Psychological Distress Linked to Increased Risk for Dementia

 

All stroke patients are under massive distress because your incompetent? doctor doesn't have 100% RECOVERY PROTOCOLS. Your doctor has known since medical school that stroke recovery is a complete shitshow and done nothing to fix that!

Psychological Distress Linked to Increased Risk for Dementia

Psychological distress in midlife was associated with an increased risk for dementia, highlighting its value as a clinical marker for identifying high-risk groups.

Psychological distress is associated with poorer later-life cognitive performance and increased risk for dementia, though not with cognitive decline over time, according to results of a study published in Alzheimer’s & Dementia.In a multi-cohort study, researchers examined associations between psychological distress and subsequent cognitive outcomes and dementia risk. They pooled data from 5 longitudinal studies: the Caerphilly Prospective Study (CAPS), English Longitudinal Study of Ageing (ELSA), National Child Development Study (NCDS), National Survey of Health and Development (NSHD), and Whitehall II (WHII).

The analysis included 24,564 participants. Across cohorts, baseline sample sizes ranged from 1180 to 9022 participants. Cohorts comprised 44.7% to 100% men, with mean baseline ages ranging from 23 to 64.1 years, and 3.3% to 25.5% of participants reporting long-term health conditions. Between 7.6% and 27.7% of participants reported clinically significant psychological distress at baseline.

 

Findings highlight the relevance of psychological distress in later cognitive outcomes, with potential future implications for dementia prevention and identifying high-risk groups.

Greater baseline psychological distress was associated with worse subsequent fluid cognitive performance at a mean age of 62 to 72 years (adjusted b, -0.03; 95% CI, -0.06 to -0.01; I2=70%). Similar associations were observed for clinically significant distress (b, -0.1; 95% CI, -0.1 to 0.0; I2=62%), intermittent distress (b, -0.1; 95% CI, -0.2 to -0.02; I2=83%), and persistent distress (b, -0.1; 95% CI, -0.1 to -0.1; I2=0%).

In analyses of cognitive trajectories, psychological distress was not associated with overall cognitive decline in pooled models. Although cohort-specific analyses showed decline in ELSA (b, -0.04; 95% CI, -0.04 to -0.04), NSHD (b, -0.01; 95% CI, -0.01 to 0.004), and WHII (b, -0.01; 95% CI, -0.01 to 0.01), these findings were not consistent across studies.

Baseline psychological distress was also associated with increased odds of dementia at follow-up (adjusted odds ratio [aOR], 1.1; 95% CI, 1.0-1.2; I2=0%). Increased dementia risk was observed for clinically significant distress (aOR, 1.3; 95% CI, 1.1-1.5; I2=0%), intermittent distress (odds ratio [OR], 1.3; 95% CI, 1.0-1.7; I2=40%), and persistent distress (OR, 1.4; 95% CI, 1.0-2.0; I2=44%).

Age-stratified analyses showed that psychological distress was associated with dementia when assessed at ages 55 to 64 years (OR, 1.3; 95% CI, 1.2-1.4; I2=0%) and 65 to 75 years (OR, 1.3; 95% CI, 1.2-1.4; I2=14%), but not at ages 45 to 54 years (OR, 1.1; 95% CI, 0.9-1.3; I2=34%).Study limitations included heterogeneity across cohorts in population characteristics, measurement of psychological distress, and outcome assessment.

The researchers concluded, “Findings highlight the relevance of psychological distress in later cognitive outcomes, with potential future implications for dementia prevention and identifying high-risk groups.” 

References:

Psychological Distress Linked to Increased Risk for Dementia

 All stroke patients are under massive distress because your incompetent? doctor doesn't have 100% RECOVERY PROTOCOLS. Your doctor has known since medical school that stroke recovery is a complete shitshow and done nothing to fix that!

Psychological Distress Linked to Increased Risk for Dementia

Psychological distress in midlife was associated with an increased risk for dementia, highlighting its value as a clinical marker for identifying high-risk groups.

Psychological distress is associated with poorer later-life cognitive performance and increased risk for dementia, though not with cognitive decline over time, according to results of a study published in Alzheimer’s & Dementia.

In a multi-cohort study, researchers examined associations between psychological distress and subsequent cognitive outcomes and dementia risk. They pooled data from 5 longitudinal studies: the Caerphilly Prospective Study (CAPS), English Longitudinal Study of Ageing (ELSA), National Child Development Study (NCDS), National Survey of Health and Development (NSHD), and Whitehall II (WHII).

The analysis included 24,564 participants. Across cohorts, baseline sample sizes ranged from 1180 to 9022 participants. Cohorts comprised 44.7% to 100% men, with mean baseline ages ranging from 23 to 64.1 years, and 3.3% to 25.5% of participants reporting long-term health conditions. Between 7.6% and 27.7% of participants reported clinically significant psychological distress at baseline.

