The Journals of Gerontology, Series A: Biological Sciences and Medical Sciences

Objectives: To evaluate change in physical function and probable sarcopenia following a 36-week community multicomponent exercise programme (Vivifrail model) across two consecutive cycles, and to assess the consistency of this change between cohorts. Study design: Quasi-experimental, single-arm, repeated-measures service evaluation. Ninety-two older adults (2025-2026 cohort; mean age 75.9 years, 88.0% women) completed baseline and post-intervention assessments; an independent 2024-2025 cohort (n = 86) was analysed jointly for replication (n = 178). Main outcome measures: Short Physical Performance Battery (SPPB) score (primary); Timed Up and Go (TUG), handgrip strength, 6-metre walk time and Mini-Mental State Examination (MMSE) (secondary); probable sarcopenia (EWGSOP2), SPPB-based frailty category, and a fall-risk indicator computed identically in both cohorts. Results: SPPB improved by a mean of 1.33 points (Cohen's d = 0.96; p < .001), with concordant improvement in all four secondary outcomes (all q < .005). 72.8% reached the substantial minimal clinically important difference. Probable sarcopenia fell from 17.4% to 5.4% (p = .006), and frailty category shifted toward higher functional levels (p < .001). Effect sizes were consistent between cohorts for SPPB, handgrip and 6-metre walk; the Time x Cohort interaction was significant for TUG only. In the pooled sample, elevated fall risk fell from 19.7% to 11.2% (p = .002). Conclusions: A 36-week multicomponent exercise programme was associated with clinically meaningful, reproducible improvement in physical function and a reduction in probable sarcopenia across two independent cohorts. The single-arm design precludes causal inference.

Background: Mitochondrial dysfunction is a hallmark of ageing and is implicated in the pathogenesis of sarcopenia. Genetically confirmed mitochondrial disease provides a biologically definitive model of impaired oxidative phosphorylation against which novel functional assessments can be validated. We investigated whether a brief, submaximal, non-ischaemic intermittent isometric handgrip exercise protocol combined with Near Infra-Red Spectroscopy (NIRS) could detect distinct muscle oxygenation signatures in mitochondrial disease and sarcopenia. Methods: Adults with genetically confirmed mitochondrial disease (n=10, 7 female) and group-matched controls (n=19, 11 female), underwent assessment of maximal grip force, handgrip relaxation kinetics and a 3-minute intermittent submaximal isometric handgrip test (40% maximal voluntary contraction, 1Hz contraction/relaxation) with continuous force recording at 2000Hz and simultaneous NIRS. Findings were compared with 23 community-dwelling older adults from the Muscle Ageing and Sarcopenia Study (MASS) Lifecourse cohort (n=23, 13 female) including seven with probable or confirmed sarcopenia according to European Working Group on Sarcopenia in Older People (EWGSOP2) criteria. Results: Participants with mitochondrial disease demonstrated an attenuated reduction in tissue saturation index (TSI) during exercise compared with controls (TSI % {middle dot} s150-180s: -59.9 {+/-} 94.5 vs -175.1 {+/-} 128.4; p=0.02). Total haemoglobin (THb) responses did not differ between groups (p=0.10). In contrast, participants with probable or confirmed sarcopenia showed exaggerated reduction in TSI compared with non-sarcopenic participants (TSI % {middle dot} s150-180s: -256.5 {+/-} 146.0 vs -121.2 {+/-} 95.2; p=0.05), while THb responses remained similar. The association between sarcopenia and TSI differed by sex (interaction coefficient -240, p=0.016), with greater TSI reductions observed in males with sarcopenia. Differences in TSI between mitochondrial disease and control groups were independent of age and sex. No statistically significant associations were observed between THb responses and age, sex or force production. Conclusions: A brief, non-ischaemic handgrip exercise protocol combined with NIRS identified divergent muscle oxygenation responses in mitochondrial disease and sarcopenia. The attenuated TSI response observed in genetically confirmed mitochondrial disease is consistent with impaired oxygen utilisation secondary to defective oxidative phosphorylation, whereas the exaggerated TSI reduction observed in sarcopenia suggests a distinct physiological mechanism, potentially involving impaired oxygen delivery, reduced muscle efficiency, or both. This portable and non-invasive approach has significant potential as a physiological biomarker for mechanistic studies and clinical trials in ageing and neuromuscular disease. More broadly, our findings demonstrate how biologically defined rare diseases can provide a powerful framework for interpreting mechanisms in common heterogeneous age-related conditions.

