# Association of Thyroid Dysfunction With Cognitive Function: An Individual Participant Data Analysis

Nicolien A. van Vliet, Diana van Heemst, Osvaldo P. Almeida, Bjorn O.

Asvold, Carole E. Aubert, Jong Bin Bae, Linda E. Barnes, Douglas C. Bauer,

Gerard J. Blauw, Carol Brayne, et al.

► To cite this version:

Nicolien A. van Vliet, Diana van Heemst, Osvaldo P. Almeida, Bjorn O. Asvold, Carole E. Aubert, et al.. Association of Thyroid Dysfunction With Cognitive Function: An Individual Participant Data Analysis. JAMA Internal Medicine, 2021, 10.1001/jamainternmed.2021.5078 . hal-03419544

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# Association of Thyroid Dysfunction With Cognitive Function
## An Individual Participant Data Analysis

Nicolien A. van Vliet, MD; Diana van Heemst, PhD; Osvaldo P. Almeida, MD, PhD; Bjørn O. Åsvold, MD, PhD; Carole E. Aubert, MD; Jong Bin Bae, MD; Linda E. Barnes, RGN; Douglas C. Bauer, MD; Gerard J. Blauw, MD, PhD; Carol Brayne, MBBS, MD; Anne R. Cappola, MD, ScM; Graziano Ceresini, MD, PhD; Hannie C. Comijs, PhD; Jean-Francois Dartigues, MD, PhD; Jean-Marie Degryse, MD, PhD; Robin P. F. Dullaart, MD, PhD; Marlise E. A. van Eersel, MD, PhD; Wendy P. J. den Elzen, PhD; Luigi Ferrucci, MD, PhD; Howard A. Fink, MD, MPH; Leon Flicker, MB, BS, PhD; Hans J. Grabe, MD; Ji Won Han, MD, PhD; Catherine Helmer, MD, PhD; Martijn Huisman, PhD; M. Arfan Ikram, MD, PhD; Misa Imaizumi, MD, PhD; Renate T. de Jongh, MD, PhD; J. Wouter Jukema, MD, PhD; Ki Woong Kim, MD, PhD; Lewis H. Kuller, MD, DrPH; Oscar L. Lopez, MD; Simon P. Mooijaart, MD, PhD; Jae Hoon Moon, MD, PhD; Elisavet Moutzouri, MD, PhD; Matthias Nauck, MD; Jim Parle, MBChB, MD; Robin P. Peeters, MD, PhD; Mary H. Samuels, MD; Carsten O. Schmidt, MD, PhD; Ulf Schminke, MD; P. Eline Slagboom, PhD; Eystein Stordal, MD, PhD; Bert Vaes, MD, PhD; Henry Völzke, MD; Rudi G. J. Westendorp, MD, PhD; Michiko Yamada, MD, PhD; Bu B. Yeap, MBBS, PhD; Nicolas Rodondi, MD, MAS; Jacobijn Gussekloo, MD, PhD; Stella Trompet, PhD; for the Thyroid Studies Collaboration

<figure><img src="image_2.png" /></figure>

Supplemental content

**IMPORTANCE** In clinical guidelines, overt and subclinical thyroid dysfunction are mentioned as causal and treatable factors for cognitive decline. However, the scientific literature on these associations shows inconsistent findings.

**OBJECTIVE** To assess cross-sectional and longitudinal associations of baseline thyroid dysfunction with cognitive function and dementia.

**DESIGN, SETTING, AND PARTICIPANTS** This multicohort individual participant data analysis assessed 114 267 person-years (median, 1.7-11.3 years) of follow-up for cognitive function and 525 222 person-years (median, 3.8-15.3 years) for dementia between 1989 and 2017. Analyses on cognitive function included 21 cohorts comprising 38 144 participants. Analyses on dementia included eight cohorts with a total of 2033 cases with dementia and 44 573 controls. Data analysis was performed from December 2016 to January 2021.

**EXPOSURES** Thyroid function was classified as overt hyperthyroidism, subclinical hyperthyroidism, euthyroidism, subclinical hypothyroidism, and overt hypothyroidism based on uniform thyrotropin cutoff values and study-specific free thyroxine values.

**MAIN OUTCOMES AND MEASURES** The primary outcome was global cognitive function, mostly measured using the Mini-Mental State Examination. Executive function, memory, and dementia were secondary outcomes. Analyses were first performed at study level using multivariable linear regression and multivariable Cox regression, respectively. The studies were combined with restricted maximum likelihood meta-analysis. To overcome the use of different scales, results were transformed to standardized mean differences. For incident dementia, hazard ratios were calculated.

**RESULTS** Among 74 565 total participants, 66 567 (89.3%) participants had normal thyroid function, 577 (0.8%) had overt hyperthyroidism, 2557 (3.4%) had subclinical hyperthyroidism, 4167 (5.6%) had subclinical hypothyroidism, and 697 (0.9%) had overt hypothyroidism. The study-specific median age at baseline varied from 57 to 93 years; 42 847 (57.5%) participants were women. Thyroid dysfunction was not associated with global cognitive function; the largest differences were observed between overt hypothyroidism and euthyroidism—cross-sectionally (−0.06 standardized mean difference in score; 95% CI, −0.20 to 0.08; *P* = .40) and longitudinally (0.11 standardized mean difference higher decline per year; 95% CI, −0.01 to 0.23; *P* = .09). No consistent associations were observed between thyroid dysfunction and executive function, memory, or risk of dementia.

**CONCLUSIONS AND RELEVANCE** In this individual participant data analysis of more than 74 000 adults, subclinical hypothyroidism and hyperthyroidism were not associated with cognitive function, cognitive decline, or incident dementia. No rigorous conclusions can be drawn regarding the role of overt thyroid dysfunction in risk of dementia. These findings do not support the practice of screening for subclinical thyroid dysfunction in the context of cognitive decline in older adults as recommended in current guidelines.

JAMA Intern Med. 2021;181(11):1440-1450. doi:10.1001/jamainternmed.2021.5078
Published online September 7, 2021.

**Author Affiliations:** Author affiliations are listed at the end of this article.

**Group Information:** The participating studies of the Thyroid Studies Collaboration are listed at the end of the article.

**Corresponding Author:** Nicolien A. van Vliet, MD, Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands (n.a.van_vliet@lumc.nl).
Thyroid dysfunction is considered a potentially reversible cause of cognitive decline; hence, thyroid function screening tests are described in guidelines as an essential component of the workup for the diagnosis of dementia.¹⁻³ Thyroid dysfunction is frequently observed in individuals with suspected dementia.⁴ However, the outcomes of treatment of overt hypothyroidism and hyperthyroidism and subclinical hyperthyroidism on cognitive function are not fully clarified.⁵⁻⁷ For subclinical hypothyroidism, 4 of 5 recent randomized clinical trials and a meta-analysis on levothyroxine treatment did not find evidence for an improvement in cognitive function.⁸⁻¹³ Moreover, meta-analyses of observational studies have yielded inconsistent results on associations of subclinical and overt thyroid dysfunction with cognitive impairment and risk of dementia.¹⁴⁻¹⁷ An individual participant data analysis of cohort studies might help clarify the conflicting results of previous studies, as it allows for uniform definitions of thyroid dysfunction and it can assess the differential associations by age groups, sex, and thyroid medication in subgroup analyses.¹⁸ In the present study, we investigated cross-sectional and longitudinal associations of thyroid dysfunction with cognitive function and dementia in an individual participant data analysis of multiple cohorts.

