@article {11156, title = {Factor structure of the Harmonized Cognitive Assessment Protocol neuropsychological battery in the Health and Retirement Study}, journal = {Neuropsychology}, year = {Forthcoming}, abstract = {Objectives: The Harmonized Cognitive Assessment Protocol (HCAP) describes an assessment battery and a family of population-representative studies measuring neuropsychological performance. We describe the factorial structure of the HCAP battery in the US Health and Retirement Study (HRS).Method: The HCAP battery was compiled from existing measures by a cross-disciplinary and international panel of researchers. The HCAP battery used in the 2016 wave of the HRS. We used factor analysis methods to assess and refine a theoretically-driven single and multiple domain factor structure for tests included in the HCAP battery among 3,347 participants with evaluable performance data. Results: For the eight domains of cognitive functioning identified theoretically (orientation, memory [immediate, delayed, \& recognition], set shifting, attention/speed, language/fluency, andvisuospatial), all single factor models fit reasonably well, although four of these domains had either 2 or 3 indicators where good fit is axiomatic. Multidimensional models suggested the eight-domain model was overly complex. A five-domain model (orientation, memory delayed and recognition, executive functioning, language/fluency, visuospatial) was identified as a reasonable model for summarizing performance in this sample (standardized root mean square residual = 0.05, root mean square error of approximation = 0.05, confirmatory fit index = 0.94). Discussion: The HCAP battery conforms adequately to a multidimensional structure of neuropsychological performance. The derived measurement models can be used as anchors for calibrating cross-national studies of cognitive performance, and to identify persons performing atthe low end as part of an algorithmic classification of probable dementia}, keywords = {Cognitive Ability, Confirmatory Factor Analysis, HCAP, Older Adults}, doi = {10.31234/osf.io/rvmhj}, author = {Richard N Jones and Jennifer J Manly and Kenneth M. Langa and Lindsay H Ryan and Deborah A Levine and Ryan J McCammon and David R Weir} } @article {11464, title = {The Influence of Cognitive Impairment on Post-Operative Outcomes.}, journal = {Annals of Surgery}, volume = {277}, year = {2023}, pages = {e212-e217}, abstract = {

OBJECTIVE: To examine differences in rates of elective surgery, postoperative mortality, and readmission by pre-existing cognitive status among Medicare beneficiaries undergoing surgery.

BACKGROUND: Mild cognitive impairment (MCI) is common among older adults, but the impact of MCI on surgical outcomes is understudied.

METHODS: We conducted a retrospective cohort study of individuals >=65 who underwent surgery between 2001 and 2015 using data from the nationally-representative Health and Retirement Study linked with Medicare claims. Cognitive status was assessed by the modified Telephone Interview for Cognitive Status score and categorized as normal cognition (score: 12-27), MCI (7-11), and dementia (<7). Outcomes were 30- and 90-day postoperative mortality and readmissions. We used Cox proportional hazard models to estimate the risk of each outcome by cognition, adjusting for patient characteristics.

RESULTS: In 6,590 patients, 69.9\% had normal cognition, 20.1\% had MCI, and 9.9\% had dementia. Patients with MCI (79.9\%) and dementia (73.6\%) were less likely to undergo elective surgery than patients with normal cognition (85.9\%). Patients with MCI had similar postoperative mortality and readmissions rates as patients with normal cognition. However, patients with dementia had significantly higher postoperative 90-day mortality (5.2\% vs. 8.4\%, p=0.002) and readmission rates (13.9\% vs. 17.3\%, p=0.038).

CONCLUSION: Patients with self-reported MCI are less likely to undergo elective surgery but have similar postoperative outcomes compared with patients with normal cognition. Despite the variability of defining MCI, our findings suggest that MCI may not confer additional risk for older individuals undergoing surgery, and should not be a barrier for surgical care.

