Hemodynamic Reactivity to Mental Stress and Cognitive Function in Coronary Artery Disease.

OBJECTIVE: People with coronary artery disease (CAD) are at higher risk of cognitive impairment than those without CAD. Psychological stress is a risk factor for both conditions and assessing the hemodynamic reactivity to mental stress could explain the link between stress and cognitive function. METHODS: Individuals with stable CAD from two prospective cohort studies were included. All individuals underwent acute mental stress testing, as well as conventional stress testing. Cognitive function was assessed both at baseline and at a 2-year follow-up. The rate-pressure product (RPP) was calculated as the mean systolic blood pressure times the mean heart rate at rest. RPP reactivity was defined as the maximum RPP during standardized mental stress test minus the RPP at rest. RESULTS: After multivariable adjustment, every standard deviation decrease in RPP reactivity with mental stress was associated with slower completion of Trail-A and Trail-B in both cohorts (13% and 11% in cohort 1, and 15% and 16% in cohort 2, respectively, p for all <0.01). After a 2-year follow-up period, every standard deviation decrease in RPP reactivity with mental stress was associated with a 8%, and 9% slower completion of Trail-A and Trail-B, respectively (p for all <0.01). There was no significant association between RPP reactivity with conventional stress testing and any of the cognitive tests. CONCLUSION: In the CAD population, a blunted hemodynamic response to mental stress is associated with slower visuomotor processing and worse executive function at baseline and with greater decline in these abilities over time.

Association between low cognitive performance and diabetes-related health indicators across racial and ethnic groups in adults with diabetes.

AIM: To examine the associations between low cognitive performance (LCP) and diabetes-related health indicators (including body mass index [BMI], HbA1c, systolic blood pressure [SBP], low-density lipoprotein [LDL] and self-reported poor physical health) and whether these associations vary across racial/ethnic subgroups. METHODS: We identified adults aged 60 years or older with self-reported diabetes from the 2011-2014 National Health and Nutrition Examination Survey. Individuals with cognitive test scores in the lowest quartile were defined as having LCP. We used regression models to measure the associations of LCP with diabetes-related biometrics (BMI, HbA1c, SBP and LDL); and self-reported poor physical health. Moreover, we explored potential variations in these associations across racial/ethnic subgroups. RESULTS: Of 873 (261 with LCP) adults with diabetes, LCP was associated with higher HbA1c, SBP and LDL (adjusted difference: 0.41%, 5.01 mmHg and 5.08 mg/dL, respectively; P < .05), and greater odds of reporting poor physical health (adjusted odds ratio: 1.59, P < .05). The association between LCP and HbA1c was consistent across racial/ethnic groups, and notably pronounced in Hispanic and Other. BMI worsened with LCP, except for non-Hispanic Black. Excluding the Other group, elevated SBP was observed in people with LCP, with Hispanic showing the most significant association. LDL levels were elevated with LCP for Hispanic and Other. Physical health worsened with LCP for both non-Hispanic Black and Hispanic. CONCLUSIONS: We quantified the association between LCP and diabetes-related health indicators. These associations were more pronounced in Hispanic and Other racial/ethnic groups.

Renal function as an effect modifier of intensive glucose control in delaying cognitive function decline among individuals with type 2 diabetes: A revisit to the ACCORD MIND trial.