 

Findings highlight the relevance of psychological distress in later cognitive outcomes, with potential future implications for dementia prevention and identifying high-risk groups.

Greater baseline psychological distress was associated with worse subsequent fluid cognitive performance at a mean age of 62 to 72 years (adjusted b, -0.03; 95% CI, -0.06 to -0.01; I2=70%). Similar associations were observed for clinically significant distress (b, -0.1; 95% CI, -0.1 to 0.0; I2=62%), intermittent distress (b, -0.1; 95% CI, -0.2 to -0.02; I2=83%), and persistent distress (b, -0.1; 95% CI, -0.1 to -0.1; I2=0%).

In analyses of cognitive trajectories, psychological distress was not associated with overall cognitive decline in pooled models. Although cohort-specific analyses showed decline in ELSA (b, -0.04; 95% CI, -0.04 to -0.04), NSHD (b, -0.01; 95% CI, -0.01 to 0.004), and WHII (b, -0.01; 95% CI, -0.01 to 0.01), these findings were not consistent across studies.

Baseline psychological distress was also associated with increased odds of dementia at follow-up (adjusted odds ratio [aOR], 1.1; 95% CI, 1.0-1.2; I2=0%). Increased dementia risk was observed for clinically significant distress (aOR, 1.3; 95% CI, 1.1-1.5; I2=0%), intermittent distress (odds ratio [OR], 1.3; 95% CI, 1.0-1.7; I2=40%), and persistent distress (OR, 1.4; 95% CI, 1.0-2.0; I2=44%).

Age-stratified analyses showed that psychological distress was associated with dementia when assessed at ages 55 to 64 years (OR, 1.3; 95% CI, 1.2-1.4; I2=0%) and 65 to 75 years (OR, 1.3; 95% CI, 1.2-1.4; I2=14%), but not at ages 45 to 54 years (OR, 1.1; 95% CI, 0.9-1.3; I2=34%).Study limitations included heterogeneity across cohorts in population characteristics, measurement of psychological distress, and outcome assessment.

The researchers concluded, “Findings highlight the relevance of psychological distress in later cognitive outcomes, with potential future implications for dementia prevention and identifying high-risk groups.”

Spiritual Distress Is a Clinical Reality in Brain Disease

 In stroke there would be no distress at all if your competent? doctor had 100% recovery protocols! But I'm sure your doctor has nothing of that at all! If they did they would be in the running for a Nobel prize in medicine.

With your risk of dementia, Parkinsons and epilepsy post stroke you'll want a competent doctor that can prevent those problems. 

Your risk of dementia, has your doctor told you of this?  Your doctor is responsible for preventing this! Is s/he willing to try this on you?

1. A documented 33% dementia chance post-stroke from an Australian study?   May 2012.

2. Then this study came out and seems to have a range from 17-66%. December 2013.`    

3. A 20% chance in this research.   July 2013.

4. Dementia Risk Doubled in Patients Following Stroke September 2018 

Parkinson’s Disease May Have Link to Stroke March 2017 

• post-stroke epilepsy (22 posts to December 2016) 

Do you prefer your doctor, hospital and board of director's incompetence NOT KNOWING? OR NOT DOING? Your choice; let them be incompetent or demand action!

The latest here:

Spiritual Distress Is a Clinical Reality in Brain Disease

Summary: Neurological diseases like Parkinson’s and dementia don’t just affect the body; they dismantle a person’s sense of self, memory, and communication. A new paper argues that because these diseases attack the core of human identity, spiritual care must become a routine part of neurological treatment.

The researchers propose a “biopsychosocial-spiritual” model, moving beyond purely physical symptoms to address the existential distress that often accompanies a life-altering diagnosis.

Key Facts

• The Identity Crisis: Neurological conditions are unique because they erode the traits that define who we are. For these patients, spirituality is often a primary tool for finding meaning and resilience.
• The 60% Gap: While roughly 60% of adults want their spiritual concerns acknowledged by doctors, most clinicians avoid the topic due to lack of training, time constraints, or personal discomfort.
• The FICA Framework: The paper recommends the FICA tool (Faith, Importance, Community, Address) to help neurologists take a quick, structured spiritual history in under two minutes.
• Spiritual Generalists: Neurologists don’t need to be clergy; they act as “spiritual generalists” who identify distress, validate a patient’s humanity, and refer them to chaplains or therapists when needed.
• Clinician Burnout: Integrating spiritual care isn’t just for patients—it’s linked to lower burnout and higher job satisfaction for physicians who feel they are treating “the whole person.”

Source: UCLA

People living with neurological diseases such as Parkinson’s disease, dementia and epilepsy face not only physical decline, but also profound questions about identity, purpose, and meaning. Yet physicians best positioned to address those concerns do not have the adequate training and tools to do so, a new paper states.