}, keywords = {cognition impairment, Postoperative Period}, issn = {1528-1140}, doi = {10.1097/SLA.0000000000004799}, author = {Blair, Emilie M and Deborah A Levine and Hu, Hsou Mei and Kenneth M. Langa and Mohammed U Kabeto and Waljee, Jennifer} } @article {10002, title = {Caregiving, recovery, and death after incident ADL/IADL disability among older adults in the United States}, journal = {Journal of Applied Gerontology}, volume = {39}, year = {2020}, type = {Journal}, abstract = {This study assesses patterns of caregiving, death, and recovery after incident disability in older adults. We used the Health and Retirement Study to follow of a cohort of adults age >=65 years in the United States with incident disability in activities of daily living (ADLs) or instrumental activities of daily living (IADLs; n = 8,713). Rates of care and function state were assessed biennially: deceased, nursing home dwelling, at home with paid help, at home with both paid and unpaid help, at home with unpaid help, at home with no assistance and recovered. In the 2 years after incident disability, 22.1\% recovered and 46.8\% died. Transitions between care and function states occurred frequently, with more than 20\% of the cohort living at home with no assistance despite disability at least once. This study demonstrates the high levels of care and function state fluctuation and unmet needs after functional disability.}, keywords = {Activities of Daily Living, Caregiving, Disabilities}, issn = {0733-4648}, doi = {10.1177/0733464819826842}, url = {https://journals.sagepub.com/doi/10.1177/0733464819826842}, author = {Claire K. Ankuda and Deborah A Levine and Kenneth M. Langa and Katherine A Ornstein and Amy Kelley} } @article {10355, title = {The Health and Retirement Study Harmonized Cognitive Assessment Protocol Project: Study Design and Methods}, journal = {Neuroepidemiology}, year = {2020}, month = {2019}, abstract = {Introduction: The Harmonized Cognitive Assessment Protocol (HCAP) Project is a substudy within the Health and Retirement Study (HRS), an ongoing nationally representative panel study of about 20,000 adults aged 51 or older in the United States. The HCAP is part of an international research collaboration funded by the National Institute on Aging to better measure and identify cognitive impairment and dementia in representative population-based samples of older adults, in the context of ongoing longitudinal studies of aging in high-, middle-, and low-income countries around the world. Methods: The HCAP cognitive test battery was designed to measure a range of key cognitive domains affected by cognitive aging (including attention, memory, executive function, language, and visuospatial function) and to allow harmonization and comparisons to other studies in the United States and around the world. The HCAP included a pair of in-person interviews, one with the target HRS respondent (a randomly selected HRS sample member, aged 65+) that lasted approximately 1 h and one with an informant nominated by the respondent that lasted approximately 20 min. The final HRS HCAP sample included 3,496 study subjects, representing a 79\% response rate among those invited to participate. Conclusion: Linking detailed HCAP cognitive assessments to the wealth of available longitudinal HRS data on cognition, health, biomarkers, genetics, health care utilization, informal care, and economic resources and behavior will provide unique and expanded opportunities to study cognitive impairment and dementia in a nationally representative US population-based sample. The fielding of similar HCAP projects in multiple countries around the world will provide additional opportunities to study international differences in the prevalence, incidence, and outcomes of dementia globally with comparable data. Like all HRS data, HCAP data are publicly available at no cost to researchers.}, keywords = {Cognition, cognitive assessment, study design}, isbn = {0251-5350}, doi = {10.1159/000503004}, author = {Kenneth M. Langa and Lindsay H Ryan and Ryan J McCammon and Richard N Jones and Jennifer J Manly and Deborah A Levine and Amanda Sonnega and Farron, M. and David R Weir} } @article {10670, title = {Methods and Early Recruitment of a Community-Based Study of Cognitive Impairment Among Mexican Americans and Non-Hispanic Whites: The BASIC-Cognitive Study}, journal = {Journal of Alzheimer{\textquoteright}s Disease}, volume = {73}, year = {2020}, month = {2020}, pages = {185-196}, type = {Journal}, abstract = {Background: As the Mexican American (MA) population grows and ages, there is an urgent need to estimate the prevalence of cognitive impairment or dementia (CID), cognitive trajectories, and identify community resource needs. The Brain Attack Surveillance in Corpus Christi (BASIC)-Cognitive project is a population-based study to address these issues among older MAs and non-Hispanic whites (NHW) and their informal care providers. Objective: Present the methodology and initial recruitment findings for the BASIC-Cognitive project. Method: Random, door-to-door case ascertainment is used in Nueces County, Texas, to recruit community-dwelling and nursing home residents >=65 and informal care providers. Households are identified from a two-stage area probability sample, using Census data to aim for equal balance of MAs and NHWs. Individuals with cognitive screens indicative of possible CID complete neuropsychological assessment (Harmonized Cognitive Assessment Protocol from the Health and Retirement Study). Informal care providers complete comprehensive interview and needs assessment. Study pairs repeat procedures at 2-year follow-up. Asset and concept mapping are performed to identify community resources and study care providers{\textquoteright} perceptions of needs for individuals with CID. Results: 1,030 age-eligible households were identified, or 27\% of households for whom age could be determined. 1,320 individuals were age-eligible, corresponding to 1.3 adults per eligible household. Initial recruitment yielded robust participation in the MA eligible population (60\% of 689 individuals that completed cognitive screening). Conclusion: The BASIC-Cognitive study will provide critical information regarding the prevalence of CID in MAs, the impact of caregiving, and allocation of community resources to meet the needs of this population.