AIM: Dysglycaemia accelerates cognitive decline. Intensive glucose control may help delay or prevent cognitive function decline (CFD). We aimed to determine how patient characteristics influence the effect of intensive glucose control [glycated haemoglobin (HbA1c) <6.0%] on delaying CFD in people with type 2 diabetes. RESEARCH DESIGN AND METHODS: In this post-hoc analysis of 2977 type 2 diabetes participants from the ACCORD MIND trial, we applied the causal forest and causal tree algorithms to identify the effect modifier of intensive glucose control in delaying CFD from 68 variables (demographics, disease history, medications, vitals and baseline biomarkers). The exposure was intensive versus standard glucose control (HbA1c <6.0% vs. 7.0%-7.9%). The main outcome was cognitive function changes from baseline to the 40th month follow-up, which were evaluated using the digit symbol substitution test, Rey auditory verbal learning test, mini-mental state examination and Stroop test. We used Cohen's d, a measure of standardized difference, to quantify the effect size of intensive glucose control on delaying CFD. RESULTS: Among all the baseline characteristics, renal function was the most significant effect modifier. Participants with urinary albumin levels <0.4 mg/dl [absolute function change (AFC): 0.51 in mini-mental state examination, 95% confidence interval (CI): 0.04, 0.98, Cohen's d: 0.25] had slower CFD with intensive glucose control. Patients with preserved renal function (estimated glomerular filtration rate between 60 and 90 ml/min/1.73 m2) were associated with small benefits (AFC: 1.28 in Stroop, 95% CI: 0.28, 2.27, Cohen's d: 0.12) when undergoing intensive glucose control. Conversely, participants with an estimated glomerular filtration rate <60 ml/min/1.73 m2 (AFC: -0.57 in the Rey auditory verbal learning test, 95% CI: -1.09, -0.05, Cohen's d: -0.30) exhibited faster CFD when undergoing intensive glucose control. Participants who were <60 years old showed a significant benefit from intensive glucose control in delaying CFD (AFC: 1.08 in the digit symbol substitution test, 95% CI: 0.06, 2.10, Cohen's d: 0.13). All p < .05. CONCLUSIONS: Our findings linked renal function with the benefits of intensive glucose control in delaying CFD, informing personalized HbA1c goals for those with diabetes and at risk of CFD.

Effect of home-based lifestyle interventions on cognition in older adults with mild cognitive impairment: a systematic review.

BACKGROUND: Mild Cognitive Impairment (MCI) is frequently a precursor to dementia, affecting aspects of cognition such as language, thinking, or memory. Lifestyle interventions are increasingly studied as potential means to slow the progression from MCI to dementia. OBJECTIVE: A systematic review was conducted to investigate the effectiveness of home-based lifestyle interventions in reducing cognitive decline in older adults with MCI. METHODS: A systematic review of randomized controlled trials (RCTs) was conducted to identify home-based lifestyle interventions for individuals with MCI from 1980 to 2023. These interventions were either single-component or multi-component and included diet, physical activity, stress-reduction, or cognitive stimulation treatments to assess their impact on cognition. We performed a comprehensive search in the PubMed, Web of Science, Google Scholar, Embase, and MEDLINE databases. RESULTS: From 320 abstracts, 20 (6.25%) studies met the criteria for inclusion, with five multi-component and fifteen single-component studies. Eighteen home-based lifestyle interventions for MCI patients were focused on physical activity, diet, and/or cognitive training, while two studies were identified that incorporated stress reduction training as a method to improve cognitive function. Nineteen studies reported significant improvements in cognitive performance between the experimental and control groups post-intervention for at least one aspect of cognition. Four studies reported nonsignificant improvements in cognitive function between the two groups for at least one area of cognition. CONCLUSIONS: Home-based lifestyle interventions have the potential to improve cognition in elderly patients with MCI. However, future RCTs with larger sample sizes and longer intervention durations are needed to confirm these findings.

Global rural health disparities in Alzheimer's disease and related dementias: State of the science.

INTRODUCTION: Individuals living in rural communities are at heightened risk for Alzheimer's disease and related dementias (ADRD), which parallels other persistent place-based health disparities. Identifying multiple potentially modifiable risk factors specific to rural areas that contribute to ADRD is an essential first step in understanding the complex interplay between various barriers and facilitators. METHODS: An interdisciplinary, international group of ADRD researchers convened to address the overarching question of: "What can be done to begin minimizing the rural health disparities that contribute uniquely to ADRD?" In this state of the science appraisal, we explore what is known about the biological, behavioral, sociocultural, and environmental influences on ADRD disparities in rural settings. RESULTS: A range of individual, interpersonal, and community factors were identified, including strengths of rural residents in facilitating healthy aging lifestyle interventions. DISCUSSION: A location dynamics model and ADRD-focused future directions are offered for guiding rural practitioners, researchers, and policymakers in mitigating rural disparities. HIGHLIGHTS: Rural residents face heightened Alzheimer's disease and related dementia (ADRD) risks and burdens due to health disparities. Defining the unique rural barriers and facilitators to cognitive health yields insight. The strengths and resilience of rural residents can mitigate ADRD-related challenges. A novel "location dynamics" model guides assessment of rural-specific ADRD issues.