The paper, published in the journal Neurology Clinical Practice by researchers from UCLA Health, the University of Colorado, Harvard Medical School and Brown University, argues that spiritual assessment should become a routine part of neurological care, and offers practical guidance for how clinicians can make it happen.

New clinical guidance encourages neurologists to adopt a four-dimensional approach to care, recognizing that spiritual health is central to how patients cope with neurological decline. Credit: Neuroscience News

The paper describes why neurologists are uniquely suited to engage patients on matters of spirituality, and why the field’s reluctance to do so may be leaving an important dimension of patient care unaddressed.

“Neurologic diseases attack the very things that define who we are: our memory, our movement, our ability to communicate,” said lead author Dr. Indu Subramanian, a movement disorders neurologist at the David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Healthcare System.

“In that context, a patient’s spirituality isn’t peripheral to their medical care. It’s often central to how they cope, find meaning and make decisions about treatment.”

Research cited in the paper suggests that roughly 60% of American adults express interest in having their religious or spiritual concerns acknowledged in a medical setting. At the same time, studies consistently show that clinicians, including neurologists, are reluctant to raise the subject, citing discomfort, lack of training and time constraints.

Subramanian and the paper coauthors argue this gap can have real consequences to patients. Unaddressed spiritual distress has been associated with poorer quality of life in patients with serious illness, while spiritual support has been linked to improved coping, stronger patient-clinician relationships and better alignment around treatment goals. For patients with progressive neurological conditions, who often experience an erosion of identity and memory alongside physical decline, these factors can be especially significant.

The paper draws on a biopsychosocial-spiritual model of care, an expansion of the widely adopted biopsychosocial framework, which recognizes spirituality as a distinct and measurable dimension of health, alongside physical, psychological and social factors. This model has been endorsed by multiple major medical organizations and is increasingly recognized as relevant to neurological care.

Simple Tools for a Sensitive Conversation

A key contribution of the paper is its practical guidance for neurologists who want to integrate spiritual assessment into their practice without extensive additional training or time.

The authors recommend beginning with a brief, two-question screen that takes less than two minutes: asking whether spirituality or faith is important to a patient in thinking about their health, and whether they have or would like someone to speak with about those concerns.

For clinicians who prefer a less direct approach, the paper suggests open-ended questions such as “What do I need to know about you as a person to give you the best care possible?” or “From where do you draw your strength?”

The authors also describe a Faith, Importance, Community and Address (FICA) framework, which is a structured tool for taking a more detailed spiritual history, as well as phrases clinicians should listen for that may signal unaddressed spiritual distress, such as “Why is this happening to me?” or “I’ve lost touch with my faith since this diagnosis.”

Subramanian emphasized that neurologists need not act as spiritual counselors but can function as “spiritual generalists” capable of identifying a patient’s needs, validating their beliefs and making referrals to chaplains, psychotherapists or community faith leaders when appropriate.

A patient’s perspective

The paper includes the voice of Kirk Hall, a patient living with Parkinson’s disease and a paper co-author, who describes how faith has been central to navigating his diagnosis.

“It has not escaped me that this is a gift from God, even if I don’t necessarily agree with His choice of gift wrap,” Hall writes. “Our belief that we will be equipped to deal with whatever happens is extremely comforting to us.”

His perspective, the authors note, illustrates what research has demonstrated: for many patients, spirituality is not a supplement to medical care, but a foundation for resilience.

Benefits for clinicians

The paper also addresses what the authors describe as an underappreciated dimension of spiritual care in medicine: its potential benefit to clinicians themselves. Studies cited in the paper indicate that spiritual care training is associated with reduced burnout, lower work-related stress and improved well-being among physicians.

Practicing medicine in a way that attends to patients’ full humanity, the authors argue, may help neurologists find greater meaning in their work.

Key Questions Answered:

Q: Why should my brain doctor care about my religion or faith?

A: Because your brain is where your “self” lives. When Parkinson’s or dementia changes how you move or think, it triggers deep questions like, “Who am I now?” and “Why is this happening?” If a doctor only fixes your tremors but ignores your existential fear, they are only treating half the problem. Spirituality is often the “engine” that drives a patient’s ability to cope with treatment.

Q: Isn’t this just going to make doctor appointments longer?

A: The study suggests it takes less than two minutes. A simple question like, “From where do you draw your strength?” can provide a neurologist with more insight into a patient’s resilience than an hour of physical testing. It’s about quality of conversation, not quantity of time.

Q: What if the patient isn’t religious?

A: In this medical context, “spirituality” is broader than religion. It’s about what gives a person purpose, meaning, and a sense of connection. Even for secular patients, addressing “spiritual distress”—feelings of hopelessness or a lost sense of purpose—is critical for mental health and physical recovery.

Editorial Notes:

• This article was edited by a Neuroscience News editor.
• Journal paper reviewed in full.
• Additional context added by our staff.

