Medical care disruptions during the first six months of the COVID-19 pandemic: the experience of older breast cancer survivors.

PURPOSE: Older cancer survivors required medical care during the COVID-19 pandemic, but there are limited data on medical care in this age group. METHODS: We evaluated care disruptions in a longitudinal cohort of non-metastatic breast cancer survivors aged 60-98 from five US regions (n = 321). Survivors completed a web-based or telephone survey from May 27, 2020 to September 11, 2020. Care disruptions included interruptions in seeing or speaking to doctors, receiving medical treatment or supportive therapies, or filling prescriptions since the pandemic began. Logistic regression models evaluated associations between care disruptions and education, medical, psychosocial, and COVID-19-related factors. Multivariate models included age, county COVID-19 death rates, comorbidity, and post-diagnosis time. RESULTS: There was a high response rate (n = 262, 81.6%). Survivors were 32.2 months post-diagnosis (SD 17.5, range 4-73). Nearly half (48%) reported a medical disruption. The unadjusted odds of care disruptions were higher with each year of education (OR 1.22, 95% CI 1.08-1.37, p = < 0.001) and increased depression by CES-D score (OR 1.04, CI 1.003-1.08, p = 0.033) while increased tangible support decreased the odds of disruptions (OR 0.99, 95% CI 0.97-0.99, p = 0.012). There was a trend between disruptions and comorbidities (unadjusted OR 1.13 per comorbidity, 95% CI 0.99-1.29, p = 0.07). Adjusting for covariates, higher education years (OR1.23, 95% CI 1.09-1.39, p = 0.001) and tangible social support (OR 0.98 95% CI 0.97-1.00, p = 0.006) remained significantly associated with having care disruptions. CONCLUSION: Older breast cancer survivors reported high rates of medical care disruptions during the COVID-19 pandemic and psychosocial factors were associated with care disruptions. CLINICALTRIALS. GOV IDENTIFIER: NCT03451383.

Medical Care Disruptions During the First Six-Months of the COVID19 Pandemic: The Experience of Older Breast Cancer Survivors.

PurposeOlder cancer survivors required medical care during the COVID-19 pandemic despite infection risks, but there are limited data on medical care in this age group. METHODS: We evaluated care disruptions in a longitudinal cohort of non-metastatic breast cancer survivors ages 60-98 from five US regions (n=321). Survivors completed a web-based or telephone survey from May 27, 2020 to September 11, 2020. Care disruptions included self-reported interruptions in ability to see doctors, receive treatment or supportive therapies, or fill prescriptions. Logistic regression models evaluated bivariate and multivariate associations between care disruptions and education, medical, psychosocial and COVID-19-related factors. Multivariate models included age, county COVID-19 rates, comorbidity and post-diagnosis time. RESULTS: There was a high response rate (n=262, 81.6%). Survivors were 32.2 months post-diagnosis (SD 17.5, range 4-73). Nearly half (48%) reported a medical disruption. The unadjusted odds of care disruptions were significantly higher with more education (OR 1.23 per one-year increase, 95% CI 1.09-1.39, p =0.001) and greater depression (OR 1.04 per one-point increase in CES-D score, CI 1.003-1.08, p=0.033); tangible support decreased the odds of disruptions (OR 0.99, 95% CI 0.97-0.99 per one-point increase, p=0.012). There was a trend for associations between disruptions and comorbidity (unadjusted OR 1.13 per 1 added comorbidity, 95% CI 0.99-1.29, p=0.07). Adjusting for covariates, only higher education (p=0.001) and tangible social support (p=0.006) remained significantly associated with having care disruptions. CONCLUSIONS: Older breast cancer survivors reported high rates of medical care disruptions during the COVID-19 pandemic and psychosocial factors were associated with care disruptions.

Fecal incontinence as a moderator between dietary intake and depressive symptoms among a sample of older adults obtained from the National Health and Nutrition Examination Survey (NHANES).

