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Importance: The benefit of blood pressure lowering for the prevention of dementia or cognitive impairment is unclear.Objective: To determine the association of blood pressure lowering with dementia or cognitive impairment.Data Sources and Study Selection: Search of PubMed, EMBASE, and CENTRAL for randomized clinical trials published from database inception through December 31, 2019, that evaluated the association of blood pressure lowering on cognitive outcomes. The control groups consisted of either placebo, alternative antihypertensive agents, or higher blood pressure targets.Data Extraction and Synthesis: Data were screened and extracted independently by 2 authors. Random-effects meta-analysis models were used to report pooled treatment effects and CIs.Main Outcomes and Measures: The primary outcome was dementia or cognitive impairment. The secondary outcomes were cognitive decline and changes in cognitive test scores.Results: Fourteen randomized clinical trials were eligible for inclusion (96 158 participants), of which 12 reported the incidence of dementia (or composite of dementia and cognitive impairment [3 trials]) on follow-up and were included in the primary meta-analysis, 8 reported cognitive decline, and 8 reported changes in cognitive test scores. The mean (SD) age of trial participants was 69 (5.4) years and 40 617 (42.2%) were women. The mean systolic baseline blood pressure was 154 (14.9) mm Hg and the mean diastolic blood pressure was 83.3 (9.9) mm Hg. The mean duration of follow-up was 49.2 months. Blood pressure lowering with antihypertensive agents compared with control was significantly associated with a reduced risk of dementia or cognitive impairment (12 trials; 92 135 participants) (7.0% vs 7.5% of patients over a mean trial follow-up of 4.1 years; odds ratio [OR], 0.93 [95% CI, 0.88-0.98]; absolute risk reduction, 0.39% [95% CI, 0.09%-0.68%]; I2 = 0.0%) and cognitive decline (8 trials) (20.2% vs 21.1% of participants over a mean trial follow-up of 4.1 years; OR, 0.93 [95% CI, 0.88-0.99]; absolute risk reduction, 0.71% [95% CI, 0.19%-1.2%]; I2 = 36.1%). Blood pressure lowering was not significantly associated with a change in cognitive test scores.Conclusions and Relevance: In this meta-analysis of randomized clinical trials, blood pressure lowering with antihypertensive agents compared with control was significantly associated with a lower risk of incident dementia or cognitive impairment. [ABSTRACT FROM AUTHOR]

Importance: Dementia (also known as major neurocognitive disorder) is defined by a significant decline in 1 or more cognitive domains that interferes with a person's independence in daily activities. Dementia affects an estimated 2.4 to 5.5 million individuals in the United States, and its prevalence increases with age.Objective: To update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a review of the evidence on screening for cognitive impairment, including mild cognitive impairment and mild to moderate dementia, in community-dwelling adults, including those 65 years or older residing in independent living facilities.Population: This recommendation applies to community-dwelling older adults 65 years or older, without recognized signs or symptoms of cognitive impairment.Evidence Assessment: The USPSTF concludes that the evidence is lacking, and the balance of benefits and harms of screening for cognitive impairment cannot be determined.Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for cognitive impairment in older adults. (I statement). [ABSTRACT FROM AUTHOR]