About this neuroscience and neuroethics research news

Author: Will Houston
Source: UCLA
Contact: Will Houston – UCLA
Image: The image is credited to Neuroscience News

Original Research: Open access.
“Spiritual Assessment of Neurologic Patients” by Indu Subramanian, Christina L. Vaughan, John R. Peteet, Kirk Hall, and W. Curt LaFrance Jr. Neurology Clinical Practice
DOI:10.1212/CPJ.0000000000200591

Dementia Risk Higher in People With Earlier Signs of Psychological Distress

Post stroke, already a major stress event, then getting fired, moving a couple of states away, getting divorced. All which should have left me a blubbering pile of Jello. Yet, the stroke was the best thing to happen to me, it got me divorced. I'm happy now. I won't be having another stroke or dementia.

Why my stroke was the best thing to ever happen to me

The latest here:

Dementia Risk Higher in People With Earlier Signs of Psychological Distress

Stress, exhaustion symptoms linked with increased dementia risk years later

by Judy George, Deputy Managing Editor, MedPage Today December 16, 2022

Dementia risk was higher in people who had signs of psychological distress earlier in life, a cohort study in Finland found.

In more than 67,000 people with an average age of 45, self-reported distress symptoms -- notably, stress, and exhaustion -- were associated with a 17% to 24% increased risk of dementia over a 25-year follow-up period, reported Sonja Sulkava MD, PhD, of the Finnish Institute for Health and Welfare in Helsinki, and co-authors.

These self-reported symptoms were tied to an 8% to 12% increase in lifetime dementia after accounting for the competing risk of death, which was more common than dementia over time, Sulkava and colleagues wrote in JAMA Network Openopens in a new tab or window.

"Our study suggests symptoms of psychological distress like exhaustion, depressive mood, and the experience of stress are risk factors for dementia, and not only prodromal symptoms of underlying dementia disorder," Sulkava wrote in an email to MedPage Today.

"Previous studies have shown an association between symptoms of psychological distress and dementia, but the nature of the association is still unclear," Sulkava wrote. "We clarified that connection using a large population data set with 10 to 45 years of follow-up and careful modeling of death for other causes."

The study used data from 67,688 people who completed National FINRISK Study surveys between 1972 and 2007. Participants self-reported symptoms of psychological distress in the prior month, including whether they experienced stress more than other people and whether they experienced depressive mood, exhaustion, and nervousness often, sometimes, or never. The cohort was linked to the Finnish Health Register for dementia and mortality data.

About half (51.7%) of participants were women. Baseline ages ranged from 25 to 74 years, with a mean age of 45.4. Findings were adjusted for age, sex, baseline year, follow-up time, educational level, BMI, smoking, diabetes, systolic blood pressure, cholesterol, and physical activity.

Over a mean follow-up of 25.4 years, 7,935 participants received a diagnosis of dementia. The competing risk of death was more common, occurring in 19,647 people.

In a Poisson cause-specific model, exhaustion was linked with subsequent all-cause dementia (incidence rate ratio [IRR] 1.17, 95% CI 1.08-1.26), as was stress (IRR 1.24, 95% CI 1.11-1.38). These relationships remained significant in sensitivity analyses.

A subdistribution hazard model that estimated the effect on cumulative incidence also showed exhaustion (HR 1.08, 95% CI 1.01-1.17) and stress (HR 1.12, 95% CI 1.00-1.25) were linked with dementia risk over time. In contrast, depressive mood (HR 1.08, 95% CI 0.98-1.20) did not show a statistically significant association.

The study of psychological distress and brain health is "far from being incisive," noted Yoram Barak, MD, MHA, psychiatrist of the University of Otago in Dunedin, New Zealand, in an accompanying editorialopens in a new tab or window.

This "sophisticated analysis" adds "an important facet to the field by accounting for competing risk of death," Barak observed. "This should become a standard when researching these questions."

But relying on survey questions about experiences in the previous month may negate the possibility of understanding how stress may be a causative agent in dementia, since no information about lifelong traits or clinically diagnosed anxiety or depression was collected, Barak pointed out.

"We need to advance the field farther by creatively studying lifelong patterns of emotional states and relationships," he wrote. "Life trajectories of individuals and couples will teach us more about stress, distress, tensity, neuroticism, and dementia."

While the study questions on psychological distress do not form a validated multi-item questionnaire, the one-item measures for different symptoms of psychological distress correlate significantly, Sulkava and colleagues noted.

The research had other limitations, they acknowledged. Data about traumatic brain injury, hearing impairment, and low social contact -- three known dementia risk factors -- were not available. In addition, participants with missing covariate information had more risk factors for dementia or mortality.

• Judy George covers neurology and neuroscience news for MedPage Today, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more. Follow

Disclosures

This study was supported by the Emil Aaltonen Foundation, Maud Kuistila Memorial Foundation, Academy of Finland, and Gyllenberg Foundation.