## Methods

### Study Population

We first approached the coordinating center of the Thyroid Studies Collaboration, a collaborative project of 25 existing longitudinal studies with information on thyroid status.¹⁸ The Medical Ethics Committee of the Leiden University Medical Center waived the need for review owing to the retrospective nature of the study using only previously collected data; no individuals underwent interventions for the present study. Each participant gave informed consent to the original study they participated in, which was oral or written depending on the original study design and legislation at the time of data collection. All 15 Thyroid Studies Collaboration cohorts that had collected data on cognitive function or dementia joined the project. The study designs for all cohorts participating in the current study have been described previously in more detail.¹⁹⁻³³ We approached 14 additional cohorts that were extracted from 4 recent meta-analyses on subclinical thyroid dysfunction and cognitive function or dementia.¹⁴⁻¹⁷ Six of these cohorts consented to collaborating and sharing data.³⁴⁻³⁹ Lastly, we included publicly available data of the National Health and Nutrition Examination Survey waves of 1999 to 2002 and 2011 to 2012, which simultaneously collected thyroid and cognitive function among many other parameters.⁴⁰

### Thyroid Function

Thyroid dysfunction was determined biochemically by measurements of thyrotropin and free thyroxine (FT₄) concentrations in all cohorts. Cohort-specific cutoff values were used for FT₄ levels (eTable 1 in the Supplement). In accordance with previous projects in the Thyroid Studies Collaboration, participants were classified as euthyroid if thyrotropin level was 0.45

## Key Points

**Question** Is thyroid dysfunction associated with cognitive decline?

**Findings** In this individual participant data analysis of 23 cohorts including 74 565 participants with cognitive function and/or dementia measurements, subclinical thyroid dysfunction was not associated with global cognitive function at baseline (standardized mean difference, -0.02 for subclinical hyperthyroidism and 0.05 for subclinical hypothyroidism) or annual decline (standardized mean difference, -0.02 for subclinical hyperthyroidism and -0.00 for subclinical hypothyroidism).

**Meaning** These findings do not support the need for screening for subclinical thyroid dysfunction for prevention of cognitive decline or dementia.

to 4.49 mIU/L.¹⁸ Overt hyperthyroidism was defined as a thyrotropin level less than 0.45 mIU/L and FT₄ level above the reference range. Subclinical hyperthyroidism was defined as a thyrotropin level less than 0.45 mIU/L and FT₄ levels within the reference range, or only as thyrotropin level less than 0.45 mIU/L in absence of an FT₄ measurement (n = 896 among 10 cohorts) because overt hyperthyroidism is rare.⁴¹ A combination of thyrotropin level of 4.50 to 20 mIU/L and FT₄ levels within the reference range was defined as subclinical hypothyroidism. Individuals who had missing FT₄ measurements with mildly elevated thyrotropin levels (4.50-20 mIU/L) were considered subclinically hypothyroid (n = 523 among 8 cohorts) because chances of overt hypothyroidism in this patient category are low.⁴¹ A thyrotropin level of 20 mIU/L or greater or thyrotropin level of 4.50 mIU/L or greater combined with FT₄ levels below the reference range was defined as overt hypothyroidism.

### Cognitive Function

The primary outcome was global cognitive function measured by Mini-Mental State Examination (MMSE), Modified Mini-Mental State (3MS), or Severe Cognitive Impairment Rating Scale.⁴²⁻⁴⁴ A difference of 1 point in MMSE score is considered the minimal clinically important difference in individuals without dementia.⁴⁵ Executive function and memory were secondary outcomes. For executive function, various tests were used: Digit Symbol Substitution Test, Trail Making Test B, Letter Digit Substitution Test (LDST), Executive Interview 15, and Ruff Figural Fluency Test.⁴⁶⁻⁵⁰ The minimal clinically important difference for executive function was defined as a difference of 4 points in LDST.⁵¹ Memory was measured using either Rey's Auditory Verbal Learning Test (also referred to as Word Learning Test or Verbal Learning Test), Digit Span Test, or Visual Association Test.⁵²⁻⁵⁵ No minimal clinically important difference for memory tests was found in the literature.

### Dementia

Depending on the study design, dementia was diagnosed either in a clinical setting or at a research center. The diagnosis was, at least in part, based on clinical presentation. Studies in which dementia diagnosis was based only on a cutoff point for the
MMSE were excluded from this analysis because cognitive function tests are insufficient to diagnose dementia.⁵⁶ Prevalence of dementia at baseline was available for 11 cohorts; 431 participants had a diagnosis of dementia at baseline, but only 78 of them were classified as noneuthyroid. Owing to the small number of participants with thyroid dysfunction at baseline, no cross-sectional analyses for dementia were performed.

## Statistical Analyses

We used a 2-stage individual participant data analysis approach, which accommodates uniform definitions and analyses for each cohort while keeping complexity to a minimum.¹⁸,⁵⁷ The first stage consisted of study-level analysis of thyroid dysfunction and cognitive function or dementia conducted on the original data sets with participant-level data. In the second stage, the effect estimates from the first stage were pooled using a random-effects model based on restricted maximum likelihood. Heterogeneity across studies was quantified using the I² statistic: less than 40% was considered low heterogeneity; 40% to 75%, moderate heterogeneity; and greater than 75%, high heterogeneity.

For both the cross-sectional and longitudinal analyses between thyroid dysfunction and cognitive function, we used multivariable linear regression models. To facilitate combination of different scales, the results were transformed to standardized mean differences. In the prospective analysis of cognitive decline, we calculated the difference between the last available measurement of cognitive function and baseline cognitive function. The difference was divided by the follow-up time in years to obtain an annual decline, irrespective of duration of follow-up. The annual decline was subsequently standardized, resulting in a standardized mean difference in annual change in cognitive function allowing comparison of changes over time.

The risk of developing dementia during follow-up was assessed using Cox regression models. In these analyses, participants with dementia at baseline were excluded. For studies without precise registration of the date of dementia diagnosis, it was assumed that dementia developed halfway between the registration date and the last date that absence of dementia was ascertained.

Thyroid dysfunction (overt hyperthyroidism, subclinical hyperthyroidism, subclinical hypothyroidism, and overt hypothyroidism) was included as a categorical variable with the euthyroid group serving as reference. All analyses were adjusted for age and sex. The longitudinal analyses of cognitive decline were adjusted for baseline cognitive function. Prespecified subgroup analyses were performed by stratification and interaction analysis for sex and for age younger or older than 75 years. Additional analyses were performed with adjustment for educational attainment, though this variable was not available in all cohorts. In sensitivity analyses, participants with missing FT₄ measurements in the subclinical hyperthyroid and subclinical hypothyroid groups were excluded, as were those who used antithyroid medication or thyroid hormone replacement therapy at baseline. Furthermore, we assessed robustness of the associations by pooling the estimates using fixed-effect models and by excluding stud-

ies with strata of fewer than 10 participants. To assess whether effects were dependent on degree of disruption of thyrotropin, analyses were repeated with thyrotropin categories of less than 0.10 mIU/L, 0.10 to 0.44 mIU/L, 4.5 to 6.9 mIU/L, 7.0 to 10 mIU/L, and greater than 10 mIU/L, in which participants with thyrotropin between 0.45 and 4.49 mIU/L served as reference. Lastly, instead of using biochemical cutoff points, thyrotropin and FT₄ were analyzed continuously across the full range with cognitive function. Thyrotropin was transformed using the natural logarithm; for both natural log-transformed thyrotropin and FT₄, models were constructed per standard deviation. Continuous models were performed minimally adjusted by age and sex and with additional adjustment for educational attainment. For sensitivity purposes, the analyses were also conducted excluding the participants who used antithyroid medication or thyroid hormone replacement therapy at baseline. Cohorts with greater than 10% missing measurements for FT₄ were excluded for the continuous analyses on FT₄. All P values were 2-tailed; statistical significance was set at P < .05.

Study-level analyses were performed using SPSS Statistics, version 25 (IBM). Effect estimates were pooled and summarized in forest plots using R, version 3.6.1 and metafor package (R Foundation for Statistical Computing).⁵⁸ This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

## Results

### Population Characteristics

Individual participant data on thyroid function and cognitive function and/or dementia were provided by 23 cohorts comprising 74 565 participants. At baseline, 66 567 (89.3%) participants were biochemically classified as euthyroid, 577 (0.8%) as overtly hyperthyroid, 2557 (3.4%) as subclinically hyperthyroid, 4167 (5.6%) as subclinically hypothyroid, and 697 (0.9%) as overtly hypothyroid (eTable 1 in the Supplement). The study-specific median age at baseline varied from 57 to 93 years; 42 847 (57.5%) participants were women.

