APOE allele frequencies in demented and nondemented elderly Jamaicans.
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Biomedical subjects
H C Hendrie
Publications and source records attributed to H C Hendrie.
Epidemiology of dementia and Alzheimer's disease.
The prevalence of dementia in subjects 65 years and older in North America is approximately 6%-10%, with Alzheimer's disease (AD) accounting for two-thirds of these cases. If milder cases are included, the prevalence rates double. Both causative and associative genes for AD have now been identified. The search for nongenetic risk factors has been less conclusive. Only age and family history of dementia are consistently associated with AD in all studies, but putative, protective agents such as estrogen, nonsteroidal anti-inflammatory agents (NSAIDs), and vitamin E are now undergoing clinical trials.
Age Distribution↗
Cognitive decline and education in mild dementia.
Recent studies suggested that education may modify the clinical expression of dementia and Alzheimer's disease through its association with a brain reserve capacity. We studied whether education would be related to degree of cognitive decline in mild dementia. Equations to estimate premorbid cognitive ability were derived from a representative normative sample of 83 community-dwelling African Americans using age, education, and gender as independent variables and Word List Learning (WLL) and Animal Fluency (AF) scores from the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological test battery as dependent variables. These equations were applied to a second sample of 131 African Americans (22 with dementia, 109 healthy) who completed CERAD test batteries as part of an epidemiologic study of dementia in the community. Differences between obtained and estimated premorbid WLL and AF test scores were calculated and then analyzed in a 2 (Education) x 2 (Diagnosis) ANOVA. A significant interaction association between Education and Diagnosis on WLL scores and a borderline significant interaction on AF scores showed that the high-education demented group had a greater cognitive decline from estimated premorbid levels than the low-education demented group. Thus, at comparable levels of clinical dementia severity, greater cognitive decline occurred in highly educated patients than in low-educated patients.
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Risk factors and Alzheimer's disease: a comparative study of two communities.
OBJECTIVE: To determine the association between demographic, lifestyle and medical history factors to Alzheimer's disease (AD), we studied samples of two community dwelling populations with significantly different prevalence rates of AD in Indianapolis, USA (6.24%) and Ibadan, Nigeria (1.4%). METHODS: The samples were drawn from African-American community dwelling residents 65 years of age and over in Indianapolis, and Yoruba community-dwelling residents 65 years of age and over in Ibadan. A two-stage epidemiological design was used in which diagnosis of AD was by National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association criteria. RESULTS: In Indianapolis, age (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 1.11-1.21), family history of dementia (OR = 5.40; 95% CI = 1.99-14.62), low education (0-6 years, OR = 3.49; 95% CI = 1.06-11.48) and rural residence (OR = 2.49; 95% CI = 1.05-5.88) were associated with a higher risk of AD. In Ibadan, age (OR = 1.15; 95% CI = 1.12-1.18) and female gender (OR = 13.9; 95% CI = 3.85-50.28) were associated with a higher risk of AD. CONCLUSIONS: The remarkably similar odds ratios between age and AD between sites suggest that biological processes associated with ageing are essential elements in the development of AD but that genetic and environmental risk factors may alter age-specific rates. In our longitudinal study, we intend to investigate in more depth the interaction between these ageing, genetic and environmental factors.
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Apolipoprotein E-associated risk for Alzheimer's disease in the African-American population is genotype dependent.
As a part of our ongoing study on Alzheimer's disease (AD) in elderly African Americans, we obtained clinical assessment and apolipoprotein E (ApoE) genotype data on 288 individuals (including 60 with AD). The ApoE epsilon4 allele frequency was significantly increased in AD patients compared with controls. The age-adjusted odds ratio (OR) for AD in epsilon4 homozygotes was 4.83 (95% confidence interval [CI], 1.71-13.64) compared with the epsilon3/epsilon3 genotype, but the OR for AD with the epsilon3/epsilon4 genotype did not reach significance (1.20; 95% CI, 0.58-2.45). These findings suggest that the association between ApoE epsilon4 and AD is weaker in African Americans than in whites.
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The dementing disorders.
Dementing disorders are found most commonly in the elderly. However, the approaches derived from the diagnosis and management of these patients exemplify principles which can equally well be applied to the management of psychiatric disorders in younger patients. These principles include the process of syndromic diagnosis, the need for multi-dimensional assessment, the recognition of the interaction of biological and psycho-social factors in the etiology and treatment of psychiatric symptoms and the crucial role of the family in the management of patients with dementia. In this paper these principles are discussed.
