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Abstract

Objective:

To report incidence and risk factors for motoric cognitive risk syndrome (MCR), a newly described predementia syndrome characterized by slow gait and cognitive complaints.

Methods:

We examined incidence rates of MCR in 3,128 adults aged 60 years and older, MCR- and dementia-free at baseline, participating in 4 US-based cohort studies. Hazard ratios (HRs) with 95% confidence intervals (CIs) for the association of modifiable risk factors with risk of MCR were computed using Cox models.

Results:

Over a median follow-up time of 3.2 years, 823 of the 3,128 participants met MCR criteria. The overall age- and sex-adjusted incidence of MCR was 65.2/1,000 person-years (95% CI: 53.3–77.1), and ranged from 50.8/1,000 person-years to 79.6/1,000 person-years in the individual cohorts. MCR incidence was higher with older age but there were no sex differences. In the pooled sample adjusted for age, sex, education, and cohort source, strokes (HR 1.42, 95% CI: 1.14–1.77), Parkinson disease (HR 2.52, 95% CI: 1.68–3.76), depressive symptoms (HR 1.65, 95% CI: 1.28–2.13), sedentariness (HR 1.76, 95% CI: 1.44–2.17), and obesity (HR 1.39, 95% CI: 1.17–1.65) predicted risk of incident MCR.

Conclusions:

The incidence of MCR is high in older adults. Identification of modifiable risk factors for MCR will improve identification of high-risk individuals and help develop interventions to prevent cognitive decline in aging.

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Letters to the Editor
1 April 2015
MCR: the expanding spectrum
Joe Verghese, Professor
Paul Kowal, PharmD, World Health Organization, Switzerland; David A Bennett, MD, Rush Alzheimer's Disease Center, Chicago, IL

We appreciate the report by Dr. Mahlknecht and colleagues, which corroborates the Motoric Cognitive Risk Syndrome (MCR) construct. While our prior work focused on the incidence, [1] prevalence, [2] and risk of dementia associated with MCR, [2, 3] Mahlknecht and colleagues report that hyposmia and vascular risk factors are associated with the development of MCR. The finding is interesting and suggests that MCR may be a common pathway for both non-Alzheimer type dementias and Alzheimer's disease.

Further, the hyposmia finding provides additional support for links between non-cognitive abilities and dementia risk. This was recently the subject of a National Institute on Aging Workshop, which highlighted what was known and gaps in knowledge regarding the interactions between motor and sensory function in aging and Alzheimer's disease. [4] The growing recognition of non-cognitive motoric and sensory features in the prodrome to dementia provides another opportunity to improve current dementia risk stratification and gain insights into potential targets of interventions.

1. Verghese J, Ayers E, Barzilai N, et al. Motoric cognitive risk syndrome: Multicenter incidence study. Neurology 2014;83:2278-2284.

2. Verghese J, Annweiler C, Ayers E, et al. Motoric cognitive risk syndrome: Multicountry prevalence and dementia risk. Neurology 2014;83:718 -726.

3. Verghese J, Wang C, Lipton RB, Holtzer R. Motoric cognitive risk syndrome and the risk of dementia. J Gerontol A Biol Sci Med Sci 2013;68:412-418.

4. Albers MW, Gilmore GC, Kaye J, et al. At the interface of sensory and motor dysfunctions and Alzheimer's disease. Alzheimers Dement 2015;11:70- 98.

For disclosures, please contact the editorial office at [email protected].