Neuropsychiatric symptoms (NPS) are highly prevalent in Mild Cognitive Impairment (MCI), conceptualized as an intermediate clinical state between normal aging and dementia. Although neuroimaging studies have reported associations between NPS and brain alterations in MCI, longitudinal evidence on NPS and their relationship with multimodal MRI measures remains limited. We aimed to investigate (1) longitudinal changes in NPS, volumetric assessment and measurement of regional cerebral blood flow (CBF) within the medial temporal lobe (MTL); (2) associations between longitudinal changes in MRI measures and NPS; (3) whether baseline MRI measures predicted longitudinal changes in NPS. Thirty individuals with MCI aged over 65 years were recruited, of whom eighteen followed up for a mean period of 29 {+/-} 8.9 months. There were significant reductions in total grey matter and white matter volumes, together with volume loss in the bilateral hippocampus, bilateral parahippocampal gyrus and right entorhinal cortex (pFDR[&le;]0.05) over the follow up period. Volume loss in the right parahippocampal gyrus was associated with increase in aggression (pFDR<0.01), and CBF increase in the right hippocampus and parahippocampal gyrus was associated with worsening in agitation (pFDR<0.01). Furthermore, lower baseline volume of the right entorhinal cortex was associated with increase in aggression, and lower baseline CBF in the right hippocampus and parahippocampal gyrus was associated with worsening of agitation (pFDR<0.05). Our findings highlight the importance of identifying NPS in individuals with MCI and the role of structural and perfusion MRI measures as promising biomarkers for monitoring disease progression and improving risk prediction of conversion to dementia.

Biological aging, the decline in physiological resilience that increases our vulnerability to disease and death as we grow older, can be measured from standard clinical-laboratory panels. Measurement of biological aging from laboratory data embedded in electronic health records (EHRs) could enhance precision healthcare. However, suitability of EHR-embedded laboratory records for this purpose is uncertain. We evaluated feasibility of EHR biological age measurement in a cohort of n=4,313 cardiothoracic-surgery patients at a large US Hospital and tested whether measured biological aging was associated with patient outcomes. Patients who were biologically older prior to surgery more often died or experienced adverse outcomes as compared to those measured to be biologically younger. Postoperative biological-aging trajectories were associated with length of intensive-care-unit (ICU) stays and in-hospital death. EHR laboratory data provide an opportunity for scalable implementation of biological aging measurement within healthcare systems, with potential to enhance patient monitoring and risk stratification.

Background: Although sleep disorders are generally associated with cognitive decline, definitions of sleep conditions and cognitive function vary greatly across studies. Therefore, we evaluated associations between consensus definitions of sleep and cognitive outcomes across multiple studies. Methods: Consensus sleep measures were ascertained at baseline visits in three cohort studies (HCHS/SOL, MESA and ARIC, N=11,563): short and long sleep ([&le;]6hours and [&ge;]9hours), insomnia (Women's Health Initiative Insomnia Rating Scale [&ge;]10 or [&ge;]6 for 3 questions), daytime sleepiness (Epworth Sleepiness [&ge;]11) and obstructive sleep apnea (OSA, Apnea-Hypopnea Index [&ge;]15). Cognitive measures were ascertained at baseline and follow-up visits in each study and used to calculate harmonized outcomes: global cognitive function (GCF) at baseline, change in GCF between baseline and follow-up, poor GCF at baseline ([&ge;]1SD below the median), and incident poor GCF at follow-up. Study-specific analyses were adjusted for age, sex, center, education, race/ethnicity, APOE4 and language of cognitive assessments as needed. Results were meta-analyzed across studies. Results: Long sleep was consistently associated with lower baseline GCF ({beta}=-0.19, SE=0.03, p=3.78x10-14, FDR p=7.56x10-13, p-heterogeneity=0.78) and increased odds of poor baseline GCF (OR=1.77, 95% CI=1.49-2.09, p=2.96x10-11, FDR p=2.96x10-10, p-heterogeneity=0.22) across cohorts. Insomnia was also suggestively associated with lower baseline GCF ({beta}=-0.051, SE=0.02, p=0.01, FDR p=0.07, p-heterogeneity=0.005) and increased odds of poor baseline GCF (OR=1.22, 95% CI=1.06-1.41, p=6.76x10-3, FDR p=0.05, p-heterogeneity=0.03). Sleep measures were not associated with change in cognitive function. Discussion: Associations of long sleep and insomnia with harmonized cross-sectional GCF across three large, multiethnic cohorts suggest that cognitive function may be associated with distinct sleep phenotypes.

