INTRODUCTION. Abstract Objectives. , Jacqueline Scali 1, Jean-François Dartigues. , Christophe Tzourio 4, Michel Poncet 5, Karen

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1 Chrcteristics of hormone therpy, cognitive function, nd dementi: the prospective 3C Study Jonne Ryn 1 2 *, Isbelle Crrière Ritchie 1, Mrie-Lure Ancelin 1 1, Jcqueline Scli 1, Jen-Frnçois Drtigues 3, Christophe Tzourio 4, Michel Poncet 5, Kren 1 Pthologies du système nerveux : recherche épidémiologique et clinique INSERM : U888, IFR76, Universit é Montpellier I, Hôpitl l colombiere 39, venue chrles flhult BP pv 42 clixte cvlier MONTPELLIER CEDEX 5,FR 2 Deprtment of Psychitry University of Melbourne, University of Melbourne, Melbourne,,AU 3 Centre épidémiologie et biosttistique INSERM : U897, Universit é Victor Seglen - Bordeux II, FR 4 Neuroépidémiologie INSERM : U708, Universit é Pierre et Mrie Curie - Pris VI, GH Pitie-Slpetriere 47, Boulevrd de L' Hopitl PARIS CEDEX 13,FR 5 Epilepsies, Lesions Cerebrles et Systemes Neurux de l Cognition INSERM : U751, Universit é de l Méditerrné e - Aix-Mrseille II, Fculte de Medecine Secteur Timone MARSEILLE 27, Boulevrd Jen Moulin MARSEILLE CEDEX 05,FR * Correspondence should be dressed to: Jonne Ryn <jonne.ryn@inserm.fr > Abstrct Objectives To exmine the ssocition between hormone therpy (HT) nd cognitive performnce or dementi, focusing on the durtion nd type of tretment used, s well s the timing of initition of HT in reltion to the menopuse. Methods Women 65 yers nd older were recruited in Frnce s prt of the Three City Study. At bseline nd 2 nd 4 yer follow-up, women were dministered short cognitive test bttery nd clinicl dignosis of dementi ws mde. Detiled informtion ws lso gthered relting to current nd pst HT use. Anlysis ws djusted for number of socio-demogrphic, behviourl, physicl nd mentl helth vribles, s well s Apolipoprotein ε4 (Apoe-ε4). Results Among 3130 nturlly postmenopusl women, current HT users performed significntly better thn never users on verbl fluency, working memory nd psychomotor speed. These ssocitions vried ccording to the type of tretment nd longer durtion of HT ppered to be more beneficil. However, initition of HT close to the menopuse ws not ssocited with better cognition. HT did not significntly reduce dementi risk over 4 yers but current tretment diminished the negtive effect ssocited with Apoe-ε4. Conclusions Current HT ws ssocited with better performnce in certin cognitive domins but these ssocitions re dependent on the durtion nd type of tretment used. We found no evidence tht HT needs to be initited close to the menopuse to hve beneficil effect on cognitive function in lter life. Current HT my decrese the risk of dementi ssocited with the Apoe-ε4 llele. MESH Keywords Aged ; Aged, 80 nd over ; Apolipoproteins E ; genetics ; Cognition Disorders ; drug therpy ; etiology ; genetics ; Cohort Studies ; Dementi ; complictions ; genetics ; Estrogen Replcement Therpy ; methods ; Femle ; Humns ; Logistic Models ; Neuropsychologicl Tests ; Retrospective Studies INTRODUCTION Postmenopusl hormone therpy (HT) remins the most effective tretment for lleviting menopusl symptoms which ffect up to 80 % of women, yet its effect on cognitive geing remins controversil 1, 2. The discordnce in findings cross studies could relte to differences in study design nd cognitive ssessment. Compred to observtionl studies, rndomised controlled trils (RCTs) re less susceptible to bis, in prticulr the helthy-user bis of women selectively tking tretment. Yet, the mjority of RCTs hve shorter follow-up, nd long-term chnges in cognitive function over time my not be recorded. In ddition, HT my hve vrying effects on specific cognitive functions, with evidence tht it could preferentilly protect verbl memory 3, lthough other specific domins hve not been extensively studied. Most studies hve focused on dementi or globl function which my hve ceiling effects in non-demented people. The type of HT nd the durtion of use might lso ply role in determining its effect 4, nd tretment my need to be dministered round the menopuse to hve n optiml beneficil effect on lter-life cognition 5. While the role plyed by HT in cognitive dysfunction remins n importnt question to be ddressed, it is unlikely to be nswered in the ner future by lrge-scle RCTs with long-term HT users. However, it is currently fesible to use existing dt on hormone exposure Pge 1/

