From the Cover: Association of improved air quality with lower dementia risk in older women

Late-life ambient air pollution is a risk factor for brain aging, but it remains unknown if improved air quality (AQ) lowers dementia risk. We studied a geographically diverse cohort of older women dementia free at baseline in 2008 to 2012 (n = 2,239, aged 74 to 92). Incident dementia was centrally adjudicated annually. Yearly mean concentrations of fine particulate matter (PM_2.5) and nitrogen dioxide (NO₂) were estimated using regionalized national universal kriging models and averaged over the 3-y period before baseline (recent exposure) and 10 y earlier (remote exposure). Reduction from remote to recent exposures was used as the indicator of improved AQ. Cox proportional hazard ratios (HRs) for dementia risk associated with AQ measures were estimated, adjusting for sociodemographic, lifestyle, and clinical characteristics. We identified 398 dementia cases during follow up (median = 6.1 y). PM_2.5 and NO₂ reduced significantly over the 10 y before baseline. Larger AQ improvement was associated with reduced dementia risks (HR_PM2.5 0.80 per 1.78 μg/m³, 95% CI 0.71–0.91; HR_NO2 0.80 per 3.91 parts per billion, 95% CI 0.71–0.90), equivalent to the lower risk observed in women 2.4 y younger at baseline. Higher PM_2.5 at baseline was associated with higher dementia risk (HR_PM2.5 1.16 per 2.90 μg/m³, 95% CI 0.98–1.38), but the lower dementia risk associated with improved AQ remained after further adjusting for recent exposure. The observed associations did not substantially differ by age, education, geographic region, Apolipoprotein E e4 genotypes, or cardiovascular risk factors. Long-term AQ improvement in late life was associated with lower dementia risk in older women.

Consistent evidence from epidemiologic studies and toxicological experiments has shown that ambient air pollution is an important modifiable risk factor of dementia (1). Several studies have shown an increased risk of dementia associated with late-life exposures to regional fine particulate matter (PM_2.5; with aerodynamic diameter < 2.5 μm) (2–15) and gaseous pollutants (e.g., NO₂; NO_x) (2–4, 11, 12, 15–17) in particular. Over the past 50 y, significant improvements in air quality (AQ) have been observed across the United States because of national policies and strategies aimed at regulating pollution from stationary (power plants; factories) and mobile (vehicles) sources (18). Several US studies have shown that these long-term reductions in air pollution levels are associated with improved lung function (19), decreased bronchitic symptoms (20), lower asthma incidence (21), lengthened life expectancy (22), and reduced mortality (23). However, it remains unclear whether improved AQ also benefits the aging brains.Therefore, we conducted a multiyear study to examine the association between improved AQ and incidence of dementia, which was based on Diagnostic and Statistical Manual of Mental Disorders (Fourth edition) criteria and centrally adjudicated annually (24, 25). We examined data from the Women’s Health Initiative (WHI) Memory Study (WHIMS)—Epidemiology of Cognitive Health Outcomes (WHIMS-ECHO) that included a combined 20 y of data on individual-level outdoor air pollution (1998 to 2012) estimated using regionalized national universal kriging models (26–28) and cognitive function assessed annually (2008 to 2018) in a geographically diverse sample of community-dwelling older women in the United States. We hypothesized that improved AQ over the span of 10 y, as indicated by reductions in PM_2.5 and NO₂ (proxy for traffic pollutants), was associated with lower dementia risk.