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Dementia – Etiology and Epidemiology Dementia – Etiology and Epidemiology A Systematic Review Volume 1 June 2008 The Swedish Council on Technology Assessment in Health Care SBU • Statens beredning för medicinsk utvärdering SBU Evaluates Healthcare Technology SBU (the Swedish Council on Technology Assessment in Health Care) is a government agency that assesses the methods employed by medical professionals and institutions. In addition to analyzing the costs and benefits of various health care measures, the agency weighs Swedish clinical practice against the findings of medical research. The objective of SBU’s activities is to provide everyone who is involved in decisions about the conduct of health care with more complete and accurate information. We welcome you to visit our homepage on the Internet at www.sbu.se. SBU issues three series of reports. The first series, which appears in a yellow binding, presents assessments that have been carried out by the agency’s project groups. A lengthy summary, as well as a synopsis of measures proposed by the SBU Board of Directors and Scientific Advisory Committee, accompanies every assessment. Each report in the second, white-cover series focuses on current research in a parti- cular healthcare area for which assessments may be needed. The Alert Reports, the third series, focus on initial assessments of new healthcare measures. To order this report (No 172E/1) please contact: SBU Mailing Address: Box 5650, SE-114 86 Stockholm, Sweden Street Address: Tyrgatan 7 Tel: +46 8 412 32 00 Fax: +46 8 411 32 60 Internet: www.sbu.se E-mail: [email protected] Graphic Design: pmochco, www.pm.se Printing: Elanders Infologistics Väst AB, Mölnlycke 2008 ISBN 978-91-85413-23-2 • ISSN 1400-1403 Dementia – Etiology and Epidemiology A Systematic Review Project Group Olof Edhag Laura Fratiglioni Anders Norlund (Chair) Lars Gustafson (Project Director) Hedda Aguero-Eklund Ingrid Håkanson Liisa Palo-Bengtsson Ove Almkvist (Project Assistant) Magnus Sjögren Kenneth Asplund Aki Johanson Eva von Strauss Kaj Blennow Ingvar Karlsson Lars-Olof Wahlund Sirkka-Liisa Ekman Mona Kihlgren Gunhild Waldemar Knut Engedal Lena Kilander Anders Wallin Elisabet Englund Elisabet Londos Anders Wimo Sture Eriksson Jan Marcusson Dag Årsland Johan Fastbom Astrid Norberg Scientific Reviewers Per Edebalk Rurik Löfmark Anneli Sarvimäki Serge Gauthier Hans Melander Hilkka Soininen Lars Lannfelt Ingalill Rahm Matti Viitanen Kim Lützén Hallberg Reference Group Ann Hedberg Balkå P-O Sandman Bengt Winblad (Swedish Association (Umeå University) (Karolinska Institute) of Local Authorities Members from the and Regions) Alzheimer Associ- ation of Sweden and from the Dementia Association The Swedish Council on Technology Assessment in Health Care SBU • Statens beredning för medicinsk utvärdering Content Preface 15 1. SBU Summary and Conclusions 19 2. A General Introduction, Including a Discussion 27 of Alzheimer’s Disease Introduction 27 Normal versus pathological aging of the brain 30 History of nosological classification 31 Subclassification of VaD 33 Other secondary dementias 34 Alzheimer’s disease 35 Aims 35 Background 36 AD – evolution of the disease concept 36 The terminology of AD 37 The clinical picture in AD 39 Age at onset of AD 40 Rate of disease progression 41 Staging AD 43 The first stage of AD 45 The second (manifest) stage of AD 48 The third (terminal) stage of AD 54 Subclassification of AD 55 EOAD and LOAD 56 Frontal lobe features in AD 59 Psychotic features in AD 60 Awareness and insight 63 Dialysis dementia of Alzheimer type 64 Checklists regarding assessment of study quality for different chapters of this report are included in the electronic version of the SBU report on Dementia diseases at www.sbu.se AD in Down’s syndrome 65 Clinical features in familial AD 65 Dementia with Lewy bodies (DLB) 67 Differential diagnosis against VaD and non-Alzheimer’s 68 degenerative dementia Attitudes toward dementia 74 AD – clinical and pathological correlates 76 AD – a strictly neuropathological entity? 76 Clinicopathological correlation studies 79 Classification and criteria 80 Delineation of AD against normal aging 81 AD and vascular manifestations 81 The vascular/degenerative dilemma 82 Summary 83 Future issues in clinical and research dementia work 84 References 87 Appendices 119 3. Vascular Dementia Nosology – Concepts and Evidence 139 Introduction 139 Historical overview 139 Aim 140 Methods 140 Evolution of concepts 142 The rise and fall of the MID concept 142 Heterogeneity of VaD 143 Mixed-type dementia 144 Vascular mild cognitive impairment 145 Disease manifestations – a clinical perspective 146 Symptom profile 146 Stroke 148 Anatomical brain imaging 151 White matter lesions 152 Neurochemical markers 155 Genetics 158 Clinical diagnostic