A total of 38 144 participants from 21 cohorts provided data on a measure of cognitive function (Table). The median age varied from 58 to 93 years, and 18 089 (47.4%) participants were women. Follow-up for cognitive decline was available for 14 cohorts, with a median follow-up duration varying from 1.7 to 11.3 years, accumulating 114 267 person-years.

Eight cohorts provided follow-up for dementia incidence on 46 606 participants (eTable 2 in the Supplement). Among these participants, 28 820 (61.8%) were women, and the median age at baseline was between 57 and 85 years. During follow-up, 2033 (4.4%) cases of incident dementia were identified. Median follow-up duration ranged from 3.8 to 15.3 years, accumulating 525 222 person-years.

### Thyroid Dysfunction and Global Cognitive Function

Cross-sectionally, thyroid dysfunction was not associated with global cognitive function among 18 cohorts (Figure 1; eFigure 1 in the Supplement). The largest observed difference was
<table><caption>Table. Baseline Characteristics of the 38 144 Participants With Cognitive Function Measurements in Included Studies</caption><thead><tr><th rowspan="2">Source</th><th rowspan="2">Location</th><th rowspan="2">Population description</th><th rowspan="2">Baseline, y</th><th rowspan="2">No.</th><th rowspan="2">Age, median (range), y</th><th colspan="3">No. (%)</th><th colspan="3">Cognitive function</th></tr><tr><th>Men</th><th>Women</th><th>Euthyroid<sup>a</sup></th><th>Thyroid medication users</th><th>Scales</th><th>Score,<sup>b</sup> mean (SD)</th><th>Follow-up duration,<sup>c</sup> median (range), y</th></tr></thead><tbody><tr><td colspan="11"><strong>Europe</strong></td></tr><tr><td>BELFRAIL cohort study</td><td>Belgium</td><td>Adults aged ≥80 y</td><td>2008-2009</td><td>523</td><td>84 (80-102)</td><td>193 (36.9)</td><td>330 (63.1)</td><td>453 (86.6)</td><td>50 (9.6)<sup>d</sup></td><td>MMSE</td><td>26 (4.0)</td><td>1.7 (0.5-2.3)</td></tr><tr><td>BETS</td><td>England</td><td>Community-dwelling adults aged ≥65 y</td><td>2002-2004</td><td>5845</td><td>72 (65-98)</td><td>2873 (49.2)</td><td>2972 (50.8)</td><td>5266 (90.1)</td><td>0 (0)</td><td>MMSE</td><td>28 (2.2)</td><td>0</td></tr><tr><td>CFAS</td><td>England and Wales</td><td>Adults aged ≥64 y</td><td>1991-1992</td><td>1015</td><td>73 (64-94)</td><td>497 (49.0)</td><td>518 (51.0)</td><td>906 (89.3)</td><td>NA</td><td>MMSE</td><td>28 (2.0)</td><td>2.0 (1.9-2.6)</td></tr><tr><td>InCHIANTI Study</td><td>Italy</td><td>Community-dwelling adults</td><td>1998-2000</td><td>1187</td><td>71 (21-102)</td><td>521 (43.9)</td><td>666 (56.1)</td><td>1044 (88.0)</td><td>33 (2.8)</td><td>MMSE</td><td>25 (4.8)</td><td>9.0 (2.8-10.0)</td></tr><tr><td>LASA</td><td>The Netherlands</td><td>Adults aged ≥65 y</td><td>1995-1997</td><td>1266</td><td>75 (65-89)</td><td>616 (48.7)</td><td>650 (51.3)</td><td>1093 (86.3)</td><td>26 (2.1)</td><td>MMSE, WLT</td><td>27 (3.1)</td><td>9.9 (2.3-20.8)</td></tr><tr><td>Leiden 85-plus Study</td><td>The Netherlands</td><td>Adults aged 85 y</td><td>1997-1999</td><td>557</td><td>85</td><td>188 (33.8)</td><td>369 (66.2)</td><td>456 (81.9)</td><td>20 (3.6)</td><td>MMSE, LDST, VLT</td><td>24 (6.3)</td><td>5.0 (1.0-5.0)</td></tr><tr><td>LLS</td><td>The Netherlands</td><td>Long-lived siblings</td><td>2002-2005</td><td>776</td><td>93 (89-103)</td><td>308 (39.7)</td><td>468 (60.3)</td><td>652 (84.0)</td><td>NA</td><td>MMSE</td><td>24 (5.1)</td><td>0</td></tr><tr><td>Paquid study</td><td>France</td><td>Community-dwelling adults aged ≥65 y</td><td>1989-1990</td><td>407</td><td>75 (66-94)</td><td>173 (42.5)</td><td>234 (57.5)</td><td>359 (88.2)</td><td>6 (1.5)<sup>d</sup></td><td>MMSE, DSST, VLT</td><td>26 (3.5)</td><td>11.3 (1.5-27.0)</td></tr><tr><td>PREVEND Study</td><td>The Netherlands</td><td>Adults</td><td>2003-2006</td><td>864</td><td>58 (35-82)</td><td>493 (57.1)</td><td>371 (42.9)</td><td>777 (88.9)</td><td>NA</td><td>REFT, VAT</td><td>64 (25.0)</td><td>5.2 (0.8-7.8)</td></tr><tr><td>PROSPER</td><td>The Netherlands, Ireland, Scotland</td><td>Older community-dwelling adults at high cardiovascular risk</td><td>1998-1999</td><td>5775</td><td>75 (69-83)</td><td>2791 (48.3)</td><td>2984 (51.7)</td><td>5063 (87.7)</td><td>256 (4.4)</td><td>MMSE, LDST, WLT<sup>c</sup></td><td>28 (1.5)</td><td>3.3 (0.8-4.0)</td></tr><tr><td>Rotterdam Study</td><td>The Netherlands</td><td>Adults aged ≥55 y</td><td>1989-1992</td><td>1875</td><td>69 (55-93)</td><td>720 (38.4)</td><td>1155 (61.6)</td><td>1611 (85.9)</td><td>46 (2.5)<sup>d</sup></td><td>MMSE</td><td>28 (1.7)</td><td>10.8 (1.5-21.7)</td></tr><tr><td>SHIP</td><td>Germany</td><td>Adults</td><td>2002-2006</td><td>1329</td><td>69 (60-88)</td><td>682 (51.3)</td><td>647 (48.7)</td><td>1008 (75.8)</td><td>190 (14.3)</td><td>MMSE</td><td>28 (3.2)</td><td>5.6 (4.3-8.8)</td></tr><tr><td colspan="11"><strong>North America</strong></td></tr><tr><td>CHS</td><td>US</td><td>Community-dwelling adults with Medicare eligibility</td><td>1994-1998</td><td>3991</td><td>74 (64-98)</td><td>1635 (41.0)</td><td>2356 (59.0)</td><td>3253 (81.5)</td><td>401 (10.0)<sup>d</sup></td><td>3MS, DSST</td><td>90 (9.9)</td><td>5.9 (0.9-7.0)</td></tr><tr><td>HABC Study</td><td>US</td><td>Community-dwelling adults aged 70-79 y with Medicare eligibility</td><td>1999-2000</td><td>2488</td><td>75 (71-82)</td><td>1208 (48.6)</td><td>1280 (51.4)</td><td>2076 (83.4)</td><td>251 (10.1)</td><td>3MS, EXIT 15</td><td>90 (8.9)</td><td>8.0 (2.0-13.0)</td></tr><tr><td>MMC</td><td>Mexico</td><td>Geriatric outpatients with and without dementia</td><td>2004</td><td>156</td><td>79 (58-98)</td><td>49 (31.4)</td><td>107 (68.6)</td><td>109 (69.9)</td><td>12 (7.7)</td><td>MMSE</td><td>15 (6.5)</td><td>0</td></tr><tr><td>MrOS Study</td><td>US</td><td>Community-dwelling men aged ≥65 y</td><td>2000-2002</td><td>1600</td><td>73 (65-99)</td><td>1600 (100)</td><td>0</td><td>1409 (88.1)</td><td>122 (7.6)<sup>d</sup></td><td>3MS, TMT</td><td>93 (6.4)</td><td>4.6 (3.5-5.9)</td></tr><tr><td>NHANES 1999-2002</td><td>US</td><td>Adults</td><td>1999-2002</td><td>853</td><td>70 (60-85)</td><td>416 (48.8)</td><td>437 (51.2)</td><td>751 (88.0)</td><td>91 (10.7)</td><td>DSST</td><td>42 (18.3)</td><td>0</td></tr><tr><td>NHANES 2011-2012</td><td>US</td><td>Adults</td><td>2011-2012</td><td>434</td><td>68 (60-80)</td><td>220 (50.7)</td><td>214 (49.3)</td><td>405 (93.3)</td><td>57 (13.1)</td><td>DSST, WLT</td><td>45 (17.6)</td><td>0</td></tr><tr><td colspan="11"><strong>Australia</strong></td></tr></tbody></table>

