Evaluating documentation of social history in paediatric medical notes at a regional paediatric centre - a quality improvement initiative.

BACKGROUND: A child's home and family environment plays a vital role in neuro-cognitive and emotional development. Assessment of a child's home environment and social circumstances is an crucial part of holistic Paediatric assessment. AIMS: Our aim is to achieve full compliance with comprehensive documentation of biopsychosocial history, for all children medically admitted to the children's inpatient unit in University Hospital Limerick. METHODS: We performed a retrospective chart review to audit documentation within our department. This was followed by teaching interventions and a survey on knowledge, attitudes and behaviour of paediatric non-consultant hospital doctors (NCHDs) towards the social history. We performed two subsequent re-audits to assess response to our interventions, and provided educational sessions to seek improvement in quality of care. RESULTS: Results showed a significant improvement in quality of documentation following interventions, demonstrated by a net increase of 53% in levels of documentation of some social history on first re-audit. Though this was not maintained at an optimum level throughout the course of the year with compliance reduced from 95% to 82.5% on second re-audit, there was nonetheless a sustained improvement from our baseline. Our qualitative survey suggested further initiatives and educational tools that may be helpful in supporting the ongoing optimisation of the quality of documentation of social history in our paediatric department. CONCLUSION: We hope this quality improvement initiative will ultimately lead to sustained improvements in the quality of patient-centred care, and early identification and intervention for children at risk in our community.

APOE epsilon4 is associated with obstructive sleep apnea/hypopnea: the Sleep Heart Health Study.

BACKGROUND: Obstructive sleep apnea/hypopnea (OSAH) has a strong heritable component, although its genetic basis remains largely unknown. One epidemiologic study found a significant association between the APOE epsilon4 allele and OSAH in middle-aged adults, a finding that was not replicated in a cohort of elderly adults. The objective of this study was to further examine the association of the APOE epsilon4 allele with OSAH in a community-dwelling cohort, exploring age dependency of the association. METHODS: A genetic association study was performed, nested within a prospective cohort study of the cardiovascular consequences of OSAH. Unattended, in-home nocturnal polysomnography was used to measure apnea-hypopnea index (AHI) in 1,775 participants age 40 to 100 years. OSAH was defined as an AHI > or = 15. The relation of APOE genotype to prevalent OSAH was analyzed using generalized estimating equations to account for non-independent observations of individuals from the same sibship. RESULTS: At least one APOE epsilon4 allele was present in 25% of subjects, with 1.3% epsilon4/epsilon4 homozygotes. The prevalence of OSAH was 19%. After adjustment for age, sex, and BMI, the presence of any APOE epsilon4 allele was associated with increased odds of OSAH (OR 1.41, 95% CI 1.06 to 1.87, p = 0.02). The effect was approximately twice as great in subjects <75 (OR 1.61, CI 1.02 to 2.54) as in those > or =75 years old (OR 1.32, CI 0.91 to 1.90). Exploratory analyses revealed that the strongest effect of APOE epsilon4 was in subjects age <65 (OR 3.08, CI 1.43 to 6.64), and was stronger in those with hypertension or cardiovascular disease than in those without. CONCLUSION: The APOE epsilon4 allele is associated with increased risk of OSAH, particularly in individuals under age 65. The mechanisms underlying this association are uncertain. Age-dependency of the APOE-OSAH association may explain previous conflicting results.

Quantification of regional glial fibrillary acidic protein levels in Alzheimer's disease.

OBJECTIVES: Our objectives were to quantify glial fibrillary acidic protein (GFAP) in brains of Alzheimer's disease (AD) cases, and non-AD controls to determine the regions with the most severe gliosis in AD. MATERIAL AND METHODS: In a case control design, we used an enzyme-linked immunosorbent assay (ELISA) to quantify GFAP in frozen brain from four areas of neocortex in 10 AD cases, 10 age-matched controls, and 10 younger controls from the Honolulu-Asia Aging Study autopsy archive. RESULTS: Median age at death was 83.5 years for cases and age-matched controls, and 77 years for younger controls. For the AD cases compared with the age-matched controls, levels of GFAP in occipital (P=0.01), parietal (P=0.028), and temporal lobes (P=0.004) (but not frontal) were significantly higher in the cases. The median GFAP excess in AD cases compared with age matched controls was highest in the temporal lobe. CONCLUSIONS: Regional quantification of GFAP reveals that the glial response is most prominent in the temporal lobe in AD.

The impact of insomnia on cognitive functioning in older adults.