systems – condensed nosology 160 Presentation of diagnostic symptoms 160 IS 160 ICD-10 161 DSM-IV 161 ADDTC 161 NINDS-AIREN 162 Other criteria 162 Lack of agreement among diagnostic systems 163 Neuropathology 164 Conclusions 168 References 179 4. Dementia with Lewy Bodies 191 Background 191 Objective 191 Questions 192 Methods 192 Inclusion 192 Results 193 Background data 193 The neuropathology of DLB 193 What criteria should be used in DLB? 197 Accuracy of diagnostic criteria 200 How is DLB classified and distinguished from other 204 degenerative diseases by means of etiological factors? Biochemical composition of the LB 204 Oxidative stress and inflammation 205 Neurochemistry and DLB 207 Genetics 208 CSF studies 212 Conclusions 212 References 213 5. Disease Entity – Frontotemporal Dementia 223 Background 223 Objectives and limits 223 Methods 224 Inclusion and exclusion criteria 224 Studies included 224 Quality assessment strategy 225 Checklist 225 Summary of the available literature 225 Results and discussion 226 Cumulative evidence that FTD is a unique disease entity 226 Possible methodological errors 228 Conclusions 228 Recommended areas for future research 229 References 233 6. Nosology and Epidemiology – Occurrence 235 Prevalence 235 Searching for literature 235 Inclusion criteria 235 Search results 235 Summary of reviews and articles included 236 Conclusions 236 Age 236 Type of dementia 236 Gender 237 Geographic variations 237 Ethics 238 Incidence 238 Searching for literature 238 Inclusion criteria 238 Search methods 238 Search results 238 Summary of articles included 239 Conclusions 239 Age 239 Type of dementia 239 Gender 240 Geographic variations 240 Ethics 240 Recommendations for future research 240 References 281 7. Nosology and Epidemiology – Consequences 287 Searching the literature 287 Mortality and survival 287 Search results 287 Summary of articles included 288 Conclusions 288 Institutionalization 289 Search results 289 Summary of articles included 290 Conclusions 290 References 300 Appendices 304 8. Nosology and Epidemiology – Risk Factors 317 Introduction 317 Searching for literature 318 Search methods 318 Inclusion criteria 318 Quality grading of the studies 318 Summary of the evidence 319 Risk and protective factors for dementia and AD 326 Familial aggregation 330 Search results from the literature 330 Summary of articles included 330 Conclusions 331 Apoliproprotein E (ApoE) 338 Search results from the literature 338 Summary of the articles included 338 Conclusions 340 Smoking 352 Search results from the literature 352 Summary of articles included 352 Conclusions 353 Alcohol 358 Search results from the literature 358 Summary of articles included 358 Conclusions 359 Blood pressure 364 Search results from the literature 364 Summary of articles included 364 Conclusions 366 Diabetes mellitus 374 Search results from the literature 374 Summary of included papers 374 Conclusions 376 Cholesterol 386 Search results from the literature 386 Summary of articles included 386 Conclusions 388 Obesity 394 Search results from the literature 394 Summary of articles included 394 Conclusions 395 Homocysteine 398 Search results from the literature 398 Summary of articles included 398 Conclusion 399 Cardiovascular disease 402 Search results from the literature 402 Summary of articles included 402 Conclusion 402 Antihypertensive drugs 403 Search results from the literature 403 Summary of articles included 403 Conclusions 404 Statin drug use 412 Search results from the literature 412 Summary of articles included 412 Conclusions 413 Hormonal replacement therapy (HRT) 416 Search results from the literature 416 Summary of articles included 416 Conclusion 417 Non-steroidal anti-inflammatory drugs (NSAIDs) 420 Search results from the literature 420 Summary of articles included 420 Conclusion 421 Inflammatory markers 426 Search results from the literature 426 Summary of articles included 426 Conclusions 427 Head trauma 427 Search results from the literature 427 Summary of articles included 427 Conclusion 428 Aluminum 434 Search results from the literature 434 Summary of articles included 434 Conclusion 434 Occupation 438 Search results from the literature 438 Summary of articles included 438 Conclusion 439 Diet 446 Search results from the literature 446 Summary of articles included 447 Conclusion 448 Vitamin B12 and folate 456 Search results from the literature 456 Summary of articles included 456 Conclusion 457 Depression 460 Search results from the literature 460 Summary of articles included 460 Conclusion 461 Education 466 Search results from the literature 466 Summary of articles included 466 Conclusions 468 Socioeconomic status (SES) 476 Search results from the literature 476 Summary of articles included 476 Conclusion 477 Leisure activities
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