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Leading opinions
In the past, this disconnection may have been partly fostered
by more strident supporters of the amyloid hypothesis, who
have argued that there is no association between Alzheimers
disease and stroke. Epidemiological studies in the 1980s and
early 1990s were focused on links between Alzheimers and
maternal age, head injury, education, and familial Downs
syndrome. Evidence for the association between AD and
vascular risk factors emerged in the late 1990s: the association
with smoking being particularly strong when industry-sponsored trials were removed from meta-analyses (7). Other risk
factors now appear very significant: type II diabetes, midlife
obesity, and midlife exercise levels (8).
As a medical community, we need to be aggressively
managing all these factors as well as developing techniques
to address the divide between the acute stroke patient in 2010
and the dementia referral in 2015. We need to be able to
longitudinally examine what is happening to the brains of
people presenting both with stroke, and with vascular risk
factors, particularly those with carotid arterial disease and type
II diabetes. In vivo, we need to harness brain imaging techniques, both structural and functional, to interrogate the
relationship between brain volume, amyloid imaging, and
cognitive trajectory. Postmortem, we need to correlate our
observations with pathology, to fully understand the incidence
and prevalence of vascular disease and AD pathology.
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The epidemic is upon us, and raises both enormous challenges and the potential for great progress. This will only happen
if we develop a connection between the discourse of the
stroke patient of today and the cognitive clinic referral of
tomorrow.
References
1 Suh GH, Kee BS. Prevalence of dementia in Asia: report of ASIADEM
collaborative studies. Alzheimers Demen 2010; 6:S124.
2 Guerchet M, Houinato D, Mouanga AM et al. Risk factors for dementia
in elderly living in three French-speaking African countries. Alzheimers
Demen 2010; 6:S124.
3 Alzheimers Disease International World Alzheimers Report. London:
Alzheimers Disease International, 2009.
4 Ferri CP, Prince M, Brayne C et al. Global prevalence of dementia: a
Delphi consensus study. Lancet 2005; 366:21127.
5 Mackay J, Mensah GA. The Atlas of Heart Disease and Stroke. World
Health Organization, 2007.
6 Srikanth VK, Quinn SJ, Donnan GA, Saling MM, Thrift AG. Long-term
cognitive transitions, rates of cognitive change, and predictors of
incident dementia in a population-based first-ever stroke cohort. Stroke
2006; 37:247983.
7 Cataldo JK, Prochaska JJ, Glantz SA. Cigarette smoking is a risk factor
for Alzheimers Disease: an analysis controlling for tobacco industry
affiliation. J Alzheimers Dis 2010; 19:46580.
8 Middleton LE, Yaffe K. Promising strategies for the prevention of
dementia. Arch Neurol 2009; 66:12105.