2 nd lter-life cognition from longitudinl popultion-bsed studies. This study ims to determine the ssocition between dementi or specific res of cognition nd different chrcteristics of HT in nturlly postmenopusl women. METHODS The Three City Study (3C) is multi-centre longitudinl study involving the French cities Bordeux, Dijon nd Montpellier of community-dwelling elderly 6. Recruitment of the study cohort took plce between 1999 nd 2001 with eligible prticipnts (ged over 65 yers nd non-institutionlised) being rndomly selected from the electorl rolls. Prticipnts were dministered stndrdised questionnires by trined stff nd underwent clinicl exmintions t bseline nd ech 2-yer follow-up. Fsting blood smples were provided nd Apoe-ε4 genotyping ws lso performed 7. The dt described here ws gthered during the first 4 yers of the study. Stndrd protocol pprovls, registrtions nd ptient consents The study protocol ws pproved by the Ethicl Committee of the University-Hospitl of Kremlin-Bicêtre (Frnce). Written informed consent ws obtined from ll prticipnts in the study. Cognitive function A bttery of cognitive tests ws dministered by trined stff nd ssessed different res of cognitive function ( Tble 1 ), s detiled previously 8. All of the tests were dministered t bseline, nd wve 1 nd 2 of follow-up, except the Tril Mking test which ws not given in wve 1. Consequently, nlysis of these tsks involves 356 fewer prticipnts. Dementi dignosis A preliminry dignosis nd clssifiction of dementi t ech follow-up ws mde by 3C study clinicl investigtors, ccording to DSM-IV revised criteri9 nd ws further vlidted by ntionl pnel of neurologists independently of the 3C investigtors. The onset of dementi ws the dte of the follow-up interview when dementi ws dignosed. HT Prticipnts recorded current nd pst HT use, the durtion nd type of tretment, nd ge when tretment ws first initited. Current tretment ws vlidted by presenttion of the prescription or the mediction. Menopuse ge nd type of menopuse were noted. Sttisticl Anlysis Logistic regression models were deemed the most pproprite for our nlysis, due to the distribution of scores on the cognitive tests. Low cognitive performnce ws defined s scoring in the lowest quintile for ech cognitive test except the TMTA nd TMTB, which were timed tsks nd thus the highest quintile ws considered. A substntil decline in cognitive function over follow-up ws defined s the lowest quintile of the difference between bseline score nd either follow-up visit, or the highest quintile for TMTA nd TMTB. Multivrite models djusted for ge, eduction, centre, mritl sttus, cffeine consumption, BMI, menopuse ge, nticholinergic mediction, depressive symptoms, comorbidity, physicl incpcities nd Apoe-ε4. Longitudinl models lso djusted for bseline cognitive score. Cox proportionl hzrds models with delyed entry ssessed the ssocition between HT nd dementi incidence. To void the non-proportionlity in dementi risk with ge, the time scle ws ge nd the time origin birth. Interction terms between HT nd other risk fctors for cognitive function or dementi were considered. SAS (v9.1) ws used for the nlyses (SAS Institute,Inc.,North Crolin). RESULTS Of the 4429 nturlly postmenopusl women initilly recruited into the study, women were excluded from this nlysis if they were dignosed with possible dementi t inclusion (n= 86), or if they died or were lost to follow-up (n= 439). Women were lso omitted if they hd missing dt concerning: cognitive testing t bseline or follow-up (n= 400); HT use (n= 118); or one of the covrites (n= 256). Compred to the nlysed smple (n= 3130), those excluded were more likely to be older, single, depressed, never HT users nd to hve lower eduction level, n erlier menopuse ge, physicl incpcities, comorbidity nd lower scores on ll cognitive tests (p<0.001). Fifteen percent of the women studied reported current HT use, nd similr number were pst users ( Tble 2 ). With the exception of the MMSE, the percentge of women who performed poorly on ech of the cognitive tests ws lowest mong current HT users nd highest mongst the never users. Bseline cognitive function In multivrite djusted models ( Tble 3 ), current HT use ws significntly ssocited with better performnce on tsks of verbl fluency, visul memory nd psychomotor speed, compred to women who hd never used HT. There ws no significnt ssocition between HT use nd globl cognitive function, verbl memory or executive function. There ws no significnt difference in cognitive Pge 2/

