months of aerobic exercise in healthy, sedentary older adults was not associated with improvements in FA or MD measures of cerebral WM microstructure.
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http://dx.doi.org/10.1016/j.bbr.2019.112042DOI Listing
November 2019

Joint impact of dementia and frailty on healthcare utilisation and outcomes: a retrospective cohort study of long-stay home care recipients.

BMJ Open 2019 06 21;9(6):e029523. Epub 2019 Jun 21.

Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.

Objectives: To examine the associations between dementia and 1-year health outcomes (urgent hospitalisation, long-term care (LTC) admission, mortality) among long-stay home care recipients and the extent to which these associations vary by clients' frailty level.

Design: A retrospective cohort study using linked clinical and health administrative databases.

Setting: Home care in Ontario, Canada.

Participants: Long-stay (≥60 days) care clients (n=153 125) aged ≥50 years assessed between April 2014 and March 2015.

Main Outcome Measures: Dementia was ascertained with a validated administrative data algorithm and frailty with a 66-item frailty index (FI) based on a previously validated FI derived from the clinical assessment. We examined associations between dementia, FI and their interactions, with 1-year outcomes using multivariable Fine-Gray competing risk (urgent hospitalisation and LTC admission) and Cox proportional hazards (mortality) models.

Results: Clients with dementia (vs without) were older (mean±SD, 83.3±7.9 vs 78.9±11.3 years, p<0.001) and more likely to be frail (30.3% vs 24.2%, p<0.001). In models adjusted for FI (as a continuous variable) and other confounders, clients with dementia showed a lower incidence of urgent hospitalisation (adjusted subdistribution HR (sHR)=0.84, 95% CI: 0.83 to 0.86) and mortality rate (adjusted HR=0.87, 95% CI: 0.84 to 0.89) but higher incidence of LTC admission (adjusted sHR=2.60, 95% CI: 2.53 to 2.67). The impact of dementia on LTC admission and mortality was significantly modified by clients' FI (p<0.001 interaction terms), showing a lower magnitude of association (ie, attenuated positive (for LTC admission) and negative (for mortality) association) with increasing frailty.

Conclusions: The strength of associations between dementia and LTC admission and death (but not urgent hospitalisation) among home care recipients was significantly modified by their frailty status. Understanding the public health impact of dementia requires consideration of frailty levels among older populations, including those with and without dementia and varying degrees of multimorbidity.
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http://dx.doi.org/10.1136/bmjopen-2019-029523DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6596979PMC
June 2019

The Incremental Health Care Costs of Frailty Among Home Care Recipients With and Without Dementia in Ontario, Canada: A Cohort Study.

Med Care 2019 07;57(7):512-520

ICES.

Objective: In this study, we investigated the incremental 1-year direct costs of health care associated with frailty among home care recipients in Ontario with and without dementia.

Methods: We conducted a cohort study of 159,570 home care clients aged 50 years and older in Ontario, Canada in 2014/2015. At index home care assessment, we ascertained dementia status using a validated algorithm and frailty level (robust, prefrail, frail) based on the proportion of accumulated to potential health deficits. Clients were followed for 1-year during which we obtained direct overall and sector-specific publicly-funded health care costs (in 2015 Canadian dollars). We estimated the incremental effect of frailty level on costs using a 3-part survival- and covariate-adjusted estimator. All analyses were stratified by dementia status.

Results: Among those with dementia (n=42,828), frailty prevalence was 32.1% and the average 1-year cost was $30,472. The incremental cost of frailty (vs. robust) was $10,845 [95% confidence interval (CI): $10,112-$11,698]. Among those without dementia (n=116,742), frailty prevalence was 25.6% and the average 1-year cost was $28,969. Here, the incremental cost of frailty (vs. robust) was $12,360 (95% CI: $11,849-$12,981). Large differences in survival between frailty levels reduced incremental cost estimates, particularly for the dementia group (survival effect: -$2742; 95% CI: -$2914 to -$2554).

Conclusions: Frailty was associated with greater 1-year health care costs for persons with and without dementia. This difference was driven by a greater intensity of health care utilization among frail clients. Mortality differences across the frailty levels mitigated the association especially among those with dementia.
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http://dx.doi.org/10.1097/MLR.0000000000001139DOI Listing
July 2019

Effects of Six-Month Aerobic Exercise Intervention on Sleep in Healthy Older Adults in the Study: A Pilot Study.

J Alzheimers Dis Rep 2018 Dec 24;2(1):229-238. Epub 2018 Dec 24.

Department of Physiology and Pharmacology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.

Background: Sleep disturbances have been shown to be associated with the presence of the apolipoprotein () 4 allele, the well-known genetic risk factor for late-onset sporadic Alzheimer's disease (AD).

Objective: This study quantifies the effects of a six-month aerobic exercise intervention on objective and subjective sleep quality in middle-aged to older individuals including those at increased genetic risk for late-onset sporadic Alzheimer's disease (AD), who carry the apolipoprotein () 4 risk allele.

Methods: 199 sedentary men and women without significant cognitive impairments were enrolled in the study, a quasi-experimental single group pre-test/post-test study with no control group. Participants completed a six-month aerobic exercise intervention and consented to genetic testing. Genotyping of confirmed that 54 individuals were carriers of the 4 allele. Participants' subjective quality of sleep was assessed with the Pittsburgh Sleep Quality Index (PSQI) pre- and post-intervention. A convenience sample of participants ( = 29, 4+ = 7) consented to undergo two nights of in-home polysomnography (PSG) pre- and post intervention. Sleep architecture and respiratory variables were assessed.

Results: The six-month aerobic exercise intervention significantly improved participants' total PSQI score, sleep efficiency, and sleep latency in the full sample ( = 199). PSG results showed that total sleep time and sleep onset latency significantly improved over the course of the exercise intervention only in individuals who carried the 4 allele. These results are, however, exploratory and need to be carefully interpreted due to the rather small number of 4+ in the PSG subgroup.

Conclusions: The six-month aerobic exercise intervention significantly improved participants' sleep quality with beneficial effects on PSG shown in individuals at increased genetic risk for late-onset sporadic AD.
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http://dx.doi.org/10.3233/ADR-180079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6311349PMC
December 2018
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