Cardiovascular Health Status in Baby Boomers with Diabetes Mellitus.

OBJECTIVES: The objective of this study was to assess the cardiovascular health status of baby boomers with diabetes mellitus (DM) in comparison to the same-age population with DM 10 years previously. METHODS: The study was conducted in baby boomers with DM using data from the National Health and Nutrition Examination Survey (NHANES) 2009-2012 compared with NHANES 1999-2002. Cardiovascular health metrics were derived from the American Heart Association's Life's Simple 7. The primary outcome was the comparison of the proportion of individuals with each characteristic, including healthy diet, healthy weight, not smoking, exercising regularly, and maintaining an optimal level of glycated hemoglobin (HbA1C), cholesterol, and blood pressure. RESULTS: Current baby boomers with DM (NHANES 2009-2012) had more obesity (70.9% vs 58.8%; P = 0.009) and a lower proportion of ideal physical activity (20.9% vs 31.7%; P = 0.01) than people of the same age 10 years ago; fewer than 1% adhere to an ideal healthy diet. Current baby boomers more often had ideal cholesterol (59.4% vs 47.2; P = 0.01) and reached an ideal HbA1C (51.0% vs 43.4%; P = 0.047). Blood pressure control, adherence to ideal diet, and smoking rates were not significantly different from 10 years ago. In logistic regression analyses controlling for likely confounders, baby boomers persisted in having more obesity and exercising less often, and reaching an ideal cholesterol level more often (P < 0.01). CONCLUSIONS: Although improving in cholesterol and HbA1C, baby boomers demonstrated worsening in several key cardiovascular health indicators, particularly obesity and physical activity.

Family history of stroke and cardiovascular health in a national cohort.

BACKGROUND: We investigated the association between family history of stroke (FHS) and Life's Simple 7 (LS7), a public health metric defined by the American Heart Association. METHODS: Reasons for Geographic and Racial Differences in Stroke is a national population-based cohort of 30,239 blacks and whites, aged 45 years or older, sampled from the US population between 2003 and 2007. Data were collected by telephone, mail questionnaires, and in-home examinations. FHS was defined as any first-degree relative with stroke. Levels of the LS7 components (total cholesterol, blood pressure, fasting glucose, physical activity, diet, smoking, and body mass index) were each coded as poor (0 points), intermediate (1 point), or ideal (2 points) health. Ordinal logistic regression was used to model the data. RESULTS: Among 20,567 subjects with complete LS7 and FHS data, there were 7702 (37%) participants with an FHS. The mean age of the participants was 64 years. The mean (± standard deviation) overall LS7 score was lower for blacks (6.5 ± 2.0) than that of whites (7.6 ± 2.1). FHS was associated with poorer levels of physiological factors, particularly high blood pressure (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07-1.19) and inversely associated with behaviors such as smoking (OR, .92; 95% CI, .85-.99). CONCLUSIONS: Our results suggest that screening for FHS can provide an opportunity for earlier detection and management of modifiable risk factors.

Empathetic Communication in Telemedicine: A Pilot Study.

Background and Objectives: In health care, empathy is a clinician's ability to understand a patient's emotional state and convey that understanding in their care; and being culturally sensitive is communicating and respecting cultural differences. Providing health care on digital platforms introduces a new challenge of conveying empathy and cultural sensitivity. This study aimed to evaluate whether patients who were seen in-person had different perceptions of clinicians' empathy and cultural sensitivity compared to those who were seen via telemedicine. Methods: In this cross-sectional pilot study, we recruited primary care clinicians (N=8) and their telemedicine (N=14) and in-person patients (N=20) from two clinics at Emory University in Atlanta, Georgia. We evaluated clinicians' empathy and cultural sensitivity by self-report and from patients' standpoints. Results: Patient perception of clinician empathy scores were similar (P value=.31) for in-person appointments (mean=33.8) and telemedicine appointments (mean=31.3). Patient perception of culturally sensitive communication varied in the sensitivity domain and was consistently low for the domain of discrimination (suggesting low discrimination among the clinicians) regardless of the modality of the visit. Conclusions: This novel pilot study demonstrated comparable empathy and culturally sensitive communication scores in telemedicine and in-person visits, highlighting the potential for continued use of telemedicine in outpatient primary care. Delivery of care via telemedicine can enable an expansion of high-quality care to underserved communities. Future studies are needed to confirm our findings to enhance the experience of telemedicine visits for patients and clinicians.