}, keywords = {Caregivers, Dementia, Epidemiology, Health Resources, mexican american, mild cognitive impairment}, isbn = {1875-8908}, doi = {10.3233/JAD-190761}, url = {https://content.iospress.com/articles/journal-of-alzheimers-disease/jad190761}, author = {Emily Brice{\~n}o and Mehdipanah, Roshanak and Gonzales, Xavier and Steven G Heeringa and Deborah A Levine and Kenneth M. Langa and Garcia, Nelda and Longoria, Ruth and Lewis B Morgenstern} } @article {10968, title = {Mild cognitive impairment and receipt of procedures for acute ischemic stroke in older adults}, journal = {Journal of Stroke and Cerebrovascular Diseases}, volume = {29}, year = {2020}, abstract = {Background and purpose Older patients with pre-existing mild cognitive impairment (MCI) receive less evidence-based care after acute myocardial infarction, however, whether they receive less care after acute ischemic stroke (AIS) is unknown. We compared receipt of guideline-concordant procedures after AIS between older adults with pre-existing MCI and normal cognition. Methods Prospective study of 591 adults >=65 hospitalized for AIS between 2000 and 2014, and followed through 2015 using data from the nationally representative Health and Retirement Study, Medicare and American Hospital Association. We assessed pre-existing MCI (modified Telephone Interview for Cognitive Status score of 7{\textendash}11) and normal cognition (score of 12{\textendash}27). Primary outcome was a composite quality measure representing the number of 4 procedures (carotid imaging, cardiac monitoring, echocardiogram, and rehabilitation assessment) received within 30 days after AIS (ordinal scale with values of 0, 1, 2, 3{\textendash}4). Results Among survivors of AIS, 26.9\% had pre-existing MCI (62.9\% were women, with a mean [SD] age of 82.4 [7.7] years), and 73.1\% had normal cognition (51.4\% were women, with a mean age of 78.4 [7.2] years). Patients with pre-existing MCI, compared to cognitively normal patients, had 39\% lower cumulative odds of receiving the composite quality measure (unadjusted cumulative odds ratio, OR, 0.61 [95\% CI, 0.43{\textendash}0.87]; P=0.006). However, this association became non-significant after adjusting for patient and hospital factors (adjusted cumulative OR, 0.83 [95\% CI, 0.56{\textendash}1.24]; P=0.37). Lower cumulative odds of receiving the composite quality measure were associated with older patient age (adjusted cumulative OR per 1-year older age, 0.97 [95\% CI, 0.95{\textendash}0.99]; P=0.01) and Southern hospitals (adjusted cumulative OR for South vs North, 0.54 [95\% CI, 0.31{\textendash}0.94]; P=0.03). Conclusions Differences in receipt of guideline-concordant procedures after AIS exist between patients with pre-existing MCI and normal cognition. These differences were largely explained by patient and regional factors associated with receiving less AIS care.}, keywords = {Aging, cognitive impairment, Health policy/outcomes research, Ischemic stroke}, isbn = {1052-3057}, doi = {https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105083}, author = {Deborah A Levine and Andrzej T Galecki and Mohammed U Kabeto and Nallamothu, Brahmajee K. and Zahuranec, Darin B. and Lewis B Morgenstern and Lynda D Lisabeth and Bruno J Giordani and Kenneth M. Langa} } @article {10181, title = {Mild Cognitive Impairment and Receipt of Treatments for Acute Myocardial Infarction in Older Adults}, journal = {Journal of General Internal Medicine}, volume = {35}, year = {2020}, pages = {28{\textendash}35}, type = {Journal}, abstract = {Background Older adults with mild cognitive impairment (MCI) should receive evidence-based treatments when indicated. Providers and patients may overestimate the risk of dementia in patients with MCI leading to potential under-treatment. However, the association between pre-existing MCI and receipt of evidence-based treatments is uncertain. Objective To compare receipt of treatments for acute myocardial infarction (AMI) between older adults with pre-existing MCI and cognitively normal patients. Design Prospective study using data from the nationally representative Health and Retirement Study, Medicare, and American Hospital Association. Participants Six hundred nine adults aged 65 or older hospitalized for AMI between 2000 and 2011 and followed through 2012 with pre-existing MCI (defined as modified Telephone Interview for Cognitive Status score of 7{\textendash}11) and normal cognition (score of 12{\textendash}27). Main Measures Receipt of cardiac catheterization and coronary revascularization within 30 days and cardiac rehabilitation within 1 year of AMI hospitalization. Key Results Among the survivors of AMI, 19.2\% had pre-existing MCI (55.6\% were women and 44.4\% were male, with a mean [SD] age of 82.3 [7.5] years), and 80.8\% had normal cognition (45.7\% were women and 54.3\% were male, with a mean age of 77.1 [7.1] years). Survivors of AMI with pre-existing MCI were significantly less likely than those with normal cognition to receive cardiac catheterization (50\% vs 77\%; P < 0.001), coronary revascularization (29\% vs 63\%; P < 0.001), and cardiac rehabilitation (9\% vs 22\%; P = 0.001) after AMI. After adjusting for patient and hospital factors, pre-existing MCI remained associated with lower use of cardiac catheterization (adjusted hazard ratio (aHR), 0.65; 95\% CI, 0.48{\textendash}0.89; P = 0.007) and coronary revascularization (aHR, 0.55; 95\% CI, 0.37{\textendash}0.81; P = .003), but not cardiac rehabilitation (aHR, 1.01; 95\% CI, 0.49{\textendash}2.07; P = 0.98). Conclusions Pre-existing MCI is associated with lower use of cardiac catheterization and coronary revascularization but not cardiac rehabilitation after AMI.}, keywords = {Cognitive Ability, Heart disease, Medicare/Medicaid/Health Insurance}, issn = {0884-8734}, doi = {10.1007/s11606-019-05155-8}, url = {https://link.springer.com/article/10.1007\%2Fs11606-019-05155-8$\#$citeas}, author = {Deborah A Levine and Kenneth M. Langa and Andrzej T Galecki and Mohammed U Kabeto and Lewis B Morgenstern and Zahuranec, Darin B. and Bruno J Giordani and Lynda D Lisabeth and Nallamothu, Brahmajee K.} } @article {10155, title = {Multimorbidity and cognitive decline over 14 years in older Americans.}, journal = {Journals of Gerontology. Series A, Biological Sciences \& Medical Sciences}, year = {2020}, abstract = {