Objective: To determine whether plasma neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) are elevated in hospitalised patients with delirium relative to patients with dementia and primary psychiatric disorders (PPD). Methods and analysis: This was a cross-sectional observational study conducted at the Royal Melbourne Hospital, Melbourne, Australia, between April and October 2024, with comparator samples from a research biobank. In Phase 1 (Delirium Discovery Cohort), we measured plasma NfL and GFAP using the Single molecule array (Simoa) platform in hospitalised patients with delirium and compared them with dementia and PPD groups. Biomarker concentrations were the primary outcome and were compared using general linear models adjusted for age, sex, and estimated glomerular filtration rate, with bootstrapped confidence intervals. Discriminative performance was assessed as a secondary outcome using receiver operating characteristic (ROC) curve analysis. In Phase 2, we applied this threshold to independent dementia and PPD groups. Results: In Phase 1 (n =176), inpatients with delirium showed higher concentrations of both NfL and GFAP than patients with dementia ({beta} = 0.78; 95% CI [0.37, 1.20] and {beta} = 0.39 [0.07, 0.73] respectively) or PPD groups ({beta} = 1.17; [0.69, 1.66] and {beta} = 0.83 [0.51, 1.24] respectively). ROC curve analysis for differentiating delirium from dementia and PPD groups yielded an optimal NfL threshold of 24.1 pg/mL (AUC = 0.89, 96% sensitivity, 70% specificity). In comparison, GFAP showed lower accuracy (AUC = 0.85), and combining NfL with GFAP (AUC = 0.90) did not significantly improve performance. In Phase 2 (n = 154), the NfL threshold of > 24 pg/ml maintained strong performance (AUC = 0.95, 96% sensitivity, and 77% specificity). Conclusions: Plasma NfL shows promise as a biomarker for delirium in hospitalised patients, distinguishing it with high sensitivity from patients with dementia and PPD. Larger multicentre studies are needed to refine cut-offs, evaluate temporal dynamics, and determine integration into acute hospital delirium pathways.

Background Emerging evidence has linked frailty to individual chronic diseases, but whether it predicts a broad disease spectrum and accelerates multimorbidity accumulation over time remains unknown. This study aimed to systematically evaluate the associations of physical frailty with the burden of incident disease across a wide range of chronic conditions, and with the long-term rates of multimorbidity accumulation. Methods In this prospective cohort study of 466,864 UK Biobank participants , frailty status was assessed using the Fried frailty phenotype and categorized as robust, pre-frailty, or frailty. Chronic diseases were defined based on International Classification of Diseases (ICD)-10 codes, and disease patterns were identified using network analysis. Cox proportional hazards models were used to examine the associations of frailty status with incident chronic diseases, and linear mixed models were used to assess the annual rate of chronic disease accumulation. Results During a median follow-up of 13.8 years (IQR: 13.1-14.5), 536 incident chronic diseases across multiple systems were recorded. Physical frailty was associated with a significantly increased risk of 458 incident diseases (Bonferroni-corrected P < 0.05/536). In the overall cohort, compared with robust participants, those with pre-frailty ({beta} = 0.266, 95% confidence interval [CI]: 0.264-0.267) and frailty ({beta} = 0.941, 95% CI: 0.936-0.946) exhibited significantly faster rates of multimorbidity accumulation. This accelerated multimorbidity accumulation was consistently observed across strata of baseline disease burden, including participant with 0 ({beta} = 0.644, 95% CI: 0.635-0.653), 1 ({beta} =0.748, 95% CI: 0.727-0.768), [&ge;] 2 ({beta} =0.940, 95% CI: 0.933-0.947) chronic conditions at baseline. Similar associations were also found across distinct disease patterns, including neurodegenerative, metabolic, and psychiatric patterns. Conclusions Physical frailty predicts a broad range of incident diseases and is associated with accelerated multimorbidity accumulation. Incorporating frailty assessment into prevention strategies may help mitigate the growing burden of multimorbidity.