OBJECTIVES: Many studies have established a relationship between diet and mental health, as well as the importance of bowel health. Further, with increased evidence of a gut-brain bidirectional relationship, an indication of dysbiosis as a potential moderator between diet and depression may be a viable target for future interventions. The current study investigated the relationship between diet and depressive symptoms (DS) among older adults, as well as gender, and whether a symptom of dysbiosis, fecal incontinence severity (FIS), moderated this relationship. METHOD: Using moderated regressions, we examined whether FIS moderates the relationship between diet and DS while controlling for covariates in the overall sample (N = 1918), as well as among the male (n = 841) and female sample (n = 1077). The dietary variables were reduced using a factor analysis. RESULTS: Results indicated significant moderating effects of FIS between Component 4 and polyunsaturated fatty acids (PFA) in the overall sample. Component 4, protein, carbohydrates, and alcohol were significant in males only while PFA only in females. Further analysis of protein/carbohydrate ratio groups indicated significant differences within males. Higher scores of FIS were related to higher DS and less consumption of Component 4 nutrients, PFA, and protein. Males that consumed higher protein and carbohydrates resulted in lower DS with increased FIS. CONCLUSION: Outcomes from the current study provide further evidence of the importance of healthy bowel function and the potential of modifying the diet to improve DS in older adults.

Impact of Dietary Factors and Inflammation on Cognition among Older Adults.

OBJECTIVE: This study examined the influence of age, nutrition (as measured through food diaries and serum/plasma biomarkers) and inflammatory markers on cognitive performance in adults 60 years of age and older. DESIGN: A cross-sectional population based study, data from the National Health and Nutrition Examination Survey (NHANES; 2001-2002 wave). PARTICIPANTS: This study included 1,048 adults who had valid dietary data, blood biomarkers, were 60 years or older, completed the cognitive test, and had complete demographic information. METHOD: A series of regression models were used to examine the relationship between cognitive function as measured by the Digit Symbol Substitution Task (DSST), dietary factors/biomarkers and inflammation. Mediation analyses were then utilized to examine whether individual nutrients accounted for the relationships between age and DSST performance. RESULTS: Dietary fat intake, serum vitamin E, serum folate, serum iron, plasma homocysteine, and serum vitamin D were significantly associated with better DSST performance. Elevated fibrinogen and C-reactive protein, were significantly associated with poorer cognitive function, but did not remain statistically significant after controlling for age, gender, education, ethnicity, income, and total calorie intake. Serum vitamin D and plasma homocysteine accounted for a portion of age-related variance in DSST. Specifically, higher levels of vitamin D were related to better DSST performance, while higher homocysteine resulted in poorer cognitive performance. CONCLUSION: Diet and nutrition are important modifiable factors that can influence health outcomes and may be beneficial to remediate age-related declines in cognition. Adequate nutrition may provide a primary preventive approach to healthy aging and maintenance of cognitive functioning in older adults.

A systematic review and meta-analysis of changes in cognitive functioning in adults undergoing hematopoietic cell transplantation.

Evidence is mixed regarding the effects of hematopoietic cell transplantation (HCT) on changes in cognitive functioning among adults. Meta-analysis, which is designed to help reconcile conflicting findings, has not yet been conducted on studies of adults receiving HCT. To fill this gap, the current study provides a systematic review and meta-analysis of cognitive functioning in adults receiving HCT. A search of PubMed, PsycInfo, CINAHL, and Cochrane Library yielded 732 abstracts, which were independently evaluated by pairs of raters. Seventeen studies were systematically reviewed; 11 were retained for meta-analysis. There was agreement that cognitive impairments are evident for a subset of patients before HCT. Meta-analytical findings of 404 patients revealed no significant changes in cognitive functioning pre- to post HCT (P-values >0.05). Age, time since transplant and TBI were not associated with changes in cognitive functioning. Patients who received autologous transplants were more likely to demonstrate improvements in attention (P=0.004). The systematic review identified several limitations of existing literature, including small, clinically heterogeneous samples. Large, cooperative group studies are needed to address these design limitations. Nevertheless, results from the current meta-analysis suggest that cognitive functioning does not significantly change following HCT.