Associations Between Postdischarge Care and Cognitive Impairment-Related Hospital Readmissions for Ketoacidosis and Severe Hypoglycemia in Adults With Diabetes.

OBJECTIVE: Patients with severe hypoglycemia (SH) or diabetic ketoacidosis (DKA) experience high hospital readmission after being discharged. Cognitive impairment (CI) may further increase the risk, especially in those experiencing an interruption of medical care after discharge. This study examined the effect modification role of postdischarge care (PDC) on CI-associated readmission risk among U.S. adults with diabetes initially admitted for DKA or SH. RESEARCH DESIGN AND METHODS: We used the Nationwide Readmissions Database (NRD) (2016-2018) to identify individuals hospitalized with a diagnosis of DKA or SH. Multivariate Cox regression was used to compare the all-cause readmission risk at 30 days between those with and without CI identified during the initial hospitalization. We assessed the CI-associated readmission risk in the patients with and without PDC, an effect modifier with the CI status. RESULTS: We identified 23,775 SH patients (53.3% women, mean age 65.9 ± 15.3 years) and 140,490 DKA patients (45.8% women, mean age 40.3 ± 15.4 years), and 2,675 (11.2%) and 1,261 (0.9%), respectively, had a CI diagnosis during their index hospitalization. For SH and DKA patients discharged without PDC, CI was associated with a higher readmission risk of 23% (adjusted hazard ratio [aHR] 1.23, 95% confidence interval 1.08-1.40) and 35% (aHR 1.35, 95% confidence interval 1.08-1.70), respectively. However, when patients were discharged with PDC, we found PDC was an effect modifier to mitigate CI-associated readmission risk for both SH and DKA patients (P < 0.05 for all). CONCLUSIONS: Our results suggest that PDC can potentially mitigate the excessive readmission risk associated with CI, emphasizing the importance of postdischarge continuity of care for medically complex patients with comorbid diabetes and CI.

Life's Simple 7 and risk of incident stroke: the reasons for geographic and racial differences in stroke study.

BACKGROUND AND PURPOSE: The American Heart Association developed Life's Simple 7 (LS7) as a metric defining cardiovascular health. We investigated the association between LS7 and incident stroke in black and white Americans. METHODS: The Reasons for Geographic And Racial Differences in Stroke (REGARDS) is a national population-based cohort of 30 239 blacks and whites, aged ≥45 years, sampled from the US population from 2003 to 2007. Data were collected by telephone, self-administered questionnaires, and an in-home examination. Incident strokes were identified through biannual participant contact followed by adjudication of medical records. Levels of the LS7 components (blood pressure, cholesterol, glucose, body mass index, smoking, physical activity, and diet) were each coded as poor (0 point), intermediate (1 point), or ideal (2 points) health. An overall LS7 score was categorized as inadequate (0-4), average (5-9), or optimum (10-14) cardiovascular health. RESULTS: Among 22 914 subjects with LS7 data and no previous cardiovascular disease, there were 432 incident strokes over 4.9 years of follow-up. After adjusting for demographics, socioeconomic status, and region of residence, each better health category of the LS7 score was associated with a 25% lower risk of stroke (hazard ratios, 0.75; 95% confidence interval, 0.63-0.90). The association was similar for blacks and whites (interaction P value=0.55). A 1-point higher LS7 score was associated with an 8% lower risk of stroke (hazard ratios, 0.92; 95% confidence interval, 0.88-0.95). CONCLUSIONS: In both blacks and whites, better cardiovascular health, on the basis of the LS7 score, is associated with lower risk of stroke, and a small difference in scores was an important stroke determinant.

