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Association of Cardiovascular Health Level in Older Age With Cognitive Decline and Incident Dementia

Educational Objective
To understand the relationship between cardiovascular health and dementia.
1 Credit CME
Key Points

Question  Is there an association between cardiovascular health level in older age and risk of incident dementia?

Findings  In this French population-based cohort study involving 6626 individuals, an increased number of optimal cardiovascular health metrics (defined using a 7-item tool from the American Heart Association) were significantly associated with lower risk of incident dementia (hazard ratio, 0.90 for each additional metric at recommended optimal level).

Meaning  These findings may support the promotion of cardiovascular health to prevent development of risk factors associated with dementia.


Importance  Evidence is limited regarding the relation between cardiovascular health level and dementia risk.

Objective  To investigate the association between cardiovascular health level, defined using the 7-item tool from the American Heart Association (AHA), and risk of dementia and cognitive decline in older persons.

Design, Setting, and Participants  Population-based cohort study of persons aged 65 years or older from Bordeaux, Dijon, and Montpellier, France, without history of cardiovascular diseases or dementia at baseline who underwent repeated in-person neuropsychological testing (January 1999–July 2016) and systematic detection of incident dementia (date of final follow-up, July 26, 2016).

Exposures  The number of the AHA’s Life’s Simple 7 metrics at recommended optimal level (nonsmoking, body mass index <25, regular physical activity, eating fish twice a week or more and fruits and vegetables at least 3 times a day, cholesterol <200 mg/dL [untreated], fasting glucose <100 mg/dL [untreated], and blood pressure <120/80 mm Hg [untreated]; score range, 0-7) and a global cardiovascular health score (range, 0-14; poor, intermediate, and optimal levels of each metric assigned a value of 0, 1, and 2, respectively).

Main Outcomes and Measures  Incident dementia validated by an expert committee and change in a composite score of global cognition (in standard units, with values indicating distance from population means, 0 equal to the mean, and +1 and −1 equal to 1 SD above and below the mean).

Results  Among 6626 participants (mean age, 73.7 years; 4200 women [63.4%]), 2412 (36.5%), 3781 (57.1%), and 433 (6.5%) had 0 to 2, 3 to 4, and 5 to 7 health metrics at optimal levels, respectively, at baseline. Over a mean follow-up duration of 8.5 (range, 0.6-16.6) years, 745 participants had incident adjudicated dementia. Compared with the incidence rate of dementia of 1.76 (95% CI, 1.38-2.15) per 100 person-years among those with 0 or 1 health metrics at optimal levels, the absolute differences in incident dementia rates for 2, 3, 4, 5, and 6 to 7 metrics were, respectively, −0.26 (95% CI, −0.48 to −0.04), −0.59 (95% CI, −0.80 to −0.38), −0.43 (95% CI, −0.65 to −0.21), −0.93 (95% CI, −1.18 to −0.68), and −0.96 (95% CI, −1.37 to −0.56) per 100 person-years. In multivariable models, the hazard ratios for dementia were 0.90 (95% CI, 0.84-0.97) per additional optimal metric and 0.92 (95% CI, 0.89-0.96) per additional point on the global score. Furthermore, the gain in global cognition associated with each additional optimal metric at baseline was 0.031 (95% CI, 0.009-0.053) standard units at inclusion, 0.068 (95% CI, 0.045-0.092) units at year 6, and 0.072 (95% CI, 0.042-0.102) units at year 12.

Conclusions and Relevance  In this cohort of older adults, increased numbers of optimal cardiovascular health metrics and a higher cardiovascular health score were associated with a lower risk of dementia and lower rates of cognitive decline. These findings may support the promotion of cardiovascular health to prevent risk factors associated with cognitive decline and dementia.

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Article Information

Corresponding Author: Cécilia Samieri, PhD, INSERM, U1219, Université de Bordeaux, ISPED, CS 61292, 146 rue Léo-Saignat, Bordeaux 33076, France (cecilia.samieri@u-bordeaux.fr).

Accepted for Publication: July 22, 2018.

Author Contributions: Dr Samieri had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Samieri, Gaye, Dartigues, Empana.

Acquisition, analysis, or interpretation of data: Samieri, Périer, Proust-Lima, Helmer, Dartigues, Berr, Tzourio, Empana.

Drafting of the manuscript: Samieri, Gaye, Empana.

Critical revision of the manuscript for important intellectual content: Périer, Proust-Lima, Helmer, Dartigues, Berr, Tzourio, Empana.

Statistical analysis: Samieri, Périer, Gaye, Proust-Lima, Empana.

Obtained funding: Helmer, Dartigues, Berr, Tzourio.

Administrative, technical, or material support: Berr, Tzourio.