3 performnce between never nd pst HT use overll (dt not shown), however recent pst use ( 2yrs go), ws still ssocited with significntly better verbl fluency. Adjusted regression models ( Tble 4 ) further indicted tht long rther thn short-term HT ws significntly ssocited with better performnce on the Iscs nd TMTA tsks. However, this durtion effect ws not observed with visul memory. Only women inititing tretment more thn 5yrs fter the menopuse hd reduced risk of poor verbl fluency compred to never HT users, but there ws no pprent beneficil effect of lter initition with regrds to visul memory nd psychomotor speed. Trnsderml estrogen preprtions combined with progestgen, nd in prticulr synthetic progestin, were most significntly ssocited with decresed risk of poor performnce in the three res of cognitive function exmined. Chnge in cognitive function We filed to find significnt djusted ssocition between bseline HT use nd 4-yer chnge in globl function (p= 0.32), verbl fluency (p= 0.63), visul memory (p= 0.65), verbl memory (p= 0.41) or executive function (p= 0.93). However, HT use ws ssocited with decresed risk of decline in psychomotor speed (OR= 0.73, 95% CI: ,p= 0.05). There ws no difference in terms of the type or the timing of initition of tretment. Dementi Incidence Over follow-up there were 79 cses of ll-cuse dementi nd 53 were clssified s Alzheimer s disese (AD). Adjusted Cox models filed to find significnt ssocition between HT use nd the incidence of dementi or AD ( Tble 5 ). However, the risk of dementi ssocited with Apoe-ε4 ppered to vry ccording to HT use. Apoe-ε4 ws strong risk fctor for dementi incidence overll, nd in strtified nlysis incresed dementi risk mong never users, with similr trend for pst users. By contrst, there ws no significnt increse in dementi risk for women with n Apoe-ε4 llele who were current users of HT. The findings were comprble when we exmined AD. DISCUSSION The effect of HT on cognitive function hs been widely debted since publiction of the results from the Women s Helth Inititive Memory Study (WHIMS). In this lrge RCT, non-hysterectomized women dministered conjugted equine estrogen (CEE) nd medroxyprogesterone cette (MPA), hd significntly incresed risk of globl cognitive decline11 nd of ll-cuse dementi12 but not of mild cognitive impirment. Combined CEE nd MPA lso hd negtive effect on verbl memory 13. These negtive results contrst with number of observtionl studies, nd our study hs ttempted to clrify such inconsistencies, by investigting different chrcteristics of HT nd their ssocition with rnge of cognitive domins. Our study supports the notion tht HT hs vrying ssocitions with different res of cognitive function. We found tht current HT users performed significntly better on the tsks of verbl fluency, visul memory nd psychomotor speed, however there ws no significnt ssocition with globl function, verbl memory or executive function. Current HT ws lso significntly ssocited with reduced risk of 4-yer decline in psychomotor speed. By contrst, pst HT ws not significntly ssocited with cognitive performnce except very recent pst use (<2yrs) nd verbl fluency. This suggests tht ny beneficil effect from current exposure is removed once tretment is stopped. Our findings corroborte previous met-nlyses of observtionl studies, showing tht HT is ssocited with better functioning in certin specific domins 14, 15, such s working memory16 nd the WHIMS RCT lso found positive effect of HT using the sme visul memory tsk (BVRT) 13. However, of the previous studies which exmined psychomotor speed, the mjority found no ssocition with HT use 13, 17. Evidence indictes tht HT my preferentilly protect verbl performnce, i.e. verbl fluency 18, 19 or verbl memory 2, lthough this hs not been found consistently 13, 16. Our study supports the beneficil effect of HT on verbl fluency, but no significnt ssocition with word recll. As we used only one mesure of