Validation of a Community-Based Approach Toward Personalized Dementia Risk Reduction: The Kimel Family Centre for Brain Health and Wellness.

BACKGROUND/OBJECTIVES: The Kimel Family Centre for Brain Health and Wellness is a research-driven community centre testing the efficacy of personalized dementia risk reduction programming on dementia risk and cognition. The objective of this protocol is to validate this approach by following people for two years. DESIGN/SETTING: Participants will receive a comprehensive dementia risk assessment, including nonmodifiable and modifiable risk factors, from which they will receive a Personalized Dementia Risk Report and Program Strategy, indicating their health conditions increasing and their risk level in five modifiable risk domains: physical activity, brain-healthy eating, cognitive engagement, social connections, and mental wellbeing. Equipped with this information, participants will enroll in programs within the Centre to address their risk factors. Changes to their dementia risk, cognition, and Personalized Program Strategy will be communicated through re-assessments of risk factors every six months (risk and cognition) and every year (comprehensive assessment). PARTICIPANTS: Participants (n = 450) will be 50 years of age or older, without a diagnosis of dementia, and sufficiently fluent in English to complete the assessments and understand program instructors. One goal is that our participant sample will include people of low income (with fundraising providing free community centre membership), and from various ethno-racial backgrounds. INTERVENTION: Participants will select programs to meet their Personalized Program Strategy. For physical activity, they will gradually work toward the Canadian Society for Exercise Physiology guidelines. For brain-healthy eating, they will learn about the Brain Health Food Guide and food label reading, and then take additional programs. For cognitive engagement and mental wellbeing, they will take at least one hour of relevant programming per week. Social connections will be reinforced throughout all programs. All participants will also have access to the Canadian Consortium on Neurodegeneration's CAN-THUMBS Up online, educational program on modifiable dementia risk factors, called Brain Health PRO. MEASUREMENTS: The comprehensive assessment includes numerous dementia risk factors, but the primary measures are risk in the five domains, health conditions proximal to those five risk domains, and cognition, and how these are affected by adherence and quality of goal-directed future simulation. We hypothesize a reduced risk in the five domains within six months, improvements in health biomarkers within a year, and maintenance of cognition within two years, with these benefits accruing with greater adherence, but only up to a point, at which benefits will plateau, and greater benefits among participants whose goal-directed simulations are more vivid, personally-relevant, achievable, and positive. CONCLUSIONS: This innovative approach overcomes a number of limitations present in prior multidomain dementia prevention trials. Adapting a preference clinical trial that is embedded in a community centre, where participants have autonomy to choose programs to address their modifiable dementia risk factors, has real-world applicability in the global effort to reduce dementia risk.

Protocol for the Brain Health Support Program Study of the Canadian Therapeutic Platform Trial for Multidomain Interventions to Prevent Dementia (CAN-THUMBS UP): A Prospective 12-Month Intervention Study.