Supervision: Dartigues, Empana.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Dartigues reports receipt of a grant from Roche. No other disclosures were reported.

Funding/Support: The Three-City Study is conducted under a partnership agreement between INSERM, the ISPED of the University of Bordeaux, and Sanofi-Aventis. The Fondation pour la Recherche Médicale funded the preparation and initiation of the study. The Three-City Study is also supported by the Caisse Nationale Maladie des Travailleurs Salariés, Direction Générale de la Santé, Mutuelle Générale de l’Education Nationale, Institut de la Longévité, Conseils Régionaux of Aquitaine and Bourgogne, Fondation de France, and Ministry of Research-INSERM Programme “Cohortes et collections de données biologiques,”French National Research Agency COGINUT ANR-06-PNRA-005 and COGICARE ANR Longvie (LVIE-003-01), the Fondation Plan Alzheimer (FCS 2009-2012), and the Caisse Nationale pour la Solidarité et l’Autonomie.

Role of the Funder/Sponsor: The sponsors were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Winblad  B, Amouyel  P, Andrieu  S,  et al.  Defeating Alzheimer’s disease and other dementias: a priority for European science and society.  Lancet Neurol. 2016;15(5):455-532. doi:10.1016/S1474-4422(16)00062-4PubMedGoogle ScholarCrossref
Norton  S, Matthews  FE, Barnes  DE, Yaffe  K, Brayne  C.  Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data.  Lancet Neurol. 2014;13(8):788-794. doi:10.1016/S1474-4422(14)70136-XPubMedGoogle ScholarCrossref
Livingston  G, Sommerlad  A, Orgeta  V,  et al.  Dementia prevention, intervention, and care.  Lancet. 2017;390(10113):2673-2734. doi:10.1016/S0140-6736(17)31363-6PubMedGoogle ScholarCrossref
Sabia  S, Nabi  H, Kivimaki  M, Shipley  MJ, Marmot  MG, Singh-Manoux  A.  Health behaviors from early to late midlife as predictors of cognitive function: the Whitehall II Study.  Am J Epidemiol. 2009;170(4):428-437. doi:10.1093/aje/kwp161PubMedGoogle ScholarCrossref
Gelber  RP, Petrovitch  H, Masaki  KH,  et al.  Lifestyle and the risk of dementia in Japanese-American men.  J Am Geriatr Soc. 2012;60(1):118-123. doi:10.1111/j.1532-5415.2011.03768.xPubMedGoogle ScholarCrossref
Lloyd-Jones  DM, Hong  Y, Labarthe  D,  et al; American Heart Association Strategic Planning Task Force and Statistics Committee.  Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond.  Circulation. 2010;121(4):586-613. doi:10.1161/CIRCULATIONAHA.109.192703PubMedGoogle ScholarCrossref
Guo  L, Zhang  S.  Association between ideal cardiovascular health metrics and risk of cardiovascular events or mortality: a meta-analysis of prospective studies.  Clin Cardiol. 2017;40(12):1339-1346. doi:10.1002/clc.22836PubMedGoogle ScholarCrossref
Gaye  B, Canonico  M, Perier  MC,  et al.  Ideal cardiovascular health, mortality, and vascular events in elderly subjects: the Three-City Study.  J Am Coll Cardiol. 2017;69(25):3015-3026. doi:10.1016/j.jacc.2017.05.011PubMedGoogle ScholarCrossref
Gardener  H, Wright  CB, Dong  C,  et al.  Ideal cardiovascular health and cognitive aging in the Northern Manhattan Study.  J Am Heart Assoc. 2016;5(3):e002731. doi:10.1161/JAHA.115.002731PubMedGoogle ScholarCrossref
González  HM, Tarraf  W, Harrison  K,  et al.  Midlife cardiovascular health and 20-year cognitive decline: Atherosclerosis Risk in Communities Study results.  Alzheimers Dement. 2018;14(5):579-589. doi:10.1016/j.jalz.2017.11.002PubMedGoogle ScholarCrossref
Thacker  EL, Gillett  SR, Wadley  VG,  et al.  The American Heart Association Life’s Simple 7 and incident cognitive impairment: the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study.  J Am Heart Assoc. 2014;3(3):e000635. doi:10.1161/JAHA.113.000635PubMedGoogle ScholarCrossref
Pase  MP, Beiser  A, Enserro  D,  et al.  Association of ideal cardiovascular health with vascular brain injury and incident dementia.  Stroke. 2016;47(5):1201-1206. doi:10.1161/STROKEAHA.115.012608PubMedGoogle ScholarCrossref
Hessler  JB, Ander  KH, Brönner  M,  et al.  Predicting dementia in primary care patients with a cardiovascular health metric: a prospective population-based study.  BMC Neurol. 2016;16:116. doi:10.1186/s12883-016-0646-8PubMedGoogle ScholarCrossref