A high-fat/high-cholesterol diet inhibits growth of fetal hippocampal transplants via increased inflammation.

A diet containing high levels of saturated fat and cholesterol is detrimental to many aspects of health and is known to lead to obesity, metabolic syndrome, heart disease, diabetes, and cancer. However, the effects of a diet rich in saturated fat and cholesterol on the brain are not currently well understood. In order to determine direct effects of a high saturated fat and cholesterol diet upon fetal hippocampal tissue, we transplanted hippocampal grafts from embryonic day 18 rats to the anterior eye chamber of 16-month-old host animals that were fed either a normal rat chow diet or a 10% hydrogenated coconut oil + 2% cholesterol diet (HFHC diet) for 8 weeks. One eye per rat received topical application of an IL-1 receptor antagonist (IL-1Ra, Kineret®) and the other served as a saline control. Results revealed that the HFHC diet led to a marked reduction in hippocampal transplant growth, and detrimental effects of the diet were alleviated by the IL-1 receptor antagonist IL-1Ra. Graft morphology demonstrated that the HFHC diet reduced organotypical development of the hippocampal neuronal cell layers, which was also alleviated by IL-1Ra. Finally, grafts were evaluated with markers for glucose transporter expression, astrocytes, and activated microglia. Our results demonstrate significant effects of the HFHC diet on hippocampal morphology, including elevated microglial activation and reduced neuronal development. IL-1Ra largely blocked the detrimental effects of this diet, suggesting a potential use for this agent in neurological disorders involving neuroinflammation.

Bereavement after caregiving or unexpected death: effects on elderly spouses.

Responses to bereavement have been shown to vary depending on whether death is expected or unexpected, and on the nature of family caregiving experiences, but little previous research has examined these factors simultaneously. To address these issues, we utilized prospective data on bereavement from 193 participants in the Changing Lives of Older Couples (CLOC) study, who were assessed both before their loss and at six and 18 months after the death. Participants who experienced either unexpected loss, or expected loss without caregiving, with low-stress caregiving, or with high-stress caregiving completed measures of psychological, social, and health functioning on each occasion. Results showed that unexpected death was associated with marked increases in depression, while the nature of caregiving did not affect the trajectory of any of the psychological well-being measures. All groups except highly stressed caregivers showed improvements in social activity and support after bereavement, suggesting that highly stressed caregivers may be at an increased risk for social isolation during bereavement. Thus experiencing an unexpected death may put bereaved spouses at risk for depression, while high-stress caregiving may lead to problems with social isolation.

APOE and cognitive decline in preclinical Alzheimer disease and non-demented aging.

OBJECTIVE: To investigate whether presence of the APOE epsilon4 allele is related to the pathologic progression of preclinical Alzheimer disease (AD), as reflected by change in Mini-Mental State Examination (MMSE) scores among persons in the preclinical phase of AD, and cognitively intact adults confirmed as dementia-free during the 6-year assessment period. METHOD: In a population-based sample, participants were stratified according to APOE genotype (epsilon4 or non-epsilon4) and whether they received a diagnosis of AD at the end of either a 3- or 6-year assessment period. Participants were aged 75 years and older, and were nondemented at baseline. At the end of the 3-year period, 17.2% of non-epsilon4 and 26.7% of epsilon4 carriers became demented. For the 6-year period those percentages were 11.2% for non-epsilon4 carriers and 16.9% for epsilon4-carriers. RESULTS: Individuals in the preclinical phase of AD showed greater decline on the MMSE as compared to nondemented adults. However, the decline was most marked in the 3 years prior to clinical diagnosis. Further, APOE-epsilon4 genotype did not modify the rate of decline among to-be-demented participants, as well as individuals who would remain free of AD. CONCLUSIONS: Although possession of the APOE epsilon4 allele is a risk factor for AD in old age, it does not modify the progression of the disease during the preclinical period. Further, in the absence of preclinical dementia, APOE did not influence global cognitive change in nondemented persons.