BACKGROUND/OBJECTIVES: CAN-THUMBS UP is designed as a comprehensive and innovative fully remote program to 1) develop an interactive and compelling online Brain Health Support Program intervention, with potential to positively influence dementia literacy, self-efficacy and lifestyle risk factors; 2) enroll and retain a community-dwelling Platform Trial Cohort of individuals at risk of dementia who will participate in the intervention; 3) support an open platform trial to test a variety of multidomain interventions that might further benefit individuals at risk of dementia. This manuscript presents the Brain Health Support Program Study protocol. DESIGN/SETTING: Twelve-month prospective multi-center longitudinal study to evaluate a fully remote web-based educational intervention. Participants will subsequently be part of a Platform Trial Cohort and may be eligible to participate in further dementia prevention clinical trials. PARTICIPANTS: Three hundred fifty older adults who are cognitively unimpaired or have mild cognitive impairment, with at least 1 well established dementia risk factor. INTERVENTION: Participants engage in the Brain Health Support Program intervention for 45-weeks and complete pre/post intervention measures. This intervention is designed to convey best available evidence for dementia prevention, consists of 181 chapters within 8 modules that are progressively delivered, and is available online in English and French. The program has been developed as a collaborative effort by investigators with recognized expertise in the program's content areas, along with input from older-adult citizen advisors. MEASUREMENTS: This study utilizes adapted remote assessments with accessible technologies (e.g. videoconferencing, cognitive testing via computer and mobile phone, wearable devices to track physical activity and sleep, self-administered saliva sample collection). The primary outcome is change in dementia literacy, as measured by the Alzheimer's Disease Knowledge Scale. Secondary outcomes include change in self-efficacy; engagement using the online program; user satisfaction ratings; and evaluation of usability and acceptance. Exploratory outcomes include changes in attitudes toward dementia, modifiable risk factors, performance on the Neuropsychological Test Battery, performance on self-administered online cognitive assessments, and levels of physical activity and sleep; success of the national recruitment plan; and the distribution of age adjusted polygenic hazard scores. CONCLUSIONS: This fully remote study provides an accessible approach to research with all study activities being completed in the participants' home environment. This approach may reduce barriers to participation, provide an easier and less demanding participant experience, and reach a broader geography with recruitment from all regions of Canada. CAN-THUMBS UP represents a Canadian contribution to the global World-Wide FINGERS program (alz.org/wwfingers).

Feasibility and preliminary efficacy of the LEAD trial: a cluster randomized controlled lifestyle intervention to improve hippocampal volume in older adults at-risk for dementia.

BACKGROUND: Healthy diet and exercise are associated with reduced risk of dementia in older adults. The impact of diet and exercise interventions on brain health is less consistent, especially with dietary interventions which rely on varying approaches. Our objective was to evaluate the feasibility and preliminary efficacy of a 6-month intervention combining exercise with a novel dietary counseling approach to improve hippocampal volume among older adults at-risk for dementia. METHODS: Participants with vascular risk factors and subjective cognitive decline or early mild cognitive impairment were cluster randomized in groups of 3-4 to the diet intervention (DIET) or control education (ED) group. All participants engaged in 1 h of supervised exercise per week and additional exercise at home. DIET involved 1 h per week of group-based dietary counseling comprising education, goal setting, and strategy training. ED involved 1 h per week of group-based brain health education classes. Our primary outcome was change in hippocampal volume from baseline to 6 months. Secondary outcomes included changes in cognitive function, blood biomarkers, diet, and fitness. Recruitment challenges and early discontinuation of the trial due to COVID-19 necessitated a revised focus on feasibility and preliminary efficacy. RESULTS: Of 190 older adults contacted, 14 (7%) were eligible and enrolled, constituting 21% of our recruitment target. All participants completed the intervention and attended 90% of exercise and DIET/ED sessions on average. All 6-month assessments prior to COVID-19 were completed but disruptions to in-person testing resulted in incomplete data collection. No serious adverse events occurred and all participants expressed positive feedback about the study. Preliminary findings did not identify any significant changes in hippocampal volume; however, substantial improvements in diet and HbA1c were observed with DIET compared to ED (d = 1.75 and 1.07, respectively). CONCLUSIONS: High adherence and retention rates were observed among participants and preliminary findings illustrate improvements in diet quality and HbA1c. These results indicate that a larger trial is feasible if difficulties surrounding recruitment can be mitigated. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03056508 .

The effect of heterologous anti-lymphocyte seerum on mouse hemopoietic stem cells.