Introduction: This study aimed to characterize the neurochemical profile of Alzheimer s disease (AD) continuum stages using proton magnetic resonance spectroscopy (1H-MRS) data for brain metabolites and macromolecules. We used Orthogonal Projection to Latent Structures Discriminant Analysis (OPLS-DA) to classify diagnostic groups and assess feature importance. Methods: Our dataset consisted of 7 T short-echo time 1H-MRS spectra of the posterior cingulate cortex/precuneus of individuals diagnosed with AD (n = 27) or Mild Cognitive Impairment (MCI, n = 27) and Healthy Controls (HC, n = 31). Classification used 100-round Monte Carlo cross-validation based on metabolite concentrations and macromolecular peak intensities. Variable importance in projection (VIP) was assessed across classification models to identify the most relevant neurochemical features. The resulting metabolite rankings were compared with previous literature to evaluate their biological plausibility. Results: Classification was strongest for AD versus HC (AUC=0.88) and lower for comparisons involving MCI. Metabolites contributing most strongly to classification included myo-inositol, ascorbate, and choline-containing compounds, consistent with previous studies on AD-related neurochemical alterations. In addition, specific macromolecular components were identified as relevant features, suggesting a potential contribution of MM signals to the characterization of AD-related neurochemistry. Discussion: These findings support the use of short-echo-time 1H-MRS as a complementary tool for characterizing neurochemical changes in the AD continuum, with potential applications in disease characterization and monitoring, warranting validation in larger cohorts.

This systematic review aimed to synthesize evidence on the association between DNA methylation (DNAm) age and all-cause and disease-specific mortality risks in adults. A systematic search of six databases from Jan 1 2011 to April 15 2026 identified articles assessing the association of DNAm age measures and all-cause or disease-specific mortality in adults from general or disease-specific populations. Effect sizes were pooled as hazard ratios (HRs) with 95% confidence intervals (CIs) using inverse-variance random-effects models. Of 42 023 records screened, 125 articles (380 705 participants) met the inclusion criteria, with 53 included in meta-analyses. Overall, 48 distinct DNAm clocks were evaluated. Higher DNAm ages were associated with higher risks of all-cause, cardiovascular, and cancer mortality risks. In general populations, GrimAge epigenetic age acceleration (EAA) showed consistent associations across mortality outcomes, with each 1 year higher GrimAge EAA associated with ~6-10% higher all-cause (31 cohorts, n=53 642, HR per SD: 1.46 [95% CI 1.38, 1.55], HR per 1-year: 1.09 [95% CI 1.08, 1.11], I^2=84.1%, p-value=1.21 x 10^(-14)), cardiovascular (6 cohorts, n=30 751, HR per SD: 1.55 [95% CI 1.38, 1.73], HR per 1-year: 1.10 [95% CI 1.07, 1.13], I^2=28.0%, p-value=1.71 x 10^(-4)), and cancer (5 cohorts, n=27 187, HR per SD: 1.31 [95% CI 1.15, 1.50], HR per 1-year: 1.06 [95% CI 1.03, 1.10], I^2=33.6%, p-value=4.76 x 10^(-3)) mortality. Clocks incorporating additional surrogates and technical refinements showed numerically larger pooled associations than their original counterparts. GrimAge2 (HR per SD: 1.65 [95% CI 1.53, 1.77] vs 1.46 [1.38, 1.55]) and PCGrimAge (1.56 [1.36, 1.78] vs 1.51 [1.32, 1.74]) showed higher pooled HR association with all-cause mortality than GrimAge. Further work is warranted to evaluate the responsiveness of DNAm clocks to interventions and potential clinical utility.