BACKGROUND: Multimorbidity is associated with greater disability and accelerated declines in physical functioning over time in older adults. However, less is known about its effect on cognitive decline.

METHODS: Participants without dementia from the Health and Retirement Study were interviewed about physician-diagnosed conditions, from which their multimorbidity-weighted index (MWI) that weights diseases to physical functioning was computed. We used linear mixed-effects models to examine the predictor MWI with the modified Telephone Interview for Cognitive Status (TICSm, global cognition), 10-word immediate recall and delayed recall, and serial 7s outcomes biennially after adjusting for baseline cognition and covariates.

RESULTS: 14,265 participants, 60\% female, contributed 73,700 observations. Participants had a meanSD age 679.3 years and MWI 4.43.9 at baseline. Each point increase in MWI was associated with declines in global cognition (0.04, 95\%CI: 0.03-0.04 TICSm), immediate recall (0.01, 95\%CI: 0.01-0.02 words), delayed recall (0.01, 95\%CI: 0.01-0.02 words), and working memory (0.01, 95\%CI: 0.01-0.02 serial 7s) (all P<0.001). Multimorbidity was associated with faster declines in global cognition (0.003 points/year faster, 95\%CI: 0.002-0.004), immediate recall (0.001 words/year faster, 95\%CI: 0.001-0.002), and working memory (0.006 incorrect serial 7s/year faster, 95\%CI: 0.004-0.009) (all P<0.001), but not delayed recall compared with premorbid slopes.

CONCLUSIONS: Multimorbidity using a validated index weighted to physical functioning was associated with acute decline in cognition and accelerated and persistent cognitive decline over 14 years. This study supports an ongoing geriatric syndrome of coexisting physical and cognitive impairment in adults with multimorbidity. Clinicians should monitor and address both domains in older multimorbid adults.

}, keywords = {Cognitive Ability, Comorbidity, Longitudinal data}, issn = {1758-535X}, doi = {10.1093/gerona/glz147}, author = {Melissa Y Wei and Deborah A Levine and Laura B Zahodne and Mohammed U Kabeto and Kenneth M. Langa} } @article {9280, title = {Association between spousal caregiver well-being and care recipient healthcare expenditures}, journal = {Journal of the American Geriatrics Society}, volume = {65}, year = {2017}, pages = {2220-2226}, abstract = {Objectives To measure the association between spousal depression, general health, fatigue and sleep, and future care recipient healthcare expenditures and emergency department (ED) use. Design Prospective cohort study. Setting Health and Retirement Study. Participants Home-dwelling spousal dyads in which one individual (care recipient) was aged 65 and older and had one or more activity of daily living or instrumental activity of daily living disabilities and was enrolled in Medicare Part B (N = 3,101). Exposure Caregiver sleep (Jenkins Sleep Scale), depressive symptoms (Center for Epidemiologic Studies Depression-8 Scale), and self-reported general health measures. Measurements Primary outcome was care recipient Medicare expenditures. Secondary outcome was care recipient ED use. Follow-up was 6 months. Results Caregiver depressive symptoms score and six of 17 caregiver well-being measures were prospectively associated with higher care recipient expenditures after minimal adjustment (P < .05). Higher care recipient expenditures remained significantly associated with caregiver fatigue (cost increase, $1,937, 95\% confidence interval (CI) = $770{\textendash}3,105) and caregiver sadness (cost increase, $1,323, 95\% CI = $228{\textendash}2,419) after full adjustment. Four of 17 caregiver well-being measures, including severe fatigue, were significantly associated with care recipient ED use after minimal adjustment (P < .05). Greater odds of care recipient ED use remained significantly associated with caregiver fatigue (odds ratio (OR) = 1.24, 95\% CI = 1.01{\textendash}1.52) and caregiver fair to poor health (OR = 1.23, 95\% CI = 1.04{\textendash}1.45) after full adjustment. Caregiver total sleep score was not associated with care recipient outcomes. Conclusion Poor caregiver well-being, particularly severe fatigue, is independently and prospectively associated with higher care recipient Medicare expenditures and ED use.}, keywords = {Caregiving, Marriage, Medical Expenses, Medicare/Medicaid/Health Insurance, Well-being}, doi = {10.1111/jgs.15039}, url = {http://doi.wiley.com/10.1111/jgs.15039http://onlinelibrary.wiley.com/wol1/doi/10.1111/jgs.15039/fullpdfhttps://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111\%2Fjgs.15039}, author = {Claire K. Ankuda and Donovan T Maust and Mohammed U Kabeto and Ryan J McCammon and Kenneth M. Langa and Deborah A Levine} } @article {8813, title = {A Comparison of the Prevalence of Dementia in the United States in 2000 and 2012.}, journal = {JAMA Intern Med}, volume = {177}, year = {2017}, month = {2017 01 01}, pages = {51-58}, abstract = {

Importance: The aging of the US population is expected to lead to a large increase in the number of adults with dementia, but some recent studies in the United States and other high-income countries suggest that the age-specific risk of dementia may have declined over the past 25 years. Clarifying current and future population trends in dementia prevalence and risk has important implications for patients, families, and government programs.