OBJECTIVES: To examine whether self-reported symptoms of insomnia independently increase risk of cognitive decline in older adults. DESIGN: Longitudinal cohort study. SETTING: The four sites of the Established Populations for Epidemiologic Studies of the Elderly. PARTICIPANTS: Six thousand four hundred forty-four community-dwelling men and women age 65 and older who had no more than one error on the Short Portable Mental Status Questionnaire (SPMSQ) at baseline and an in-person interview at the third annual follow-up (FU3). MEASUREMENTS: Insomnia was defined as report of trouble falling asleep or waking up too early most of the time. Cognitive decline was defined as two or more errors on the SPMSQ at FU3. Logistic regression was used to determine risk of cognitive decline associated with insomnia, controlling for demographic, behavioral, and health-related factors. Analyses were stratified by sex and depressed mood. RESULTS: Among nondepressed men, those reporting symptoms of insomnia at both baseline and FU3 had an adjusted odds ratio (OR) of 1.49 (95% CI = 1.03-2.14) for cognitive decline, relative to those with no insomnia at FU3. Men with insomnia at FU3 only were not at increased risk (OR = 1.16, 95% CI = 0.82-1.65). These relationships were not found in women. Men and women with depressive symptoms at FU3 were at increased risk for cognitive decline independent of insomnia. CONCLUSION: Chronic insomnia independently predicts incident cognitive decline in older men. More sensitive measures of cognitive performance may identify more subtle declines and may confirm whether insomnia is associated with cognitive decline in women.

Eosinophilic pleural effusion due to dantrolene: resolution with steroid therapy.

A quadriplegic patient with severe spasticity, treated with dantrolene (400 mg daily) for 5 years, had dyspnea, orthopnea, hypoxia, and right-sided opacity of the chest on radiograph. At thoracentesis, an exudative effusion containing 64% eosinophils was documented, with simultaneous peripheral eosinophilia of 11%. An allergic reaction to dantrolene was postulated. Despite withdrawal of the offending medication and repeated thoracenteses, symptomatic recurrence of effusion persisted for 4 days. After institution of prednisone therapy, rapid resolution of symptoms, signs, hypoxia, and radiologic abnormalities was observed. In contrast to five previously reported cases of dantrolene-associated eosinophilic pleural effusion (EPE), ours represents the first in which the patient was treated with steroids and suggests that steroid therapy may be of benefit in drug-related EPE.

Genotypes and phenotypes for apolipoprotein E and Alzheimer disease in the Honolulu-Asia aging study.

BACKGROUND: The utility of apolipoprotein E (ApoE) type as an indicator of genetic susceptibility to Alzheimer disease (AD) depends on the reliability of typing. Although ApoE protein isoform phenotyping is generally assumed equivalent to genotyping from DNA, phenotype-genotype differences have been reported. METHODS: ApoE genotype and phenotype results were examined for 3564 older (ages 71-93 years) Japanese-American male participants of the Honolulu-Asia Aging Study, an ongoing population-based study of aging and dementia. RESULTS: Both methods demonstrated similar associations of ApoE type with AD: a direct association with ApoE4 and a less dramatic inverse association ApoE2. Advanced age did not appear to influence the ApoE4-AD association. The association with AD among ApoE4 homozygotes [odds ratio (OR) = 14.7] was higher than expected based on an observed OR of 2.0 in heterozygotes. Phenotype-genotype nonconcordance was more frequent for ApoE2 than for ApoE4. The ApoE2 phenotype occurred at a frequency of 7.9% vs a genotype frequency of 4.9%, corresponding to a probability of 56% that an individual with ApoE2 phenotype had the same genotype. CONCLUSIONS: Whereas E4 and E2 phenotypes and genotypes were comparably associated with AD, neither method would be expected to substantially improve the efficiency of case finding in the context of population screening beyond prediction based on age and education. Nonconcordance of phenotype and genotype was substantial for E2 and modest for E4 in this population. The ApoE4-AD association was independent of age.

Driving cessation in older men with incident dementia.