Risk Factors Associated With Polypharmacy and Potentially Inappropriate Medication Use in Ambulatory Care Among the Elderly in the United States: A Cross-Sectional Study.

INTRODUCTION: Polypharmacy, defined as the concurrent use of multiple (commonly five or more) prescription drugs, is widely prevalent among the elderly. It is a preventable and significant contributor to morbidity and mortality among older people. It is linked to prescribing potentially inappropriate medications (PIMs), which have been shown to be associated with an increased risk of adverse drug interactions and reduced compliance, and in some cases result in prescribing cascades where more drugs are prescribed to manage adverse outcomes. This study aimed to examine risk factors associated with polypharmacy and PIMs among elderly patients in outpatient settings in the US. METHODS: We conducted a cross-sectional analysis using the nationally representative National Ambulatory Medical Care Survey, between 2010 and 2016. We extracted data from all people aged 65 years or older and evaluated factors associated with polypharmacy and PIMs using multivariable logistic regression. Weights were applied to obtain national estimates. RESULTS: During the study period, there were a total of 81,295 ambulatory visits among adults 65 years and older. Being a woman (compared with a man) was more likely to be associated with greater prevalence of PIMs (OR: 1.31, 95% CI 1.23-1.40), and living in rural areas were more likely to be associated with both polypharmacy (OR: 1.15, 95% CI 1.07-1.23) and PIMs (OR: 1.19, 95% CI 1.09-1.29), compared with living in urban areas. Older age was positively associated with polypharmacy (OR: 1.08, 95% CI 1.06-1.10), but negatively associated with PIMs (OR: 0.97, 95% CI 0.95-0.99). CONCLUSIONS: Our study suggests age, being a woman, and living in rural areas are risk factors for both polypharmacy and PIMs usage. Aside from primary care providers' roles in managing polypharmacy, collaborative care with other specialty providers, such as clinical pharmacists, should also be considered as an approach to improving the quality of prescribing in geriatric patients. Future research should further explore reasons for polypharmacy and focus on deprescribing and quality improvement initiatives in primary care to lower polypharmacy among the elderly.

Trends in Provision of Medications and Lifestyle Counseling in Ambulatory Settings by Gender and Race for Patients With Atherosclerotic Cardiovascular Disease, 2006-2016.

Importance: Atherosclerotic cardiovascular disease (ASCVD) continues to be highly prevalent in the US. The 2013 American College of Cardiology and American Heart Association (ACC/AHA) treatment guidelines reevaluated evidence-based practices for reduction of ASCVD in men and women from high-quality randomized trials and meta-analyses recommending the use of statin therapy, aspirin prescription, and lifestyle counseling for adults with ASCVD. Population trends in secondary prevention strategies for patients with ASCVD among primary care settings is currently lacking, limiting ability to evaluate impact of guideline implementation. Objective: To examine temporal and sociodemographic trends in secondary prevention strategies in patients with ASCVD between 2006 and 2016 in a nationally representative, ambulatory care database. Design, Setting, and Participants: This cross-sectional study analyzed data from the National Ambulatory Medical Care Survey (NAMCS), which is an annual survey conducted to represent the national US population and contains information on ambulatory office-based patient visits, including medical conditions, services provided, and demographic characteristics. Participants were adults aged 21 years and older with prevalent ASCVD identified via International Classification of Disease codes between 2006 and 2016. Data were extracted and analyzed in March 2021. Main Outcomes and Measures: Data were separated by calendar year pre-2013 (2006 to 2013) and post-2013 (2014 to 2016). Outcomes included statin therapy, aspirin prescription, and lifestyle counseling (eg, nutrition, exercise, weight reduction) service provided at clinic visits. Results: There were 11 033 visits for adults with ASCVD, representing a weighted total of 275.3 million visits nationwide; 40.7% (112.1 million [weighted]) were women, 9.2% (25.4 million [weighted]) were Hispanic, 9.9% (19.0 million [weighted]) were non-Hispanic Black, 90.1% (172.7 million [weighted]) were non-Hispanic White, and 40.6% (112.1 million [weighted]) were from cardiology clinics. Of 11 033 patient visits, 5507 patients (49.9%) were prescribed statin therapy, 5165 patients (46.8%) were using aspirin, 2233 patients (20.2%) received lifestyle counseling. Statin therapy increased from 9.3 million individuals (45.3%) in 2006 to 14.9 million individuals (46.5%) in 2016, and aspirin prescriptions increased from 8.5 million individuals (41.3%) in 2006 to 15.2 individuals (47.5%) in 2016. Women were less likely than men to receive medications for secondary prevention: among women, 48.8 million (43.3%) received statins (vs 85.9 million men [52.7%]), 44.7 million (39.8%) received aspirin (vs 79.1 million men [48.5%]), and 25.7 million (22.9%) received lifestyle counseling services (vs 37.5 million men [23.0%]). Conclusions and Relevance: These findings suggest only modest increases in statin and aspirin prescription since 2006; however, lifestyle counseling use decreased in recent years. Women and Black patients continued to be less likely to receive secondary prevention ASCVD treatment. Adherence to guideline-directed secondary prevention recommendations remained low (less than 50%) in patients with ASCVD, especially with regards to lifestyle counseling, suggesting the need for more implementation research.