The present study has demonstrated that rabbit anti-mouse lymphocyte serum (RAMLS) has the capability of destroying bone marrow cells and suppressing hemopoietic stem cell function. The in vitro incubation of bone marrow suspensions with RAMLS caused extensive cell lysis with an apparent preferential destruction of lymphoid, erythroid, and blastoid elements. Using the spleen colony assay, the number of functional hemopoietic stem cells was found to be markedly reduced in bone marrow populations exposed to RAMLS in vitro. Further, this loss of stem cell function could be produced by exposing marrow suspensions to small concentrations of antiserum which did not produce detectable cytotoxic effects on the general marrow population. A similar effect of RAMLS upon hemopoietic stem cells was found in vivo. The intravenous injection of RAMLS into lethally irradiated mice immediately after the infusion of isogeneic marrow cells reduced the number of spleen colonies formed, indicating that the antiserum could exhibit a deleterious effect upon stem cells in the bloodstream of the intact animal. Normal animals treated with daily subcutaneous injections of RAMLS for 3 wk had a significantly reduced marrow content of functional hemopoietic stem cells, suggesting that RAMLS can affect stem cells located in situ in the bone marrow. The experiments indicate that RAMLS possesses potential marrow toxicity.

Rationale and protocol of the ENGAGE study: a double-blind randomized controlled preference trial using a comprehensive cohort design to measure the effect of a cognitive and leisure-based intervention in older adults with a memory complaint.

BACKGROUND: Leisure activities can be both enjoyable and cognitively stimulating, and participation in such activities has been associated with reduced age-related cognitive decline. Thus, integrating stimulating leisure activities in cognitive training programs may represent a powerful and innovative approach to promote cognition in older adults at risk of dementia. The ENGAGE study is a randomized controlled, double-blind preference trial with a comprehensive cohort design that will test the efficacy and long-term impact of an intervention that combines cognitive training and cognitively stimulating leisure activities. METHODS: One hundred and forty-four older adults with a memory complaint will be recruited in Montreal and Toronto. A particular effort will be made to reach persons with low cognitive reserve. Participants will be randomly assigned to one of two conditions: cognitive + leisure training (ENGAGE-MUSIC/SPANISH) or active control (ENGAGE-DISCOVERY). The ENGAGE-MUSIC/SPANISH training will include teaching of mnemonic and attentional control strategies, casual videogames selected to train attention, and classes in music or Spanish as a second language. The ENGAGE-DISCOVERY condition will comprise psychoeducation on cognition and the brain, low-stimulating casual videogames and documentary viewing with discussions. To retain the leisure aspect of the activities, participants will be allowed to exclude either music or Spanish at study entry if they strongly dislike one of these activities. Participants randomized to ENGAGE-MUSIC/SPANISH who did not exclude any activity will be assigned to music or Spanish based on a second random assignment. Training will be provided in 24 2-h sessions over 4 months. Outcomes will be measured at baseline, at 4-month follow-up, and at 24-month follow-up. The primary outcome will be cognitive performance on a composite measure of episodic memory (delayed recall scores for words and face-name associations) measured at baseline and at the 4-month follow-up. Secondary outcomes will include a composite measure of attention (speed of processing, inhibition, dual tasking, and shifting), psychological health, activities of daily living, and brain structure and function and long-term maintenance measured at the 24-month follow-up. Information on cognitive reserve proxies (education and lifestyle questionnaires), sex and genotype (apolipoprotein (Apo)E4, brain-derived neurotrophic factor (BDNF), and catechol-O-methyltransferase (COMT)) will be collected and considered as moderators of training efficacy. DISCUSSION: This study will test whether a program combining cognitive training with stimulating leisure activities can increase cognition and reduce cognitive decline in persons at risk of dementia. TRIAL REGISTRATION: NCT03271190 . Registered on 5 September 2017.

The effects of divided attention on encoding and retrieval processes in human memory.

The authors examined the effects of divided attention (DA) at encoding and retrieval in free recall, cued recall, and recognition memory in 4 experiments. Lists of words or word pairs were presented auditorily and recalled orally; the secondary task was a visual continuous reaction-time (RT) task with manual responses. At encoding, DA was associated with large reductions in memory performance, but small increases in RT; trade-offs between memory and RT were under conscious control. In contrast, DA at retrieval resulted in small or no reductions in memory, but in comparatively larger increases in RT, especially in free recall. Memory performance was sensitive to changes in task emphasis at encoding but not at retrieval. The results are discussed in terms of controlled and automatic processes and speculatively linked to underlying neuropsychological mechanisms.