OBJECTIVE: To determine the prevalence and cessation of driving among older men with incident dementia in the Honolulu-Asia Aging Study. DESIGN: Retrospective cohort data from a community-based study of incident dementia. SETTING: The Honolulu Heart Program and the Honolulu-Asia Aging Study. PARTICIPANTS: A total of 643 men who were evaluated for the incidence of Alzheimer's disease or other dementia between the fourth and the fifth examination of the Honolulu Heart Program. MEASUREMENTS: Driving history, diagnosis of dementia, grip strength, walking speed, standing balance test, interviewer's rating of vision status, and the neurologist's notes on mentions of driving behavior from informal interviews with a caregiver or family informant. RESULTS: The prevalence of driving declined dramatically with level of cognitive functioning. Among 162 men evaluated and found to have normal cognitive functioning, 78% still drove, compared with 62% of 287 men with poor cognitive functioning but no clinical dementia, 46% of 96 men with a new diagnosis of very mild dementia (Clinical Dementia Rating = 0.5), and 22% of 98 men with a new diagnosis of mild dementia (CDR = 1). Only one of 23 men diagnosed with moderate or more severe staged incident dementia (CDR > 1) was driving. About 10% of the 59 demented persons still driving relied on co-pilots, and only one driver was reported as involved in a crash according to a review of the neurologists' notes. CONCLUSIONS: Incident dementia is a major cause of driving cessation. Based on these data, we estimate that approximately 4% of male drivers aged 75 years and older nationwide (about 175,000 men) have dementia. This number will increase with the projected growth of drivers aged 75 years and older.

Midlife blood pressure and neuritic plaques, neurofibrillary tangles, and brain weight at death: the HAAS. Honolulu-Asia aging Study.

Midlife hypertension is associated with later development of cognitive impairment, vascular dementia (VsD), and possibly Alzheimer's disease (AD). Neuropathic cerebrovascular lesions and brain atrophy have been associated with elevated blood pressure (BP), however, to our knowledge there have been no prospective investigations of an association of blood pressure levels measured in midlife with the microscopic lesions of AD. We investigated the relationship of BP level in midlife to development of neurofibrillary tangles (NFT), neuritic plaques (NP), and low brain weight at autopsy among Japanese-American men who were members of the Honolulu Heart Program/Honolulu-Asia aging Study (HHP/HAAS) cohort. The HHP/HAAS is a population-based, longitudinal study of cognitive function and dementia with 36 years of follow-up. Neocortical and hippocampal NFT and NP were counted per mm(2), and fixed brain weight was measured for 243 decedents. Elevated systolic BP, (> or =160 mm Hg) in midlife was associated with low brain weight and greater numbers of NP in both neocortex and hippocampus. Diastolic BP elevation, (> or =95 mm Hg) was associated with greater numbers of NFT in hippocampus. Results indicate that in addition to the accepted association of high BP with neuropathic cerebrovascular lesions, there is a direct relationship with brain atrophy, NP and NFT.

Association of vitamin E and C supplement use with cognitive function and dementia in elderly men.

OBJECTIVE: To determine whether use of vitamin E and C supplements protects against subsequent development of dementia and poor cognitive functioning. METHODS: The Honolulu-Asia Aging Study is a longitudinal study of Japanese-American men living in Hawaii. Data for this study were obtained from a subsample of the cohort interviewed in 1982, and from the entire cohort from a mailed questionnaire in 1988 and the dementia prevalence survey in 1991 to 1993. The subjects included 3,385 men, age 71 to 93 years, whose use of vitamin E and C supplements had been ascertained previously. Cognitive performance was assessed with the Cognitive Abilities Screening Instrument, and subjects were stratified into four groups: low, low normal, mid normal, and high normal. For the dementia analyses, subjects were divided into five mutually exclusive groups: AD (n = 47), vascular dementia (n = 35), mixed/other types of dementia (n = 50), low cognitive test scorers without diagnosed dementia (n = 254), and cognitively intact (n = 2,999; reference). RESULTS: In a multivariate model controlling for other factors, a significant protective effect was found for vascular dementia in men who had reported taking both vitamin E and C supplements in 1988 (odds ratio [OR], 0.12; 95% CI, 0.02 to 0.88). They were also protected against mixed/other dementia (OR, 0.31; 95% CI, 0.11 to 0.89). No protective effect was found for Alzheimer's dementia (OR, 1.81; 95% CI, 0.91 to 3.62). Among those without dementia, use of either vitamin E or C supplements alone in 1988 was associated significantly with better cognitive test performance at the 1991 to 1993 examination (OR, 1.25; 95% CI, 1.04 to 1.50), and use of both vitamin E and C together had borderline significance (OR, 1.18; 95% CI, 0.995 to 1.39). CONCLUSIONS: These results suggest that vitamin E and C supplements may protect against vascular dementia and may improve cognitive function in late life.