Effects of candesartan on cerebral microvascular function in mild cognitive impairment: Results of two clinical trials.

BACKGROUND: Cerebral microvascular dysfunction is commonly seen in Alzheimer's disease (AD) and vascular cognitive impairment (VCI). Cerebrovascular reactivity (CVR) to CO2 reflects cerebral microvascular health and may be modulated by the renin-angiotensin system (RAS). This study aimed to investigate the effects of RAS modulation on CVR in individuals with mild cognitive impairment (MCI) due to underlying vascular or AD etiologies. METHODS: This study presents findings of candesartan's effects on the secondary outcomes of two double-blind randomized clinical trials of 12-month therapy of candesartan versus lisinopril in VCI (CALIBREX (Candesartan vs Lisinopril Effects on the Brain and Endothelial Function in Executive MCI)) and candesartan versus placebo in prodromal AD (Candesartan's Effects on Alzheimer's Disease and Related Biomarkers (CEDAR)). Primary outcome results of these trials have been reported in previous publications. Participants underwent identical brain blood oxygenation level dependent (BOLD)-CVR in response to a 2-min CO2 challenge at baseline and 12 months. Regions of interest and voxel-wise CVR maps were derived from BOLD signal changes during CO2 challenge. CVR effects were compared between candesartan and lisinopril (CALIBREX) and candesartan and placebo (CEDAR) using mixed-model repeated measures. RESULTS: Data from 102 participants in the CALIBREX study (mean age = 65 years, 45% female, 63% African American) and 59 in the CEDAR study (mean age = 67 years, 32% female, 20% African American) were analyzed. Candesartan was associated with improved whole brain CVR compared to placebo in the CEDAR study (adjusted within-group mean difference for candesartan = 0.27 (95% confidence interval (CI) = 0.006, 0.53) vs placebo = -0.17 (95% CI = 0.42, 0.08), p-value = 0.018), and compared to lisinopril in the CALIBREX study (adjusted within-group mean difference for candesartan = 0.28 (95% CI = 0.10, 0.46) vs lisinopril = -0.08 (95% CI = -0.31, 0.14), p-value = 0.012), independent of blood pressure. In an exploratory meta-analysis of the two trials, improved CVR in the hippocampus was linked to improved attention and working memory (p = 0.044) and a trend for improved executive function (p = 0.087) with candesartan therapy. CONCLUSION: This study suggests that candesartan is associated with improved microvascular function in MCI, and these findings are independent of its blood pressure effect in these VCI and prodromal AD populations.

Association of Stress With Cognitive Function Among Older Black and White US Adults.