Objective: To compare the prevalence of dementia in the United States in 2000 and 2012.

Design, Setting, and Participants: We used data from the Health and Retirement Study (HRS), a nationally representative, population-based longitudinal survey of individuals in the United States 65 years or older from the 2000 (n = 10 546) and 2012 (n = 10 511) waves of the HRS.

Main Outcomes and Measures: Dementia was identified in each year using HRS cognitive measures and validated methods for classifying self-respondents, as well as those represented by a proxy. Logistic regression was used to identify socioeconomic and health variables associated with change in dementia prevalence between 2000 and 2012.

Results: The study cohorts had an average age of 75.0 years (95\% CI, 74.8-75.2 years) in 2000 and 74.8 years (95\% CI, 74.5-75.1 years) in 2012 (P = .24); 58.4\% (95\% CI, 57.3\%-59.4\%) of the 2000 cohort was female compared with 56.3\% (95\% CI, 55.5\%-57.0\%) of the 2012 cohort (P < .001). Dementia prevalence among those 65 years or older decreased from 11.6\% (95\% CI, 10.7\%-12.7\%) in 2000 to 8.8\% (95\% CI, 8.2\%-9.4\%) (8.6\% with age- and sex-standardization) in 2012 (P < .001). More years of education was associated with a lower risk for dementia, and average years of education increased significantly (from 11.8 years [95\% CI, 11.6-11.9 years] to 12.7 years [95\% CI, 12.6-12.9 years]; P < .001) between 2000 and 2012. The decline in dementia prevalence occurred even though there was a significant age- and sex-adjusted increase between years in the cardiovascular risk profile (eg, prevalence of hypertension, diabetes, and obesity) among older US adults.

Conclusions and Relevance: The prevalence of dementia in the United States declined significantly between 2000 and 2012. An increase in educational attainment was associated with some of the decline in dementia prevalence, but the full set of social, behavioral, and medical factors contributing to the decline is still uncertain. Continued monitoring of trends in dementia incidence and prevalence will be important for better gauging the full future societal impact of dementia as the number of older adults increases in the decades ahead.

}, keywords = {Aged, Dementia, Female, Humans, Male, Prevalence, Risk Factors, United States}, issn = {2168-6114}, doi = {10.1001/jamainternmed.2016.6807}, url = {http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.6807http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2587084}, author = {Kenneth M. Langa and Eric B Larson and Eileen M. Crimmins and Jessica Faul and Deborah A Levine and Mohammed U Kabeto and David R Weir} } @article {8323, title = {The association of depression, cognitive impairment without dementia, and dementia with risk of ischemic stroke: a cohort study.}, journal = {Psychosom Med}, volume = {77}, year = {2015}, month = {2015 Feb-Mar}, pages = {200-8}, publisher = {77}, abstract = {

OBJECTIVE: To determine if depression, cognitive impairment without dementia (CIND), and/or dementia are each independently associated with risk of ischemic stroke and to identify characteristics that could modify these associations.

METHODS: This retrospective-cohort study examined a population-based sample of 7031 Americans older than 50 years participating in the Health and Retirement Study (1998-2008) who consented to have their interviews linked to their Medicare claims. The eight-item Center for Epidemiologic Studies Depression Scale and/or International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) depression diagnoses were used to identify baseline depression. The Modified Telephone Interview for Cognitive Status and/or ICD-9-CM dementia diagnoses were used to identify baseline CIND or dementia. Hospitalizations for ischemic stroke were identified via ICD-9-CM diagnoses.

RESULTS: After adjusting for demographics, medical comorbidities, and health-risk behaviors, CIND alone (odds ratio [OR] = 1.37, 95\% confidence interval [CI] = 1.11-1.69) and co-occurring depression and CIND (OR = 1.65, 95\% CI = 1.24-2.18) were independently associated with increased odds of ischemic stroke. Depression alone was not associated with odds of ischemic stroke (OR = 1.11, 95\% CI = 0.88-1.40) in unadjusted analyses. Neither dementia alone (OR = 1.09, 95\% CI = 0.82-1.45) nor co-occurring depression and dementia (OR = 1.25, 95\% CI = 0.89-1.76) were associated with odds of ischemic stroke after adjusting for demographics.

CONCLUSIONS: CIND and co-occurring depression and CIND are independently associated with increased risk of ischemic stroke. Individuals with co-occurring depression and CIND represent a high-risk group that may benefit from targeted interventions to prevent stroke.

}, keywords = {Aged, Aged, 80 and over, Cognitive Dysfunction, Cohort Studies, Dementia, depression, Female, Humans, Male, Middle Aged, Psychiatric Status Rating Scales, Retrospective Studies, Risk Factors, Stroke, United States}, issn = {1534-7796}, doi = {10.1097/PSY.0000000000000136}, author = {Dimitry S Davydow and Deborah A Levine and Zivin, Kara and Wayne J Katon and Kenneth M. Langa} } @article {8289, title = {Does Stroke Contribute to Racial Differences in Cognitive Decline?}, journal = {Stroke}, volume = {46}, year = {2015}, month = {2015 Jul}, pages = {1897-902}, publisher = {46}, abstract = {

BACKGROUND AND PURPOSE: It is unknown whether blacks{\textquoteright} elevated risk of dementia is because of racial differences in acute stroke, the impact of stroke on cognitive health, or other factors. We investigated whether racial differences in cognitive decline are explained by differences in the frequency or impact of incident stroke between blacks and whites, controlling for baseline cognition.

