Skip to main content

Main menu

  • Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Info for
    • Authors
    • Reviewers
  • About Us
    • About the Ochsner Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
  • Other Publications
    • Ochsner Journal Blog

User menu

  • My alerts
  • Log in

Search

  • Advanced search
Ochsner Journal
  • Other Publications
    • Ochsner Journal Blog
  • My alerts
  • Log in
Ochsner Journal

Advanced Search

  • Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Info for
    • Authors
    • Reviewers
  • About Us
    • About the Ochsner Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
Research ArticleORIGINAL RESEARCH
Open Access

Rates of Cognitive Decline in 100 Patients With Alzheimer Disease

Monica Miyakawa-Liu, Amy K. Feehan, Shannon Pai and Julia Garcia-Diaz
Ochsner Journal June 2022, 22 (2) 129-133; DOI: https://doi.org/10.31486/toj.21.0084
Monica Miyakawa-Liu
1Department of Pathology, Stanford University, Stanford, CT
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Amy K. Feehan
2Department of Infectious Diseases, Ochsner Clinic Foundation, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: amy.feehan@ochsner.org
Shannon Pai
3The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Julia Garcia-Diaz
2Department of Infectious Diseases, Ochsner Clinic Foundation, New Orleans, LA
3The University of Queensland Medical School, Ochsner Clinical School, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
Loading

Abstract

Background: In the state of Louisiana, the prevalence of Alzheimer disease (AD) is projected to increase 26.4% by 2025 because of the rapidly increasing geriatric population. While significant research is available on risk factors for developing AD, less data are available regarding AD progression and the rate of change among patients with the disease. To date, no research has established the baseline cognitive decline of patients with AD residing in New Orleans, Louisiana.

Methods: We evaluated 100 patients in the Ochsner Health system from September 2013 to December 2019 who had a diagnosis of AD and repeated Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) scores to determine annual rates of decline. Associated variables that were analyzed included race, age at diagnosis, social factors, and comorbidities.

Results: The average annual rates of decline for MMSE and MoCA scores were 2.43 (SD 2.82) points and 2.39 (SD 1.88) points, respectively. Our results were significant for a faster rate of decline in MMSE scores among smokers (3.50 points, SD 3.20) vs nonsmokers (1.54 points, SD 2.07). We found no significant difference in MoCA scores for smokers vs nonsmokers, in addition to other demographic and lifestyle variables.

Conclusion: The rate of decline seen in an urban population of patients with AD is lower than the average rate of decline reported in the literature, a finding that can help inform future interventional studies that use rate of decline as a primary outcome.

Keywords:
  • Alzheimer disease
  • cognitive dysfunction
  • dementia
  • mental status and dementia tests
  • neuropsychological tests

INTRODUCTION

In 2015, Alzheimer disease (AD) was identified as the sixth leading cause of death in Louisiana, which also had the tenth highest AD death rate in America in the same year.1 In Louisiana alone, the prevalence of the disease is projected to increase 26.4% by 2025 because of the rapidly increasing geriatric population.1 AD is the most common cause of dementia and poses a significant health care cost and burden to families and caregivers. The lifetime cost of care for an American living with dementia was estimated to be $341,840 in 2017.1 AD is associated with numerous polymorphisms that are often geographic-specific.2,3 One example is the low-density lipoprotein receptor-related protein 1, which is a candidate gene for AD pathogenesis and has a decreasing prevalence from the northern to the southern regions of Europe.3 While significant research is available on risk factors for developing AD, less data are available regarding AD progression and the rate of change among patients with the disease.

No definitive test is available for diagnosis of AD, but screening tools such as the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) can be used to assess different cognitive domains—visuospatial, language, concentration, memory recall, and orientation—and these assessments can be used as reference points for individual cognitive decline. Both tests have a maximum of 30 points; scores ≥26 are considered normal. The MMSE is one of the most common ways of assessing the progression of AD at follow-up visits. The Han et al meta-analysis showed that the average annual rate of decline in the MMSE score is 3.3 points.4 However, significant heterogeneity exists among studies, and the rates of decline vary widely among individuals of different demographics.5 Many additional factors likely contribute to the variation in disease progression, including cognitive reserve, genetics, comorbidities, and medical and social support.5 Even the effect of comorbidities on disease progression is controversial. For example, diabetes mellitus was associated with both fast and slow rates of cognitive decline in different articles.5,6 In terms of sex, AD has disproportionately affected more women than men; however, the evidence as to whether sex influences the rate of decline is complicated.7,8 The presence of the APOE4 allele has been reported to increase the risk of AD in women,9 yet other studies support estrogen as a neuroprotectant.10