Multiple cognitive deficits during the transition to Alzheimer's disease.

The literature on cognitive markers in preclinical AD is reviewed. The findings demonstrate that impairment in multiple cognitive domains is typically observed several years before clinical diagnosis. Measures of executive functioning, episodic memory and perceptual speed appear to be most effective at identifying at-risk individuals. The fact that these cognitive domains are most implicated in normal cognitive aging suggests that the cognitive deficit observed preclinically is not qualitatively different from that observed in normal aging. The degree of cognitive impairment prior to the diagnosis of Alzheimer's disease (AD) appears to generalize relatively well across major study characteristics, including sample ascertainment procedures, age and cognitive status of participants, as well as time to diagnosis of dementia. In episodic memory, there is evidence that the size of the preclinical deficit increases with increasing cognitive demands. The global cognitive impairment observed is highly consistent with observations that multiple brain structures and functions are affected long before the diagnosis of AD. However, there is substantial overlap in the distribution of cognitive scores between those who will and those who will not be diagnosed with AD, hence limiting the clinical utility of cognitive markers for early identification of cases. Future research should consider combining cognitive indicators with other types of markers (i.e. social, somatic, genetic, brain-based) in order to increase prediction accuracy.

Moderating effects of psychosocial attributes on the association between risk factors and disability in later life.

This study examined the roles of psychosocial attributes in the associations between potential risk factors (age, gender, marital status, education, and chronic conditions) and disability in later life, and in particular how neuroticism and social resources (social network, received support, and satisfaction with support) modify the linkages between risk factors and disability. The main and moderating effects were empirically tested using a sample of 444 community-dwelling older adults in Florida (MU age = 72.3) who were cognitively intact. The likelihood of disability increased with advancing age, more chronic conditions, higher levels of neuroticism, more received support, and less satisfaction w ith support. In addition to the main effects, neuroticism and received support interacted with age and chronic conditions, strengthening the associations between risk factors and disability. Results suggested that personality and social support deserve greater attention as factors that can alter the disability process.

Predictors of cognitive change from preclinical to clinical Alzheimer's disease.

We examined individual-difference variables in relation to the rate of change in global cognitive performance, measured by the MMSE, from 3 years prior to diagnosis of Alzheimer's disease (AD) to the time of diagnosis. The population-based sample consisted of 230 incident AD persons who were followed over a 3-year interval. The average annual decline in MMSE was 1.81 points. Being older and acquiring additional diseases during the 3 years preceding diagnosis predicted a faster rate of decline in global cognitive functioning. However, other individual difference variables such as sex, education, depression, vitamin levels (vitamin B12 and folic acid), apolipoprotein status, and social network did not precipitate the rate of decline in the preclinical phase of AD.

Cross-cultural comparability of the Geriatric Depression Scale: comparison between older Koreans and older Americans.

It is becoming increasingly clear that, in order to better understand the implications of global aging, more cross-cultural research is needed. In the present study, the structure and validity of the Geriatric Depression Scale-Short Form (GDS-SF) was examined in Korean and US samples of older adults. The participants included 153 older adults living in Korea (mean age=65.9 years) and 459 older adults from Florida (mean age=72.4 years). All participants completed the original or translated versions of the GDS-SF, as well as additional demographic and health-related measures. The results indicated that the GDS-SF exhibited good reliability in both samples. However, the results of a principal components analysis indicated that the structure was not well replicated across the two samples. In general, the present study suggests that, despite great efforts to make the questionnaires equivalent in the two cultures, the concept of depression for older adults may vary greatly in Korea and the USA. Possible explanations for cross-cultural differences are discussed, as well as implications.

Stability of the preclinical episodic memory deficit in Alzheimer's disease.