METHODS: Among 4908 black and white participants aged >=65 years free of stroke and cognitive impairment in the nationally representative Health and Retirement Study with linked Medicare data (1998-2010), we examined longitudinal changes in global cognition (modified version of the Telephone Interview for Cognitive Status) by race, before and after adjusting for time-dependent incident stroke followed by a race-by-incident stroke interaction term, using linear mixed-effects models that included fixed effects of participant demographics, clinical factors, and cognition, and random effects for intercept and slope for time.

RESULTS: We identified 34 of 453 (7.5\%) blacks and 300 of 4455 (6.7\%) whites with incident stroke over a mean (SD) of 4.1 (1.9) years of follow-up (P=0.53). Blacks had greater cognitive decline than whites (adjusted difference in modified version of the Telephone Interview for Cognitive Status score, 1.47 points; 95\% confidence interval, 1.21 to 1.73 points). With further adjustment for cumulative incidence of stroke, the black-white difference in cognitive decline persisted. Incident stroke was associated with a decrease in global cognition (1.21 points; P<0.001) corresponding to ≈7.9 years of cognitive aging. The effect of incident stroke on cognition did not statistically differ by race (P=0.52).

CONCLUSIONS: In this population-based cohort of older adults, incident stroke did not explain black-white differences in cognitive decline or impact cognition differently by race.

}, keywords = {African Continental Ancestry Group, Aged, Aged, 80 and over, Cognition Disorders, European Continental Ancestry Group, Female, Humans, Longitudinal Studies, Male, Risk Factors, Stroke}, issn = {1524-4628}, doi = {10.1161/STROKEAHA.114.008156}, url = {http://stroke.ahajournals.org/content/early/2015/05/20/STROKEAHA.114.008156.abstract}, author = {Deborah A Levine and Mohammed U Kabeto and Kenneth M. Langa and Lynda D Lisabeth and Mary A M Rogers and Andrzej T Galecki} } @article {8036, title = {Acute infection contributes to racial disparities in stroke mortality.}, journal = {Neurology}, volume = {82}, year = {2014}, note = {Times Cited: 0}, month = {2014 Mar 18}, pages = {914-21}, publisher = {82}, abstract = {

OBJECTIVE: It is unknown whether racial differences in exposure to acute precipitants of stroke, specifically infection, contribute to racial disparities in stroke mortality.

METHODS: Among participants in the nationally representative Health and Retirement Study with linked Medicare data (1991-2007), we conducted a case-crossover study employing within-person comparisons to study racial/ethnic differences in the risks of death and hospitalization from ischemic stroke following acute infection.

RESULTS: There were 964 adults hospitalized for ischemic stroke. Acute infection increased the 30-day risks of ischemic stroke death (5.82-fold) and ischemic stroke hospitalization (1.87-fold). Acute infection was a more potent trigger of acute ischemic stroke death in non-Hispanic blacks (odds ratio [OR] 39.21; 95\% confidence interval [CI] 9.26-166.00) than in non-Hispanic whites (OR 4.50; 95\% CI 3.14-6.44) or Hispanics (OR 5.18; 95\% CI 1.34-19.95) (race-by-stroke interaction, p = 0.005). When adjusted for atrial fibrillation, infection remained more strongly associated with stroke mortality in blacks (OR 34.85) than in whites (OR 3.58) and Hispanics (OR 3.53). Acute infection increased the short-term risk of incident stroke similarly across racial/ethnic groups. Infection occurred often before stroke death in non-Hispanic blacks, with 70\% experiencing an infection in the 30 days before stroke death compared to a background frequency of 15\%.

CONCLUSIONS: Acute infection disproportionately increases the risk of stroke death for non-Hispanic blacks, independently of atrial fibrillation. Stroke incidence did not explain this finding. Acute infection appears to be one factor that contributes to the black-white disparity in stroke mortality.

}, keywords = {Black or African American, Case-Control Studies, Female, Health Status Disparities, Healthcare Disparities, Hispanic or Latino, Humans, Infections, Male, Odds Ratio, Retrospective Studies, Risk Factors, Stroke, White People}, issn = {1526-632X}, doi = {10.1212/WNL.0000000000000214}, author = {Deborah A Levine and Kenneth M. Langa and Mary A M Rogers} } @article {8126, title = {Functional disability and cognitive impairment after hospitalization for myocardial infarction and stroke.}, journal = {Circ Cardiovasc Qual Outcomes}, volume = {7}, year = {2014}, note = {Times Cited: 1 0 1}, month = {2014 Nov}, pages = {863-71}, publisher = {7}, abstract = {

BACKGROUND: We assessed the acute and long-term effect of myocardial infarction (MI) and stroke on postevent functional disability and cognition while controlling for survivors{\textquoteright} changes in functioning over the years before the event.