When comparing the rates of cognitive decline between races, the Chicago Health and Aging Project (CHAP) revealed that a higher proportion of African Americans had rapid and moderate decline in global cognition than European Americans (7% vs 5% for rapid decline and 20% vs 15% for moderate decline, respectively).11,12 Based on 4 tests, including the MMSE, the CHAP study used a composite cognitive score to calculate and categorize the rate of decline.2 In a separate Italian study, additional factors such as younger age at diagnosis, significant family history of AD, or more years of education were also associated with a higher rate of decline.7 However, in their meta-analysis, Han et al concluded that many of these covariants were not statistically significant in explaining the variability in decline rates.4

No studies have evaluated the rate of decline in patients with AD in New Orleans, Louisiana. Establishing a registry of the current population of patients with AD at Ochsner Medical Center-New Orleans and their demographics could help inform future studies and power analyses for interventional studies that use cognitive decline as a primary outcome. Overall, the literature characterizes AD as a disease that has significant variability in different geographic locations and patient populations, and this study is the first, to our knowledge, to describe the rate of decline in patients with AD in New Orleans.

METHODS

Institutional review board approval was obtained (2019.384). Medical record numbers of patients with a diagnosis of dementia—International Classification of Diseases-10 codes for vascular dementia without behavioral disturbance (F01.50), unspecified dementia without behavioral disturbance (F03.90), unspecified dementia with behavioral disturbance (F03.91), Alzheimer disease with early onset (G30.0), Alzheimer disease with late onset (G30.1), Alzheimer disease, unspecified (G30.9), or mild cognitive impairment, so stated (G31.84)—and who were evaluated by either neurology or neuropsychiatry at the Ochsner Medical Center-New Orleans campus were extracted via Slicer Dicer, the search tool available in the Epic electronic medical record (Epic Systems Corporation). Cognitive screening tests were administered predominantly in the outpatient clinical setting by a board-certified neurologist, psychiatrist, or allied health care professional. The report was generated on December 13, 2019, and included 354 patients since September 2013.

Inclusion criteria required that individuals have at least 2 MMSE or MoCA scores in clinical visits separated by at least 6 months and a clinical notes statement that a diagnosis of AD was suspected or confirmed. Participants whose MMSE or MoCA scores were >26 were excluded because these patients would not be considered cognitively impaired. One hundred patients met the inclusion criteria and were included in this analysis. Differences in mean annual change of MMSE or MoCA scores by demographic and lifestyle factors were assessed by t test. Differences were deemed significant at P<0.05.

RESULTS

Of the 100 patients with AD, 59% were female and 41% were male. The average age at diagnosis was 74.75 years, and 73% of patients self-identified as White. Sixty-one percent of patients were married, and 28% were widowed. The average MMSE score was 22.63 points (SD 5.77), and the average annual decline was 2.43 points (SD 2.82). The average MoCA score was 18.19 points (SD 5.56), and the average annual decline was 2.39 points (SD 1.88). Notable comorbidities for the population included smoking (40%), alcohol use (36%), and major depressive disorder (34%) (Table 1).

View this table:
  • View inline
  • View popup
Table 1.

Clinical and Demographic Data for All Patients

In the assessment of annual rate of decline in MMSE or MoCA scores between different populations, the only variable with a significant difference was smokers vs nonsmokers in MMSE scores (Figure). Other variables such as sex, race, depression, diabetes, history of cerebrovascular accident, hypothyroidism, alcohol usage, marital status, and age at diagnosis did not reveal significant changes in annual cognitive decline in this cohort (Table 2).

Figure.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure.

Average annual decline in Mini-Mental State Examination (MMSE) scores in smokers vs nonsmokers.

View this table:
  • View inline
  • View popup
Table 2.