Activities of Daily Living↗
The association between Apo E genotype and depressive symptoms in elderly African-American subjects.
In this study of 138 elderly subjects (112 without and 26 with dementia) obtained from a community sample of elderly African-American subjects, there were no significant differences in mean Geriatric Depression Scale scores by Apo E epsilon 4 status for dementia or nondementia subjects. Three subjects received a diagnosis of major depressive disorder. None of these subjects were Apo E epsilon 4-positive. These results do not support an association between depressive symptoms and Apo E allele status in this elderly African-American population.
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Profile of dementia in a Nigerian community--types, pattern of impairment, and severity rating.
Out of 2494 subjects screened in a Nigerian community, 28 patients with dementia were identified. Alzheimer's disease was diagnosed in 18 patients (64.3%), 16 of whom had probable Alzheimer's disease. Eight patients (28.6%) had vascular dementia while one patient each had parkinsonism with dementia and depression with dementia. Patients with Alzheimer's disease were significantly older, predominantly females and illiterates. Cognitive deficit commonly took the form of memory and judgment impairment while financial mismanagement was the most frequent impaired activity of daily living. More than half of the cases had mild disease on severity rating and were comprised mainly of Alzheimer's disease subjects. These results confirm the higher frequency of Alzheimer's disease over the other types as reported in other communities.
Age Distribution↗
Epidemiology of Alzheimer's disease.
Epidemiologic studies of disease fall into two large categories: descriptive and analytic. Both approaches have been used in studies of dementia and Alzheimer's disease (AD). The prevalence of dementia in persons age 65 and older in North America is approximately 6 to 10%, with AD accounting for two-thirds of these cases. If milder cases are included, the prevalence rates double. Only age and family history of dementia are consistently associated with AD in all studies, but putative protective agents such as estrogen, NSAIDs, and vitamin E are undergoing clinical trials.
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Relationship of age, education, and occupation with dementia among a community-based sample of African Americans.
OBJECTIVE: To explore the relationship between age, education, and occupation with dementia among African Americans. DESIGN: Community-based survey to identify subjects with and without evidence of cognitive impairment and subsequent diagnostic evaluation of a stratified sample of these subjects using formal diagnostic criteria for dementia. SETTING: Urban neighborhoods in Indianapolis, Ind. SUBJECTS: A random sample of 2212 African Americans aged 65 years and older residing in 29 contiguous census tracts. MEASUREMENTS: Subjects's scores on the Community Screening Instrument for Dementia (CSI-D), formal diagnostic clinical assessments for dementia, years of education, rural residence, primary occupation, self-reported disease, and alcohol and smoking history. Caseness was defined by four separate criteria: (1) cognitive impairment as defined by the subject's performance on the CSI-D cognitive scale; (2) cognitive impairment as defined by the total CSI-D score that included a relative's assessment of the subject's functional abilities; (3) dementia as defined by explicit diagnostic criteria; and (4) possible or probable Alzheimer's disease as defined by explicit diagnostic criteria. RESULTS: The mean age was 74 years (age range, 65 to 100 years), 65% of subjects were women, the mean education was 9.6 years (age range, 0 to 16 years), 98% of the subjects were literate, and 32% reported living in a rural area until age 19 years. Service, domestic, and production occupations accounted for 55.2% of the subjects' primary occupations with a mean of 25.8 years (range, 1 to 75 years) in the primary occupation. Years of education, rural residence to age 60 years, and primary occupation were highly correlated. Caseness defined by any of the four criteria was associated with functional impairment, but the frequency of impairment increased with increasing diagnostic specificity. Age, education, and rural residence to age 60 years were significantly independently associated with caseness for cognitive impairment, dementia, and Alzheimer's type dementia. White-collar occupation was independently associated only with caseness for cognitive impairment. History of stroke was associated with caseness for cognitive impairment and dementia but not Alzheimer's disease, while history of smoking was negatively correlated with Alzheimer's disease. CONCLUSIONS: Education was independently associated with cognitive impairment and dementia among a representative community-based sample of African Americans and the association remains significant across a variety of sensitivity analyses designed to control for measurement and confounding biases. The potential protective role of education against the development of dementia among African Americans deserves further evaluation.
Black or African American↗
Cross-cultural perspectives: Caribbean, Native American, and Yoruba.
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Black or African American↗
The relationship between alcohol consumption, cognitive performance, and daily functioning in an urban sample of older black Americans.