Sulkava reported grants from Emil Aaltonen Foundation, Maud Kuistila Memorial Foundation, Gyllenberg Foundation; and a family member employed by Amialife Ltd.

Barak reported no disclosures.

Primary Source

JAMA Network Open

Source Reference: opens in a new tab or windowSulkava S, et al "Association between psychological distress and incident dementia in a population-based cohort in Finland" JAMA Netw Open 2022; DOI: 10.1001/jamanetworkopen.2022.47115.

Secondary Source

JAMA Network Open

Source Reference: opens in a new tab or windowBarak Y "Stress, distress, tensity, neuroticism, and risk of dementia" JAMA Netw Open 2022; DOI: 10.1001/jamanetworkopen.2022.47124.

Psychological distress associated with increased risk for dementia

I assume that anxiety and depression post stroke is emotional distress and as such is your doctor's responsibility to prevent. 

Psychological distress associated with increased risk for dementia

Psychological distress symptoms were significantly associated with increased risk for all-cause dementia, researchers reported in JAMA Network Open.

“Symptoms of psychological distress have shown association with subsequent dementia, but the nature of association remains unclear,” Sonja Sulkava, MD, PhD, of the Finnish Institute for Health and Welfare in Helsinki, Finland, and colleagues wrote.

Psychological distress symptoms were significantly associated with increased risk for all-cause dementia. Source: Adobe Stock

Sulkava and colleagues sought to examine the association between psychological distress and etiological risk for dementia and incidence of dementia.

The experts conducted a cohort study that consisted of population-based cross-sectional national surveys collected in Finland every 5 years from 1972 to 2007. The cohort was linked to Finnish Health Register data for dementia and mortality for each participant until the end of 2017.

Participants self-reported symptoms of psychological distress, such as stress, depressive mood, exhaustion and nervousness. Incident all-cause dementia was collected through national health registers.

Among 67,688 participants (mean age, 45.4 years; 51.7% women), 7,935 received a diagnosis of dementia over a mean follow-up period of 25.4 years. Psychological distress was significantly associated with all-cause dementia, with incidence rate ratios ranging from 1.17 (95% CI, 1.08-1.26) for exhaustion to 1.24 (95% CI, 1.11-1.38) for stress.

“We suggest that symptoms of psychological distress are etiological risk factors for dementia but only weakly increase the incidence of dementia in the presence of competing risk of death,” Sulkava and colleagues wrote.

In an editorial comment from Yoram Barak, MD, MHA, of the University of Otago in New Zealand, he argues that because depression was based on self-reported responses, the possibility of understanding the role of stress as a causative agent in the development of dementia is negated, as no information on lifelong neurotic-like traits and clinical diagnoses of anxiety and depression are included.

“These findings suggest that to solve the conundrum surrounding the association of depression and anxiety with risk of dementia we need to look into enduring patterns of perceiving the internal and external environment over long periods and through phases of our lifecycle,” Barak wrote.

Reference:

Barak Y. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.47124.

Psychological Distress and Risk of Myocardial Infarction and Stroke in the 45 and Up Study

Stroke survivors are under massive psychological distress because their doctors know nothing and tell them nothing about getting 100% recovered. Bad research because they excluded stroke and MI patients, now further research will be required.  Take the test yourself to see how distressed you are;
Kessler Psychological Distress

Psychological Distress and Risk of Myocardial Infarction and Stroke in the 45 and Up Study

A Prospective Cohort Study

Caroline A. Jackson

,

Cathie L.M. Sudlow

, and

Gita D. Mishra

Originally published28 Aug 2018Circulation: Cardiovascular Quality and Outcomes. 2018;11:e004500

Abstract

Background

The interplay between mental and physical health remains poorly understood. We investigated whether psychological distress is associated with risk of myocardial infarction (MI) and stroke in a population-based prospective study.

Methods and Results

We included participants without prior stroke/MI from the New South Wales 45 and Up Study. We categorized baseline psychological distress as low, medium, and high/very high on the 10-item Kessler Psychological Distress scale and identified stroke and MI through linkage to hospital admission and mortality records. We obtained sex and age-stratified adjusted and unadjusted hazard ratios for the association between psychological distress and MI and stroke. We investigated for interaction between psychological distress and each of age and sex. Among 221 677 participants, 16.2% and 7.3% had moderate and high/very high psychological distress at recruitment, respectively. During 4.7 (±0.98 SD) years of follow-up, 4573 MIs and 2421 strokes occurred. Absolute risk of MI and stroke increased with increasing psychological distress level. In men aged 45 to 79 years, high/very high versus low psychological distress was associated with a 30% increased risk of MI (fully adjusted hazard ratios, 1.30; 95% CI, 1.12–1.51), with weaker estimates in those aged ≥80 years. Among women, high/very high psychological distress was associated with an 18% increased risk of MI (adjusted hazard ratio, 1.18; 95% CI, 0.99–1.42) with similar findings across age groups. In the age group of participants aged 45 to 79 years, high/very high psychological distress and male sex had a supra-additive effect on MI risk. Similar estimates were observed for stroke, with high/very high psychological distress associated with a 24% and 44% increased stroke risk in men and women, respectively, with no evidence of interaction with age or sex.