T Test Results for Two Independent Means to Assess Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) Score Changes Over Time in Patients With Alzheimer Disease

DISCUSSION

Our study found an average annual decrease in the MMSE (2.43 points) and MoCA (2.39 points) scores that were almost a full point smaller than reported in the Han et al meta-analysis (MMSE score, 3.3 points).4 An important point is that meta-analyses capture a wide variety of patients and their socioeconomic status, access to care, and genetic variants. Studies analyzing patients from a single community population have shown smaller annual decline rates in MMSE scores, including a study from Shanghai, China, in which the decline was as low as 1.52 points.13 The patients in our specific population were all insured and followed by specialists in neurology and psychiatry. Furthermore, the majority were married and were assumed to have familial support, which could explain the lower rate of decline when compared to the Han et al meta-analysis.4 Recent evidence (2018) suggests that social isolation and its role in epigenetics can increase the risk of or worsen cognitive decline in AD.14

In our study, the MoCA average score was lower than the MMSE average (18.19 and 22.63 points, respectively). While both the MMSE and MoCA are reliable screening tools for a diagnosis of AD, the 2 tests were developed under different contexts. MMSE was developed in 1975 as a faster way to quantitatively assess cognitive performance compared to previously established cognitive testing.15 The MoCA was formulated 30 years later for differentiating mild cognitive impairment from healthy cognition.16 Lower MoCA scores can provide a greater sensitivity to capture individuals who are at earlier stages of AD.17 On the other hand, the average annual rate of decline was not significantly different between the 2 measures, suggesting that either measure can be used to examine the clinical course of cognitive decline in patients with AD. However, each test should only be compared to itself; we found discrepancies in the rate of decline for patients with and without diabetes mellitus that were nearly significant (P=0.09) but opposite in directionality depending on the test. Additionally, the difference in decline for smokers vs nonsmokers was not significant across changes in MoCA scores despite being significant in MMSE scores. Tobacco smoking has long been studied as a substantial risk factor for AD development18; however, little research highlights its effects on increasing the actual rate of decline. Tobacco smoking is assumed to contribute to mental state decline through effects on atherosclerotic disease and oxidative stress that can exacerbate vascular dementia and neural death.19

Limitations to this research include differences among MMSE and MoCA test administrators. Confounding variables also include level of education, primary language, and poor vision. Additionally, some patients had cognitive impairment that was too severe for MMSE and MoCA testing and was not captured in this study. We used a cutoff score of 26 to exclude unimpaired individuals, which is sensitive and specific to indicate normal vs cognitive impairment,17 so this study also did not capture individuals who may have begun to develop early symptoms of cognitive impairment. Furthermore, some patients had only 2 time points available to compare MMSE and MoCA scores. With only 2 time points available, determining whether a difference in MMSE or MoCA scores is representative of a true difference from baseline cognitive state is difficult. Other confounding variables, such as time of day or even the mood status of the patient, could introduce confounding variables.

Overall, our results support previous research that suggests most variables are not significant in explaining decline rate variabilities.7 This study provides a useful comparison for future clinical trials to better understand the rate of cognitive decline in patients with AD at Ochsner Medical Center-New Orleans.

CONCLUSION

AD is a devastating disease with significant impacts on morbidity, mortality, and health care costs. We describe the rate of decline and characteristics of patients with AD in urban Louisiana, data that will help serve as a baseline comparison as novel diagnostic tools and treatment modalities are implemented to reduce the impact of AD in the area.

This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.

ACKNOWLEDGMENTS

The authors have no financial or proprietary interest in the subject matter of this article.

  • ©2022 by the author(s); Creative Commons Attribution License (CC BY)

©2022 by the author(s); licensee Ochsner Journal, Ochsner Clinic Foundation, New Orleans, LA. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (creativecommons.org/licenses/by/4.0/legalcode) that permits unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