verbl memory, which is subject to ceiling effects in non-demented people, it is still possible tht HT could be ssocited with other tsks ssessing this sme cognitive domin. We found tht the ssocition of HT with cognitive function vried ccording to the durtion nd type of tretment, which emphsizes the importnce of considering chrcteristics of HT. The mjority of RCTs re short nd only one type of tretment is dministered, so importnt effects my not hve been observed. To dte, few observtionl studies hve exmined whether the type of HT used cn influence the ssocitions found. In contrst with the WHIMS where equine estrogen nd MPA were used, the mjority of women in our study used combined trnsderml estrdiol-progestgen preprtions nd this tretment ws ssocited with better verbl fluency, visul memory nd psychomotor speed. Interestingly however, the ssocitions with cognitive function remined significnt fter djustment only mong women using synthetic progestin, most commonly 19-norprogesterone derivtives (medrogestone or promegestone). The demogrphic chrcteristics of women using the different HT preprtions were very similr, with the exception tht users of estrogen lone were slightly older thn women reporting other formultions. While vribility in neuroprotective effect depending on the type of progestgen is not surprising, previous reserch suggests nturl progestgens my be preferred over synthetic ones such s MPA 20. The effect of 19-norprogesterone derivtives hs however, not been evluted in epidemiologicl studies, lthough they re mong the most Pge 3/

4 selective gonists of the progesterone receptor (lso referred s pure progestgens), notbly devoid of estrogenic, ndrogenic or glucocorticoid ctivities in contrst with MPA 21. Definite conclusions cnnot be drwn regrding the impct of progestgens however, s the bsence of significnt ssocitions my result from the smller smple size nd thus difference in sttisticl power. Our finding tht women reporting long-term rther thn short-term tretment, performed significntly better on the tsks of verbl fluency nd psychomotor speed, is in ccordnce with other studies reporting beneficil effects from incresing HT durtion 17, 19. Thus tretment my need to be dministered for sufficient length of time before ny positive effects re observed. This could help explin the bsence of significnt effects in some RCTs, due to the shorter tretment period. Likewise, in the WHIMS, the positive nd negtive effects of HT on visul nd verbl memory respectively, were only evident fter long-term tretment. As one of the few studies to directly exmine the criticl window hypothesis, we found no evidence to suggest tht HT needs to be initited close to the menopuse to hve beneficil effect on lter-life cognitive function. In fct in terms of verbl fluency, only women inititing tretment >5yrs fter the menopuse performed significntly better thn women who hd never used HT. The criticl window hypothesis ws thought to prtilly explin why positive ssocitions between HT nd cognition hve been found more frequently mong peri- or erly postmenopusl women, compred to older popultions 2, 22. However, only couple of smll studies hve directly tested this hypothesis 23, 24. Among 343 nturlly postmenopusl women, those receiving 2 3yrs of tretment in the erly postmenopusl hd decresed risk of overll cognitive impirment 23. Similr results were lso seen for women who were either current or long-term HT users, lthough with hlf the smple size, this did not rech significnce. Thus this study showed tht tretment in the erly postmenopuse cn hve long-lsting effects on cognitive function, but lter initition my lso be beneficil 23. In the REMEMBER pilot study 25 of 428 women ged over 60yrs, those who commenced HT before 56yrs hd significntly better globl function, compred with women inititing HT lter, s well s better performnce on the TMTA, finding tht ws not supported by our dt. However, with respect to the other cognitive domins exmined, no significnt difference ws found between erly nd lte inititors, including the positive ssocition between HT nd verbl fluency. In this study ge t HT initition ws exmined, rther thn timing in reltion to the menopuse, nd the uthors did not differentite current from pst HT users or the durtion of HT use. They lso included