30 December 2014
Hyposmia predicts incident motoric cognitive risk syndrome
Philipp Mahlknecht, Resident
Stefan Kiechl, Innsbruck, Austria; Johann Willeit, Innsbruck, Austria; Werner Poewe, Innsbruck, Austria; and Klaus Seppi, Innsbruck, Austria

Verghese et al. described motoric cognitive risk syndrome (MCR), a pre-dementia syndrome characterized by slow gait and cognitive complaints. [1] Strokes, Parkinson disease, depressive symptoms, sedentariness, and obesity predicted incident MCR. [1] As hyposmia may accompany Alzheimer dementia [2,3] and precede incident gait disturbances, [4] we hypothesized that hyposmia could be a risk factor for MCR. Participants from the population-based Bruneck study-- representative of the general elderly white community-- underwent a baseline and 5- year follow-up neurological examination including a gait speed assessment. [4,5] We assessed baseline olfactory function and vascular risk using the Sniffin' Sticks odor-identification test and Framingham risk score. [4] MCR was defined exactly as reported by Verghese et al. [1] Subjects with dementia or immobility at baseline or follow-up and subjects with MCR at baseline were excluded. Of 464 eligible subjects (age at baseline, mean+/-SD: 67.5+/-8.3 years, range: 54.9-90.0 years; 53.0% females), 103 (22.2%) present with MCR at follow-up. A logistic regression analysis adjusted for age and sex revealed an odds ratio for incident MCR of 2.56 (95%CI, 1.46-4.36) for hyposmia and 2.03 (95%CI, 1.03-3.99) for high vascular risk. Our results suggest that hyposmia is associated with an increased risk of developing MCR and, as expected, an increased vascular risk.

1. Verghese J, Ayers E, Barzilai N, et al. Motoric cognitive risk syndrome: Multicenter incidence study. Neurology 2014; 83: 2278-2284.

2. Wilson R, Arnold SE, Schneider JA, Tang Y, Bennett DA. The relationship between cerebral Alzheimer's disease pathology and odour identification in old age. J Neurol Neurosurg Psychiatry 2007;78:30-35.

3. Doty RL, Perl DP, Steele JC, et al. Odor identification deficit of the parkinsonism-dementia complex of Guam: equivalence to that of Alzheimer's and idiopathic Parkinson's disease. Neurology 1991;41(5 Suppl 2):77-81.

4. Mahlknecht P, Kiechl S, Stockner H, et al. Predictors for incident mild parkinsonian signs: A prospective population-based study. Parkinsonism Relat Disord. In press. DOI: http://dx.doi.org/10.1016/j.parkreldis.2014.12.021.

5. Mahlknecht P, Kiechl S, Bloem BR, et al. Prevalence and burden of gait disorders in elderly men and women aged 60-97 years: a population-based study. PLoS One. 2013;24:e69627.

For disclosures, please contact the editorial office at [email protected].

Information & Authors

Information

Published In

Neurology®
Volume 83Number 24December 9, 2014
Pages: 2278-2284
PubMed: 25361778

Publication History

Received: July 22, 2014
Accepted: September 8, 2014
Published online: October 31, 2014
Published in print: December 9, 2014

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Disclosure

The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.

Study Funding

No funding received for this analysis. Funding agencies for the participating cohorts are as follows. The Einstein Aging Study is funded by the NIH/National Institute on Aging (grant PO1 AG03949). The LonGenity study was funded by the NIH (R00AG037574, 1P01AG034906, R01AG046949, 1R01AG042188, P30AG038072, and NIH R37AG18381), CTSA KL2TR000088, Einstein Glenn Center, Paul Glenn Foundation, and the American Federation for Aging Research. The Memory and Aging Project and the Religious Orders Study are supported by the NIH/National Institute on Aging (grants P30AG10161, R01AG15819, R01AG17917, R01AG34374, and R01AG33678) and the Illinois Department of Public Health.