(continued)
<table><caption>Table. Baseline Characteristics of the 38 144 Participants With Cognitive Function Measurements in Included Studies (continued)</caption><thead><tr><th rowspan="2">Source</th><th rowspan="2">Location</th><th rowspan="2">Population description</th><th rowspan="2">Baseline, y</th><th rowspan="2">No.</th><th rowspan="2">Age, median (range), y</th><th colspan="2">No. (%)</th><th colspan="4">Cognitive function</th></tr><tr><th>Men</th><th>Women</th><th>Euthyroid<sup>a</sup></th><th>Thyroid medication users</th><th>Scales</th><th>Score,<sup>b</sup> mean (SD)</th><th>Follow-up duration,<sup>c</sup> median (range), y</th></tr></thead><tbody><tr><td>HIMS</td><td>Australia</td><td>Men aged ≥65 y</td><td>2001-2004</td><td>3168</td><td>76 (71-89)</td><td>3168 (100)</td><td>0</td><td>2897 (91.4)</td><td>112 (3.5)</td><td>MMSE</td><td>28 (1.3)</td><td>0</td></tr><tr><td>Asia</td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>KLOSCAD</td><td>Republic of Korea</td><td>Adults aged ≥60 y</td><td>2010-2017</td><td>3854</td><td>70 (61-109)</td><td>1702 (44.2)</td><td>2152 (55.8)</td><td>3476 (90.2)</td><td>NA</td><td>SCIRS, TMT, DST</td><td>29 (1.7)</td><td>3.7 (0.8-7.3)</td></tr><tr><td>KLOSHA</td><td>Republic of Korea</td><td>Adults aged ≥65 y</td><td>2010-2012</td><td>181</td><td>75 (70-96)</td><td>2 (1.1)</td><td>179 (98.9)</td><td>154 (85.1)</td><td>NA</td><td>MMSE, TMT, DST</td><td>24 (3.9)</td><td>0</td></tr><tr><td>Overall</td><td></td><td>21 Cohorts</td><td>1989-2017</td><td>38 144</td><td>74 (21-109)</td><td>20 055 (84.6)</td><td>18 089 (47.4)</td><td>33 218 (87.1)</td><td>1673 (5.3)</td><td></td><td></td><td>5.4 (0.5-27.0)</td></tr></tbody></table>

Abbreviations: BETS, Birmingham Elderly Thyroid Study; CFAS, Cognitive Function and Aging Study; CHS, Cardiovascular Health Study; DSST, Digit Symbol Substitution Test; DST, Digit Span Test; EXIT 15, 15-item Executive Interview; HABC, Health, Aging and Body Composition; HIMS, Health in Men Study; InCHIANTI, Invecchiare in Chianti Study; KLOSCAD, Korean Longitudinal Study on Cognitive Aging and Dementia; KLOSHA, Korean Longitudinal Study on Health and Aging; LASA, Longitudinal Aging Study Amsterdam; LDST, Letter Digit Substitution Test; LLS, Leiden Longevity Study; MMC, Mexican Memory Clinic; MMSE, Mini-Mental State Examination; MrOS, Osteoporotic Fractures in Men Study; NA, not available; NHANES, National Health and Nutrition Examination Survey; Paqul, Personnes-Ages QUID; PREVEND, Prevention of Renal and Vascular End-stage Disease; PROSPER, Prospective Study of Pravastatin in the Elderly at Risk; RFFT, Ruff Figural Fluency Test; SCIRS; Severe Cognitive Impairment Rating Scale; SHIP, Study of Health in Pomerania; 3MS, Modified Mini-Mental State Examination; TMT, Trail Making Test; VAT, Visual Association Test; VLT, Verbal Learning Test; WLT, Word Learning Test.

-0.06 standardized mean difference (95% CI, -0.20 to 0.08; *P* = .40) global cognitive function for overt hypothyroidism compared with euthyroidism, which could be interpreted as an approximately 0.1-point lower MMSE score based on the SD for the 2 largest cohorts included. No statistically significant association was observed between thyroid dysfunction at baseline and annual change in global cognitive function during follow-up among 13 cohorts (Figure 2). Participants with overt hypothyroidism had 0.11 standardized mean difference (95% CI, -0.01 to 0.23; *P* = .09) higher decline per year in global cognitive function than participants who were euthyroid, which translates to approximately 0.1 point on the MMSE scale faster decline per year based on the SD in the largest cohort for this analysis. Additional adjustment for educational attainment did not materially change the results (eFigure 2 in the Supplement). Stratification by age and sex did not show any differential effects for global cognitive function (eTable 3 in the Supplement). No statistically significant associations were found when individuals were categorized by severity of thyrotropin abnormality (eFigure 3 in the Supplement). Reanalyzing the data with a fixed-effects model or without strata with fewer than 10 participants did not yield different results (eTable 4 in the Supplement). Leaving out participants with missing FT₄ measurements or those using antithyroid medication or thyroid hormone replacement therapy at baseline also did not change the results. A positive association was found between continuous thyrotropin and global cognition only when thyroid supplementation and antithyroid medication users were excluded (0.028 higher standardized mean difference per SD; 95% CI, 0.003 to 0.053; *P* = .03; eTable 5 in the Supplement). No association between continuous FT₄ levels and global cognitive function was found. Heterogeneity across studies was low for the cross-sectional main analyses (*I*² = 0%-40%), while heterogeneity was low to moderate for the longitudinal and sensitivity analyses (*I*² = 0%-70%).