We sought to determine the course of the preclinical episodic memory deficit in Alzheimer's disease. Using data from a population-based study, we compared persons who developed Alzheimer's disease n = 15) with persons who were non-demented n = 105) 6 and 3 years prior to the diagnosis of dementia. Participants were tested on tasks assessing episodic memory free recall and recognition of words) and short-term memory digit span). The incident Alzheimer's disease cases performed more poorly than their non-demented counterparts both 3 and 6 years before diagnosis on recall and recognition. There were no group differences in either forward or backward digit span. The selective impairment of episodic memory before the diagnosis of Alzheimer's disease is consistent with the view that early changes in the hippocampal complex play an important role in the memory deficit in preclinical Alzheimer's disease. On both preclinical measurement occasions, recall and recognition made independent contributions to group classification in logistic regression analyses. However, there was no evidence for accelerated decline of episodic memory in the incident Alzheimer's disease group from 6 to 3 years before diagnosis. These results indicate that Alzheimer's disease is characterized by a long preclinical period during which episodic memory deficits are detectable. The magnitude of these deficits appears to be quite stable, at least up to 3 years before diagnosis. This may reflect the fact that those biological events that eventually result in clinically diagnosed Alzheimer's disease e.g. the appearance of amyloid plaques and neurofibrillary tangles) accumulate at a relatively slow rate.

The structure of self-rated health among community-dwelling older adults with stroke.

OBJECTIVE: To examine whether depressive symptomatology is a third fundamental component of the structure of self-rated health, in addition to two other components (physical disease and functional disability) among community-dwelling older adults with stroke. DATA SOURCES AND STUDY SETTING: A total of 591 community-dwelling older adults with stroke were identified from the 1993 Asset and Health Dynamics among the Oldest-Old (AHEAD) national survey of community-dwelling older adults. STUDY DESIGN: A cross-sectional study. Structural equation modeling was applied to compare a widely used two-factor model of self-rated health with a model adding depression as a third possible factor. PRINCIPLE FINDINGS: The hypothesized three-factor model explained additional 21% more variance of self-rated health of older adults with stroke (R2 = 79%, NNFI = 0.95, CFI = 0.96, RMSEA = 0.04) as compared with the two-factor biomedical model (R2 = 58%, NNFI = 0.95, CFI = 0.98, RMSEA = 0.05). The three-factor model was statistically different from the two-factor model. CONCLUSIONS: Greater attention should be given to the theoretical structure of self-rated health of older adults with stroke, particularly, the significant impact of depression on their self-rated health.

The course of cognitive impairment in preclinical Alzheimer disease: three- and 6-year follow-up of a population-based sample.

OBJECTIVES: To examine the ability of the total score and individual items from the Mini-Mental State Examination in predicting the development of Alzheimer disease (AD) across a 3- and 6-year period in a population-based sample, and to describe the longitudinal changes in these measures across the same follow-up periods. DESIGN: Prospective follow-up of a community-based cohort, with 3 times of testing across a 6-year period. At each time of measurement, participants were clinically examined by physicians to identify demented and nondemented participants according to Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, criteria. PARTICIPANTS: The study population consisted of all participants who were nondemented at the first follow-up and participated in the second follow-up examination. Among those, 459 remained nondemented and 73 developed AD during the second follow-up period. RESULTS: Baseline differences in the total Mini-Mental State Examination score and the delayed memory item were seen 6 years before eventual dementia diagnosis (P<.01). Analysis of the longitudinal changes showed no differences in the rate of decline for the incident AD or nondemented group between time 1 and time 2 (P>.10). However, the incident AD group exhibited precipitous declines in 8 of the 10 subscales between time 2 and time 3, the point at which they were clinically diagnosed (P<.01). Logistic regression analyses showed that only the delayed memory item was a significant predictor of who would develop AD, independent of age, sex, and years of education, at both of the first 2 times of measurement (P<.001). CONCLUSIONS: The diagnosis of AD is preceded by a long preclinical phase in which deficits in memory performance are most common. These deficits remain relatively stable up until the time that a dementia diagnosis can be rendered. Arch Neurol. 2000.

Is APOE--epsilon4 a risk factor for cognitive impairment in normal aging?