APOE-epsilon4 predicts incident AD in Japanese-American men: the honolulu-asia aging study.

The authors assessed the 3-year incidence of dementia, including subtypes, in 2,603 Japanese-American men 71 to 93 years of age who were dementia free at baseline. There were 137 new cases of dementia according to the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised, including 51 with a primary diagnosis of AD. The rates for all subtypes increased with age. Men with an APOE4 allele had a significantly increased risk of AD of 2.39 (95% CI, 1.07, 5.31), after adjusting for age and education. There was no significant relationship of APOE4 with other subtypes of dementia.

Characterization of risk factors for vascular dementia: the Honolulu-Asia Aging Study.

BACKGROUND: The Honolulu Heart Program (HHP) is a prospective study of heart disease and stroke that has accumulated risk factor data on a cohort of 8,006 Japanese American men since the study began in 1965. A recent examination of the cohort identified all patients with vascular dementia (VaD) using the criteria of the California Alzheimer's Disease Diagnostic and Treatment Center. OBJECTIVE: To characterize patients with VaD by stroke subtype and to investigate risk factors for VaD in a cohort of Japanese American men, aged 71 to 93, living in Hawaii and participating in the HHP. METHODS: Sixty-eight men with VaD were compared with 3,335 men without dementia or stroke (NSND). Men with VaD were also compared with 106 men with stroke who were not demented (SND). Candidate risk factors were measured prospectively. RESULTS: Of the 68 men with VaD there were 34 (50%) whose VaD was attributed to small vessel infarcts, 16 (23%) whose VaD was related to large vessel infarcts, and 11 (16%) with both large and small vessel infarcts. The remainder could not be classified. In a multivariate logistic regression model for VaD compared with NSND containing variables found to be associated with VaD in a univariate analysis, age (odds ratio [OR] 1.19, 95% confidence interval [CI] 1.13 to 1.27), coronary heart disease (OR 2.50, 95% CI 1.35 to 4.62), and 1-hour postprandial glucose (OR 1.41, 95% CI 1.06 to 1.88) remained significantly predictive of VaD, whereas preference for a Western diet (OR 0.54, 95% CI 0.30 to 0.98) as opposed to an Oriental or mixed diet and use of supplementary vitamin E (OR 0.32, 95% CI 0.12 to 0.82) were protective. A similar model for the comparison of men with VaD and SND revealed age (OR 1.24, 95% CI 1.14 to 1.35) was predictive of VaD, whereas preference for a Western diet (OR 0.43, 95% CI 0.22 to 0.86) was protective. CONCLUSIONS: The most common stroke subtype associated with VaD was lacunar stroke. Age and traditional vascular risk factors are important contributors to the development of VaD in late life. The antioxidant vitamin E and presently unknown factors related to a Western diet as opposed to an Oriental diet may be protective against developing VaD.

Incidence and remission of insomnia among elderly adults: an epidemiologic study of 6,800 persons over three years.

To determine incidence and remission rates of insomnia in older adults and associated risk factors. Three-year longitudinal study, 1982-198--East Boston, MA; New Haven, CT; Iowa and Washington counties, IA. Participants were 6,899 men and women aged 65 years and older. Self-reported difficulty falling asleep or early morning arousal (insomnia), along with physician diagnosis of heart disease, stroke, cancer, diabetes, or hip-fracture, self-report of physical disability, depressive symptomatology, perceived health status, and use of medications ascertained at both baseline and three-year follow-up. Nearly 15% of the 4,956 participants without symptoms of insomnia at baseline reported chronic difficulty falling asleep or early morning arousal at follow-up, suggesting an annual incidence rate of approximately 5%. Incident insomnia was associated with depressed mood, respiratory symptoms, fair to poor perceived health, and physical disability. In multivariate analyses, these risk factors explained the higher incidence of insomnia among those with medical conditions such as heart disease, stroke, and diabetes. Other factors associated with an increased risk of insomnia included use of prescribed sedatives, and widowhood. Only 7% of the incident cases of insomnia occurred in the absence of associated risk factors. Of the nearly 2,000 survivors with chronic insomnia at baseline, almost half no longer reported symptoms upon follow-up and were more likely to report improved self-perceived health compared to those who continued to report symptoms. Chronic disease, depressed mood, physical disability, poor perceived health, widowhood, and use of sedatives are associated with development and remission of insomnia symptoms. Because the vast majority of incident cases of insomnia were among persons with one or more of these risk factors, these data do not support a model of incident insomnia caused by the aging process per se.