Conclusions

Psychological distress has a strong, dose-dependent, positive association with MI and stroke in men and women, despite adjustment for a wide range of confounders.

Leisure-Time Physical Activity Is Associated With Reduced Risk of Dementia-Related Mortality in Adults With and Without Psychological Distress: The Cohort of Norway

My main leisure time activity was whitewater canoeing. My doctors did nothing to get me back to that activity so I was under lots of psychological distress. Your doctors are supposed to do no harm, mine left me with continuing disability and a higher risk for dementia.

Original Research ARTICLE

Front. Aging Neurosci., 25 May 2018 | https://doi.org/10.3389/fnagi.2018.00151

 

Ekaterina Zotcheva^1*, Geir Selbæk^2,3,4, Espen Bjertness⁴, Linda Ernstsen¹ and Bjørn H. Strand^2,4,5

• ¹Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
• ²Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust, Tønsberg, Norway
• ³Center for Old Age Psychiatric Research, Innlandet Hospital Trust, Ottestad, Norway
• ⁴Faculty of Medicine, University of Oslo, Oslo, Norway
• ⁵Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway

Background: Leisure-time physical activity (PA) has been proposed as a protective factor against dementia, whereas psychological distress is associated with an increased risk of dementia. We investigated the associations of leisure-time PA and psychological distress with dementia-related mortality, and whether the association between leisure-time PA and dementia-related mortality differs according to level of psychological distress.

Methods: 36,945 individuals from the Cohort of Norway aged 50-74 years at baseline (1994–2002) were included and followed up until January 1st 2015. Leisure-time PA and psychological distress were assessed through questionnaires, whereas dementia-related mortality was obtained through the Norwegian Cause of Death Registry. Adjusted Cox regression analyses were used to estimate hazard ratios (HR) and 95% confidence intervals (95%CI).

Results: Compared to inactivity, leisure-time PA was associated with a decreased risk of dementia-related mortality; low intensity leisure-time PA (HR = 0.73, 95% CI 0.59–0.89); high intensity leisure-time PA (HR = 0.61, 95%CI 0.49-0.77). A statistically significant difference in dementia-related mortality risk was observed between low and high intensity leisure-time PA (p < 0.05). Psychological distress was associated with an increased risk of dementia-related mortality (HR = 1.45, 95% CI 1.16–1.81). Among non-distressed, leisure-time PA was associated with a decreased dementia-related mortality risk; low intensity leisure-time PA (HR = 0.77, 95% CI 0.61–0.97); high intensity leisure-time PA (HR = 0.65, 95% CI 0.51–0.84). The same applied for those with psychological distress; low intensity leisure-time PA (HR = 0.57, 95% CI 0.35–0.94); high intensity leisure-time PA (HR = 0.42, 95% CI 0.22–0.82). The interaction between leisure-time PA and psychological distress on dementia-related mortality was not statistically significant (p = 0.38).

Conclusions: Participating in leisure-time PA was associated with a reduced risk of dementia-related mortality, whereas psychological distress was associated with an increased risk of dementia-related mortality. Leisure-time PA appears to be equally strongly related with dementia-related mortality among those with and without psychological distress, underlining the importance of leisure-time PA for various groups of middle-aged and older adults.

Introduction

Physical activity (PA) is widely considered one of the key lifestyle factors associated with reduced risk of mortality (Arem et al., 2015) and a number of non-communicable diseases (Reiner et al., 2013). Furthermore, a large body of research indicates that participating in regular PA may reduce the risk of cognitive decline (Blondell et al., 2014) and dementia (Rosness et al., 2014; Guure et al., 2017). A recently published meta-analysis of prospective studies demonstrated a dose-response relationship between volume and intensity of PA and risk of dementia (Xu et al., 2017). For every 10 metabolic equivalent of task hours (MET-h) increase per week, there was a 10% decrease in the risk of all-cause dementia (Xu et al., 2017). As populations across the globe age, the prevalence of dementia is predicted to increase substantially, from approximately 47 million in 2015, to 132 million by 2050 (Prince et al., 2015). Hence, measures to prevent or delay new cases of dementia are required, and research on protective and risk factors for dementia has intensified during the last decade (Livingston et al., 2017).

Both early- and late-life depression has been linked to an increased risk of dementia (Byers and Yaffe, 2011). Likewise, psychological distress, characterized by general symptoms of anxiety and depression, has been associated with a higher risk of dementia (Skogen et al., 2015) and dementia-related mortality (Rosness et al., 2016). However, PA has repeatedly been associated with reduced symptoms of depression and anxiety in non-clinical populations (Rebar et al., 2015). A recent randomized exercise trial revealed that increases in moderate-to-vigorous PA predicted reductions in psychological distress in older adults (Awick et al., 2017), and a meta-analysis of randomized controlled studies showed that exercise has a significant antidepressant effect among individuals with depression (Schuch et al., 2016). Thus, existing research indicates that PA is beneficial for both mental and cognitive health.