3C Study Group.  Vascular factors and risk of dementia: design of the Three-City Study and baseline characteristics of the study population.  Neuroepidemiology. 2003;22(6):316-325. doi:10.1159/000072920PubMedGoogle ScholarCrossref
Larrieu  S, Letenneur  L, Berr  C,  et al.  Sociodemographic differences in dietary habits in a population-based sample of elderly subjects: the 3C Study.  J Nutr Health Aging. 2004;8(6):497-502.PubMedGoogle Scholar
Barberger-Gateau  P, Raffaitin  C, Letenneur  L,  et al.  Dietary patterns and risk of dementia: the Three-City Cohort Study.  Neurology. 2007;69(20):1921-1930. doi:10.1212/01.wnl.0000278116.37320.52PubMedGoogle ScholarCrossref
Samieri  C, Morris  MC, Bennett  DA,  et al.  Fish intake, genetic predisposition to Alzheimer disease, and decline in global cognition and memory in 5 cohorts of older persons.  Am J Epidemiol. 2018;187(5):933-940. doi:10.1093/aje/kwx330PubMedGoogle ScholarCrossref
American Psychiatric Association.  Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Press; 1994.
Folstein  MF, Folstein  SE, McHugh  PR.  “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician.  J Psychiatr Res. 1975;12(3):189-198. doi:10.1016/0022-3956(75)90026-6PubMedGoogle ScholarCrossref
Isaacs  B, Kennie  AT.  The Set Test as an aid to the detection of dementia in old people.  Br J Psychiatry. 1973;123(575):467-470. doi:10.1192/bjp.123.4.467PubMedGoogle ScholarCrossref
Benton  A.  Manuel pour l’application du Test de Rétention Visuelle: Applications cliniques et expérimentales. Paris, France: Centre de Psychologie appliquée; 1965.
Reitan  RM.  The relation of the trail making test to organic brain damage.  J Consult Psychol. 1955;19(5):393-394. doi:10.1037/h0044509PubMedGoogle ScholarCrossref
Carcaillon  L, Amieva  H, Auriacombe  S, Helmer  C, Dartigues  JF.  A subtest of the MMSE as a valid test of episodic memory? comparison with the Free and Cued Reminding Test.  Dement Geriatr Cogn Disord. 2009;27(5):429-438. doi:10.1159/000214632PubMedGoogle ScholarCrossref
Grober  EBH.  Genuine memory deficits 1 in dementia.  Dev Neuropsychol. 1987;3:13-36. doi:10.1080/87565648709540361Google ScholarCrossref
Law  CG, Brookmeyer  R.  Effects of mid-point imputation on the analysis of doubly censored data.  Stat Med. 1992;11(12):1569-1578. doi:10.1002/sim.4780111204PubMedGoogle ScholarCrossref
Eilers  PHC, Marx  BD.  Flexible smoothing with B-splines and penalties.  Stat Sci. 1996;11(2):89-121. doi:10.1214/ss/1038425655Google ScholarCrossref
Laird  NM, Ware  JH.  Random-effects models for longitudinal data.  Biometrics. 1982;38(4):963-974. doi:10.2307/2529876PubMedGoogle ScholarCrossref
Proust-Lima  C, Philipps  V, Dartigues  JF,  et al.  Are latent variable models preferable to composite score approaches when assessing risk factors of change? evaluation of type-I error and statistical power in longitudinal cognitive studies [published online January 1, 2017].  Stat Methods Med Res. doi:10.1177/0962280217739658PubMedGoogle Scholar
Touraine  C, Helmer  C, Joly  P.  Predictions in an illness-death model.  Stat Methods Med Res. 2016;25(4):1452-1470. doi:10.1177/0962280213489234PubMedGoogle ScholarCrossref
Leffondré  K, Touraine  C, Helmer  C, Joly  P.  Interval-censored time-to-event and competing risk with death: is the illness-death model more accurate than the Cox model?  Int J Epidemiol. 2013;42(4):1177-1186. doi:10.1093/ije/dyt126PubMedGoogle ScholarCrossref
Reis  JP, Loria  CM, Launer  LJ,  et al.  Cardiovascular health through young adulthood and cognitive functioning in midlife.  Ann Neurol. 2013;73(2):170-179. doi:10.1002/ana.23836PubMedGoogle ScholarCrossref
Gorelick  PB, Furie  KL, Iadecola  C,  et al; American Heart Association/American Stroke Association.  Defining optimal brain health in adults: a presidential advisory from the American Heart Association/American Stroke Association.  Stroke. 2017;48(10):e284-e303. doi:10.1161/STR.0000000000000148PubMedGoogle ScholarCrossref
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