both nturl nd surgiclly menopusl women, who my respond differently to HT in terms of cognitive outcomes 5, 26. Hence, the criticl window hypothesis is still witing definitive proof. On the other hnd, dditionl experimentl nd clinicl imging observtions suggest tht even delyed initition of HT my still hve beneficil effects on prticulr brin functions; the longer the durtion of HT, the better the spring of brin tissue nd the greter the effects on brin structure with incresing ge 21. In our study we found no ssocition between HT use nd dementi incidence over follow-up, which is in contrst with some27 29 but not ll previous longitudinl studies 22, 30. The WHIMS RCT lso filed to find significnt ssocition between dementi incidence nd unopposed estrogen tretment 31, lthough combined CEE+ MPA ws ctully found to increse dementi risk 12. The discrepncies between studies could results from differences in the ge or helth sttus of the popultions or the length of follow-up. HT my only be protective ginst AD when dministered to younger women 22. It is lso possible tht with longer follow-up time for our study, nd higher number of incident dementi cses, we would hve incresed power to detect significnt ssocition with HT. An interesting finding from our study ws tht HT my modify the ssocition between Apoe-ε4 nd dementi, possibility tht hs rrely been ddressed previously. Women crrying the ε4 llele re known to hve n incresed risk for dementi, nd such significnt ssocition ws found in our study. However, mong current HT users, the risk of dementi ws not significntly incresed for Apoe-ε4 positive women. This finding is supported by recent study 32, reporting tht the 2-fold incresed risk of fmilil AD ssocited with Apoe-ε4 ws ttenuted in women using HT. Experimentl models hve lso shown tht estrdiol modultes Apoe expression. In mouse memory model expressing humn Apoe-ε4, which hs reduced long-term potentition (LTP) compred with wild-type mice, estrdiol tretment selectively enhnced LTP 33. On the other hnd, nother study found tht orl tretment ws ssocited with reduced risk of globl cognitive dysfunction, but only in women without n Apoe-ε4 llele 34. It hs lso being reported tht Apoe-ε4 negtive women using unopposed estrogen hd better episodic lerning nd memory 35, in undjusted nlysis. Surprisingly however, they found no difference in cognitive performnce between Apoe-ε4 negtive nd positive non-ht users. Whether these different results re prtly due to residul confounding remins uncertin, but these studies ll highlight the importnce of considering both HT nd Apoe-ε4 sttus when exmining cognition function/dementi. Importntly, the mjority of previous studies on HT nd the risk of incident dementi, including the WHIMS, did not control for Apoe-ε4 genotype. There re some limittions to our study. Dt concerning HT use were gthered retrospectively nd re subject to recll errors. Current HT users were however encourged to present medictions or prescriptions, so tht tretment could be verified. The 4-yer follow-up time my hve been insufficient to exmine decline in cognition, prticulrly s there is component of lerning with repet cognitive tsks. Likewise, with only 79 cses of incident dementi we hd reduced sttisticl power to detect ny ssocitions with HT. Bis due to the exclusion of prticipnts, including women with possible dementi t inclusion my hve lso reduced our power to detect significnt ssocitions if they were present. The strengths of our results relte to the design of the 3C study nd its community-bsed popultion. In ddition to dementi, number of specific res of cognitive function were exmined nd we were ble to investigte prticulr chrcteristics ssocited with HT. The size of the dtset nd the vst informtion relting to ech prticipnt enbled djustment for n Pge 4/