## Thyroid Dysfunction and Executive Function and Memory

No negative association was observed cross-sectionally between thyroid dysfunction and executive function or memory among 11 and 8 cohorts, respectively (Figure 1; eFigures 4 and 5 in the Supplement). Participants with overt hyperthyroidism had 0.20 standardized mean difference (95% CI, 0.07 to 0.33; *P* = .002) higher executive function score compared with participants who were euthyroid; transformed, this would account for 1.6 more correct substitutions within 60 seconds for the LDST based on the largest cohort in this analysis. In both executive function and memory, participants with subclinical hypothyroidism performed better than participants who were euthyroid (executive function: 0.07 standardized mean difference; 95% CI, 0.01 to 0.13; *P* = .03; memory: 0.08 standardized mean difference; 95% CI, 0.01 to 0.15; *P* = .03). Longitudinally, no association was found between thyroid dysfunction at baseline and decline in executive function among 7 cohorts or memory among 6 cohorts; all differences were smaller than 0.1 standardized mean difference (Figure 2). Additional adjustment for educational attainment did not materially change the results (eFigure 2 in the Supplement). No statistically significant interaction with sex or age was present (*P* > .05 for all; supporting data in eTable 3 in the Supplement). Using a fixed-effects model or excluding strata with

<footnote>a We used a common definition for biochemical euthyroidism of thyrotropin level of 0.45 to 4.49 mIU/L, resulting in different numbers from previous reports.</footnote>

<footnote>b Test scores are shown for global cognitive function tests. If no global cognitive function test scores were provided, executive function test scores are shown.</footnote>

<footnote>c Follow-up in years for participants who had a follow-up measurement for cognitive function.</footnote>

<footnote>d Data on baseline medication use (thyroid replacement therapy, antithyroid drugs) were unavailable for 2 participants of the BELFRAIL Study, 3 participants of the CHS, 64 participants of the MrOS Study, 12 participants of the PAQUID Study. 1 participant of the Rotterdam Study.</footnote>
<table><caption>Figure 1. Cross-sectional Association Between Thyroid Dysfunction and Cognitive Function Test Scores</caption><thead><tr><th>Cognitive function by thyroid status</th><th>No. of studies</th><th>No. of participants</th><th>I², %</th><th>Standardized mean difference (95% CI)</th><th>Favors worse cognition</th><th>Favors better cognition</th></tr></thead><tbody><tr><td><strong>Global cognition</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Overt hyperthyroidism</td><td>16</td><td>344</td><td>0</td><td>-0.00 (-0.10 to 0.10)</td><td></td><td></td></tr><tr><td>Subclinical hyperthyroidism</td><td>17</td><td>1492</td><td>33.34</td><td>-0.02 (-0.09 to 0.04)</td><td></td><td></td></tr><tr><td>Euthyroidism</td><td>18</td><td>31214</td><td>Reference</td><td>0.00 (-0.00 to 0.00)</td><td></td><td></td></tr><tr><td>Subclinical hypothyroidism</td><td>18</td><td>2519</td><td>37.02</td><td>0.05 (-0.01 to 0.10)</td><td></td><td></td></tr><tr><td>Overt hypothyroidism</td><td>18</td><td>345</td><td>40.43</td><td>-0.06 (-0.20 to 0.08)</td><td></td><td></td></tr><tr><td><strong>Executive function</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Overt hyperthyroidism</td><td>9</td><td>212</td><td>0</td><td>0.20 (0.07 to 0.33)</td><td></td><td></td></tr><tr><td>Subclinical hyperthyroidism</td><td>10</td><td>604</td><td>0</td><td>-0.04 (-0.12 to 0.04)</td><td></td><td></td></tr><tr><td>Euthyroidism</td><td>11</td><td>17468</td><td>Reference</td><td>0.00 (-0.00 to 0.00)</td><td></td><td></td></tr><tr><td>Subclinical hypothyroidism</td><td>11</td><td>1701</td><td>27.70</td><td>0.07 (0.01 to 0.13)</td><td></td><td></td></tr><tr><td>Overt hypothyroidism</td><td>11</td><td>208</td><td>10.15</td><td>-0.05 (-0.20 to 0.09)</td><td></td><td></td></tr><tr><td><strong>Memory</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Overt hyperthyroidism</td><td>6</td><td>144</td><td>0</td><td>0.04 (-0.12 to 0.20)</td><td></td><td></td></tr><tr><td>Subclinical hyperthyroidism</td><td>7</td><td>442</td><td>0</td><td>0.02 (-0.07 to 0.11)</td><td></td><td></td></tr><tr><td>Euthyroidism</td><td>8</td><td>11206</td><td>Reference</td><td>0.00 (-0.00 to 0.00)</td><td></td><td></td></tr><tr><td>Subclinical hypothyroidism</td><td>8</td><td>745</td><td>0</td><td>0.08 (0.01 to 0.15)</td><td></td><td></td></tr><tr><td>Overt hypothyroidism</td><td>8</td><td>140</td><td>0.20</td><td>-0.07 (-0.23 to 0.09)</td><td></td><td></td></tr></tbody></table>

<figure><img src="image_3.png" /></figure>

Standardized mean differences were adjusted for age and sex. Error bars indicate 95% CIs.

<table><caption>Figure 2. Longitudinal Association Between Thyroid Dysfunction and Cognitive Function Test Scores</caption><thead><tr><th>Cognitive function by thyroid status</th><th>No. of studies</th><th>No. of participants</th><th>I², %</th><th>Standardized mean difference (95% CI)</th><th>Favors slower decline</th><th>Favors faster decline</th></tr></thead><tbody><tr><td><strong>Global cognition</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Overt hyperthyroidism</td><td>13</td><td>240</td><td>5.02</td><td>0.03 (-0.10 to 0.16)</td><td></td><td></td></tr><tr><td>Subclinical hyperthyroidism</td><td>13</td><td>894</td><td>24.50</td><td>-0.02 (-0.10 to 0.06)</td><td></td><td></td></tr><tr><td>Euthyroidism</td><td>13</td><td>18752</td><td>Reference</td><td>0.00 (-0.00 to 0.00)</td><td></td><td></td></tr><tr><td>Subclinical hypothyroidism</td><td>13</td><td>1651</td><td>47.81</td><td>-0.00 (-0.09 to 0.08)</td><td></td><td></td></tr><tr><td>Overt hypothyroidism</td><td>13</td><td>242</td><td>0</td><td>0.11 (-0.01 to 0.23)</td><td></td><td></td></tr><tr><td><strong>Executive function</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Overt hyperthyroidism</td><td>6</td><td>177</td><td>0</td><td>0.07 (-0.07 to 0.21)</td><td></td><td></td></tr><tr><td>Subclinical hyperthyroidism</td><td>7</td><td>416</td><td>0</td><td>-0.02 (-0.12 to 0.07)</td><td></td><td></td></tr><tr><td>Euthyroidism</td><td>7</td><td>12368</td><td>Reference</td><td>0.00 (-0.00 to 0.00)</td><td></td><td></td></tr><tr><td>Subclinical hypothyroidism</td><td>7</td><td>1156</td><td>69.48</td><td>-0.02 (-0.15 to 0.11)</td><td></td><td></td></tr><tr><td>Overt hypothyroidism</td><td>7</td><td>137</td><td>49.42</td><td>0.02 (-0.23 to 0.26)</td><td></td><td></td></tr><tr><td><strong>Memory</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Overt hyperthyroidism</td><td>5</td><td>122</td><td>0</td><td>-0.02 (-0.20 to 0.15)</td><td></td><td></td></tr><tr><td>Subclinical hyperthyroidism</td><td>6</td><td>372</td><td>0</td><td>-0.07 (-0.17 to 0.02)</td><td></td><td></td></tr><tr><td>Euthyroidism</td><td>6</td><td>9397</td><td>Reference</td><td>0.00 (-0.00 to 0.00)</td><td></td><td></td></tr><tr><td>Subclinical hypothyroidism</td><td>6</td><td>643</td><td>0</td><td>0.02 (-0.06 to 0.09)</td><td></td><td></td></tr><tr><td>Overt hypothyroidism</td><td>6</td><td>109</td><td>0</td><td>-0.07 (-0.25 to 0.11)</td><td></td><td></td></tr></tbody></table>

<figure><img src="image_4.png" /></figure>

Standardized mean differences were adjusted for age, sex, and baseline cognitive function. Error bars indicate 95% CIs.

fewer than 10 participants did not change the results for executive function or memory (eTable 4 in the Supplement). The association of subclinical hypothyroidism and better executive function was attenuated when participants with missing FT₄ measurements were left out, while the association with memory was unchanged. The positive association between overt hyperthyroidism and executive function disappeared when participants using thyroid medication were removed. No association was found when individuals were categorized by severity of thyrotropin abnormality or when thyrotropin level was analyzed continuously (eFigure 3 and eTable 5 in the Supplement). Continuous analysis of FT₄ levels showed a posi-

tive association with executive function (0.019 higher standardized mean difference per SD; 95% CI, 0.002 to 0.036; *P* = .03), which was attenuated when participants using thyroid medication were left out. Heterogeneity across studies was low for the cross-sectional main analyses (I² = 0%-40%), while heterogeneity was low to moderate for the longitudinal analyses (I² = 0%-70%) and up to high heterogeneity in the sensitivity analyses (I² ≤ 73%).

