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The CHS Cognition Study: Evaluating Dementia in the Cardiovascular Health Study Cohort

This study investigates the association between cognitive function and cerebral MRI measurements in the Cardiovascular Health Study (CHS) cohort. It includes 5,888 participants aged 65+ years old and examines various factors such as cognition, medical history, depression, physical function, medications, cardiovascular disease events, and hospitalizations. Screening criteria are used to identify individuals for further evaluation, including those with low cognitive scores, decline in cognitive function, and incident stroke. The study aims to classify participants as normal cognition, mild cognitive impairment, or dementia using various neuropsychological tests and informant questionnaires. The data collected also allows for the evaluation of dementia onset and type. The study findings suggest racial differences in the incidence and prevalence of dementia. Several published papers have been produced based on the research findings.

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The CHS Cognition Study: Evaluating Dementia in the Cardiovascular Health Study Cohort

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  1. The CHS Cognition StudyMethodology PI: Lewis H. Kuller, MD, DrPhCo-investigators: Oscar Lopez (Pitt)Annette L. Fitzpatrick (UW) Richard Kronmal (UW) Claudia H. Kawas (UCI)William Jagust (UCB)Contantine Lyketsos (JHU)Linda Fried (JHU)Greg Burke (WFU)John Robbins (UCD)National Institute on Aging, NIH

  2. RECAP Cardiovascular Health Study • Observational cohort initiated in 1989/90 • Followed prospectively through present • 5,888 participants 65+ years old at baseline • 4 Clinical Sites: NC, MD, CA, PA • Annual clinic visits through 1998/99 • Longitudinal data: cognition, medical history, depression, physical function, medications, CVD events, all hospitalizations • Cerebral MRI completed in 1992/3 and 1998/9

  3. CHS Cognition Study • Ancillary study to the CHS • CHS Cognition Study funded by NIA in 1999/2000 • Funded to evaluate dementia in CHS • Investigate associations with cerebral MRI measurements

  4. CHS Cognition StudyCohort Entry Criteria • Completion of the MRI 1992/4 (several outside window) • Concurrent 3MSE • N = 3,608

  5. CHS Cognition Study Timeline 1989/90: Original Cohort 1990/91 1991/92 1992/93 A-A Cohort MRI 1993/94 MRI 1994/95 1995/96 1996/97 1997/98 1998/99 Last Clinic Visit 1999/2000 Evaluation of Dementia 2000/03 Continue Events Surveillance

  6. Screening Used for Further Evaluation • Not enough funding for all 3,608 participants • Decision to use data already available in CHS as screening mechanism • Individuals “passing” screening would be considered “normal cognition” • Others would require further evaluation for classification

  7. Screening Criteria for Evaluation • 3MSE < 80 in one of last two visits • Decline of > 5 points from first to last visit • TICS < 28 • IQCode > 3.6 • Incident Stroke • Medical Record Review with Dx Dementia • Residing in Nursing Home • ALL MINORITIES

  8. Screening Criteria for Evaluation • Criteria Used at 3 Sites • 3 = WFU • 4 = UCD • 5 = JHU • Evaluation on All Participants at 1 Site • 6 = PITT

  9. Evaluation of Dementia Living Participants Invited for NP Battery: • American version of the National Reading test • Raven’s Couloured Progressive Matrices • California Verbal Learning Test • Rey-Osterreith figure • Immediate and Delayed Recall • Boston Naming test • Verbal fluency test • Block design (modified Wechsler Adult Intelligence Scale-revised) • Stroop Neuropsychological Screening Test • Trail Making • Digit Spans • Baddeley & Papagno Divided Attention Task • Grooved Pegboard Test

  10. Evaluation of Dementia Deceased/Refused/Unable Participants • TICS (Telephone Interview for Cognitive Status) if possible • Physician Questionnaire / Records • Medical Record Review • Informant Questionnaires • Neuropsychiatric Inventory • IQCode (Informant Questionnaire for Cognitive Decline in the Elderly) • Dementia Questionnaire

  11. Classification Process • Review committee of Neurologists/ Psychiatrists • Review Packet Made • CHS Data • Cognition Study Data • Dementia Status Normal, MCI, Dementia • Type of Dementia (various criteria) • Date of Onset

  12. Results of Dementia Classfication Normal = 2318 Mild Cognitive Impairment = 577 Prevalent Dementia = 227 Incident Dementia = 480 Unknown = 6 TOTAL 3608

  13. Dementia Type • AD: DSM IV NINDS ADRDA • VaD : NINCDS AIRENS ADDTC • Other : Parkinson’s Dementia Dementia with Lewy Bodies Due to Comorbidies

  14. Dementia Type (Recommended) • AD Only: NINCDS-ADRDA AD probable or possible NO ADDTC VaD n=245 • VaD Only: ADDTC VaD probable or possible No NINCDS-ADRDA AD n=62 • Mixed: NINCDS-ADRDA AD probable or possible ADDTC VaD probable or possible n=151 • No Dementia: n=2318

  15. Evaluation of Dementia Onset of Dementia • Longitudinal CHS Data • 3MSE • DSST • BVRT • CES-D Depression • Medications • History of CHD Events and Stroke / Hospitalizations • Functional Status (ADLs and IADLs) • Informant Questionnaires