Despite the aforementioned associations between PA, psychological distress, and dementia, little is known on how PA is associated with dementia risk among individuals with psychological distress. Khatri et al. (2001) randomized clinically depressed older adults to either an anti-depressive medication group, an aerobic exercise group, or a combined exercise and medication group. After 4 months, the researchers found that aerobic exercise improved cognitive function among depressed older adults, and that these improvements corresponded to decreases in depressive symptoms (Khatri et al., 2001). However, the latter study did not investigate risk of incident dementia. The aim of the present study was to investigate the associations of leisure-time PA and psychological distress with dementia-related mortality in middle-aged and older adults, and to examine whether the association between leisure-time PA and dementia-related mortality differs according to level of psychological distress.

Methods

Study Population

The present study is part of the Gene-Environment Interaction in Dementia (GENIDEM) project, which aims to investigate environmental and genetic factors for dementia. The study population comprised 36,945 individuals free from symptoms or diagnosis of heart disease from the Cohort of Norway (CONOR) aged 50–74 years at baseline (1994–2002) linked with the Norwegian Cause of Death Registry and the National Education Database by means of a unique personal identification number. CONOR is a multipurpose study set up to study aetiological factors for a large variety of diseases, and includes 10 epidemiological cohorts from different geographical areas in Norway (Naess et al., 2008). In the present study, three epidemiological cohorts were excluded, as they did not include the CONOR Mental Health Index (CONOR-MHI) scale used to assess psychological distress.

Baseline data collection in CONOR was carried out from 1994 to 2002, following a standardized procedure, where participants received a letter of invitation containing an information brochure by mail 2 weeks prior to a health examination. The health examination included a physical checkup including measurements of participants' height, weight, and blood pressure, as well as drawing blood samples. After completing the examination, the participants returned a self-report questionnaire assessing health- and lifestyle-related variables by mail (Naess et al., 2008). Study participants were followed from baseline until death, emigration, or January 1st 2015, whichever occurred first, with a maximum follow-up time of 20.4 years (mean 15.3). Mean age at follow-up was 76.5 years (max 94.1 years).

All participants included in CONOR gave their written informed consent. The participants' names and personal ID numbers were omitted before data were made available for research purposes. The study was approved by the Norwegian Data Inspectorate and the Regional Committees for Medical Research Ethics, and was conducted in accordance with the Declaration of Helsinki.

Physical Activity

Participants were asked to define the intensity and duration of their leisure-time PA in an average week during the past year. The leisure-time PA question was divided into intensity categories of “low intensity” (not causing perspiration or panting) and “high intensity” (causing perspiration and/or panting) leisure-time PA, each with four alternatives related to average hours per week: “none,” “ <1 h,” “1–2 h,” and “≥3 h.” To ensure sufficient statistical power, all individuals participating in any low intensity leisure-time PA were placed in one group and all individuals participating in any high intensity leisure-time PA were placed in one group, irrespective of hours of weekly leisure-time PA. Participants who replied “none” to both categories of leisure-time PA were considered inactive. Participants who replied “none” on one category of but did not provide an answer to the other category of leisure-time PA, or who had missing answers on both categories were excluded. In the present study, participants were categorized into the following three categories of leisure-time PA based on intensity: “inactive,” “low intensity leisure-time PA,” and “high intensity leisure-time PA.”

Psychological Distress

Psychological distress was assessed with the CONOR Mental Health Index (CONOR-MHI). CONOR-MHI consists of seven items assessing general symptoms of depression and anxiety, and is based on a modification of the General Health Questionnaire (GHQ) and the Hopkins Symptom Check List (HSCL-10) (Søgaard et al., 2003). The items on the CONOR-MHI are shown below. Each item has four answer categories: “no,” “a little,” “a good amount,” and “very much,” and are given values 1–4. The CONOR-MHI score is calculated by dividing the total score (range 7–28) on all seven items by seven, resulting in a range of 1–4, where 1 represents low level of psychological distress, and 4 represents high level of psychological distress. In records containing one missing value, the value was replaced with the sample mean value for each item, whereas records with two or more missing items were excluded.

CONOR Mental Health Index

Have you, in the course of the last two weeks, felt:

Nervous and unsettled?

Troubled by anxiety?

Secure and calm (inverse score)?

Irritable?

Happy and optimistic (inverse score)?

Sad/depressed?

Lonely?

