OGNITIVE IMPAIRMENT, ESPEcially severe impairment or dementia, is one of the primary indications for nursing home placement. As many as 90% of patients with dementia reportedly become institutionalized before death. 1 However, most patients with dementia continue to live in the community until family caregivers are no longer able to care for them. 2 The decision to place a patient with dementia in long-term care is complex and is based on patient and caregiver characteristics and the sociocultural context of patient and caregiver. Yet most studies that have assessed the predictors of nursing home placement have focused primarily on the characteristics of either the patient, such as dementia severity or difficult behaviors, 1,[3][4][5][6][7][8] or the caregiver, such as subjective burden or health status, 9,10 and few studies have comprehensively investigated how both caregiver and patient characteristics influence nursing home placement. In addition, most studies that have investigated predictors of nursing home placement of Author Affiliations are listed at the end of this article.

ARDIOVASCULAR AND METAbolic risk factors such as hypertension and diabetes have been hypothesized to play a role in the pathogenesis of Alzheimer disease (AD) as well as in development of vascular dementia. [1][2][3][4] The metabolic syndrome, 5 a clustering of several commonly occurring disorders that include (1) abdominal obesity, (2) hypertriglyceridemia, (3) low highdensity lipoprotein (HDL) level, (4) hypertension, and (5) hyperglycemia, has not been specifically investigated as a risk factor for cognitive decline in elderly individuals. The metabolic syndrome may be a risk factor for cognitive decline because it summarizes the joint effects of these risk factors. As obesity and sedentary lifestyle rise in the United States, identification and explication of the role of these modifiable behaviors in increasing risk for developing deleterious outcomes such as cognitive impairment is critical. If the metabolic syndrome is associated with increased risk of developing cognitive impairment, then early identification and treatment of these individuals might offer avenues for disease course modification.High levels of inflammation increase the risk of the development of diabetes and atherosclerosis and are thought to be a possible mechanism for the adverse consequences of the metabolic syndrome. 6,7 Indeed, level of inflammation in the setting of the meta-bolic syndrome may help identify those at especially high risk for adverse outcomes. Furthermore, subclinical inflammation might be an underlying factor for an association between the

This prognostic index, incorporating age, sex, self-reported comorbid conditions, and functional measures, accurately stratifies community-dwelling older adults into groups at varying risk of mortality.

Serum markers of inflammation, especially IL-6 and CRP, are prospectively associated with cognitive decline in well-functioning elders. These findings support the hypothesis that inflammation contributes to cognitive decline in the elderly.

Context Post-traumatic stress disorder (PTSD) is highly prevalent among veterans because of combat and may impair cognition. Objective To determine whether PTSD is associated with the risk of developing dementia among older US veterans receiving treatment in Department of Veterans Affairs medical centers. Design A stratified, retrospective cohort study conducted using the Department of Veterans Affairs National Patient Care Database. Setting Department of Veterans Affairs medical centers in the United States. Participants A total of 181,093 veterans 55 years or older without dementia from fiscal years 1997 through 2000 (53,155 veterans with and 127,938 veterans without PTSD). Main Outcome Measures During the follow-up period between October 1, 2000, and December 31, 2007, 31,107 (17.2%) veterans were ascertained to have newly diagnosed dementia according to International Classification of Diseases, Ninth Revision, Clinical Modification codes. Results The mean baseline age of the veterans was 68.8 years, and174,806 (96.5%) were men. Veterans with PTSD had a 7-year cumulative incident dementia rate of 10.6% whereas those without had a rate of 6.6% (P<.001). With age as the time scale, Cox proportional hazards models indicated that patients with PTSD were more than twice as likely to develop incident dementia compared with those without PTSD (Hazard Ratio [HR] = 2.31, 95% Confidence Interval [CI] 2.24–2.39). After multivariable adjustment for demographics, medical and neuropsychiatric comorbidities, patients with PTSD were still more likely to develop dementia (HR = 1.77, 95% CI 1.70–1.85). Results were similar when we excluded those with a history of head injury, substance abuse, or clinical depression. Conclusions We found that in a predominantly male veteran cohort, those diagnosed as having PTSD were at a nearly 2-fold-higher risk of developing dementia compared with those without PTSD. Mechanisms linking these important disorders need to be identified with the hope of finding ways to reduce the increased risk of dementia associated with PTSD.

Elders who maintain cognitive function have a unique profile that differentiates them from those with minor decline. Importantly, some of these factors are modifiable and thus may be implemented in prevention programs to promote successful cognitive aging. Further, factors associated with maintenance may differ from factors associated with major cognitive decline, which may impact prevention vs treatment strategies.

Prostate-specific antigen screening rates among elderly veterans with limited life expectancies should be much lower than current practice given the known harms of screening. More attention to prognosis is needed when making screening PSA recommendations to elderly men.

Background: Mild cognitive impairment (MCI) represents a common cognitive state between normal cognitive aging and dementia. There is limited information about the heterogeneity of MCI and how this heterogeneity may influence the clinical course of MCI. We determined the longitudinal course of subtypes of MCI and assessed the rate of progression to dementia and to death. Methods: As part of the Alzheimer’s Disease Research Centers of California, we studied 327 patients with MCI (250 with amnestic MCI, 34 with single nonmemory MCI, and 43 with multiple domain MCI) who were followed longitudinally. We determined if subtype of MCI was independently associated with time to dementia diagnosis and time to death using Cox proportional hazard models, and type of dementia using Fisher’s exact test. Results: Mean age of the patients with MCI was 72.9 ± 9.3 years and mean Mini-Mental State Examination score was 25.7 ± 4.3. After a mean follow-up of 3.1 years, 199 (65%) progressed to dementia and 80 (24%) died. After multivariate adjustment, compared to those with amnestic MCI, patients with single nonmemory or multiple subtype MCI were less likely to receive a diagnosis of dementia (HR = 0.60; 95% CI 0.35–1.05 and HR = 0.71; 95% CI 0.44–1.14) but more likely to die (HR = 2.57; 95% CI 1.13–5.84 and HR = 1.73; 95% CI 0.72–4.18), but these results were of borderline statistical significance. There were significant differences in the type of dementia diagnosed across MCI subtypes (p = 0.006). Among the patients who progressed to Alzheimer’s disease, 76% had prior amnestic MCI; of the patients who progressed to vascular dementia, 50% had prior amnestic MCI; all patients who progressed to a frontal dementia syndrome had single nonmemory MCI previously. Conclusions: The majority of patients with MCI progressed to dementia and a significant proportion died. Subtype of MCI may influence rates of progression to death and to dementia and has a major influence on subsequent type of dementia diagnosis.