Authors

Affiliations & Disclosures

Joe Verghese, MBBS
From the Departments of Neurology (J.V., E.A., R.H., M.J.K., R.B.L.), Medicine (J.V., N.B.), and Epidemiology and Population Health (R.B.L., C.W.), Albert Einstein College of Medicine, Bronx, NY; Rush Alzheimer's Disease Center (D.A.B., A.S.B.), Rush University Medical Center, Chicago, IL; and Ferkauf School of Psychology (R.H.), Yeshiva University, Bronx, NY.
Disclosure
Scientific Advisory Boards:
1.
Scientific advisory board for NIH funded Claude D Pepper disability center at University of Pittsburgh, Pittsburgh, PA and University of Florida, Gainesville, Fl.
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Journal of the American Geriatrics Society, Editorial board, 2012 to present
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
National Institute on Aging grants PO1 AG03949 (2004-2016), R01 AG039330-01 (2011-2016), R01 AG036921-01A1 (2011-2016), RO1AGO44007-01A1 (2013-2018), R01AG044829-01A1 (2014-2019) and U01AG022376 (2010-2015).
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
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1.
NONE
License Fee Payments, Technology or Inventions:
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NONE
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NONE
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NONE
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Expert witness for plaintiff
Emmeline Ayers, MPH
From the Departments of Neurology (J.V., E.A., R.H., M.J.K., R.B.L.), Medicine (J.V., N.B.), and Epidemiology and Population Health (R.B.L., C.W.), Albert Einstein College of Medicine, Bronx, NY; Rush Alzheimer's Disease Center (D.A.B., A.S.B.), Rush University Medical Center, Chicago, IL; and Ferkauf School of Psychology (R.H.), Yeshiva University, Bronx, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
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NONE
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Nir Barzilai, MD
From the Departments of Neurology (J.V., E.A., R.H., M.J.K., R.B.L.), Medicine (J.V., N.B.), and Epidemiology and Population Health (R.B.L., C.W.), Albert Einstein College of Medicine, Bronx, NY; Rush Alzheimer's Disease Center (D.A.B., A.S.B.), Rush University Medical Center, Chicago, IL; and Ferkauf School of Psychology (R.H.), Yeshiva University, Bronx, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
CohBar INc.-activities not related to this manuscript
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
Founder of Cohbar Inc., activities not related to this manuscript
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
1. NIH/NIH; 5R37AG018381-14; Principal Investigator 09/01/2000-05/31/2015 2. NIH/NIA; 5T32AG023475-10; Principal Investigator; 05/01/2004-04/30/2014 3. NIH/NIA; 5P30AG038072-04; Principal Investigator; 08/15/2010-06/30/2015 4. NIH/NIA; 5R01AG042188-03; Co-Investigator; 09/30/2011-07/31/2016 5. NIH/NIA; 1R24AG044396; Co-Principal Investigator 06/06/2013-05/06/2016 6. NIH/NIA; 1R24AG044284; Co-Principal Investigator; 06/06/2013-05/06/2016 7. NIH/NIA; 1R01AG046949-01; Principal Investigator 09/01/13-05/31/18
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
1. Glenn Foundation for Medical Research 2. American Federation for Aging Research
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1.
NONE
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NONE
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NONE
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David A. Bennett, MD
From the Departments of Neurology (J.V., E.A., R.H., M.J.K., R.B.L.), Medicine (J.V., N.B.), and Epidemiology and Population Health (R.B.L., C.W.), Albert Einstein College of Medicine, Bronx, NY; Rush Alzheimer's Disease Center (D.A.B., A.S.B.), Rush University Medical Center, Chicago, IL; and Ferkauf School of Psychology (R.H.), Yeshiva University, Bronx, NY.
Disclosure
Scientific Advisory Boards:
1.
(1) Vigorous Minds, Scientific Advisory Board (2) Takeda Pharm - Adjudication committee AD4833/TOMM40_301 study
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
Nutricia, paid for travel to scientific meeting
Editorial Boards:
1.
(1) Neurology, Editorial Board; (2) Current Alzheimer Research, Editorial Board; (3) Neuroepidemiology, Editorial Board