Importance: Early identification of cognitive impairment may improve patient and caregiver health outcomes.Objective: To systematically review the test accuracy of cognitive screening instruments and benefits and harms of interventions to treat cognitive impairment in older adults (≥65 years) to inform the US Preventive Services Task Force.Data Sources: MEDLINE, PubMed, PsycINFO, and Cochrane Central Register of Controlled Trials through January 2019, with literature surveillance through November 22, 2019.Study Selection: Fair- to good-quality English-language studies of cognitive impairment screening instruments, and pharmacologic and nonpharmacologic treatments aimed at persons with mild cognitive impairment (MCI), mild to moderate dementia, or their caregivers.Data Extraction and Synthesis: Independent critical appraisal and data abstraction; random-effects meta-analyses and qualitative synthesis.Main Outcomes and Measures: Sensitivity, specificity; patient, caregiver, and clinician decision-making; patient function, quality of life, and neuropsychiatric symptoms; caregiver burden and well-being.Results: The review included 287 studies with more than 280 000 older adults. One randomized clinical trial (RCT) (n = 4005) examined the direct effect of screening for cognitive impairment on patient outcomes, including potential harms, finding no significant differences in health-related quality of life at 12 months (effect size, 0.009 [95% CI, -0.063 to 0.080]). Fifty-nine studies (n = 38 531) addressed the accuracy of 49 screening instruments to detect cognitive impairment. The Mini-Mental State Examination was the most-studied instrument, with a pooled sensitivity of 0.89 (95% CI, 0.85 to 0.92) and specificity of 0.89 (95% CI, 0.85 to 0.93) to detect dementia using a cutoff of 23 or less or 24 or less (15 studies, n = 12 796). Two hundred twenty-four RCTs and 3 observational studies including more than 240 000 patients or caregivers addressed the treatment of MCI or mild to moderate dementia. None of the treatment trials were linked with a screening program; in all cases, participants were persons with known cognitive impairment. Medications approved to treat Alzheimer disease (donepezil, galantamine, rivastigmine, and memantine) improved scores on the ADAS-Cog 11 by 1 to 2.5 points over 3 months to 3 years. Psychoeducation interventions for caregivers resulted in a small benefit for caregiver burden (standardized mean difference, -0.24 [95% CI, -0.36 to -0.13) over 3 to 12 months. Intervention benefits were small and of uncertain clinical importance.Conclusions and Relevance: Screening instruments can adequately detect cognitive impairment. There is no empirical evidence, however, that screening for cognitive impairment improves patient or caregiver outcomes or causes harm. It remains unclear whether interventions for patients or caregivers provide clinically important benefits for older adults with earlier detected cognitive impairment or their caregivers. [ABSTRACT FROM AUTHOR]

Importance: Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effects with substantial health care costs.Objective: To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.Evidence Review: Search of Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011, until March 16, 2017, using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.Findings: Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment; 4 A's Test; and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of delirium, based on recent reviews of the evidence, recommend reserving use of antipsychotics and other sedating medications for treatment of severe agitation that poses risk to patient or staff safety or threatens interruption of essential medical therapies.Conclusions and Relevance: Advances in diagnosis can improve recognition and risk stratification of delirium. Prevention of delirium using nonpharmacologic approaches is documented to be effective, while pharmacologic prevention and treatment of delirium remains controversial. [ABSTRACT FROM AUTHOR]

IMPORTANCE Surgery in older patients often poses risks of death, complications, and functional decline. Prior to surgery, evaluations of health-related priorities, realistic assessments of surgical risks, and individualized optimization strategies are essential. OBJECTIVE To review surgical decision making for older adult patients by 2 measures: defining treatment goals for elderly patients and reviewing the evidence relating risk factors to adverse outcomes. Assessment and optimization strategies for older surgical patients are proposed. EVIDENCE ACQUISITION A review of studies relating geriatric conditions such as functional and cognitive impairment, malnutrition, facility residence, and frailty to postoperative mortality and complications (including delirium, discharge to an institution, and functional decline).Medline, EMBASE, and Web of Science databases were searched for articles published between January 1, 2000, and December 31, 2013, that included patients older than 60 years. RESULTS This review identified 54 studies of older patients; 28 that examined preoperative clinical features associated with mortality (n=1 422 433 patients) and 26 that examined factors associated with surgical complications (n = 136 083 patients). There was substantial heterogeneity in study methods, measures, and outcomes. The absolute risk and risk ratios relating preoperative clinical conditions to mortality varied widely: 10% to 40% for cognitive impairment (adjusted hazard ratio [HR], 1.26 [95% CI, 1.06-1.49] to 5.77 [95% CI, 1.55-21.55]), 10% to 17% for malnutrition (adjusted odds ratio [OR], 0.88 [95% CI, 0.78-1.01] to 59.2 [95% CI, 3.6-982.9]), and 11% to 41% for institutionalization (adjusted OR, 1.5 [95% CI, 1.02-2.21] to 3.27 [95% CI, 2.81-3.81]).) Risk ratios for functional dependence relating to mortality ranged from an adjusted HR of 1.02 (95% CI, 0.99-1.04) to an adjusted OR of 18.7 (95% CI, 1.6-215.3) and for frailty relating to mortality, ranged from an adjusted HR of 1.10 (95% CI, 1.04-1.16) to an adjusted OR of 11.7 (95% CI not reported) (P < .001). Preoperative cognitive impairment (adjusted OR, 2.2; 95% CI, 1.4-2.7) was associated with postoperative delirium (adjusted OR, 17.0; 95% CI, 1.2-239.8; P < .05). Frailty was associated with a 3- to 13-fold increased risk of discharge to a facility (adjusted OR, 3.16 [95% CI, 1.0-9.99] to 13.02 [95% CI, 5.14-32.98]). CONCLUSIONS AND RELEVANCE Geriatric conditions may be associated with adverse surgical outcomes. A comprehensive evaluation of treatment goals and communication of realistic risk estimates are essential to guide individualized decision making. [ABSTRACT FROM AUTHOR]