5 extensive rnge of covrites, which my confound the cognition-ht reltionship, reducing the risk of prescription bis in regrds to women using HT. While the ssocition between HT nd lter-life cognition remins complex, our study suggests tht HT is preferentilly ssocited with certin cognitive domins nd these ssocitions vry depending on the durtion ) nd type of tretment used which might explin some discrepncies with previous RCTs, including the WHIMS. We hve no evidence tht HT needs to be initited close to the menopuse to hve beneficil effect on lter-life cognitive function. Our finding tht HT cn modify the ssocition between Apoe-ε4 nd dementi risk is potentilly very interesting nd thus wrrnts further investigtion. Obviously recognised contrindictions of HT use should be considered nd HT prescription proceeded by screening exmintion to determine probbility of rel benefit, rther thn generlized prescription to ll women. Study sponsorship The 3C Study is conducted under prtnership greement between Inserm, the Victor Seglen Bordeux II University nd Snofi-Synthélbo. The Fondtion pour l Recherche Médicle funded the preprtion nd first phse of the study. The 3C-Study is lso supported by the Cisse Ntionle Mldie des Trvilleurs Slriés, Direction Générle de l Snt é, MGEN, Institut de l Longévit é, Agence Frnçise de Sécurit é Snitire des Produits de Snt é, the Regionl Governments of Aquitine, Bourgogne nd Lnguedoc-Roussillon nd, the Fondtion de Frnce, the Ministry of Reserch-Inserm Progrmme Cohorts nd collection of biologicl mteril. Prt of this project is finnced by grnt from the Agence Ntionle de l Recherche (ANR) project 07 LVIE 004. Ackowledgements: We thnk the Génopôle of Lille, the Lbortories of Biochemistry of the University Hospitls of Dijon nd Montpellier, the Town Council of Dijon nd the Conseil Générl of Côte d'or. Footnotes: Disclosure All uthors report no disclosures. References: 1. Ancelin ML, Ritchie K. Lifelong endocrine fluctutions nd relted cognitive disorders. Current Phrm Design ; 11 : Sherwin BB, Henry JF. Brin ging modultes the neuroprotective effects of estrogen on selective spects of cognition in women: criticl review. Front Neuroendocrinol ; 29 : Sherwin BB. Estrogen nd cognitive functioning in women. Endocr Rev ; 24 : Ryn J, Scli J, Crriere I, Ritchie K, Ancelin ML. Hormonl tretment, mild cognitive impirment nd Alzheimer s disese. Int Psychogeritr ; 20 : Henderson VW, Sherwin BB. Surgicl versus nturl menopuse: cognitive issues. Menopuse ; 14 : The 3C Study Group. Vsculr fctors nd risk of dementi: Design of the three city study nd bseline chrcteristics of the study popultion. Neuroepidemiology ; 22 : Dufouil C, Richrd F, Fievet N. APOE genotype, cholesterol level, lipid-lowering tretment nd dementi. Neurology ; 64 : Ryn J, Crriere I, Scli J, Ritchie K, Ancelin ML. Life-time estrogen exposure nd cognitive functioning in lter life. Psychoneuroendocrinology ; 34 : Americn Psychitric Assocition. Dignostic nd Sttisticl Mnul of Mentl Disorders (DSM-IV). Wshington, DC Americn Psychitric Assocition ; 1994 ;. Commenges D, Letenneur L, Joly P, Alioum A, Drtigues JF. Modelling ge-specific risk: ppliction to dementi. Stt Med ; 17 : Rpp SR, Espelnd MA, Shumker SA. Effect of estrogen plus progestin on globl cognitive function in postmenopusl women: the Women s Helth Inititive Memory Study: rndomized controlled tril. Jm ; 289 : Shumker SA, Legult C, Thl L. Estrogen plus progestin nd the incidence of dementi nd mild cognitive impirment in postmenopusl women: the Women s Helth Inititive Memory Study: rndomized controlled tril. Jm ; 289 : Resnick SM, Mki PM, Rpp SR. Effects of combintion estrogen plus progestin hormone tretment on cognition nd ffect. J Clin Endocrinol Metb ; 91 : Hogervorst E, Willims J, Budge M, Riedel W, Jolles J. The nture of the effect of femle gondl hormone replcement therpy on cognitive function in post-menopusl women: met-nlysis. Neuroscience ; 1 : Leblnc ES, Jnowsky J, Chn BK, Nelson HD. Hormone replcement therpy nd cognition: systemtic review nd met-nlysis. Jm ; 285 : Duff SJ, Hmpson E. A beneficil effect of estrogen on working memory in postmenopusl women tking hormone replcement therpy. Horm Behv ; 38 : Smith YR, Giordni B, Ljiness-O Neill R, Zubiet JK. Long-term estrogen replcement is ssocited with improved nonverbl memory nd ttentionl mesures in postmenopusl women. Fertil Steril ; 76 : Brrett-Connor E, Kritz-Silverstein D. Estrogen replcement therpy nd cognitive function in older women. Jm ; 269 : Grodstein F, Chen J, Pollen DA. Postmenopusl hormone therpy nd cognitive function in helthy older women. J Am Geritr Soc ; 48 : L Hermite M, Simoncini T, Fuller S, Genzzni AR. Could trnsderml estrdiol + progesterone be sfer postmenopusl HRT? A review. Mturits ; 60 : Schumcher