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
(1) Nutricia, Inc., (2) Eli Lilly, Inc., (3) Enzymotec Ltd.,
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
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NONE
Research Support, Commercial Entities:
1.
(1) Nutricia Inc., co-PI (2) Zinfandel, PI
Research Support, Government Entities:
1.
NIH: P30AG10161, PI; R01AG15819, PI; R01AG17917, PI; R01AG36042, PI; U01AG32984, Co-I; R01AG22018, Co-I; R01AG33678, Co-I; R01AG36836, Co-I; R01AG41797, Co-I; R01AG42210, Co-I; U01AG46152, MPI; and Illinois Department Public Health
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Aron S. Buchman, MD
From the Departments of Neurology (J.V., E.A., R.H., M.J.K., R.B.L.), Medicine (J.V., N.B.), and Epidemiology and Population Health (R.B.L., C.W.), Albert Einstein College of Medicine, Bronx, NY; Rush Alzheimer's Disease Center (D.A.B., A.S.B.), Rush University Medical Center, Chicago, IL; and Ferkauf School of Psychology (R.H.), Yeshiva University, Bronx, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
(1) NIH R01AG17917, co-I, 2001-13; (2) NIH R01AG24480, PI, 2005-12, R01AG043379 (PI), 2012-2017, R01NS078009 (PI), 2012-2017
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
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Roee Holtzer, PhD
From the Departments of Neurology (J.V., E.A., R.H., M.J.K., R.B.L.), Medicine (J.V., N.B.), and Epidemiology and Population Health (R.B.L., C.W.), Albert Einstein College of Medicine, Bronx, NY; Rush Alzheimer's Disease Center (D.A.B., A.S.B.), Rush University Medical Center, Chicago, IL; and Ferkauf School of Psychology (R.H.), Yeshiva University, Bronx, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
Journal: Journal of Gerontology Medical Sciences Role: Associate editor Years: 2012 to present
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
Central Control of Mobility in Aging 03/11 � 02/16 Type: R01 1R01AG036921-01A1 Role: Principal Investigator Agency: National Institute on Aging Supplement: Central Control of Mobility in Aging 08/12 � 02/16 Type: 3R01AG036921-02S1 Role: PI Agency: National Institute on Aging Biological and neural mechanisms of falls 09/13-08/18 Type: R01 AG044007-01A1 Role: Investigator PI: Verghese Joe Kerala-Einstein Study: Healthy lifestyle, vascular disease, and cognitive decline 2011-2016 Type: R01 1R01AG039330-01 Role: Investigator PIs: Mathuranath, Pavagada S; Verghese, Joe (Contact) Agency: National Institute on Aging Einstein Aging Study 1998-2016 Type: 2PO1 AG03949 Role: Co-PI (Project 2) Program Director: Richard B. Lipton, M.D. Agency: National Institute of Aging Research Support, Foundations and Societies: Pharmacological Treatment of Rett Syndrome with Glatiramer Acetate (Copaxone) 2013 - ongoing Agency: Rett syndrome Research Trust Role: Investigator PI: Aleksandra Djukic, M.D.,PhD. Cognitive Trajectories of the PASAT and SDMT and their relations to clinical and functional outcomes in Multiple Sclerosis 10/10 � 7/12 Type: Investigator-Initiated Role: Principal Investigator Agency: Bayer
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Mindy J. Katz, MPH
From the Departments of Neurology (J.V., E.A., R.H., M.J.K., R.B.L.), Medicine (J.V., N.B.), and Epidemiology and Population Health (R.B.L., C.W.), Albert Einstein College of Medicine, Bronx, NY; Rush Alzheimer's Disease Center (D.A.B., A.S.B.), Rush University Medical Center, Chicago, IL; and Ferkauf School of Psychology (R.H.), Yeshiva University, Bronx, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Bristol Myers Squibb
Research Support, Government Entities:
1.
NIH/NIA 2P01 AG03949 Investigator, NIH/NIA R01 AG039409-01 (Investigator), and R03 AG045474 (Principal Investigator).
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
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NONE
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NONE
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NONE
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NONE
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NONE
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1.
NONE
Richard B. Lipton, MD