REFERENCES

  1. 1.↵
    Alzheimer's Association. 2018 Alzheimer's disease facts and figures. Alzheimers Dement. 2018;14(3):367-429. doi: 10.1016/j.jalz.2018.02.001. Erratum in: Alzheimers Dement. 2018;14(5):701. doi: 10.1016/j.jalz.2018.04.001
    OpenUrlCrossRef
  2. 2.↵
    1. Bullido MJ,
    2. Guallar-Castillón P,
    3. Artiga MJ,
    4. et al.
    Alzheimer's risk associated with human apolipoprotein E, alpha-2 macroglobulin and lipoprotein receptor related protein polymorphisms: absence of genetic interactions, and modulation by gender. Neurosci Lett. 2000;289(3):213-216. doi: 10.1016/s0304-3940(00)01304-5
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Panza F,
    2. D'Introno A,
    3. Colacicco AM
    , et al. Regional European differences in allele and genotype frequencies of low density lipoprotein receptor-related protein 1 polymorphism in Alzheimer's disease. Am J Med Genet B Neuropsychiatr Genet. 2004;126B(1):69-73. doi: 10.1002/ajmg.b.20146
    OpenUrlCrossRef
  4. 4.↵
    1. Han L,
    2. Cole M,
    3. Bellavance F,
    4. McCusker J,
    5. Primeau F
    . Tracking cognitive decline in Alzheimer's disease using the Mini-Mental State Examination: a meta-analysis. Int Psychogeriatr. 2000;12(2):231-247. doi: 10.1017/s1041610200006359
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Clark CM,
    2. Sheppard L,
    3. Fillenbaum GG,
    4. et al.
    Variability in annual Mini-Mental State Examination score in patients with probable Alzheimer disease: a clinical perspective of data from the Consortium to Establish a Registry for Alzheimer's Disease. Arch Neurol. 1999;56(7):857-862. doi: 10.1001/archneur.56.7.857
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Sanz C,
    2. Andrieu S,
    3. Sinclair A,
    4. Hanaire H,
    5. Vellas B
    , REAL.FR Study Group. Diabetes is associated with a slower rate of cognitive decline in Alzheimer disease. Neurology. 2009;73(17):1359-1366. doi: 10.1212/WNL.0b013e3181bd80e9
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Roselli F,
    2. Tartaglione B,
    3. Federico F,
    4. Lepore V,
    5. Defazio G,
    6. Livrea P
    . Rate of MMSE score change in Alzheimer's disease: influence of education and vascular risk factors. Clin Neurol Neurosurg. 2009;111(4):327-330. doi: 10.1016/j.clineuro.2008.10.006
    OpenUrlCrossRefPubMed
  8. 8.↵
    1. Pike CJ
    . Sex and the development of Alzheimer's disease. J Neurosci Res. 2017;95(1-2):671-680. doi: 10.1002/jnr.23827
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Altmann A,
    2. Tian L,
    3. Henderson VW,
    4. Greicius MD
    , Alzheimer's Disease Neuroimaging Initiative Investigators. Sex modifies the APOE-related risk of developing Alzheimer disease. Ann Neurol. 2014;75(4):563-573. doi: 10.1002/ana.24135
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Engler-Chiurazzi EB,
    2. Brown CM,
    3. Povroznik JM,
    4. Simpkins JW
    . Estrogens as neuroprotectants: estrogenic actions in the context of cognitive aging and brain injury. Prog Neurobiol. 2017;157:188-211. doi: 10.1016/j.pneurobio.2015.12.008
    OpenUrlCrossRefPubMed
  11. 11.↵
    1. Rajan KB,
    2. McAninch EA,
    3. Wilson RS,
    4. Weuve J,
    5. Barnes LL,
    6. Evans DA
    . Race, APOEε4, and long-term cognitive trajectories in a biracial population sample. J Alzheimers Dis. 2019; 72(1):45-53. doi: 10.3233/JAD-190538
    OpenUrlCrossRef
  12. 12.↵
    1. Bienias JL,
    2. Beckett LA,
    3. Bennett DA,
    4. Wilson RS,
    5. Evans DA
    . Design of the Chicago Health and Aging Project (CHAP). J Alzheimers Dis. 2003;5(5):349-355. doi: 10.3233/jad-2003-5501
    OpenUrlCrossRef
  13. 13.↵
    1. Zhao Q,
    2. Zhou B,
    3. Ding D,
    4. et al.
    Cognitive decline in patients with Alzheimer's disease and its related factors in a memory clinic setting, Shanghai, China. PLoS One. 2014;9(4):e95755. doi: 10.1371/journal.pone.0095755
    OpenUrlCrossRefPubMed
  14. 14.↵
    1. Hsiao YH,
    2. Chang CH,
    3. Gean PW
    . Impact of social relationships on Alzheimer's memory impairment: mechanistic studies. J Biomed Sci. 2018;25(1):3. doi: 10.1186/s12929-018-0404-x
    OpenUrlCrossRef
  15. 15.↵
    1. Folstein MF,
    2. Folstein SE,
    3. 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)90026-6
    OpenUrlCrossRefPubMed
  16. 16.↵
    1. Nasreddine ZS,
    2. Phillips NA,
    3. Bédirian V,
    4. et al.
    The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-699. doi: 10.1111/j.1532-5415.2005.53221.x. Erratum in: J Am Geriatr Soc. 2019;67(9):1991. doi: 10.1111/jgs.15925
    OpenUrlCrossRefPubMed
  17. 17.↵
    1. Roalf DR,
    2. Moberg PJ,
    3. Xie SX,
    4. Wolk DA,
    5. Moelter ST,
    6. Arnold SE
    . Comparative accuracies of two common screening instruments for classification of Alzheimer's disease, mild cognitive impairment, and healthy aging. Alzheimers Dement. 2013;9(5):529-537. doi: 10.1016/j.jalz.2012.10.001
    OpenUrlCrossRefPubMed
  18. 18.↵
    1. Cataldo JK,
    2. Prochaska JJ,
    3. Glantz SA
    . Cigarette smoking is a risk factor for Alzheimer's Disease: an analysis controlling for tobacco industry affiliation. J Alzheimers Dis. 2010;19(2):465-480. doi: 10.3233/JAD-2010-1240
    OpenUrlCrossRef
  19. 19.↵
    1. Peters R,
    2. Poulter R,
    3. Warner J,
    4. Beckett N,
    5. Burch L,
    6. Bulpitt C
    . Smoking, dementia and cognitive decline in the elderly, a systematic review. BMC Geriatr. 2008;8:36. doi: 10.1186/1471-2318-8-36
    OpenUrlCrossRefPubMed
PreviousNext
Back to top