The attentional demands of encoding and retrieval in younger and older adults: 2. Evidence from secondary task reaction time distributions.

Three studies examined the effects of encoding or retrieval on properties of secondary task reaction time (RT) distributions in younger and older adults. Relative to full attention conditions, encoding and retrieval increased secondary task RT medians and standard deviations more for older adults than for younger adults, and the age-related RT increase was most pronounced among the slowest RTs. Hierarchical regression analyses revealed two age-related mechanisms underlying these effects, which were interpreted as cognitive slowing and reductions in attentional resources. Cognitive slowing affects the entire RT distribution regardless of the memory task. By contrast, reduced attentional resources result in very long RTs, especially when the tasks require self-initiated encoding or retrieval operations.

The attentional demands of encoding and retrieval in younger and older adults: 1. Evidence from divided attention costs.

Four studies examined the effects of divided attention in younger and older adults. Attention was divided at encoding or retrieval in free recall (Experiment 1), cued recall (Experiments 2 and 3), and recognition (Experiment 4). Dividing attention at encoding disrupted memory performance equally for the two age groups; by contrast, for both age groups, dividing attention at retrieval had little or no effect on memory performance. Secondary task reaction times (RTs) were slowed to a greater extent for the older adults than for the younger adults, especially at retrieval. Age-related differences in RT costs at retrieval were largest in free recall, smaller in cued recall, and smallest in recognition. These results provide evidence for an age-related increase in the attentional demands of encoding and retrieval.

Divided attention during encoding and retrieval: differential control effects?

Previous studies have shown that divided attention (DA) during retrieval has little effect on recall of episodic memories, although DA during encoding has a large detrimental effect. One possible reason for this asymmetry is that stimulus presentation at encoding is under experimenter control, whereas retrieval operations and responses are under participant control. This experiment tested this possibility by presenting paired-associate word lists for learning and recall, either at a fixed 4-s rate or at a rate controlled by the participant. The results showed that the higher recall levels for DA at retrieval than for DA at encoding held under all combinations of experimenter and participant control. The implications of these results for a fuller understanding of encoding and retrieval processes are discussed.

Basic mechanisms of lymphocyte recirculation in Lewis rats.

Lymphocyte locomotion in vivo depends upon an intact network of subplasmalemmal contractile microfilaments which are linked through the membrane to surface receptors, and the distribution and stabilization of recognition receptors may be controlled by microtubules and/or 10-nm filaments in the cytoplasm. The differential effects of cytochalasin-A and colchicine on lymphocyte homing and locomotion have proven useful in dissecting the subcellular events underlying the process of lymphocyte recirculation.

Studies on the structure and permeability of the microvasculature in normal rat lymph nodes.

The structure and permeability of the microvasculature in normal rat lymph nodes was studied by regional perfusion techniques. The results indicated that characteristic vascular units supplied each cortical lobule of lymphatic tissue. Numerous arteriovenous communications and venous sphincters innervated by unmyelinated nerve fibers were found in this vascular bed. These specialized vascular structures permitted regional control of blood flow through high endothelial venules. Lymphocytes migrated across these venular walls by moving through intercellular spaces in the endothelium and between gaps in the laminated, reticular sheath. No direct anastomoses between blood vessels and lymphatics were seen, but tracer studies with horseradish peroxidase suggested that functional lymph node-venous communications were present in the walls of high endothelial venules.

Lymphocyte emigration from high endothelial venules in rat lymph nodes.