OBJECTIVES: To examine the relationship between APOE genotype and cognitive functioning in normal aging, and to determine whether this relationship was moderated by age or the presence of a number of disease conditions, including cardiovascular disease and diabetes. METHODS: The sample was drawn from the Charlotte County Healthy Aging Study, a community-based, cross-sectional study of randomly selected older adults in Charlotte County, FL. A total of 413 older adults (mean age = 72.90 years) were examined in the current study. Participants completed tasks that indexed a variety of dimensions of cognitive functioning, including episodic memory, implicit memory, psychomotor speed, and attention. In addition, participants provided self-reported and objective indices of health status and were genotyped for APOE. RESULTS: Mean-level results indicated that groups with and without the APOE-epsilon4 allele performed similarly on all domains of cognitive functioning. Significant age group differences were observed in episodic memory, psychomotor speed, and attention but not implicit memory. Significant gender differences were present for episodic memory and the Stroop test. Analyses also indicated that participants' age did not exert an impact on the relationship between APOE-epsilon4 and cognitive functioning. Further, the presence of cardiovascular disease or diabetes did little to moderate the relationship between APOE-epsilon4 and cognition. CONCLUSIONS: The authors found no evidence for a relationship between presence of the APOE-epsilon4 allele and cognitive functioning. Further, age or the presence of a number of chronic conditions did not significantly moderate the effect of APOE genotype on cognitive performance. These results indicate that the presence of the epsilon4 allele is not a risk factor for cognitive impairment in normal aging.

Elderly norms for the Hopkins Verbal Learning Test-Revised.

The present study evaluates the effects of age, education, and gender in a representative sample of older adults and provides normative data for community-dwelling elderly. Age and gender had significant effects on HVLT-R performance. We provide age- and gender-adjusted normative data. Surprisingly, education level did not affect HVLT-R performance, indicating that education-adjusted norms are not necessary for this measure within this age range. We evaluated a subsample of subjects census-matched on age, education, and gender. These subjects did not differ in overall performance from our entire sample. Therefore, the normative data provided in this paper can be considered to be census-comparable for age, education, and gender.

Use it or lose it: engaged lifestyle as a buffer of cognitive decline in aging?

Data from the Victoria Longitudinal Study were used to examine the hypothesis that maintaining intellectual engagement through participation in everyday activities buffers individuals against cognitive decline in later life. The sample consisted of 250 middle-aged and older adults tested 3 times over 6 years. Structural equation modeling techniques were used to examine the relationships among changes in lifestyle variables and an array of cognitive variables. There was a relationship between changes in intellectually related activities and changes in cognitive functioning. These results are consistent with the hypothesis that intellectually engaging activities serve to buffer individuals against decline. However, an alternative model suggested the findings were also consistent with the hypothesis that high-ability individuals lead intellectually active lives until cognitive decline in old age limits their activities.

Longitudinal changes in quantitative and qualitative indicators of word and story recall in young-old and old-old adults.

The present study examined longitudinal changes in quantitative and qualitative measures of episodic memory. The sample, taken from the Victoria Longitudinal Study, consisted of 158 young-old adults (initially 55 to 70 years old) and 84 old-old adults (initially 71 to 86 years old) who were tested three times over six years. Average word and text recall, as well as five indicators of qualitative aspects of word recall (e.g., number of categories recalled) and one indicator of structure of text recall (i.e., levels of information) were used. For word recall, although both age groups exhibited negative longitudinal changes in quantitative performance, overall qualitative performance was generally stable. Two qualitative indicators (number of categories and intrusions) showed modest decline and one (organization at recall) showed improvement. Results for overall text recall showed significant performance increments for the young-old group, whereas the old-old group exhibited slight declines in overall performance. Analyses of qualitative measures showed stable structure of hierarchical recall, with the old-old being impaired at all levels of detail in the stories. Overall results suggest that some underlying structural characteristics of word and text recall may be maintained into late life even when significant overall decline is observed.