METHODS AND RESULTS: Among participants in the nationally representative Health and Retirement Study with linked Medicare data (1998-2010), we determined within-person changes in functional limitations (basic and instrumental activities of daily living) and cognitive impairment after hospitalization for stroke (n=432) and MI (n=450), controlling for premorbid functioning using fixed-effects regression. In persons without baseline impairments, an acute MI yielded a mean acute increase of 0.41 functional limitations (95\% confidence interval [CI], 0.18-0.63) with a linear increase of 0.14 limitations/year in the following decade. These increases were 0.65 limitations (95\% CI, 0.07-1.23) and 0.27 limitations/year afterward for those with mild-to-moderate impairment at baseline. Stroke resulted in an acute increase of 2.07 (95\% CI, 1.51-2.63) limitations because of the acute event and an increase of 0.15 limitations/year afterward for those unimpaired at baseline. There were 2.65 new limitations (95\% CI, 1.86-3.44) and 0.19/year afterward for those with baseline mild-to-moderate impairment. Stroke hospitalization was associated with greater odds of moderate-to-severe cognitive impairment (odds ratio, 3.86; 95\% CI, 2.10-7.11) at the time of the event, after adjustment for premorbid cognition but MI hospitalization was not.

CONCLUSIONS: In this population-based cohort, most MI and stroke hospitalizations were associated with significant increases in functional disability at the time of the event and in the decade afterward. Survivors of MI and stroke warrant screening for functional disability over the long-term.

}, keywords = {Activities of Daily Living, Cognition, Cognition Disorders, Disability Evaluation, Disabled Persons, Female, Follow-Up Studies, Hospitalization, Humans, Incidence, Male, Middle Aged, Myocardial Infarction, Odds Ratio, Retrospective Studies, Stroke, Time Factors, United States}, issn = {1941-7705}, doi = {10.1161/HCQ.0000000000000008}, author = {Deborah A Levine and Dimitry S Davydow and Catherine L Hough and Kenneth M. Langa and Mary A M Rogers and Theodore J Iwashyna} } @article {7801, title = {Functional disability, cognitive impairment, and depression after hospitalization for pneumonia.}, journal = {Am J Med}, volume = {126}, year = {2013}, month = {2013 Jul}, pages = {615-24.e5}, abstract = {

OBJECTIVE: The study objective was to examine whether hospitalization for pneumonia is associated with functional decline, cognitive impairment, and depression, and to compare this impairment with that seen after known disabling conditions, such as myocardial infarction or stroke.

METHODS: We used data from a prospective cohort of 1434 adults aged more than 50 years who survived 1711 hospitalizations for pneumonia, myocardial infarction, or stroke drawn from the Health and Retirement Study (1998-2010). Main outcome measures included the number of Activities and Instrumental Activities of Daily Living requiring assistance and the presence of cognitive impairment and substantial depressive symptoms.

RESULTS: Hospitalization for pneumonia was associated with 1.01 new impairments in Activities and Instrumental Activities of Daily Living (95\% confidence interval [CI], 0.71-1.32) among patients without baseline functional impairment and 0.99 new impairments in Activities and Instrumental Activities of Daily Living (95\% CI, 0.57-1.41) among those with mild-to-moderate baseline limitations, as well as moderate-to-severe cognitive impairment (odds ratio, 2.46; 95\% CI, 1.60-3.79) and substantial depressive symptoms (odds ratio, 1.63; 95\% CI, 1.06-2.51). Patients without baseline functional impairment who survived pneumonia hospitalization had more subsequent impairments in Activities and Instrumental Activities of Daily Living than those who survived myocardial infarction hospitalization. There were no significant differences in subsequent moderate-to-severe cognitive impairment or substantial depressive symptoms between patients who survived myocardial infarction or stroke and those who survived pneumonia.

CONCLUSIONS: Hospitalization for pneumonia in older adults is associated with subsequent functional and cognitive impairment. Improved pneumonia prevention and interventions to ameliorate adverse sequelae during and after hospitalization may improve outcomes.

}, keywords = {Activities of Daily Living, Aged, Aged, 80 and over, Cognitive Dysfunction, depression, Hospitalization, Humans, Logistic Models, Longitudinal Studies, Middle Aged, Myocardial Infarction, Pneumonia, Stroke}, issn = {1555-7162}, doi = {10.1016/j.amjmed.2012.12.006}, author = {Dimitry S Davydow and Catherine L Hough and Deborah A Levine and Kenneth M. Langa and Theodore J Iwashyna} } @article {7713, title = {Antigenic challenge in the etiology of autoimmune disease in women.}, journal = {J Autoimmun}, volume = {38}, year = {2012}, note = {Rogers, Mary A M Levine, Deborah A Blumberg, Neil Fisher, Gwenith G Kabeto, Mohammed Langa, Kenneth M 5R21HL093129-02/HL/NHLBI NIH HHS/ HL078603/HL/NHLBI NIH HHS/ HL095467/HL/NHLBI NIH HHS/ HL100051/HL/NHLBI NIH HHS/ R21 HL093129-01A1/HL/NHLBI NIH HHS/ R21 HL093129-02/HL/NHLBI NIH HHS/ U01AG009740/AG/NIA NIH HHS/ England J Autoimmun. 2012 May;38(2-3):J97-J102. Epub 2011 Aug 30.}, month = {2012 May}, pages = {J97-J102}, publisher = {38}, abstract = {