Importance: Perceived stress can have long-term physiological and psychological consequences and has shown to be a modifiable risk factor for Alzheimer disease and related dementias. Objective: To investigate the association between perceived stress and cognitive impairment in a large cohort study of Black and White participants aged 45 years or older. Design, Setting, and Participants: The Reasons for Geographic and Racial Differences in Stroke (REGARDS) study is a national population-based cohort of 30 239 Black and White participants aged 45 years or older, sampled from the US population. Participants were recruited from 2003 to 2007, with ongoing annual follow-up. Data were collected by telephone, self-administered questionnaires, and an in-home examination. Statistical analysis was performed from May 2021 to March 2022. Exposures: Perceived stress was measured using the 4-item version of the Cohen Perceived Stress Scale. It was assessed at the baseline visit and during 1 follow-up visit. Main Outcomes and Measures: Cognitive function was assessed with the Six-Item Screener (SIS); participants with a score below 5 were considered to have cognitive impairment. Incident cognitive impairment was defined as a shift from intact cognition (SIS score >4) at the first assessment to impaired cognition (SIS score ≤4) at the latest available assessment. Results: The final analytical sample included 24 448 participants (14 646 women [59.9%]; median age, 64 years [range, 45-98 years]; 10 177 Black participants [41.6%] and 14 271 White participants [58.4%]). A total of 5589 participants (22.9%) reported elevated levels of stress. Elevated levels of perceived stress (dichotomized as low stress vs elevated stress) were associated with 1.37 times higher odds of poor cognition after adjustment for sociodemographic variables, cardiovascular risk factors, and depression (adjusted odds ratio [AOR], 1.37; 95% CI, 1.22-1.53). The association of the change in the Perceived Stress Scale score with incident cognitive impairment was significant in both the unadjusted model (OR, 1.62; 95% CI, 1.46-1.80) and after adjustment for sociodemographic variables, cardiovascular risk factors, and depression (AOR, 1.39; 95% CI, 1.22-1.58). There was no interaction with age, race, and sex. Conclusions and Relevance: This study suggests that there is an independent association between perceived stress and both prevalent and incident cognitive impairment. The findings suggest the need for regular screening and targeted interventions for stress among older adults.

Infrastructure Features Associated With Increased Department Research Capacity.

PURPOSE: Although researchers have identified factors associated with research capacity in academic medicine departments, less is known about how a department builds research capacity over time. The Association of Departments of Family Medicine's Research Capacity Scale (RCS) can be used by departments to self-categorize into five capacity levels. Our current study aimed to describe the distribution of infrastructure features and to evaluate how the addition of infrastructure features influences movement of a department along the RCS. METHOD: An online survey was sent to US family medicine department chairs in August 2021. Survey questions asked chairs to categorize their department's research capacity in 2018 and 2021 and also about the presence of infrastructure resources and changes in these features across 6 years. RESULTS: The response rate was 54.2%. Departments identified substantial variation in research capacity. Most departments classified into the middle three levels. Departments in higher levels were more likely than those at lower levels to have any of the infrastructure resources in 2021. Department size, as measured by full time faculty, was highly associated with department level. From 2018 and 2021, 43% of responding departments climbed at least one level. Of these, more than half added three or more infrastructure features. Adding a PhD researcher was the feature most associated with increasing research capacity (P<.001). CONCLUSIONS: Most departments that increased their research capacity added multiple additional infrastructure features. For chairs of departments without a PhD researcher, this additional resource may be the most impactful investment to increase research capacity.

Comparing Resident and Program Director Perspectives on Wellness Curricula: A CERA Study.

Introduction: Mitigating the stress of graduate medical education has been the focus of residency leadership in the United States. This study examined family medicine (FM) resident and program director (PD) satisfaction with current wellness curricula, including perceptions of availability of resources and emphasis on well-being. Methods: The Council of Academic Family Medicine Educational Research Alliance administered online surveys to PDs accredited by the Accreditation Council for Graduate Medical Education, US-based FM residencies, and resident American Academy of Family Physicians members from April to May 2021. The present study included an assessment of wellness curriculum implementation using the Wellness Element Count (WEC), a satisfaction rating with wellness programming, and a single question assessing perceived changes in emphasis on wellness during COVID-19. Results: A total of 242 residents (5% response rate) and 263 PDs (42% response rate) completed the survey. Residents reported lower WEC indicators compared to PDs (P<.001). Overall, 67.8% of resident respondents were satisfied with their program's wellness efforts, compared to 89.3% of PDs ( P<.001). Perceived emphasis on wellness curricula in the program was associated with greater resident satisfaction (OR=2.75, P<.05); less emphasis on wellness was associated with less resident satisfaction (OR=0.15, P<.001). Conclusions: Residents reported overall lower perceived availability and satisfaction with program wellness efforts compared to PDs, suggesting a disparity between perspectives. Ongoing efforts should be directed at encouraging use of available wellness resources and supporting a culture of well-being.