Sequential events during lymphocyte emigration from high endothelial venuses (HEV) were studied by scanning and transmission electron microscopy combined with regional perfusion techniques. The results indicate that blood lymphocytes selectively adhere to HEV surfaces through microvilli which attach to shallow pits on the luminal surfaces of high endothelial cells. These intercellular contact points resist hydrodynamic and osmotic shearing forces, but can be disrupted by treatments which remove endothelial glycocalyx, hydrolyse lymphocyte surface glycoproteins, or chelate divalent cations. After this initial attachment phase, lymphocytes enter apical clefts between endothelial cells where they assume a motile configuration characterized by loss of microvilli and formation of irregular surface folds. Intramural lymphocytes adhere to adjacent endothelial cells through macular and villous contacts. Fibrillar electron-dense material traverses the 15-20 nm gap at these points of adhesion. Microtubules and microfilaments are also seen around areas of cytoplasmic constriction in these motile lymphocytes. The migrating lymphocytes show cytoplasmic polarity which is oriented in the direction of movement as they pass through extracellular spaces in the venular wall and cross successive laminations in the perivascular sheath to enter the node. Since these lymphocytes enter channels between endothelial cells which are stained by intralymphatic injections with horseradish peroxidase, it is suggested that their entry into the node depends upon migration along a chemotactic gradient.

Skeletal changes during prolonged external irradiation: alterations in marrow, growth plate and osteoclast populations.

This report describes hematologic and skeletal changes in young mice subjected to continuous external whole body irradiation (45 rads/day) for 4 days to 12 weeks. Irradiation caused a rapid depletion of hematopoietic stem cells, marrow aplasia and pancytopenia, all of which persisted during the period of irradiation but resolved afterward. In spite of suppressed cellular proliferation and disarray of cartilage cell columns in metaphyseal plates, linear bone growth appeared to continue at physiologic rates. Histologic and morphometric studies provided no evidence of impaired osteoblast function, but the presence of thickended trabeculae beneath the growth plate and of cartilagenous islands within cortical shafts of long bones indicated that bone remodeling was deficient. Direct osteoclast counts demonstrated that marrow aplasia was followed by a progressive decline that could not be reversed by parathormone injections or infusions with mature macrophages and lymphocytes but that resolved once the bone marrow recovered following cessation of irradiation. Therefore, the altered bone remodeling probably resulted from radiation injury to osteoclast precursors in the hematopoietic compartment.

Microvascular changes in lymph nodes draining skin allografts.

Histological, histochemical, ultrastructural, and radiolabeling characteristics of the microvasculature in regional nodes draining skin allograft sites are described. From 12 to 48 hours after grafting, these nodes show increased vascular permeability and altered lymphocyte traffic pattern. The rapid rise in lymphocyte migration indices and the apparent plugging of intermediate sinuses by lymphocytes suggest that both increased entry and decreased egress of recirculating cells contribute in "lymphocyte trapping." This is followed by redistribution of cortical capillary arcades as existing germinal centers dissolve and proliferating lymphocytes infiltrate the cortex. Normal microvascular patterns reappeared at 7 to 14 days as primary and secondary nodules form in the enlarged nodes. Increased length and arborization of high endothelial venules resulted from focal proliferation of endothelial cells in transition zones from high to low endothelium. In stimulated nodes, high endothelial cells exhibit increased cytoplasmic basophilia and acid hydrolase activities which correlate with the appearance of numerous polyribosomes, RER cisternae, and lysosomes in their cytoplasm. These "activated" endothelial cells phagocytose microthrombi within venular lumens.

Heparin-induced coagulopathy.

Intravenous heparin, at doses of 3.0 U./gm of body weight, produced an intravascular coagulopathy in rats which was manifested by intestinal tract hemorrhage, a reduction in plasma fibrinogen concentration, a rise in fibrinogen-fibrin degradation products, and the absence of a rise in platelet count noted in the control animals. This coagulopathy could not be produced by conventional anticoagulant doses of heparin or the injection of large doses of heparin in the presence of protamine sulfate. Specific studies excluded hypoxemia, metabolic acidosis, and endotoxemia as possible etiologic factors. The coagulation abnormalities observed in this study differ from those produced by injection of other polyanionic substances but their precise pathogenesis is still uncertain.