## Thyroid Dysfunction and Dementia

Cross-sectional analysis of thyroid dysfunction and dementia were unfeasible owing to few participants who were not eu-
<table><caption>Figure 3. Longitudinal Association Between Thyroid Dysfunction and Incident Dementia</caption><thead><tr><th>Thyroid status</th><th>No. of studies</th><th>No. of cases</th><th>No. of controls</th><th>I², %</th><th>Hazard ratio (95% CI)</th><th>Favors lower risk</th><th>Favors higher risk</th></tr></thead><tbody><tr><td>Overt hyperthyroidism</td><td>3</td><td>9</td><td>243</td><td>10.63</td><td>1.54 (0.76-3.10)</td><td></td><td></td></tr><tr><td>Subclinical hyperthyroidism</td><td>8</td><td>86</td><td>1310</td><td>6.35</td><td>1.23 (0.98-1.56)</td><td></td><td></td></tr><tr><td>Euthyroidism</td><td>8</td><td>1781</td><td>40627</td><td>Reference</td><td>1.00 (1.00-1.00)</td><td></td><td></td></tr><tr><td>Subclinical hypothyroidism</td><td>8</td><td>136</td><td>1941</td><td>0</td><td>1.08 (0.91-1.29)</td><td></td><td></td></tr><tr><td>Overt hypothyroidism</td><td>7</td><td>21</td><td>422</td><td>16.47</td><td>0.79 (0.48-1.28)</td><td></td><td></td></tr></tbody></table>

<figure><img src="image_5.png" /></figure>

Hazard ratios were adjusted for age and sex. Error bars indicate 95% CIs.

thyroid with dementia at baseline (78 participants among 11 cohorts). In longitudinal analyses among 12 cohorts, no association was found between thyroid dysfunction and incident dementia (Figure 3; eFigure 6 in the Supplement). The hazard ratio of dementia ranged from 1.54 (95% CI, 0.76 to 3.10) for overt hyperthyroidism to 0.79 (95% CI, 0.48 to 1.28) for overt hypothyroidism. Continuous analysis of thyrotropin and FT₄ levels also did not provide evidence for an association; hazard ratio, 0.96 per SD increase of natural log-transformed thyrotropin (95% CI, 0.91 to 1.02; *P* = .16); hazard ratio, 1.05 per SD increase of FT₄ (95% CI, 0.98 to 1.13; *P* = .16). Heterogeneity between studies was low (*I*² = 0%-40%).

## Discussion

In this individual participant data analysis of 74 565 participants from 23 cohorts, there was no association between subclinical thyroid dysfunction and cognitive function, cognitive decline, or the onset of dementia. Owing to uncertainty of the results for overt hypothyroidism and hyperthyroidism, no rigorous conclusions can be drawn regarding the association between overt thyroid dysfunction and cognitive decline and dementia.

While prior study-level meta-analyses also reported no association between subclinical hypothyroidism and cognitive function, cognitive decline, or dementia, they were limited by heterogeneity in definitions of thyroid dysfunction and choices of covariates in the statistical models.¹⁴⁻¹⁷ Because we performed an individual participant data analysis, we could standardize definitions of thyroid function categories and of cognitive function and cognitive decline and standardize the statistical models. By addressing these limitations and reaching the same results, the present study provides the strongest observational evidence to date suggesting that subclinical hypothyroidism is not associated with cognitive function or cognitive decline.

Various studies and 2 meta-analyses did show an association between subclinical or overt hyperthyroidism or low thyrotropin level within the reference range and a higher risk of dementia.¹⁴,¹⁷,²⁰,²⁶,⁵⁹⁻⁶¹ Although our findings for subclinical and overt hyperthyroidism and dementia did not reach statistical significance, they are directionally consistent with the literature. Despite combining 8 cohorts comprising more than 45 000 participants, the number of individuals with subclinical and overt hyperthyroidism and the number of individuals

who developed dementia during follow-up are limited. Therefore, we cannot exclude a higher risk of dementia in individuals with hyperthyroidism. In addition, individuals with overt hyperthyroidism had a slightly higher rate of cognitive decline, though not statistically significant. Considering the existing literature and the other results in the present study, the observed cross-sectional association between overt hyperthyroidism and better executive function was most likely a chance finding. Moreover, the observed difference in executive function was less than half the minimal clinically important difference, making it a clinically insignificant finding regardless of the *P* value.

Higher vulnerability among subgroups has been proposed; younger adults and women might be more susceptible to cognitive dysregulation associated with thyroid dysfunction.¹⁶,⁶² Moreover, cognitive decline might only be present in individuals with more extreme values of thyrotropin,²¹,⁶³ or variation in FT₄ instead of thyrotropin levels could be associated with dementia risk.²² In the present multicohort study, we did not observe differential associations for participants younger and older than 75 years or for men and women, nor any association with variation in FT₄ level or more extreme values of thyrotropin. Therefore, subgroup associations reported in prior studies might not be generalizable outside the original cohorts.

As mentioned before, all but 1 randomized clinical trial on levothyroxine treatment for subclinical hypothyroidism also did not provide evidence for improvement of cognitive function.⁸⁻¹² Moreover, both undertreatment and overtreatment with levothyroxine are common, estimated at 27% and 14%, respectively.⁶⁴ Overtreatment is associated with increased risk of atrial fibrillation and atherosclerosis⁶⁵,⁶⁶ and, via cerebrovascular damage, might be associated with increased risk of cognitive decline. Therefore, screening for subclinical thyroid dysfunction in older adults to prevent cognitive impairment and dementia does not appear to be effective.

The current individual participant data analysis has several strengths. The use of individual participant data from cohorts from all over the globe enhances generalization while allowing standardized definitions and relevant subgroup analyses. All but 5 of the included studies had a median age of 70 years or older, which is essential but often not the case in research concerning outcomes that are most relevant for older adults.⁶⁷ The present study approached cognition comprehensively; we assessed multiple domains of cognitive function, cross-sectionally and longitudinally, and incidence of dementia.
## Limitations

Some limitations need to be acknowledged. Thyroid function categorization was based on biochemical characteristics. For 20% to 30% of the participants who were categorized as subclinical hypothyroid or hyperthyroid, we could not confirm subclinical thyroid dysfunction owing to the absence of FT₄ measurement. This may have led to some misclassification, yet sensitivity analyses excluding those participants with missing FT₄ data yielded similar results. We could not include educational attainment in our main analysis because 5 out of 18 cohorts did not collect these data. Even though the sensitivity analyses with adjustment for educational attainment yielded similar results as the main analysis, education is a possible confounder that could not be accounted for. For most cohorts, only 1 measurement of thyroid function was available, which is why only baseline thyroid function was used in the present individual participant data analysis. This study could therefore not capture any changes in cognitive function that might occur at the transition of one thyroid status to another. Moreover, for the vast majority of study participants, a maximum of 2 measurements of cognitive function was available, which precluded advanced modeling of change over time including nonlinear trajectories. In addition, the interpretation of longitudinal studies of cognitive function can be complicated by practice effects.⁶⁸ Standardization of change over time might not fully alleviate this; hence, residual practice effects may still be present. Furthermore, because dementia is clinically difficult to diagnose, some misclassification could have occurred, which may have led to an underestimation of the association. In addition, the number of incident dementia cases in the included cohort studies was low; we therefore cannot rule out a clinically relevant association between thyroid dysfunction and risk of dementia. The heterogeneity between studies may have been increased by the use of different cognitive function tests, different durations of follow-up, differences in age and sex distribution, different lifestyles across con-

tinents, and different inclusion criteria. As heterogeneity was expected a priori, we performed all meta-analyses with random effects. Nonetheless, results for fixed-effects meta-analyses were not materially different. The observed heterogeneity was larger in the longitudinal analyses heterogeneity ($I^2$ = 0%-70%) than in the cross-sectional analyses ($I^2$ = 0%-40%), likely owing to the additional variation of follow-up duration. We hypothesize that the minor differences in $I^2$ estimates between different cross-sectional analyses are attributable to differences in sample size per exposure. Because individuals with thyroid disease generally receive medical treatment, we cannot address the question of whether long-term untreated hyperthyroidism or hypothyroidism is associated with cognitive function and dementia risk. Moreover, these results only apply to objectifiable cognitive decline, which is not synonymous with the more subjective cognitive complaints.

