Association of Alzheimer Disease With Life Expectancy in People With Down Syndrome

IMPORTANCE People with Down syndrome have a high risk of developing Alzheimer disease dementia. However, penetrance and age at onset are considered variable, and the association of this disease with life expectancy remains unclear because of underreporting in death certificates. OBJECTIVE To assess whether the variability in symptom onset of Alzheimer disease in Downsyndrome is similar to autosomal dominant Alzheimer disease and to assess its association with mortality. DESIGN, SETTING, AND PARTICIPANTS This study combines ameta-analysis with the assessment of mortality data from US death certificates (n = 77 347 case records with a International Classification of Diseases code for Down syndrome between 1968 to 2019; 37 900 [49%] female) and from a longitudinal cohort study (n = 889 individuals; 46% female; 3.2 [2.1] years of follow-up) from the Down Alzheimer Barcelona Neuroimaging Initiative (DABNI). MAIN OUTCOMESANDMEASURES Ameta-analysiswas conducted to investigate the age at onset, age at death, and duration of Alzheimer disease dementia in Downsyndrome. PubMed/Medline, Embase, Web of Science, and CINAHL were searched for research reports, and OpenGraywas used for gray literature. Studies with data about the age at onset or diagnosis, age at death, and disease duration were included. Pooled estimates with corresponding 95% CIs were calculated using random-effects meta-analysis. The variability in disease onsetwas compared with that of autosomal dominant Alzheimer disease. Based on these estimates, a hypothetical distribution of age at deathwas constructed, assuming fully penetrant Alzheimer disease. These resultswere compared with real-world mortality data. RESULTS In this meta-analysis, the estimate of age at onset was 53.8 years (95% CI, 53.1-54.5 years; n = 2695); the estimate of age at death, 58.4 years (95% CI, 57.2-59.7 years; n = 324); and the estimate of disease duration, 4.6 years (95% CI, 3.7-5.5 years; n = 226). Coefficients of variation and 95% prediction intervals of age at onset were comparable with those reported in autosomal dominant Alzheimer disease. US mortality data revealed an increase in life expectancy in Down syndrome (median [IQR], 1 [0.3-16] years in 1968 to 57 [49-61] years in 2019), but with clear ceiling effects in the highest percentiles of age at death in the last decades (90th percentile: 1990, age 63 years; 2019, age 65 years). The mortality data matched the limits projected by a distribution assuming fully penetrant Alzheimer disease in up to 80% of deaths (corresponding to the highest percentiles). This contrasts with dementia mentioned in 30% of death certificates but is in agreement with the mortality data in DABNI (78.9%). Important racial disparities persisted in 2019, being more pronounced in the lower percentiles (10th percentile: Black individuals, 1 year; White individuals, 30 years) than in the higher percentiles (90th percentile: Black individuals, 64 years; White individuals, 66 years). CONCLUSIONS AND RELEVANCE These findings suggest that the mortality data and the consistent age at onset were compatible with fully penetrant Alzheimer disease. Lifespan in persons with Down syndrome will not increase until disease-modifying treatments for Alzheimer disease are available.

Automated summary

This study aimed to assess the variability in symptom onset of Alzheimer disease in individuals with Down syndrome and its association with mortality. The study found that the age at onset and age at death of Alzheimer disease in Down syndrome were similar to those of autosomal dominant Alzheimer disease. The life expectancy of individuals with Down syndrome has increased over time, but there are ceiling effects in the highest percentiles of age at death. Importantly, racial disparities exist, with lower life expectancy in Black individuals compared to White individuals.