Rationale: Conventional CT-derived pulmonary vascular metrics quantify vascular pruning but do not assess the spatial heterogeneity of vascular architecture. In COPD, peripheral microvascular pruning coexists with compensatory central vessel dilation, paradoxically preserving total vessel volume while reducing effective vascular penetration into lung parenchyma. Objectives: To develop and evaluate Vascular Proximity Coverage (VPC), a distance-based CT biomarker quantifying the spatial efficiency of pulmonary vascular distribution. Methods: This retrospective analysis included 7,881 COPDGene participants [PHASE] with complete vascular segmentations. VPC was estimated by integrating the area under the cumulative lung tissue coverage curve at distances of 0-10 mm from segmented vessel voxels. Multivariable models assessed associations with lung function, six-minute walk distance (6MWD), St. George's Respiratory Questionnaire (SGRQ) score, mMRC dyspnea score, and all-cause mortality over a median follow-up of [10.8] years, adjusting for demographics, smoking, emphysema, scanner type, and BV5. The cohort was stratified at median BV5 and VPC into concordant (high/high, low/low) and discordant (high-BV5/low-VPC, low-BV5/high-VPC) vascular phenotypes. Results: VPC declined across disease severity (5.82 {+/-} 0.50 [UNITS] in non-smokers to 5.21 {+/-} 0.64 in GOLD 4; p < 0.001). Among spirometrically normal smokers, current smokers had lower VPC than former smokers (5.31 vs. 5.68; p < 0.001). Each standard deviation decrease in VPC was independently associated with reduced 6MWD ({beta} = -16.8 m, 95% CI: -19.5 to -14.0), worse SGRQ ({beta} = 1.9, 95% CI: 1.4 to 2.4), and greater dyspnea (RR = 1.05, 95% CI: 1.03 to 1.08; all p < 0.001). The lowest VPC quartile was associated with 38% higher mortality than the reference quartile (HR = 1.38, 95% CI: 1.18 to 1.62; p < 0.001). The high-BV5/low-VPC phenotype showed 24% higher mortality than high-BV5/high-VPC (HR = 1.24, 95% CI: 1.08 to 1.42; p = 0.002) despite preserved vessel volume. Conclusions: VPC captures spatial heterogeneity of vascular architecture independent of vessel volume, is reduced in smokers without airflow obstruction, and identifies excess mortality risk among individuals whose total vessel volume appears preserved.

Introduction: HIV and childhood maltreatment (CM) are both chronic stressors that disproportionately affect women, with each contributing to accelerated biological aging. Whether biological aging markers are convergent and associate with HIV and CM is unclear. Methods: We studied 238 women (122 with HIV), characterised for CM severity, and assessed biological aging using absolute telomere length (aTL), mitochondrial DNA copy number (mtDNAcn), magnetic resonance imaging-based brain-predicted age difference (MRI-BPAD), and DNA methylation age (DNAmAge) clocks. CM was measured with the Childhood Trauma Questionnaire-Short Form total score. We examined intercorrelations among biological aging markers to assess convergence and conducted linear regression models to test moderation by HIV status and CM severity. Results: PWH had shorter aTL, lower MRI-BPAD, and higher Horvath age acceleration (HorvathAA), HannumAA, PhenoAA, and extrinsic epigenetic age acceleration (EEAA). CM had limited associations with biological aging markers. Absolute TL correlated weakly with mtDNAcn (p = 0.36), PhenoAA (p = -0.18), and EEAA (p = -0.18), while MRI-BPAD correlated weakly with PhenoAA (r = 0.20). DNAmAge clocks were moderately to strongly intercorrelated (r = 0.35 - 0.93). No robust two- or three-way moderation effects were observed after false discovery rate correction. Conclusion: Our findings support a multidimensional pattern of biological aging, with substantial convergence among epigenetic aging measures but limited relationships across different markers, largely independent of HIV status and CM severity. Longitudinal approaches are needed to clarify how distinct biological aging markers relate to one another and to health outcomes over time in vulnerable populations.

Study Objectives: Glucagon-like peptide-1 (GLP-1) receptor agonists raise resting heart rate. We asked whether, after semaglutide initiation, the increase is larger during rapid eye movement (REM) sleep than during non-rapid eye movement (NREM) sleep. Methods: In the Human Phenotype Project, an Israeli cohort of generally healthy adults aged 40 to 70 years, 96 of 494 self-reported semaglutide initiators had a home sleep study (WatchPAT; sleep stages estimated from peripheral arterial tone and actigraphy) before and at least three months after starting. Each was propensity-matched 1:1 to a never-user of GLP-1 drugs measured at the same visits. We estimated the initiators' change minus their controls' change (difference-in-differences). The REM minus NREM contrast was designated primary after an exploratory analysis. Results: Relative to controls (90 to 94 pairs), heart rate rose during nocturnal wake (+3.89 beats per minute [bpm], 95% confidence interval 2.35 to 5.44), NREM sleep (+4.82 bpm, 3.12 to 6.52) and REM sleep (+6.25 bpm, 4.42 to 7.91); the REM increase exceeded the NREM increase by 1.42 bpm (0.98 to 1.89). The excess persisted across matching designs and on a relative scale; the proportion of REM sleep did not change. Never-users with similar weight loss showed no REM sleep heart-rate rise (+0.40 bpm, -0.63 to 1.50). Heart-rate variability decreases disappeared after adjustment for heart rate. Conclusions: Semaglutide initiation was associated with higher heart rate throughout sleep, most during REM sleep, unexplained by weight loss. Clinic measurements may understate this effect. Confirmation with polysomnographic staging is needed.