From the Departments of Neurology (J.V., E.A., R.H., M.J.K., R.B.L.), Medicine (J.V., N.B.), and Epidemiology and Population Health (R.B.L., C.W.), Albert Einstein College of Medicine, Bronx, NY; Rush Alzheimer's Disease Center (D.A.B., A.S.B.), Rush University Medical Center, Chicago, IL; and Ferkauf School of Psychology (R.H.), Yeshiva University, Bronx, NY.
Disclosure
Scientific Advisory Boards:
1.
Allergan, e-Neura, Merck
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
Serve as consultant, advisory board member or received honoraria from: Alder, Allergan, American Headache Society, Arteaus, Autonomic Technologies, Boston Scientific, Bristol Myers Squibb, Cognimed, CoLucid, Electrocore, Eli Lilly, eNeura, Labrys, Market Force Communications, Merck, Novartis, Dr. Reddy's, Vedanta
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
Oxford University Press; Baxter Publishing
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
Serve as consultant, advisory board member or received honoraria from: Alder, Allergan, American Headache Society, Arteaus, Autonomic Technologies, Boston Scientific, Bristol Myers Squibb, Cognimed, CoLucid, Electrocore, Eli Lilly, eNeura, Labrys, Market Force Communications, Merck, Novartis, Dr. Reddy's, Vedanta
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
Bristol Myers Squibb Eaarly Detection of Alzheimer's Disease June 2010 - present Vedanta Research Migraine epidemiology and Progression June 2010 - present Boston Scientific Occipital Nerve Stimulation in Migraine March 2013 - present ElectroCore Vagal Nerve Stimulation for Migraine and Cluster May 2013 Novartis Sleep and Migraine September 2012 - present Allergan Botox in Migraine April 2012 - present Allergan Chronic Migraine Epidemiology and Outcome Study January 2012 - present
Research Support, Government Entities:
1.
P01 AG03949 4/1/11-3/31/16 Einstein Aging Study Role: Principle Investigator 1KL2RR025749 07/01/09-06/30/13 Clinical and Translational Science Award (CTSA) Research Career Development Award Role: Primary Mentor R01AG022374 8/1/10-7/31/15 Biomarkers in Early Alzheimer�s Disease Role: Investigator R01AG034119 8/1/10-7/31/15 Two Preclinical Latent Scores to Predict Occurrence of DAT Role: PI, Einstein Site R01AG012101 9/15/10-7/31/15 MRI Progression Markers of Cognitive Decline in the Elderly Role: PI, Einstein Site 1R01AG039409-01 Stress, Unconstructive Repetitive Thought & Cognitive Aging 4/1/11-3/31/16 Role: PI, Einstein Site 1R01AG038651-01A1 Role of impaired cognitive states & risk factors in conversion to mixed dementias 9/1/11-8/31/16 Role: PI, Einstein Site 1U10NS077308-01 9/30/11-8/31/18 Einstein Center for Excellence for Clinical Trials in Neuroscience Role: PI NIH 4/1/12-3/31/17 Behavioral Weight Loss as a Treatment for Migraine in Obese Women Role: Investigator NIH 1R01AG042595 - 01A1 Stress, cognition, repetitive unconstructive thoughts and inflammatory markers Role: Investigator
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
S & L Marx Foundation Alzheimer's Research
Stock/stock Options/board of Directors Compensation:
1.
Minster Pharma
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Cuiling Wang, PhD
From the Departments of Neurology (J.V., E.A., R.H., M.J.K., R.B.L.), Medicine (J.V., N.B.), and Epidemiology and Population Health (R.B.L., C.W.), Albert Einstein College of Medicine, Bronx, NY; Rush Alzheimer's Disease Center (D.A.B., A.S.B.), Rush University Medical Center, Chicago, IL; and Ferkauf School of Psychology (R.H.), Yeshiva University, Bronx, NY.
Disclosure
Scientific Advisory Boards:
1.
NONE
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
NONE
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
NONE
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence to Dr. Verghese: [email protected]
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

Author Contributions

Verghese was responsible for study concept, acquisition of data, initial draft, and analysis of data. Ayers and Wang were responsible revising draft for content and analysis of data. Barzilai, Bennett, Buchman, Holtzer, Katz, and Lipton were responsible for acquisition of data, interpretation of data, and revising draft for content.

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