The article discusses the challenges of driving with cognitive impairment for both the patient, a 92-year-old retired college professor, and caregiver. A summary of the literature on dementia and driving is presented and significant ethical and legal issues are addressed. The role of physician assessment, referral for neuropsychological testing, and screening for functional ability are described. The article also discusses several approaches to evaluating driving safety and national guidelines and physician practice.

The article discusses a study which investigated the effectiveness of the herbal product Ginkgo biloba in slowing the rates of global or domain-specific cognitive decline in older adults. The randomized, double-blind, placebo-controlled clinical trial was conducted in six academic medical centers across the U.S. involving 3,069 community-dwelling participants aged 72 to 96 years. The researchers found that the herbal product, 120 milligrams twice daily, did not result in less cognitive decline in older adults with normal or mild cognitive impairment.

The article discusses mild cognitive impairment in people, examining the evidence-based approach to evaluation and treatment. The case of a 60-year-old divorced woman who starts noticing her forgetfulness is detailed and analyzed. The author explores possible lifestyle changes, comorbid medical conditions, and the potential for pharmacotherapy. Other topics include white matter lesions on magnetic resonance imaging (MRI), the risk of conversion to dementia, and questions that face the patient, family, and clinician.

This article discusses the use of neuropsychological tests to screen for dementia. multiple neuropsychological tests were administered with attention paid to variations in their results were studied to determine whether they indicated dementia. Tests used include the Free and Cued Selective Reminding Test and two subtests from the Weschler Adult Intelligence Scale Revised. The application of these variations to increase the sensitivity of tests detecting dementia and its precursor, mild cognitive impairment, is noted. The authors caution that this result requires confirmation across populations because of the locally focused approach to resting.

Presents research to determine if conjugated equine estrogen (CEE) changes global cognitive function in older women and to compare the effects with CEE plus medroxyprogesterone acetate (CEE plus MPA). Design, setting, participants, interventions, and main outcome measures; Results; Conclusion hormone therapy in women aged 65 or older had an adverse effect on cognition, which was greater in those with lower cognitive function at baseline.