Financial well-being (FWB) encompasses objective and subjective financial status and may influence health. We developed and validated a parsimonious FWB index using data from 23,006 Health and Retirement Study (HRS) participants aged 50 years and older from 2006 to 2022. The FWB-5 Index was derived using correlated two-factor confirmatory factor analysis accounting for household clustering. Indicators included household wealth, household income-to-poverty ratio, monthly financial strain, satisfaction with one's financial situation, and perceived financial mastery. We assessed convergent and discriminant validity using the Consumer Financial Protection Bureau Financial Well-Being (CFPB-FWB) Scale and Satisfaction with Life Scale, respectively. Associations with pre-baseline socioeconomic factors and subsequent depressive symptoms and health conditions were examined to assess construct and predictive validity. Model fit indices supported the two-factor structure (robust comparative fit index = 0.99; robust root mean square error of approximation = 0.05). Correlations were stronger with the CFPB-FWB Scale (Spearman P = 0.80) than with life satisfaction (Spearman P = 0.43). Associations with socioeconomic factors and subsequent health outcomes were in the hypothesized directions. These findings support the FWB-5 Index as a parsimonious measure for examining financial well-being and its associations with health across HRS waves, including those predating the CFPB-FWB Scale.

Polyendocrine metabolic ovarian syndrome (PMOS) and early-life irregular cycles (ELIC) carry higher metabolic risks, but real-world glycemic patterns remain inadequately characterized. We analyzed 247,316 continuous glucose monitoring (CGM) days from 716 consented and enrolled participants (11/2019-08/2026) in the Apple Women's Health Study, using cluster-weighted generalized estimating equations to evaluate associations between PMOS, ELIC, and glycemic metrics. Same-day wearable-assessed physical activity, digital dietary logs, and medication health records were assessed as effect modifiers. Compared to participants without PMOS and with regular cycles, those with PMOS had higher mean glucose (6.81 mg/dL; 95% CI: -0.70, 14.72) and %observations above target range (3.77%; 95% CI: 0.04, 8.14). Estimates were smaller-in-magnitude for participants without PMOS but with ELIC, and larger for PMOS with androgen excess. Meeting activity goals, consuming protein-/fiber-rich diets, or using metformin/GLP-1 receptor agonists attenuated these associations. PMOS/ELIC were associated with unfavorable glycemic profiles, suggesting opportunities for risk identification and modification.

Objective To examine the association between patient-reported shared decision-making (SDM) and documented advance care planning (ACP) among adults with Alzheimer disease and related dementias (ADRD), and to assess whether this association differed between adults with and without ADRD. Design Retrospective observational study using linked survey and electronic health record (EHR) data. Setting and Participants Participants aged [&ge;]50 years in the All of Us Research Program who completed a patient-reported SDM measure and had linked EHR records. The primary analytic cohort included 3,635 adults with ADRD; 123,681 adults without ADRD comprised a secondary comparison cohort. Methods SDM was measured by how often clinicians asked participants about their opinions or preferences regarding medical care or treatment and was categorized as high (always/most of the time) or low (some of the time/ None of the time). Documented ACP was identified within 3 years before or after the SDM assessment. Modified Poisson regression with robust variance estimated prevalence ratios (PRs) and adjusted PRs (aPRs). Results Among adults with ADRD, 60.6% reported high SDM. Documented ACP prevalence was 5.1% among participants with high SDM and 3.6% among those with low SDM (P=0.027). High SDM was associated with greater ACP prevalence in the unadjusted model (PR, 1.44; 95% CI, 1.04-1.99); the association remained positive but was attenuated after full adjustment (aPR, 1.28; 95% CI, 0.93-1.77). Among adults without ADRD, high SDM was associated with documented ACP (aPR, 1.17; 95% CI, 1.03-1.33). Conclusions and Implications Among adults with ADRD, high SDM was associated with greater ACP prevalence in unadjusted analyses, although the fully adjusted association was not statistically significant. In contrast, higher SDM remained significantly associated with ACP among those without ADRD. The low prevalence of ACP highlights an important opportunity to expand discussions of current and future care preferences as a routine component of patient-centered care.