Incidence and remission of insomnia among elderly adults in a biracial cohort.

OBJECTIVES: To determine the incidence and remission rates of insomnia in older adults according to race and associated risk factors in a three-year longitudinal study. METHODS: 2,971 men and women, aged 65 years and older, completed questionnaires administered by trained interviewers at baseline and three years later. Data concerning difficulty falling asleep or early morning arousal (insomnia), along with self-reports of physical disability, respiratory symptoms, depressive symptomatology, perceived health status, and use of prescribed sedative medication, were collected and analyzed. RESULTS: Overall, 15% of the participants without symptoms of insomnia at baseline reported chronic difficulty falling asleep or early morning arousal three years later in follow-up interviews. African-American women had a significantly (p < 0.01) higher incidence of insomnia (19%) compared with African-American men (12%) or with white men and women (both 14%). Men were more likely than women to no longer report symptoms at follow-up (64% vs 42%; p < 0.01). For both races, the presence of depressed mood was a risk factor for the incidence of insomnia, and the absence of depressed mood was a predictor of remission. CONCLUSIONS: Insomnia occurs more frequently in African-American women than in African-American men or than in white men or women. Regardless of race, women are less likely than men to resolve their insomnia. The high prevalence and incidence of morbidity in elderly African-American women may contribute to their high rate of insomnia.

Associations of symptoms of sleep apnea with cardiovascular disease, cognitive impairment, and mortality among older Japanese-American men.

OBJECTIVES: To examine the association between symptoms of sleep apnea and prevalent cardiovascular disease, cognitive impairment, and subsequent 3-year mortality. DESIGN: A longitudinal study. SETTING: Participants lived in the community on Oahu, Hawaii. PARTICIPANTS: A total of 2905 older Japanese-American men participating in the fourth examination of the Honolulu Heart Program cohort study from 1991-1993, which is the baseline for the Honolulu-Asia Aging Study of dementia. MEASUREMENTS: Self-reported snoring, daytime sleepiness, and breathing pauses; diagnosed cardiovascular disease and dementia; cognitive functioning and vital status approximately 3 years later. RESULTS: More than 12% of the participants reported that they often or always snored loudly, and 8% reported being sleepy most of the day. Fewer than 2% reported that they stop breathing when sleeping, and this was found more frequently among habitual snorers (7%, P < .001) and those sleepy during the day (5%, P < .001). The prevalence of habitual snoring declined in the older age groups, was higher among those with greater Body Mass Index scores, and was not associated with the reporting of daytime sleepiness, diagnosis of heart disease, stroke, dementia, or cognitive impairment. Daytime sleepiness was more prevalent at older ages and was associated with a higher prevalence of heart disease and with cognitive impairment and dementia, chronic obstructive pulmonary disease, and diabetes. Self-reported apnea was associated only with a history of pneumonia. Three-year mortality was not associated with these symptoms after adjusting for prevalent heart disease and cognitive impairment. CONCLUSION: Symptoms of sleep apnea are reported less frequently in older Japanese-American men. Excessive daytime sleepiness is associated with poor cognition and dementia, but whether it also is an indicator for sleep apnea in this age group remains unclear. Epidemiologic studies of sleep apnea in older adults will require polysomnography to determine accurately the correlates and consequences of this condition.

Predictors of healthy aging in men with high life expectancies.

OBJECTIVE: The purpose of this study was to identify risk factors that consistently predict staying healthy in contrast to developing clinical illness and/or physical and mental impairments. METHODS: More than 8000 men of Japanese ancestry were followed for 28 years with repeat examinations and surveillance for deaths and incident clinical illness. Physical and cognitive functions were measured in 1993. Measures of healthy aging included surviving and remaining free of major chronic illnesses and physical and cognitive impairments. RESULTS: Of 6505 healthy men at baseline, 2524 (39%) died prior to the final exam. Of the 3263 available survivors, 41% remained free of major clinical illnesses, 40% remained free of both physical and cognitive impairment, and 19% remained free of both illness and impairment. The most consistent predictors of healthy aging were low blood pressure, low serum glucose, not smoking cigarettes, and not being obese. CONCLUSIONS: Beyond the biological effects of aging, much of the illness and disability in the elderly is related to risk factors present at midlife.

Crash risks of older drivers: a panel data analysis.