## Conclusions

In this individual participant data analysis combining the individual participant data of 74 565 participants from 23 cohorts, subclinical thyroid dysfunction was not associated with cognitive function, cognitive decline, or risk of dementia. Hence, it is unlikely that treatment for otherwise undetected subclinical thyroid dysfunction would improve cognitive function. Moreover, the chance of overtreatment is considerable, which increases the risk of atrial fibrillation, atherosclerosis, and cerebral infarction and thereby might increase the risk of cognitive decline. Whether treatment of overt hypothyroidism or hyperthyroidism is associated with cognitive decline and risk of dementia remains uncertain. Existing clinical guidelines that prescribe screening of subclinical thyroid dysfunction for prevention of cognitive decline or dementia should therefore be revisited.

## ARTICLE INFORMATION

**Accepted for Publication:** July 15, 2021.

**Published Online:** September 7, 2021.
doi:10.1001/jamainternmed.2021.5078

**Open Access:** This is an open access article distributed under the terms of the CC-BY License. © 2021 van Vliet NA et al. JAMA Internal Medicine.

**Author Affiliations:** Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands (van Vliet, van Heemst, Blauw, Mooijaart, Westendorp, Gussekloo, Trompeta); Medical School, University of Western Australia, Perth, Western Australia, Australia (Almeida, Flicker, Yeap); Western Australian Centre for Health and Ageing, University of Western Australia, Perth, Western Australia, Australia (Almeida, Flicker); K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway (Åsvold); Department of Endocrinology, Clinic of Medicine, St Olav's Hospital, Trondheim University Hospital, Trondheim, Norway (Åsvold); HUNT Research

Center, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Levanger, Norway (Åsvold); Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland (Aubert, Moutzouri, Rodondi); Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland (Aubert, Moutzouri, Rodondi); Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (Aubert); Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (Aubert); Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, South Korea (Bae, Han, Kim); Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom (Barnes, Brayne); Division of General Internal Medicine, School of Medicine, University of California, San Francisco (Bauer); Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia (Cappola); Department of Medicine and Surgery, University of Parma, Unit

of Internal Medicine and Oncological Endocrinology, University Hospital of Parma, Parma, Italy (Ceresini); Department of Psychiatry, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (Comijs); GGZ inGeest Specialized Mental Health Care, Research and Innovation, Amsterdam, the Netherlands (Comijs); UMR 1219, Bordeaux Population Health Research Center, Inserm, University of Bordeaux, Bordeaux, France (Dartigues, Helmer); Department of Public Health and Primary Care, Katholieke Universiteit Leuven, Leuven, Belgium (Degryse, Vaes); Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium (Degryse); Division of Endocrinology, Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (Dullaart); University Center for Geriatric Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands (van Eersel); Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands (den Elzen); Atalmedial Diagnostics Centre, Amsterdam, the Netherlands (den Elzen); Department of Clinical Chemistry,
Amsterdam UMC, Amsterdam, the Netherlands (den Elzen); Longitudinal Studies Section, Translational Gerontology Branch, Harbor Hospital, Baltimore, Maryland (Ferrucci); National Institute on Aging NIA-Astra Unit, Baltimore, Maryland (Ferrucci); Geriatric Research Education and Clinical Center, VA Healthcare System, Minneapolis, Minnesota (Fink); Department of Medicine, University of Minnesota, Minneapolis (Fink); Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany (Grabe); German Center for Neurodegenerative Diseases (DZNE), Site Rostock/ Greifswald, Germany (Grabe); Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (Huisman); Department of Sociology, VU University Amsterdam, Amsterdam, the Netherlands (Huisman); Department of Epidemiology, Erasmus MC, Rotterdam, the Netherlands (Ikram); Department of Clinical Studies, Radiation Effects Research Foundation, Hiroshima and Nagasaki, Japan (Imaizumi, Yamada); Department of Internal Medicine and Endocrinology, Amsterdam UMC, Amsterdam, the Netherlands (de Jongh); Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (Jukema); Netherlands Heart Institute, Utrecht, the Netherlands (Jukema); Department of Brain and Cognitive Science, Seoul National University College of Natural Sciences, Seoul, South Korea (Kim); Department of Psychiatry, Seoul National University, College of Medicine, Seoul, South Korea (Kim); Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Kuller); Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (Lopez); Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea (Moon); Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany (Nauck); DZHK (German Centre for Cardiovascular Research), partner site, Greifswald, Germany (Nauck); Institute of Clinical Sciences, University of Birmingham, Birmingham, United Kingdom (Parle); Department of Internal Medicine, Erasmus MC, Rotterdam, the Netherlands (Peeters); Academic Center for Thyroid Diseases, Erasmus MC, Rotterdam, the Netherlands (Peeters); Division of Endocrinology, Diabetes and Clinical Nutrition, Department of Medicine, Oregon Health & Science University, Portland (Samuels); Department of Radiology, University Medicine Greifswald, Greifswald, Germany (Schmidt); Department of Neurology, University Medicine Greifswald, Greifswald, Germany (Schminke); Department of Biomedical Data Sciences, Section of Molecular Epidemiology, Leiden University Medical Center, Leiden, the Netherlands (Slagboom); Max Planck Institute for Biology of Ageing, Cologne, Germany (Slagboom); Namsos Hospital, Nord-Trøndelag Hospital Trust, Namsos, Norway (Stordal); Department of Mental Health, NTNU, Norwegian University of Science and Technology, Trondheim, Norway (Stordal); Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany (Völzke); Department of Public Health, Section of Epidemiology, Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark (Westendorp); Department of Endocrinology and

Diabetes, Fiona Stanley Hospital, Western Australia, Australia (Yeap); Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands (Gussekloo).

**Author Contributions:** Drs van Vliet and Trompet had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

**Concept and design:** van Vliet, Blauw, Comijs, Dartigues, den Elzen, Imaizumi, Mooijaart, Stordal, Westendorp, Gussekloo, Trompet.

**Acquisition, analysis, or interpretation of data:** van Vliet, van Heemst, Almeida, Åsvold, Aubert, Bae, Barnes, Bauer, Brayne, Cappola, Ceresini, Dartigues, Degryse, Dullaart, van Eersel, den Elzen, Ferrucci, Fink, Flicker, Grabe, Han, Helmer, Huisman, Ikram, Imaizumi, de Jongh, Jukema, Kim, Kuller, Lopez, Mooijaart, Moon, Moutzouri, Nauck, Parle, Peeters, Samuels, Schmidt, Schminke, Slagboom, Vaes, Völzke, Westendorp, Yamada, Yeap, Rodondi, Trompet.

**Drafting of the manuscript:** van Vliet, Barnes, Comijs, Dullaart, Mooijaart.

**Critical revision of the manuscript for important intellectual content:** van Vliet, van Heemst, Almeida, Åsvold, Aubert, Bae, Bauer, Blauw, Brayne, Cappola, Ceresini, Dartigues, Degryse, van Eersel, den Elzen, Ferrucci, Fink, Flicker, Grabe, Han, Helmer, Huisman, Ikram, Imaizumi, de Jongh, Jukema, Kim, Kuller, Lopez, Mooijaart, Moon, Moutzouri, Nauck, Parle, Peeters, Samuels, Schmidt, Schminke, Slagboom, Stordal, Vaes, Völzke, Westendorp, Yamada, Yeap, Rodondi, Gussekloo, Trompet.