INTRODUCTION: Whether APOE e4 modifies relationships between subclinical cardiac phenotypes and brain structure is unknown. METHODS: In Framingham Heart Study Offspring participants, we related antecedent echocardiographic remodeling (Examinations 4-6) to repeated brain MRI, and cardiac magnetic resonance phenotypes to regional cortical morphometry, testing cardiac x APOE e4 interactions with false-discovery-rate (FDR) correction and permutation testing of the regional screen. RESULTS: APOE e4 modified the association between antecedent left atrial (LA) remodeling and subsequent lateral ventricular expansion (beta=-0.00858, P=1.45 x 10^-4, q=0.0023; N=1,305; 3,787 MRI observations), the only FDR-significant result of 16 longitudinal tests, including with participant-specific MRI-time slopes (q=0.034); it weakened when intracranial volume x MRI time was modeled. Four regional ventricular cardiac x APOE e4 interactions met within-family FDR criteria, but their number was consistent with chance (permutation P=0.70). Maximum LA volume index showed an APOE e4-dependent association with left middle-occipital cortical-thickness variability (whole-brain q=0.017; permutation P=0.041) that persisted after ventricular adjustment. Cardiac phenotypes and trajectories showed no FDR-significant APOE e4-dependent associations with plasma Abeta42/40, p-tau181, GFAP, or NfL, and adjustment for these biomarkers changed the regional interactions by at most 3.2%. Allen Human Brain Atlas data showed cholesterol-biosynthesis enrichment in the right superior frontal cortex, implicated by the LV end-systolic volume interaction, but without convergent pathway evidence. DISCUSSION: APOE e4 modified atrial-brain relationships, with the strongest evidence linking antecedent atrial remodeling to later ventricular expansion. Replication with prespecified models is needed.

Background: Plasma biomarkers offer a minimally invasive alternative for detecting Alzheimer disease (AD) pathology, yet the genetic determinants influencing their levels remain largely underexplored. Objective: To identify genetic variants associated with AD-related plasma biomarker levels in a Midwestern Amish cohort. Methods: We analyzed plasma levels of amyloid beta (A{beta}42/A{beta}40), phosphorylated tau 181 (p-tau181), and the p-tau181/A{beta}42 ratio in the Midwestern Amish. Genome-wide association studies (GWAS) were used to examine associations with common genetic variants, while genetic linkage analysis was used to assess the potential impact of rare variants. Results: GWAS found associations between plasma biomarkers and the APOE gene. Additionally, novel candidate genes were implicated, including MME for A{beta}42/A{beta}40 ratio, and VEGFC and LRRTM4 for p-tau181. Linkage analysis identified significant signals for p-tau181 on chromosome 1, potentially involving the CSF1 and AHCYL1genes. Conclusions: The novel genetic variants associated with AD pathology implicate metabolic, synaptic, neuronal, and immune pathways. The use of GWAS and linkage analysis sheds light on the genetic architecture of AD-related plasma biomarkers.

Introduction: Cognitive intraindividual variability (IIV), a measure of fluctuation in performance across time or tasks, is an emerging marker of cognitive decline. However, little is known about within-domain IIV in Latino adults. To address this gap, we examined memory IIV and hippocampal integrity in older Latino individuals. Methods: Sixty-seven participants from the Boston Latino Aging Study underwent cognitive testing and MRI. Linear regressions assessed whether memory IIV was associated with hippocampal volume and hippocampus-cingulum tract fractional anisotropy. Additional analyses evaluated associations using mean memory performance as the outcome. Results: Higher mean performance was associated with greater hippocampal volume (=0.24, p=.03), while memory IIV was not (=0.028, p=.84). Higher memory IIV was associated with lower fractional anisotropy in the hippocampus-cingulum tract (=-0.34, p<.01), while mean performance was not (=-0.07, p=.52). Discussion: Memory IIV may be more closely linked to hippocampal white matter, while mean memory performance may better reflect hippocampal volume.