Stroke in South Asia: a systematic review of epidemiologic literature from 1980 to 2010.

BACKGROUND: Globally 15 million people have an acute stroke every year and one third of them die secondary to stroke events. Most research on stroke prevention and treatment is done in developed countries, yet more than 85% of strokes occur in developing countries. In particular, stroke remains an underrecognized cause of death and disability in South Asia. METHODS: We conducted a systematic review to identify reliable and comparable epidemiological evidence on stroke in South Asia from 1980 to 2010. Publications were screened for eligibility to identify only population-based stroke studies. RESULTS: Of the 71 studies retrieved, only 6 studies from South Asia gave us acceptable estimates of the burden of stroke. Population-based studies from South Asia have stroke prevalence in the range of 45-471 per 100,000. The age-adjusted incidence rate varied from approximately 145 per 100,000 to 262 per 100,000. Rural parts of South Asia have a lower stroke prevalence compared with urban areas. CONCLUSIONS: Our review highlights the paucity of research data in South Asia. This must be addressed in order to accurately determine the burden of stroke in South Asia, so that specific policy recommendations can be formulated to combat the stroke epidemic in this region.

An internet-based virtual coach to promote physical activity adherence in overweight adults: randomized controlled trial.

BACKGROUND: Addressing the obesity epidemic requires the development of effective, scalable interventions. Pedometers and Web-based programs are beneficial in increasing activity levels but might be enhanced by the addition of nonhuman coaching. OBJECTIVES: We hypothesized that a virtual coach would increase activity levels, via step count, in overweight or obese individuals beyond the effect observed using a pedometer and website alone. METHODS: We recruited 70 participants with a body mass index (BMI) between 25 and 35 kg/m(2) from the Boston metropolitan area. Participants were assigned to one of two study arms and asked to wear a pedometer and access a website to view step counts. Intervention participants also met with a virtual coach, an automated, animated computer agent that ran on their home computers, set goals, and provided personalized feedback. Data were collected and analyzed in 2008. The primary outcome measure was change in activity level (percentage change in step count) over the 12-week study, split into four 3-week time periods. Major secondary outcomes were change in BMI and participants' satisfaction. RESULTS: The mean age of participants was 42 years; the majority of participants were female (59/70, 84%), white (53/70, 76%), and college educated (68/70, 97%). Of the initial 70 participants, 62 completed the study. Step counts were maintained in intervention participants but declined in controls. The percentage change in step count between those in the intervention and control arms, from the start to the end, did not reach the threshold for significance (2.9% vs -12.8% respectively, P = .07). However, repeated measures analysis showed a significant difference when comparing percentage changes in step counts between control and intervention participants over all time points (analysis of variance, P = .02). There were no significant changes in secondary outcome measures. CONCLUSIONS: The virtual coach was beneficial in maintaining activity level. The long-term benefits and additional applications of this technology warrant further study. TRIAL REGISTRATION: ClinicalTrials.gov NCT00792207; http://clinicaltrials.gov/ct2/show/NCT00792207 (Archived by WebCite at http://www.webcitation.org/63sm9mXUD).

Alzheimer's Disease Mortality as a Function of Urbanization Level: 1999-2019.

This study investigated Alzheimer's disease (AD) mortality trends by urbanization level and geographical location in the U.S. The CDC's WONDER database was used to investigate AD mortality from 1999-2019 stratified by urbanization level, census division, race, and sex. Data showed that while AD mortality increased across the U.S., rural areas, particularly in the South, had higher mortality compared to urban counterparts. AD mortality was higher among the female and White population. Data suggested that the urban-rural discrepancy is widening over time. Identifying health disparities underlying the urban-rural discrepancy in AD mortality is critical for allocating social and public health resources.