Context: Little is known about nursing home residents' injuries that are inflicted by other residents. Objective: To assess risk factors for violent injury to nursing home residents by other residents. Design, Setting, and Subjects: Case-control study using data from the Massachusetts Department of Public Health's Complaint and Incident Reporting System and from Minimum Data Set assessments for Massachusetts nursing home residents. Cases had an injury sustained from an incident with another nursing home resident between January 1, 2000, and December 31, 2000, which left visible evidence (ie, fracture, dislocation, bruise or hematoma, laceration, and reddened area) (median age, 81 years). Controls were randomly selected from all residents who had a Minimum Data Set assessment completed in 2000 (n = 101 429) and no injury report (median age, 83 years). A total of 1994 controls were included in the analyses. Main Outcome Measures: Injury type and risk of being injured by resident-to-resident aggressive physical behaviors based on the specific characteristics of the injured resident. Results: During the first incident, 294 residents sustained fractures (n = 39), dislocations (n = 6), bruises or hematomas (n = 105), lacerations (n = 113), and reddened areas (n = 31). Injured residents (cases) were more likely to be cognitively impaired, exhibit symptoms of wandering, be verbally abusive, and have socially inappropriate behavior than the controls. Residents who were classified as needing extensive assistance (adjusted odds ratio [AOR], 0.3; 95% confidence interval [CI], 0.2-0.6) and being severely dependent (AOR, 0.12; 95% CI, 0.05-0.27) had a significant reduction in being injured. Residents in an Alzheimer disease unit were almost 3 times as likely to be injured than those living in other units (AOR, 3.2; 95% CI, 1.4-7.5). Conclusions: Injured residents were more likely, perhaps unknowingly, to "put themselves in harm's way," be verbally aggressive, and be cognitively impaired. Interventions to prevent these incidents should focus on the behavior of the injured persons. [ABSTRACT FROM AUTHOR]

Examines the relationship of blood pressure (BP) with the level of and change in cognitive function in the elderly. Context; Objective; Design; Setting; Participants; Main outcome measures; Results; Conclusion.

This article focuses on the diagnosis of presymptomatic Alzheimer's disease. It is necessary to identify Alzheimer's disease in its early phase since the early phase is the best and maybe the only effective time to reverse pathological abnormalities and prevent loss of cognition. A reliable biomarker is necessary that is present many years prior to the appearance of symptoms, such as pathogenic plaque. Recent findings that levels of certain cerebrospinal fluids are substantially reduced with age in people who may be normal in cognition, but who have the apolipoprotein E allele provide a way to identify people who may develop Alzheimer disease. Genomic prediction and pharmacogenomic intervention are desirable goals in the treatment of Alzheimer's disease in a timely manner.

The authors reflect on issues related to driving fitness and cognitive impairment in the U.S. that are of importance to physicians. They cite some challenges faced by physicians whose roles involve addressing the needs and safety of such patients and their community. They describe some variations in how driver rehabilitation specialists can perform detailed evaluation of the driver. The authors also discuss the responsibilities of medical advisory boards in helping with issues on medical fitness to drive.

The author reflects on the scientific value of several studies in support of an original study on the associations of the Mediterranean-type of diet adherence with the risk of late-life cognitive impairment. He presents an overview of the studies including their limitations in supporting the original research on the subject. He argues that there is no question about the scientific value of the studies, but it is not clear whether and how they can or should be translated into recommendations for the public.

The article presents updates on clinical trials as of May 28, 2014. A study published in "Neurology" journal discussed how the onset of diabetes and hypertension in midlife affects brain pathology and may lead to cognitive impairment later in life. A study published in "Stroke" journal found people with insomnia may be more likely to experience a stroke compared with people who sleep well. A study published in "Lancet" journal recommended low-dose colchicine to treat pericarditis.

The article discusses a study by the U.S. Centers for Disease Control and Prevention (CDC) which shows the incidence of cognitive decline in American adults aged 60 years or older. The percentage of individuals who said their cognitive problems interfere with their social activities or work is mentioned. The need for more research on the association between age and functional problems that arise from confusion and memory loss is addressed.

Introduces topics of discussion in this issue of the 'Journal of the American Medical Association.' Theme issue on aging; Cognitive training in older adults; Growth hormones and sex steroid in elderly; Role of biofeedback in urge incontinence treatment; Physical activity and risk of hip fracture; Olfactory impairment; Others.

Presents an abstract of `Preserved Cognitive Skills in Dementia of the Alzheimer Type,' by William W. Beatty et al, which was lifted from a neurology journal. Neuropsychological tests; Preservation of certain cognitive abilities in patients with dementia.