M, Guennoun R, Ghoumri A. Novel perspectives for progesterone in hormone replcement therpy, with specil reference to the nervous system. Endocr Rev ; 28 : Henderson VW, Benke KS, Green RC, Cupples LA, Frrer LA. Postmenopusl hormone therpy nd Alzheimer s disese risk: interction with ge. J Neurol Neurosurg Psychitry ; 76 : Bgger YZ, Tnko LB, Alexndersen P, Qin G, Christinsen C. Erly postmenopusl hormone therpy my prevent cognitive impirment lter in life. Menopuse ; 12 : McLennn AH, Henderson VW, Pine BJ. Hormone therpy, timing of initition, nd cognition in women ged older thn 60 yers: the REMEMBER pilot study. Menopuse ; 13 : McLennn AH, Henderson VW, Pine BJ. Hormone therpy, timing of initition, nd cognition in women ged older thn 60 yers: the REMEMBER pilot study. Menopuse ; 13 : Pge 5/

6 26. Rocc WA, Bower JH, Mrgnore DM. Incresed risk of cognitive impirment or dementi in women who underwent oophorectomy before menopuse. Neurology ; 69 : Kws C, Resnick S, Morrison A. A prospective study of estrogen replcement therpy nd the risk of developing Alzheimer s disese: the Bltimore Longitudinl Study of Aging. Neurology ; 48 : Tng MX, Jcobs D, Stern Y. Effect of oestrogen during menopuse on risk nd ge t onset of Alzheimer s disese. Lncet ; 348 : Zndi PP, Crlson MC, Plssmn BL. Hormone replcement therpy nd incidence of Alzheimer disese in older women: the Cche County Study. Jm ; 288 : Petitti DB, Crooks VC, Chiu V, Buckwlter JG, Chui HC. Incidence of dementi in long-term hormone users. Am J Epidemiol ; 167 : Shumker SA, Legult C, Kuller L. Conjugted equine estrogens nd incidence of probble dementi nd mild cognitive impirment in postmenopusl women: Women s Helth Inititive Memory Study. Jm ; 291 : Rippon GA, Tng MX, Lee JH, Lntigu R, Medrno M, Myeux R. Fmilil Alzheimer disese in Ltinos: interction between APOE, stroke, nd estrogen replcement. Neurology ; 66 : Yun SH, Prk KA, Kwon S. Estrdiol enhnces long term potentition in hippocmpl slices from ged poe4-tr mice. Hippocmpus ; 17 : Yffe K, Hn M, Byers A, Tngen C, Kuller L. Estrogen use, APOE, nd cognitive decline: evidence of gene-environment interction. Neurology ; 54 : Burkhrdt MS, Foster JK, Lws SM. Oestrogen replcement therpy my improve memory functioning in the bsence of APOE epsilon4. J Alzheimers Dis ; 6 : Folstein MF, Folstein SE, McHugh PR. Mini-mentl stte. A prcticl method for grding the cognitive stte of ptients for the clinicin. J Psychitr Res ; 12 : Iscs B, Kennie AT. The Set Test s n id to the detection of dementi in old people. British Journl of Psychitry ; 45 : Benton AL. Mnuel pour l ppliction du test de retention visuelle. Applictions cliniques et experimentles. Pris Centre de Psychologie Appliquee ; 1965 ; 39. Dubois B. L epreuve des cinq mots. Neurology Psychitrie Geritr ; 1 : Reitn RM. Vlidity of the Tril Mking Test s n indictor of orgnic brin dmge. Percept Motor Skills ; 8 : Pge 6/

7 Tble 1 Cognitive functions which were ssessed nd prticipnt s bseline scores. Cognitive Test Domin Rnge Medin Score [ Interqurtile Rnge] Mini-Mentl Stte Exmintion (MMSE) 36 Globl Function Isc s Set Test (Iscs) 37 Verbl Fluency [ 42 55] Benton s Visul Retention Test (BVRT) 38 Visul Memory [ 13] Immedite nd Delyed Recll (Word Recll) 39 Verbl Memory ] Tril Mking test A (TMTA) 40 Psychomotor Speed Tril Mking test B (TMTB) 40 Executive Function Tble 2 Bseline socio-demogrphic, helth nd lifestyle chrcteristics of the 3130 prticipnts, ccording to their use of hormone therpy (HT). Chrcteristic Never user (n 2169 = ) Pst HT user (n 487 = ) Current HT user (n 474 = ) Sttistic Test for difference Men (S.D.) ANOVA ( df ) Age 74.9 (5.3) 72.4 (4.7) 70.2 (3.3) (2) <0.001 Age t menopuse 50.5 (4.1) 50.5 (4.3) 51.2 (4.2) 5.2 (2) Body mss index (BMI, kg/m ² ) 25.5 (4.4) 24.9 (3.8) 24.4 (3.4) 16.5 (2) <0.001 % χ 2 (df) 12 yers of eduction (2) <0.001 Mrried or hs prtner (2) <0.001 High cffeine intke b (2) Depressive symptoms (CESD 16) c (2) 0.46 Crrier of the Apoe-ε4 llele (2) 0.18 Anticholinergic mediction (2) 0.54 Comorbidity d (2) <0.001 Physicl Incpcities e (2) <0.001 Centre f Bordeux (4) <0.001 Dijon Montpellier MMSE score < (2) 0.35 Iscs set test score (2) <0.001 Benton score (2) <0.001 Word recll score (2) <0.001 Tril Mking Tsk A score (2) <0.001 Tril Mking Tsk B score (2) <0.001 p Pge 7/