A study comparing the CONOR-MHI to the HSCL-10 and the Hospital Anxiety and Depression Scale (HADS) showed a strong correlation with both scales, r = 0.70 and r = 0.76, respectively (Søgaard et al., 2003). The same study showed that a cut-off at ≥2.15 on the CONOR-MHI has a sensitivity and specificity of, respectively, 41 and 98% for caseness of HADS-anxiety, 38 and 96% for HADS-depression, and 66 and 95% for HSCL-10 (Søgaard et al., 2003). Based on the cut-off of ≥2.15 on the CONOR-MHI, participants in the present study were categorized into two groups: “no psychological distress” or “psychological distress.”

Dementia-Related Mortality

Dementia-related mortality was used as a proxy for dementia illness, and was obtained from death certificates from the Norwegian Cause of Death Registry (Rosness et al., 2014). Dementia was identified when it served either as the underlying, immediate, or accompanying cause of death, according to the International Statistics Classification of Diseases and Related Health Problems, 10th revision, codes F00-F03 and G30.0-G30.9. In the present study population, a total of 919 dementia-related deaths were registered during the follow-up period. For validity purposes, we re-ran analyses with cases restricted to those with dementia as underlying cause.

Covariates

The following variables that could possibly affect the association between leisure-time PA, psychological distress, and dementia-related mortality were identified based on prior studies: sex, education, diabetes, smoking, body mass index (BMI; weight in kilograms divided by height in meters squared), and hypertension. Demographic and health-related covariates were obtained from the results of the physical checkup and the self-report questionnaire at baseline. Attained educational level was obtained by coupling the participants' unique identification number to the National Education Database. The education variable was then divided into three groups: “high” (university degree/college, corresponding to 13 or more years of schooling), “medium” (secondary qualifications, corresponding to 10 years of schooling), and “low” (elementary school, corresponding to 7 years of schooling) (Strand et al., 2014). Participants who reported currently or previously suffering from diabetes were categorized as diabetic. Smoking habits were dichotomized into daily or non-daily smoker. BMI was divided into four categories: underweight (BMI < 18.5), normal weight (BMI 18.5–24.9), overweight (BMI 25–29.9), and obesity (BMI ≥30). Participants were categorized as hypertensive at a systolic pressure of ≥160 mm Hg and/or a diastolic pressure of ≥100 mm Hg, according to the National Institutes of Health guidelines (National Institutes of Health, 2015).

Statistical Analyses

Adjusted Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for the associations of leisure-time PA and psychological distress with dementia-related mortality. Attained age was used as the time variable in the regression models, and thereby all the models were finely adjusted by age. Emigration or non-dementia-related mortality were censored. For leisure-time PA, the “inactive” group served as the reference group, whereas for psychological distress, “no psychological distress” served as the reference group. Leisure-time PA served as the main exposure in the regression models. In the first regression model (model 1), the analyses were adjusted for sex. Next, education, smoking, and psychological distress were added to the model (model 2). The final model (model 3) included the covariates from model 1 and 2, in addition to diabetes, BMI, and hypertension.

To investigate whether psychological distress modified the association between leisure-time PA and dementia-related mortality, an interaction term between leisure-time PA and psychological distress was added to the regression models. In addition, relative excess risk due to interaction (RERI) estimates were calculated to investigate possible additive interaction between leisure-time PA and psychological distress. To obtain psychological distress-specific associations between leisure-time PA and dementia-related mortality, the regression models 1, 2, and 3 were stratified by psychological distress. In these analyses, psychological distress was removed as a covariate from the regression models. Stata version 14 was used for all statistical analyses.

Results

Baseline characteristics of the study sample by leisure-time PA group are presented in Table 1. Participants in the leisure-time PA groups had higher education, less psychological distress, hypertension, and diabetes, and were less likely to smoke compared to inactive participants. The high intensity leisure-time PA group consisted of less women than the low intensity leisure-time PA group and the inactive group.

Leisure-time PA was associated with a decreased risk of dementia-related mortality when compared to inactivity; low intensity leisure-time PA (HR = 0.68, 95% CI 0.56–0.84); high intensity leisure-time PA (HR = 0.54, 95% CI 0.43–0.68) in a model adjusted by sex (Table 2, Model 1). The results were slightly attenuated, but remained statistically significant after additional adjustment for education, smoking and psychological distress; low intensity leisure-time PA (HR = 0.76, 95% CI 0.62–0.93); high intensity leisure-time PA (HR = 0.63, 95% CI 0.50–0.80) (Model 2). Additional adjustment for diabetes, hypertension and BMI did not attenuate the results noteworthy; low intensity leisure-time PA (HR = 0.73, 95% CI 0.59–0.89); high intensity leisure-time PA (HR = 0.61, 95% CI 0.49–0.77) (Model 3). A statistically significant difference in dementia-related mortality hazard ratios was observed between low and high intensity leisure-time PA (P < 0.05). Psychological distress was associated with an increased risk of dementia-related mortality (HR = 1.45, 95% CI 1.16–1.81) in the fully adjusted model 3.