OBJECTIVE: To report on moderate alcohol consumption and measurements of cognitive function and activities of daily living in an older, urban, community-dwelling sample of black Americans. DESIGN: As part of a community prevalence study of dementia, information on alcohol consumption and cognitive performance was collected on 2040 randomly selected black subjects living in Indianapolis. MEASUREMENTS: From questions in the screening interview, alcohol consumption was grouped into four categories: lifetime abstainers, regular drinkers less than 4 drinks per week, 4 to 10 drinks per week, and more than 10 drinks per week. Current and past drinkers were analyzed separately. Three measurements were used: (1) a total cognitive score; (2) the delayed recall score from the East Boston Memory Test; (3) a score for daily functioning based upon information from the informant. Multiple regression models were fitted with drinking variables as the major predictor, including covariates of age, gender, education, history of stroke, hypertension, being treated for depression, and a family history of dementia. MAIN RESULTS: In all analyses, there was a very consistent pattern for both current and past drinkers. There was a small but significant dose effect of drinking for the drinkers, with subjects in the heaviest drinking category scoring poorest, i.e., lowest scores in cognitive tests and highest scores in scales of daily functioning indicating more impairment. The scores of abstainers were worse than those of subjects in the lightest drinking category. The pattern of scores for cognitive performance and daily functioning was similar between current and past drinkers. These patterns remained the same even after potential confounders were included. CONCLUSIONS: Previous research on effects of alcohol on health indices have suggested a J-shaped relationship between amounts of alcohol consumption and measurements of heart disease, stroke, and mortality rates. Our study provides some support for the concept of a similar J-shaped relationship between cognitive performance and alcohol consumption, but the differences between drinking categories were modest and the clinical significance of these findings uncertain.
Activities of Daily Living↗
Suicidal ideation among older primary care patients.
OBJECTIVE: To describe the prevalence and sociodemographic and clinical correlates of suicidal ideation among older primary care patients. DESIGN: Baseline screening for depressive symptoms, functional status, and suicidal ideation, with prospective assessment of mortality. SETTING: An academic primary care group practice at an ambulatory care clinic. PARTICIPANTS: 301 patients who screened positive for depression and a random sample of 101 patients who screened negative from among 3767 patients aged 60 and older who completed screening for depression during routine office visits. MEASUREMENTS: Centers for Epidemiologic Studies Depression (CES-D) scale, Hamilton Depression Rating (HAM-D) scale, Sickness Impact Profile (SIP), structured psychiatric interview, sociodemographic and clinical variables, and mortality. RESULTS: Among the 301 patients with CES-D scores > or = 16, 14 (4.6%) reported suicidal ideation and received urgent evaluation by mental health professionals. The estimated prevalence of suicidal ideation in this cohort of older primary care patients was 0.7 to 1.2%. All patients with suicidal ideation had evidence of a current affective disorder, and nearly all had moderate to severe functional impairment. However, even though all 14 patients endorsed suicidal ideation, corresponding HAM-D scores ranged from 3 to 40, and only four of 14 met diagnostic criteria for major depression. The most common suicide plan involved use of a hand gun. Depressed patients with suicidal ideation did not differ significantly from depressed non-suicidal patients on any of the following variables: age, gender, race, education, alcohol abuse, cognitive impairment, or mean CES-D, HAM-D, or SIP scores. None of the suicidal patients had died within 12 months of the screening date. CONCLUSION: The prevalence of suicidal ideation was about 1% among this cohort of older primary care patients, and the prevalence approaches 5% among those older adults who report significant symptoms of depression. However, asking patients directly about the presence of active suicidal ideation appears to be the only effective means of identifying those at risk.
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Psychiatric disorders in African American nursing home residents.
OBJECTIVE: High prevalence rates of psychiatric illness and high levels of behavioral disturbance have been reported in studies of nursing home residents; however, the populations evaluated have been predominantly Caucasian. The aims of the present study were to identify prevalence rates of psychiatric disorders and behavioral disturbances in a sample of African American nursing home residents. METHODS: The authors evaluated 106 African American nursing home residents, aged 65 and over, from a representative sample of nursing homes. The evaluation included informant interview with nursing home staff, cognitive assessment, and a psychiatric interview that included a physical and neurological examination. Consensus diagnoses were reached by using DSM-III-R criteria. RESULTS: Of the 106 subjects, 90% received at least one primary psychiatric diagnosis, and 71% had at least one behavioral problem; dementia was the most common psychiatric diagnosis (68%). Thirty -one percent of the patients were treated with neuroleptic medication; most of these patients received diagnoses of dementia or schizophrenia. Fifteen percent of the patients had been in physical restraints, which correlated with physical disability. CONCLUSIONS: The prevalence of psychiatric illness in this sample of African American nursing home residents is similar to that reported in previous studies with predominantly Caucasian populations. Behavioral disturbances, while commonly reported, were somewhat less frequent than reported in previous studies.
