The protocol was approved by the Institutional Review Board for the Protection of Human Subjects at the Tri-Service General Hospital (TSGHIRB 1-107-05-111). Written informed consent was obtained from all participants. Between January 2015 and December 2019, participants were recruited from the memory clinic of the Tri-Service General Hospital of the National Defense Medical Center, Taiwan. Individuals were eligible if they were aged 60 years or older and had negative findings on physical and neurological examinations, laboratory tests (assessment of creatinine, fasting blood sugar, free-thyroxine 4, high-sensitivity thyroid-stimulating hormone, vitamin B12, and folic acid; serologic test for syphilis; and routine blood tests) and neuroimaging examinations (brain computed tomography or magnetic resonance imaging).

Individuals were excluded if they had: (a) a history of major or uncontrolled medical conditions, such as heart failure, sepsis, liver cirrhosis, renal failure, chronic obstructive pulmonary disease, poorly controlled diabetes (Hemoglobin A1c > 8.5), myocardial infarction, or malignancy; (b) substance abuse; (c) a history of major neurological disorders, such as stroke or Parkinson’s disease; (d) a score >9 in the short-form Geriatric Depression Scale (GDS-S) or >3 for the modified Rankin Scale; and (e) a history of major psychiatric conditions that can impair cognition, such as major depressive disorder, bipolar disorder, or schizophrenia.

On recruitment, participants underwent the following examinations: Mini-Mental Status Examination (MMSE); Clinical Dementia Rating (CDR); short-form GDS-S; verbal fluency test; Hopkins Verbal Learning Test (HVLT); forward and backward digit span; Trail Making Test, Part A; Modified Boston Naming Test; and Hachinski Ischemia Scale (HIS). The second MMSE was conducted after the 1-year follow-up.

Participants were classified into the control, aMCI, and AD groups based on the results of HVLT, MMSE, and CDR examinations, as well as the recommendations from the National Institute on Aging and Alzheimer’s Association (NIA-AA) workgroups on diagnostic guidelines for AD and aMCI due to AD (Albert et al., 2011; McKhann et al., 2011). A diagnosis of AD was made if patients satisfied the following criteria: (a) NIA-AA criteria (McKhann et al., 2011); (b) CDR ≥ 0.5; (c) MMSE ≤ 26 (middle school), MMSE score ≤ 22 (primary school), or MMSE score ≤ 19 (illiteracy); (d) HIS score ≤ 3; and (e) HVLT score ≤ 19 (Hogervorst et al., 2014). aMCI was diagnosed if patients satisfied the following criteria: (a) NIA-AA criteria (Albert et al., 2011); (b) CDR = 0.5; (c) MMSE score > 26 (middle school), MMSE score > 22 (primary school), or MMSE score > 19 (illiteracy); (d) HIS score ≤ 3; and (e) HVLT score ≤ 22 (Hogervorst et al., 2014). Healthy controls were required to satisfy the following criteria: (a) no active neurological or psychiatric disorders; (b) no psychotropic drugs; (c) MMSE score > 26 (middle school), MMSE score > 22 (primary school), or MMSE score > 19 (illiteracy); and (d) CDR score = 0.

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