Abstract Background: Respiratory failure (RF) and atrial fibrillation/flutter (AF/AFL) often occur together in older adults, but long-term national mortality trends for the two conditions combined have not been described. We examined trends and disparities in deaths with co-listed RF and AF/AFL among U.S. adults aged 65 years and older from 1999 to 2024, and projected rates through 2035. Methodology: We used the CDC WONDER Multiple Cause of Death database to identify deaths with ICD 10 codes J96 (RF) and I48 (AF/AFL) listed together. Age-adjusted mortality rates (AAMRs) per 100,000 were standardized to the 2000 U.S. population and stratified by sex, race/ethnicity, census region, urbanization, state, and place of death. Joinpoint regression was used to estimate annual percent changes (APCs) and average annual percent changes (AAPCs). Forecasts for 2025 to 2035 were generated with an exponential smoothing (ETS) model. Results: A total of 433,598 deaths were recorded. The overall AAMR rose from 12.8 in 1999 to 66.7 in 2024 (AAPC 8.11%; 95% CI, 7.35 to 8.87; P < 0.0001). Three segments were identified: an increase from 1999 to 2018 (APC 7.73%), a sharp rise from 2018 to 2021 (APC 18.10%), and a decline from 2021 to 2024 (APC -5.25%). Males had a higher AAMR and a steeper increase than females (AAPC 8.44% vs 7.81%). Non-Hispanic White adults had the highest mean AAMR, Hispanic adults had the largest relative increase (AAPC 8.72%), and Non-Hispanic Asian/Pacific Islander adults had the smallest (AAPC 6.23%). The Midwest had the fastest regional growth (AAPC 9.35%). From 1999 to 2020, non-metropolitan areas increased faster than metropolitan areas (AAPC 10.09% vs 8.21%). State AAMRs ranged from 24.7 in Ohio to 85.1 in Louisiana. Most deaths occurred in hospital inpatient settings (64.1%), followed by nursing homes (14.1%) and the home (11.9%). The model projects an AAMR of 122.96 per 100,000 by 2035 (95% prediction interval, 85.42 to 160.50). Conclusions: Mortality involving RF with AF/AFL among older U.S. adults increased more than fivefold over 25 years, with a marked surge during the COVID 19 period and only a partial decline afterward. Differences by sex, race/ethnicity, region, and urbanization point to groups that may benefit from earlier detection and coordinated cardiopulmonary care.

OBJECTIVE: To describe (1) US emergency department-treated pickleball injury burden and the injury-to-participation measure among total players, with burden among adults aged 60 to 79 years as a descriptive subgroup, and (2) determine whether general internet search interest for 'pickleball' is also associated with total pickleball-related injuries. DESIGN: Ecological time series study, United States, 2014 to 2023. DATA SOURCES: National Electronic Injury Surveillance System (NEISS) emergency department microdata yielded 1,738 adjudicated pickleball cases, 921 of them orthopedic, weighted to an estimated 101,450 injuries nationally. Google Trends, English Wikipedia pageviews, and GDELT news volume served as general pickleball attention signals, with the Trends index for 'sourdough' as a negative control. Sports and Fitness Industry Association (SFIA) participation estimates supplied a total player denominator. MAIN OUTCOME MEASURES: Annual national injury estimates with design-based 95 percent confidence intervals; injury-to-participation measures; and correlations between total pickleball-related injuries and general pickleball attention signals before and after removing trend and seasonality. RESULTS: Estimated emergency department-treated pickleball injuries rose 17.5-fold, from 1,391 in 2014 (highly unstable) to 24,294 in 2023. 70 percent of adjudicated cases involved adults aged 60 to 79. During 2017-2023, injury estimates rose 4.0-fold and participation rose about 4.4-fold. No temporal trend was detected in the injury-to-participation measure (P=0.59). Search interest looked like an excellent proxy: in annual levels it correlated with total pickleball-related injuries at R=0.96, and Pickleball Wikipedia pageviews at R=0.98. However, so did searches for "sourdough", at R=0.76. Removing trend and seasonality left little (monthly residual R=0.084; year-on-year R=0.28 over 96 months, 2015-2023), and the seasons ran opposite, with injuries peaking in February and searches in July, such that, on 12-month mean profiles, the sourdough negative control fitted the injury season (R=0.96) while pickleball ran against it (R=-0.40). General pickleball search interest and pickleball news coverage remained correlated in year-on-year changes in 2017-2023 (R=0.64), whereas their corresponding correlations with total pickleball-related injuries in 2017-2023 were 0.25 and 0.20. CONCLUSIONS: The absolute burden of emergency department-treated pickleball injury has grown substantially, but the available surveillance data cannot resolve whether the sport has become more hazardous per participant. The observed rise is consistent with growth in exposure alone. The strong correlation between search interest and injury counts was not specific, the association was substantially attenuated after detrending, and the seasonal patterns were opposed. These descriptive results do not establish that search interest can substitute for injury surveillance, and series that rise together should not be assumed to be related.