Considerable progress has been made on understanding older drivers' safety issues. None the less, findings from previous research have been rather inconclusive. Differences in data and research methodology have been suggested as factors that contribute to the discrepancies in previous findings. One of the methodological limitations is the lack of considering temporal order between events (i.e. the time between onset of medical condition, symptom and crash). Without time-series data, a 'snap-shot' of medical conditions and driving patterns were often linked to more than 1 year--of crash data, hoping to accumulate enough data on crashes. The interpretation of the results from these studies is difficult in that one cannot explicitly attribute the increase in highway crash rates to medical conditions and/or physical limitations. This paper uses a panel data analysis to identify factors that place older drivers at greater crash risk. Our results show that factors that place female drivers at greater crash risk are different from those influencing male drivers. More risk factors were found to be significant in affecting older men's involvement in crashes than older women. When the analysis controlled for the amount of driving, women who live alone or who experience back pain were found to have a higher crash risk. Similarly, men who are employed, score low on word-recall tests, have a history of glaucoma, or use antidepressant drugs were found to have a higher crash risk. The most influential risk factors in men were the number of miles driven, and use of antidepressants.

Demography and epidemiology of dying in the U.S. with emphasis on deaths of older persons.

As chronic disease continues to be the major cause of death and as the elderly population grows, it is important to evaluate the adequacy and completeness of health care strategies for the elderly. Two studies, the National Mortality Followback Survey and the National Institute on Aging Survey of the Last Days of Life, were designed to examine the circumstances of death for representative samples of decedents. Four areas of focus are location of death, transitions among health care settings, circumstances at the time of death, and changes in physical and cognitive function in the last year of life. Although the data are helpful for family planning, they are limited by a lack of data on costs.

Sleep complaints in community-dwelling older persons: prevalence, associated factors, and reported causes.

OBJECTIVES: To determine the prevalence rates of self-reported sleep complaints and their association with health-related factors. DESIGN: A cross-sectional study. SETTING: People living in the community. PARTICIPANTS: A total of 2398 noninstitutionalized individuals, aged 65 years and older, residing in the Veneto region, northeast Italy. MEASUREMENTS: Odds ratios for the association of sleep complaints with potential risk factors. RESULTS: The prevalence of insomnia was 36% in men and 54% in women, with increased risks for women (odds ratio (OR) = 1.69, 95% CI: 1.3-2.1), depression (OR = 1.93, 95% CI, 1.5-2.5), and regular users of sleep medications (OR = 5.58, 95% CI, 4.3-7.3). About 26% of men and 21% of women reported no sleep complaints. Night awakening, reported by about two-thirds of the participants, was the most common sleep disturbance. Women and regular users of sleep medications had significantly increased odds for insomnia and for not feeling rested upon awakening in the morning. Depressive symptomatology was more strongly associated with insomnia and night awakening than with awakening not rested, whereas physical disability was more strongly associated with awakening not rested than with the other two sleep disturbances. CONCLUSION: Our findings show that sleep complaints, highly common among older Italians, are associated with a wide range of medical conditions and with the use of sleep medications. Further longitudinal studies are needed to investigate the causes and the negative health consequences of sleep disturbances to improve both the diagnosis and treatment.

Smoking history in middle age and subsequent cognitive performance in elderly Japanese-American men. The Honolulu-Asia Aging Study.

The associations between cigarette smoking history and later cognitive performance were examined among 3,429 Japanese-American participants of the Honolulu Heart Program (HHP) and its extension, the Honolulu-Asia Aging Study (HAAS). Cognitive performance was measured by the Cognitive Abilities Screening Instrument (CASI), administered as part of HAAS (mean age at HAAS exam (standard deviation (SD)): 77.7 (4.6) years). Information on smoking history was collected during the first and third HHP exams (mean age (SD) at Exam III: 58.6 (4.7) years). Compared with never-smokers, those who had smoked continuously between Exams I-III and those who had quit smoking during that period had significantly lower CASI scores, after adjustment for age, education, Japanese acculturation, and Exam III alcohol intake. In multiple logistic regression controlling for the above covariates, a significantly higher risk of cognitive impairment (CASI score < 82) was associated with continuous smoking (odds ratio (OR) = 1.36, 95% confidence interval (CI) 1.10-1.69) and quitting between Exams I-III (OR = 1.36, 95% CI 1.03-1.80) compared with never smoking. This excess risk of cognitive impairment among continuous smokers and Exam I-III quitters was slightly diminished by further adjustment for body mass index and several vascular covariates. Additional analyses suggested a reduced risk of cognitive impairment among the longer-term quitters. This study suggests a positive association between smoking during middle age and later risk of cognitive impairment.