Infection has long been implicated as a trigger for autoimmune disease. Other antigenic challenges include receipt of allogeneic tissue or blood resulting in immunomodulation. We investigated antigenic challenges as possible risk factors for autoimmune disease in women using the Health and Retirement Study, a nationally representative longitudinal study, linked to Medicare files, years 1991-2007. The prevalence of autoimmune disease (rheumatoid arthritis, Hashimoto{\textquoteright}s disease, Graves{\textquoteright} disease, systemic lupus erythematosus, celiac disease, systemic sclerosis, Sj{\"o}gren syndrome and multiple sclerosis) was 1.4\% in older women (95\% CI: 1.3\%, 1.5\%) with significant variation across regions of the United States. The risk of autoimmune disease increased by 41\% (95\% CI of incidence rate ratio (IRR): 1.10, 1.81) with a prior infection-related medical visit. The risk of autoimmune disease increased by 90\% (95\% CI of IRR: 1.36, 2.66) with a prior transfusion without infection. Parity was not associated with autoimmune disease. Women less than 65 years of age and Jewish women had significantly elevated risk of developing autoimmune disease, as did individuals with a history of heart disease or end-stage renal disease. Antigenic challenges, such as infection and allogeneic blood transfusion, are significant risk factors for the development of autoimmune disease in older women.

}, keywords = {Aged, Aged, 80 and over, Antigens, Autoimmune Diseases, Female, Humans, Incidence, Middle Aged, Prevalence, Risk Factors, United States}, issn = {1095-9157}, doi = {10.1016/j.jaut.2011.08.001}, author = {Mary A M Rogers and Deborah A Levine and Neil Blumberg and Gwenith G Fisher and Mohammed U Kabeto and Kenneth M. Langa} } @article {7711, title = {Triggers of hospitalization for venous thromboembolism.}, journal = {Circulation}, volume = {125}, year = {2012}, note = {Rogers, Mary A M Levine, Deborah A Blumberg, Neil Flanders, Scott A Chopra, Vineet Langa, Kenneth M 5R21HL093129-02/HL/NHLBI NIH HHS/ R01 HL095467/HL/NHLBI NIH HHS/ U01AG009740/AG/NIA NIH HHS/ Circulation. 2012 May 1;125(17):2092-9. Epub 2012 Apr 3.}, month = {2012 May 01}, pages = {2092-9}, publisher = {125}, abstract = {

BACKGROUND: The rate of hospitalization for venous thromboembolism (VTE) is increasing in the United States. Although predictors of hospital-acquired VTE are well-known, triggers of VTE before hospitalization are not as clearly defined. The objective of this study was to evaluate triggers of hospitalization for VTE.

METHODS AND RESULTS: A case-crossover study was conducted. Subjects were participants in the Health and Retirement Study, a nationally representative sample of older Americans. Data were linked to Medicare files for hospital and nursing home stays, emergency department visits, outpatient visits including physician visits, and home health visits from years 1991 to 2007 (n=16 781). The outcome was hospitalization for venous thromboembolism (n=399). Exposures during the 90-day period before hospitalization for VTE were compared with exposures occurring in 4 comparison periods. Infection was the most common trigger of hospitalization for VTE, occurring in 52.4\% of the risk periods before hospitalization. The adjusted incidence rate ratios (IRRs; 95\% confidence interval) were 2.90 (2.13, 3.94) for all infection, 2.63 (1.90, 3.63) for infection without a previous hospital or skilled nursing facility stay, and 6.92 (4.46, 10.72) for infection with a previous hospital or skilled nursing facility stay. Erythropoiesis-stimulating agents and blood transfusion were also associated with VTE hospitalization (IRR=9.33, 95\% confidence interval: 1.19, 73.42; IRR=2.57, 95\% confidence interval: 1.17, 5.64; respectively). Other predictors included major surgeries, fractures (IRR=2.81), immobility (IRR=4.23), and chemotherapy (IRR=5.70). These predictors, combined, accounted for a large proportion (69.7\%) of exposures before VTE hospitalization as opposed to 35.3\% in the comparison periods.

CONCLUSIONS: Risk prediction algorithms for VTE should be reevaluated to include infection, erythropoiesis-stimulating agents, and blood transfusion.

}, keywords = {Aged, Ambulatory Care Facilities, Comorbidity, Cross-Over Studies, Emergency Service, Hospital, Female, Hematinics, Home Care Services, Hospitalization, Humans, Immobilization, Incidence, Infections, Male, Medicare, Middle Aged, Office Visits, Postoperative Complications, Pulmonary Embolism, Risk Factors, Skilled Nursing Facilities, Transfusion Reaction, United States, Venous Thrombosis}, issn = {1524-4539}, doi = {10.1161/CIRCULATIONAHA.111.084467}, url = {http://www.ncbi.nlm.nih.gov/pubmed/22474264}, author = {Mary A M Rogers and Deborah A Levine and Neil Blumberg and Scott A Flanders and Vineet Chopra and Kenneth M. Langa} }