In this issue

Ochsner Journal: 22 (2)
Ochsner Journal
Vol. 22, Issue 2
Jun 2022
  • Table of Contents
  • Table of Contents (PDF)
  • About the Cover
  • Index by author
  • Advertising (PDF)
  • Back Matter (PDF)
  • Ed Board (PDF)
  • Front Matter (PDF)
Print
Download PDF
Email Article

Thank you for your interest in spreading the word on Ochsner Journal.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Rates of Cognitive Decline in 100 Patients With Alzheimer Disease
(Your Name) has sent you a message from Ochsner Journal
(Your Name) thought you would like to see the Ochsner Journal web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Rates of Cognitive Decline in 100 Patients With Alzheimer Disease
Monica Miyakawa-Liu, Amy K. Feehan, Shannon Pai, Julia Garcia-Diaz
Ochsner Journal Jun 2022, 22 (2) 129-133; DOI: 10.31486/toj.21.0084

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Rates of Cognitive Decline in 100 Patients With Alzheimer Disease
Monica Miyakawa-Liu, Amy K. Feehan, Shannon Pai, Julia Garcia-Diaz
Ochsner Journal Jun 2022, 22 (2) 129-133; DOI: 10.31486/toj.21.0084
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • METHODS
    • RESULTS
    • DISCUSSION
    • CONCLUSION
    • ACKNOWLEDGMENTS
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • References
  • PDF

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Adductor Canal Blocks Are Not Associated With Improved Early Postoperative Outcomes in Patients Undergoing Total Knee Arthroplasty
  • Differential Impact of Body Mass Index in Hip Arthroscopy: Obesity Does Not Impact Outcomes
  • Revision Carpal Tunnel Release With Umbilical Cord Allograft: A Four-Year Retrospective Cohort Study
Show more ORIGINAL RESEARCH

Similar Articles

Keywords

  • Alzheimer disease
  • cognitive dysfunction
  • dementia
  • mental status and dementia tests
  • neuropsychological tests

Current Post at the Blog

American Association for the Advancement of Science Surveys Scientists About Article Publishing Charges—And Uncovers More Problems

Our Content

  • Home
  • Current Issue
  • Ahead of Print
  • Archive
  • Featured Contributors
  • Ochsner Journal Blog
  • Archive at PubMed Central

Information & Forms

  • Instructions for Authors
  • Instructions for Reviewers
  • Submission Checklist
  • FAQ
  • License for Publishing-Author Attestation
  • Patient Consent Form
  • Submit a Manuscript

Services & Contacts

  • Permissions
  • Sign up for our electronic table of contents
  • Feedback Form
  • Contact Us

About Us

  • Editorial Board
  • About the Ochsner Journal
  • Ochsner Health
  • University of Queensland-Ochsner Clinical School
  • Alliance of Independent Academic Medical Centers

© 2023 Ochsner Clinic Foundation

Powered by HighWire