8 Except for Tril Mking Tsks A nd B where N= 2774 (1907 never users; 439 pst HT users; 428 current HT user). b Equivlent to three or more cups of coffee ech dy. c The presence of depressive symptoms ws ssessed using the 20-item centre for epidemiology studies depression scle (CES-D), with cut-off of 16. d Prticipnts were clssified s hving comorbidity if they hd history of vsculr disese (ngin pectoris, myocrdil infrction, stroke, crdiovsculr surgery, brdycrdi or plpittions), other chronic illnesses (sthm, dibetes (fsting glucose 7.0mmol/l or tretment), hypercholesterolemi (totl cholesterol 6.2mmol/l), hypertension (resting blood pressure 160/95mm Hg or tretment) nd thyroid problems) or dignoses of cncer within the lst 2 yers. e Prticipnts were clssified s disbled if they were unble to complete t lest two tsks from either the Instrumentl Activities of Dily Living or the Activities of Dily Living (ADL) scles. f Percentges given within ech tretment type. Tble 3 Logistic regression models for the ssocition between HT nd cognitive function. Use of Hormone Therpy N Globl function, MMSE<26 Verbl fluency, Iscs 40 Visul memory, BVRT Verbl memory, word recll 8 Psychomotor speed, TMTA 69 Executive Function, TMTB 139 OR [ 95 % CI] p OR [ 95 % CI] p OR [ 95 % CI] p OR [ 95 % CI] p N OR [ 95 % CI] p OR [ 95 % CI] p UNADJUSTED Never Current [ ] [ ] [ ] [ ] [ ] [ ] Pst: 2 yers go [ ] [ ] [ ] [ ] [ ] [ ] 0.38 Pst: >2 & 12yrs go [ ] [ ] [ ] [ ] [ ] [ ] 0.16 Pst: >12 & 22yrs go [ ] [ ] [ ] [ ] [ ] [ ] 0.07 Pst: >22yrs go [ ] [ ] [ ] [ ] [ ] [ ] 0.73 MULTIVARIATE Never Current [ ] [ ] [ ] [ ] [ ] [ ] 0.16 Pst: 2 yers go [ ] [ ] [ ] [ ] [ ] [ ] 0.95 Pst: >2 & 12yrs go [ ] [ ] [ ] [ ] [ ] [ ] 0.53 Pst: >12 & 22yrs go [ ] [ ] [ ] [ ] [ ] [ ] 0.39 Pst: >22yrs go [ ] [ ] [ ] [ ] [ ] [ ] 0.73 Adjusted for centre, ge, eduction level, ge t menopuse, mritl sttus, depressive symptoms, physicl incpcities, comorbidity, Apoe-ε4 llele, high cffeine consumption, nticholinergic drugs nd BMI. Pge 8/

9 Tble 4 Logistic regression models for the ssocition between chrcteristics of current HT use nd poor cognitive function t bseline. Chrcteristics current HT users of N Undjusted Verbl fluency, Iscs 40 Multivrite Verbl fluency, Iscs 40 Undjusted Visul memory, BVRT Multivrite Visul memory, BVRT Undjusted Psychomotor speed, TMTA 69 Multivrite Psychomotor speed, TMTA 69 OR [ 95 % CI] p OR [ 95 % CI] p OR [ 95 % CI] p OR [ 95 % CI] p N OR [ 95 % CI] p OR [ 95 % CI] p Durtion of use: Never used <yrs [ ] [ ] [ ] < [ ] [ ] [ ] 0.46 > & 15yrs [ ] < [ ] [ ] < [ ] [ ] < [ ] 0.45 >15yrs [ ] < [ ] [ ] < [ ] [ ] < [ ] 0.04 Initition of use: Never used yrs of menopuse [ ] < [ ] [ ] < [ ] [ ] < [ ] 0.12 >5yrs fter menopuse [ ] < [ ] [ ] < [ ] [ ] < [ ] 0.18 Type of HT: Never used Estrogen lone [ ] [ ] [ ] [ ] [ ] [ ] 0.24 Orl estrogen & [ ] [ ] [ ] [ ] [ ] [ ] 0.19 progestgen Trnsderml estrogen & [ ] < [ ] [ ] < [ ] [ ] < [ ] 0.07 progestgen Nturl progesterone [ ] < [ ] [ ] < [ ] [ ] [ ] 0.55 Synthetic progestin [ ] < [ ] [ ] < [ ] [ ] < [ ] 0.04 Other / unsure 21 Nd Nd Nd Nd 19 Nd Adjusted for centre, ge, eduction level, ge t menopuse, mritl sttus, depressive symptoms, physicl incpcities, comorbidity, Apoe-ε4 llele, high cffeine consumption, nticholinergic drugs nd BMI. Pge 9/

10 Tble 5 Cox proportionl hzrds models for the incidence of dementi nd Alzheimer s Disese ccording to HT use. Exposure N Incidence of Dementi (n= 79 cses) Undjusted HR [ 95 % CI] p Multivrite HR 95 CI Incidence of Alzheimer s Disese (n= 53 cses) b N [ % ] p Undjusted HR [ 95 % CI] p Multivrite HR [ 95 % CI] p Never use of HT Pst use of HT ( ) ( ) ( ) ( ) 0.86 Current use of HT ( ) ( ) ( ) ( ) 0.59 Apoe-ε 4 + (ll women) ( ) < ( ) < ( ) ( ) Apoe-ε4 & never HT user Apoe-ε4 & pst HT user ( ) ( ) ( ) ( ) 0.23 Apoe-ε4 & current HT user ( ) ( ) ( ) ( ) 0.51 Apoe-ε 4 + & never HT user ( ) < ( ) < ( ) ( ) 0.01 Apoe-ε 4 + & pst HT user ( ) ( ) (0.98.7) ( ) 0.13 Apoe-ε 4 + & current HT user ( ) ( ) ( ) ( ) 0.71 Adjusted for ge, eduction level, centre, high cffeine consumption, depressive symptoms, physicl incpcities, comorbidity, mritl sttus, nticholinergic drugs, body mss index nd ge t menopuse (djustment ws lso mde for Apoe-ε4 when the ssocition with HT use ws exmined). Pge /