Pathogenesis of vascular injury in rejecting rat renal allografts.

Unmodified rejection of rat renal allografts was characterized by the early onset and rapid progression of endothelial damage in venules and capillaries which culminated in ischemic cortical necrosis. This pattern of endothelial injury correlated with lymphocyte accumulation in vascular lumens and could not be duplicated by renal perfusion with alloantibodies or prevented by C'3 depletion. In contrast, endothelial integrity and normal graft function were maintained over study intervals extending to 200 days when Brown Norway (BN) rat kidneys were transplanted into Lewis (Le) rat kidney recipients subjected to neonatal thymectomy or lymph drainage. Vascular lesions occurred when syngeneic thoracic duct lymphocytes were transfused into these recipients, but irreversible endothelial injury could be prevented by simultaneous injections of immune plasma. These findings indicate that the destruction of donor endothelium is mediated by thymus-dependent immune mechanisms which can be altered by thoracic duct drainage to promote indefinite survival of renal allografts across major histocompatibility loci.

Specialized structure and metabolic activities of high endothelial venules in rat lymphatic tissues.

Microscopic, histochemical and ultrastructural techniques were used to define characteristics of high endothelial venules (HEV) in rat lymphatic tissues. This endothelium contained acetyl esterase and acid hydrolase activities which were not altered by lymphocyte depletion. No immunoglobulins were detected on luminal surfaces of HEV by fluorescent antibody staining. Only minor structural differences were seen between HEV within lymph nodes and Peyer's patches. At both sites, high endothelial cells were linked together by macular junctional complexes and interlocking basal foot processes. Endothelial cell cytoplasm moulded about surfaces of lymphocytes migrating through the venular wall, and flocculant deposits of basement membrane formed over lymphocytes penetrating the basal lamina. The endothelium was ensheathed by three to five layers of overlapping reticular cell plates and connective tissue. Each plate was linked to the reticular meshwork of the node by collagen bundles and anchoring filaments which inserted into the plate's external limiting membrane. This permitted individual paltes to separate or approximate each other as tissue and intravascular pressure varied, and lymphocytes moved across the sheath by insinuating themselves into gaps between overlapping plates. This composite structure of the HEV wall appeared to facilitate lymphocyte entry into the node and minimized vascular leakge.

The effect of divided attention on encoding and retrieval in episodic memory revealed by positron emission tomography.

The effects of divided attention (DA) on episodic memory encoding and retrieval were investigated in 12 normal young subjects by positron emission tomography (PET). Cerebral blood flow was measured while subjects were concurrently performing a memory task (encoding and retrieval of visually presented word pairs) and an auditory tone-discrimination task. The PET data were analyzed using multivariate Partial Least Squares (PLS), and the results revealed three sets of neural correlates related to specific task contrasts. Brain activity, relatively greater under conditions of full attention (FA) than DA, was identified in the occipital-temporal, medial, and ventral-frontal areas, whereas areas showing relatively more activity under DA than FA were found in the cerebellum, temporo-parietal, left anterior-cingulate gyrus, and bilateral dorsolateral-prefrontal areas. Regions more active during encoding than during retrieval were located in the hippocampus, temporal and the prefrontal cortex of the left hemisphere, and regions more active during retrieval than during encoding included areas in the medial and right-prefrontal cortex, basal ganglia, thalamus, and cuneus. DA at encoding was associated with specific decreases in rCBF in the left-prefrontal areas, whereas DA at retrieval was associated with decreased rCBF in a relatively small region in the right-prefrontal cortex. These different patterns of activity are related to the behavioral results, which showed a substantial decrease in memory performance when the DA task was performed at encoding, but no change in memory levels when the DA task was performed at retrieval.