  16. Results Onset of Dementia 1992 4 1993 19 1994 95 1995 104 1996 103 1997 92 1998 48 1999 15 TOTAL 480

  17. Data Collection Protocol

  18. Dementia Classification by Clinic

  19. Dementia Status by Protocol

  20. Dementia Status by Race

  21. Incidence of Dementia By Race * Adjusted for age at MRI, rate shown for age 80 3 p=.003 (test for race adjusted for age)

  22. Dementia in Pitt Cases that would have been Normal

  23. Adjustment for Bias • Incidence Paper: • Added 3.8% incident cases (n=56) • White • Random selection • Concluded no racial difference in incidence • Race Paper: • Logistic regression of Pitt data • Predict inc and prev dementia in those who would not have been evaluated • Used model to select pts who may have been missed (with dementia, n=56 whites) • Reclassified these “normals” with dementia • Conclusion: Racial difference present (bias did not change associations

  24. Published Papers • Lopez OL, Kuller LH, Fitzpatrick AL, Ives D, Becker JT, Beauchamp N. Evaluation of dementia in the Cardiovascular Health Cognition Study. Neuroepidemiology 2003; 22:1-12. • Kuller LH, Lopez OL, Newman A, Beauchamp NJ, Burke G, Dulberg C, Fitzpatrick AL, Fried LP. Haan MN. Risk factors for dementia in the Cardiovascular Health Cognition Study. Neuroepidemiolgy 2003; 22:13-22. • Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky. Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment. JAMA 2002; 288 (12):1475-1483. • Lopez OL, Jagust WJ, DeKosky ST, Becker JT, Fitzpatrick AL, Dulberg C, Breitner J, Lyketsos C, Jones B, Kawas C, Carlson M, Kuller LK. Prevalence and classification of mild cognitive impairment in the Cardiovascular Health Study Cognition Study. Arch Neurol 2003; 60:1385-1289. • Lopez OL, Jagust WJ, Dulberg C, Becker JT, DeKosky ST, Fitzpatrick AL, Breitner J, Lyketsos C, Jones B, Kawas C, Carlson M, Kuller LK. Risk factors for mild cognitive impairment in the Cardiovascular Health Study Cognition Study. Arch Neurol 2003; 60: 1394-1399.

  25. Published Papers • Mukamal KJ, Kuller LH, Longstreth WT, Mittleman MA, Fitzpatrick AL, Siscovick DS. A prospective study of alcohol consumption and risk of dementia in older adults: The Cardiovascular Health Study. JAMA 2003; 289:1405-1413. • Fitzpatrick AL, Kuller LH, Ives D, Lopez OL, Jagust W, Breitner J, Beauchamp N, Lyketsos C, Dulberg C. Incidence and Prevalence of Dementia in the Cardiovascular Health Study. J Am Geriatr Soc 2004; 52:195-204. • Seliger S, Siscovick DS, Stehman-Breen CO, Gillen DL, Fitzpatrick AL, Bleyer A, Kuller L. Moderate renal impairment and risk of dementia among older adults: the Cardiovascular Health Cognition Study. J Am Soc Nephrology (in press). • Fitzpatrick AL, Kuller LH, Lopez OL, Kawas CH, Jagust W. Survival following dementia onset: Alzheimer’s disease and vascular dementia. J Neurol Sci (in press). • Rea TD, Psaty BM, Breitner J, Fitzpatrick AL, Zandi PP. Statins and the risk of incident dementia: The Cardiovascular Health Study. Arch Neurology (in press).

  26. Under Review • Newman AB, Fitzpatrick AL, Lopez OL, Jackson S, Lyketsos C, Jagust WJ, Ives D, DeKosky ST, Kuller LH. Dementia and Alzheimer’s disease incidence in relationship to cardiovascular disease in the Cardiovascular Health Study cohort. Submitted to the J Am Geriatr Soc. • Lopez OL, Kuller LH, Becker JT, Jagust WJ, DeKosky ST, Fitzpatrick AL, Dulberg C, Breitner JCS, Lyketsos C, Kawas C, Carlson M. Classification of vascular dementia in the Cardiovascular Health Cognition Study. Submitted to Neurology. • Kuller LH, Lopez OL, Jagust WJ, Becker JT, DeKosky ST, Lyketsos C, Kawas C, Breitner JCS, Fitzpatrick AL, Dulberg C. Clinical and MRI factors for vascular dementia in the Cardiovascular Health Study. Submitted to Neurology. • Lopez OL, Breitner JCS, Lyketsos C, Fitzpatrick AL, Carlson, M. Neuropsychological characteristics of mild cognitive impairment subgroups. Submitted to Journal of Neurology, Neurosurgery, and Psychiatry. • Fitzpatrick AL, Kuller LH, , Lopez A, Longstreth W, Bernick C, Cushman M, Burke G, MR Malinow, Lyketsos C. Associations between Plasma Homocysteine and Type of Dementia: The Cardiovascular Health Cognition Study. Almost submitted to Neuroogy.

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