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The recognition and treatment of late-life depression: a view from primary care.
OBJECTIVE: Efforts to improve the recognition and treatment of late-life depression in primary care are often based on the assumption that primary care physicians underutilize currently available and effective treatments. This article reviews the validity of this assumption and offers recommendations for future research. METHODS: Clinical trials designed to improve the recognition and treatment of late-life depression in primary care are reviewed. Because studies limited to older adults are rare, we also include studies enrolling younger patients. These data are reviewed in the context of recent reviews on the prevalence of depression in primary care settings and the effectiveness of available treatments. RESULTS: Although depressive symptoms are common among older adults, there is insufficient literature documenting the proportion of these patients who respond to currently available treatments. Patients with uncomplicated major depressive disorder constitute the minority of primary care patients with depressive symptoms. Nearly all available studies of treatment effectiveness of pharmacotherapy or psychotherapy focus on older adults with uncomplicated major depression. Currently available treatment options may apply to less than 15 percent of depressed primary care patients. CONCLUSIONS: More research is needed to help primary care providers manage their depressed patients with comorbid medical conditions, functional disability, or minor or chronic depressions. In addition, more research is needed to identify those patients who would benefit from specialized or interdisciplinary care.
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Improved procedure for eluting DNA from dried blood spots.
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Alzheimer Disease↗
Association of the epsilon 4 allele of apolipoprotein E with poor performance on a dementia screen in African Americans.
In a community-based study of Alzheimer's disease in African Americans age 65 and over, subjects were classified into three levels of performance based on their scores as measured by the Community Screening Instrument for Dementia (CSI"D"), consisting of cognitive and functioning components. In a subset of 268 subjects with apolipoprotein E (APOE) genotype data, we found that the epsilon 4 allele of APOE was associated with intermediate/poor performance (single copy epsilon 4 odds ratio 1.51, 95% CI 1.18 to 1.92; double copy epsilon 4 odds ratio 3.42, 95% CI 2.18 to 5.43). From these data, we believe it would be possible to conduct population screening for the effects of possession of the APOE-epsilon 4 allele using information derived from the CSI"D".
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Documentation and evaluation of cognitive impairment in elderly primary care patients.
OBJECTIVE: To describe the prevalence of cognitive impairment among elderly primary care patients and to compare diagnostic evaluations and use of health services among patients with and those without cognitive impairment. DESIGN: Prospective cohort study. SETTING: Academic primary care group practice. PATIENTS: 3954 patients aged 60 years and older who completed the Short Portable Mental Status Questionnaire during routine office visits. MEASUREMENTS: Demographics and comorbid illness at baseline, diagnostic evaluations for cognitive impairment, use of standard and preventive health services, use of psychoactive drugs, and death in the year after the screening date. RESULTS: The prevalence of cognitive impairment among all patients aged 60 years and older at baseline was 15.7%; 10.5% had mild impairment and 5.2% had moderate to severe impairment. Patients with moderate to severe impairment were significantly older than patients with no impairment (76.2 years and 67.4 years, respectively), were more likely to be black (85.8% and 61.3%), had fewer years of education (7.3 years and 9.2 years), and were more likely to have cerebrovascular disease (20.4% and 6.3%) and evidence of undernutrition (30.6% and 16.9%). Dementia was recorded as a diagnosis for less than 25% of patients with moderate to severe cognitive impairment, but patients with documented impairment were more likely to have been evaluated for reversible causes. In the year after screening, patients with moderate to severe impairment were more likely than those with no impairment both to be hospitalized (29.1% and 16.5%) and to visit the emergency department (55.8% and 38.5%) but had fewer outpatient visits (6.0 and 7.6) and greater mortality (8.2% and 2.8%). CONCLUSIONS: Cognitive impairment is associated with increased use of health services and increased mortality. Patients with undocumented cognitive impairment were significantly less likely to be evaluated for reversible causes. Research is needed to determine if better documentation of cognitive impairment would improve not only diagnostic evaluations but also patient management, counseling, and outcomes.
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