Association of Factors With Elevated Amyloid Burden in Clinically Normal Older Individuals

Question Is elevated amyloid-beta deposition associated with demographic, genetic, and lifestyle factors; decreased performance on neuropsychological tests; and increased reports of recent changes in cognitive function among clinically normal older individuals? Findings In this cross-sectional analysis of the A4 Study screening demographic, cognitive and amyloid positron emission tomography data, elevated amyloid was significantly associated with higher age, apolipoprotein E epsilon 4 allele, and family history but not with sex, education, marital or retirement status, or multiple self-reported lifestyle variables. Elevated amyloid was significantly associated with lower performance on the Preclinical Alzheimer Cognitive Composite and each of its components, as well as with increased reports of recent subjective declines in high-level daily cognitive function by the participant and their study partner. Meaning Elevated amyloid is associated with worse cognition and subtle changes in daily function, even among the restricted range of normal performance required for eligibility in this secondary prevention trial. Importance The Anti-Amyloid Treatment in Asymptomatic Alzheimer disease (A4) Study is an ongoing prevention trial in clinically normal older individuals with evidence of elevated brain amyloid. The large number of participants screened with amyloid positron emission tomography (PET) and standardized assessments provides an unprecedented opportunity to evaluate factors associated with elevated brain amyloid. Objective To investigate the association of elevated amyloid with demographic and lifestyle factors, apolipoprotein E (APOE), neuropsychological testing, and self- and study partner reports of cognitive function. Design, Setting, and Participants This cross-sectional study included screening data in the Anti-Amyloid Treatment in Asymptomatic Alzheimer Disease (A4) Study collected from April 2014 to December 2017 and classified by amyloid status. Data were was analyzed from 2018 to 2019 across 67 sites in the US, Canada, Australia, and Japan and included 4486 older individuals (age 65-85 years) who were eligible for amyloid PET (clinically normal [Clinical Dementia Rating = 0] and cognitively unimpaired [Mini-Mental State Examination score, >= 25; logical memory IIa 6-18]). Main Outcomes and Measures Screening demographics, lifestyle variables, APOE genotyping, and cognitive testing (Preclinical Alzheimer Cognitive Composite), self- and study partner reports of high-level daily cognitive function (Cognitive Function Index). Florbetapir amyloid PET imaging was used to classify participants as having elevated amyloid (A beta+) or not having elevated amyloid (A beta-). Results Amyloid PET results were acquired for 4486 participants (mean [SD] age, 71.29 [4.67] years; 2647 women [59%]), with 1323 (29.5%) classified as A beta+. A beta+ participants were slightly older than A beta-, with no observed differences in sex, education, marital or retirement status, or any self-reported lifestyle factors. A beta+ participants were more likely to have a family history of dementia (3320 A beta+ [74%] vs 3050 A beta- [68%]) and at least 1 APOE epsilon 4 allele (2602 A beta+ [58%] vs 1122 A beta- [25%]). A beta+ participants demonstrated worse performance on screening Preclinical Alzheimer Cognitive Composite results and reported higher change scores on the Cognitive Function Index. Conclusions and Relevance Among a large group of older individuals screening for an Alzheimer disease (AD) prevention trial, elevated brain amyloid was associated with family history and APOE epsilon 4 allele but not with multiple other previously reported risk factors for AD. Elevated amyloid was associated with lower test performance results and increased reports of subtle recent declines in daily cognitive function. These results support the hypothesis that elevated amyloid represents an early stage in the Alzheimer continuum and demonstrate the feasibility of enrolling these high-risk participants in secondary prevention trials aimed at slowing cognitive decline during the preclinical stages of AD. This cross-sectional analysis examines the association of elevated amyloid with demographic and lifestyle factors, apolipoprotein E, neuropsychological testing, and self- and study partner reports of cognitive function among participants in the A4 Study.