**Statistical analysis:** van Vliet, Gussekloo.

**Obtained funding:** van Heemst, Almeida, Barnes, Comijs, Dartigues, Degryse, Dullaart, Flicker, Grabe, Helmer, Ikram, Kim, Mooijaart, Slagboom, Völzke, Yeap, Rodondi.

**Administrative, technical, or material support:** Bae, Barnes, Ceresini, Comijs, Dartigues, Dullaart, den Elzen, Flicker, Han, Kim, Moon, Moutzouri, Nauck, Peeters, Slagboom, Stordal, Vaes, Völzke, Yamada, Yeap, Rodondi.

**Supervision:** van Heemst, Blauw, van Eersel, Grabe, Ikram, Jukema, Kim, Lopez, Mooijaart, Westendorp, Gussekloo, Trompet.

**Conflict of Interest Disclosures:** Dr van Vliet reported grants from European Commission Horizon 2020 program during the conduct of the study. Dr van Heemst reported grants from European Commission during the conduct of the study; grants from Velux Stiftung (grant No. 1156) outside the submitted work. Dr Almeida reported grants from National Health and Medical Research Council of Australia during the conduct of the study and outside the submitted work. Dr Brayne reported grants from Medical Research Council during the conduct of the study. Dr Degryse reported grants from Fondation Louvain during the conduct of the study. Dr Flicker reported grants to the University of Western Australia from Australian National Health and Medical Research Council during the conduct of the study. Dr Grabe has received travel grants and speakers honoraria from Fresenius Medical Care, Neuraxpharm, Servier, and Janssen Cilag as well as research funding from Fresenius Medical Care outside the submitted work. Dr Huisman reported grants from Ministry of Health, Welfare and Sport for setting up and maintaining a prospective cohort study, of which data were used during the conduct of the study. Dr Lopez reported personal fees for consulting

from Biogen and Grifols outside the submitted work.

Dr Mooijaart reported nonfinancial support (provision of medication free of charge) from Merck during the conduct of the study. Dr Nauck reported grants from Federal Ministry of Education and Research, Germany, European Union Interreg IVa grants No. 01ZZ9603, 01ZZ0103, 01ZZ0403, 81Z7400171, 81Z7400173, INT-10-0008; personal fees for advisory boards and presentations from Radiometer, Becton Dickinson, AstraZeneca, Technopath Clinical Diagnostics, Novartis, Sysmex, Tosoh, medpoint Medizinkommunikations GmbH, ProteinT, and MDI Limbach; and travel/accommodations expenses covered or reimbursed from German Medical Association (BAK), German Centre for Cardiovascular Research (GCCR), National Cohort, German Society for Clinical Chemistry and Laboratory Medicine e.V. (DGKL), ISBER, DAKKS, Deutsche Forschungsgemeinschaft (DFG), European Association for the Study of Diabetes (EASD), and Max Rubner-Institut outside the submitted work. Dr Yeap reported grants from National Health and Medical Research Council of Australia during the conduct of the study. Dr Rodondi reported grants from Swiss National Science Foundation during the conduct of the study. No other disclosures were reported.

**Funding/Support:** This work was supported by the European Commission project THYRAGE (Horizon 2020 research and innovation program, 666869). The Thyroid Studies Collaboration is funded by a grant from the Swiss National Science Foundation (SNSF 320030-172676 to Dr Rodondi). This research was supported by contracts HHSN268201200036C, HHSN268200800007C, HHSN268201800001C, N01HC55222, N01HC85079, N01HC85080, N01HC85081, N01HC85082, N01HC85083, N01HC85086, 75N92021D00006, and grants U01HL080295 and U01HL130114 from the National Heart, Lung, and Blood Institute, with additional contribution from the National Institute of Neurological Disorders and Stroke. Additional support was provided by R01AG023629 from the National Institute on Aging. Dr Cappola received additional support from R01AG027058, Dr Kuller from R01AG15928, and Dr Lopez from R01AG20098. A full list of principal Cardiovascular Health Study investigators and institutions can be found at https://chs-nhlbi.org/. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH). This research was supported by National Institute on Aging contracts N01-AG-6-2101; N01-AG-6-2103; N01-AG-6-2106; National Institute on Aging grant R01-AG028050, and National Institute of Nursing Research grant R01-NR012459. This research was funded in part by the Intramural Research Program of the NIH National Institute on Aging. The Trøndelag Health Study (The HUNT Study) is a collaboration between HUNT Research Centre (Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology), Trøndelag County Council, Central Norway Regional Health Authority, and the Norwegian Institute of Public Health. Information on incident dementia diagnoses for the HUNT study population was provided by Nord-Trøndelag Hospital Trust. The InCHIANTI study was supported as a "targeted project" (ICS110.1/RF97.71) by the Italian Ministry of Health and in part by the US National Institute on Aging (contracts: 263 MD
9164 and 263 MD 821336), supported in part by the Intramural Research Program of the NIH National Institute on Aging, Baltimore, Maryland. This study was supported by a grant from the Korean Health Technology R&D Project, Ministry of Health and Welfare, Republic of Korea (grant no. H109C1379 [A092077]). The Longitudinal Aging Study Amsterdam is supported by a grant from the Netherlands Ministry of Health Welfare and Sports, Directorate of Long-Term Care. The Osteoporotic Fractures in Men Study is supported by NIH funding. The following institutes provide support: the National Institute on Aging, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Center for Advancing Translational Sciences, and NIH Roadmap for Medical Research under the following grant numbers: U01 AG027810, U01 AG042124, U01 AG042139, U01 AG042140, U01 AG042143, U01 AG042145, U01 AG042168, U01 AR066160, and UL1 TRO00128. MHS is supported by NIH NCATS UL1TRO02369, The Oregon Clinical and Translational Institute. The PREVEND study was funded by the Dutch Kidney Foundation (https://nierstichting.nl/; grant E.033). This study was partly funded by the Dutch Alzheimer Foundation (https://www.alzheimer-nederland.nl/). The Radiation Effects Research Foundation (RERF), Hiroshima and Nagasaki, Japan is a public interest foundation funded by the Japanese Ministry of Health, Labour and Welfare and the US Department of Energy. This publication was supported by RERF Research Protocol RP-A2-16. The views of the authors do not necessarily reflect those of the 2 governments. SHIP (Study of Health in Pomerania) is part of the Community Medicine Research Network of the University Medicine Greifswald, which is supported by the German Federal State of Mecklenburg-West Pomerania.

**Role of the Funder/Sponsor:** The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

**Participating Studies of the Thyroid Studies Collaboration:** United States: Cardiovascular Health Study; Health, Aging, and Body Composition Study; and the Osteoporotic Fractures in Men (MrOS) Study. Norway: Nord-Trøndelag Health Study (HUNT Study). The Netherlands: Leiden 85-Plus Study; Prevention of Renal and Vascular End-stage Disease Study (PREVEND Study); and the Rotterdam Study. The Netherlands/Ireland/ Scotland: Prospective Study of Pravastatin in the Elderly at Risk (PROSPER Study). Italy: Invecchiare in Chianti (InCHIANTI) Study. Belgium: BELFRAIL Study. Germany: Study of Health in Pomerania (SHIP). Australia: Health in Men Study. Japan: Nagasaki Adult Health Study (Radiation Effects Research Foundation, RERF). Republic of Korea: Korean Longitudinal Study on Cognitive Aging and Dementia KLoSCAD); and Korean Longitudinal Study on Health and Aging (KLoSHA).

**Additional Contributions:** We thank all study participants for making this study possible. We thank Lilia Cárdenas-Ibarra, MD, for providing data from the Mexican Memory Clinic; she was compensated for this contribution.

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