Validation of neuroimaging-based brain age gap as a mediator between modifiable risk factors and cognition

Neuroimaging-based brain age gap (BAG) is presumably a mediator linking modifiable risk factors to cognitive changes, but this has not been verified yet. To address this hypothesis, modality-specific brain age models were constructed and applied to a population-based cohort (N = 326) to estimate their BAG. Structural equation modeling was employed to investigate the mediation effect of BAG between modifiable risk factors (assessed by 2 cardiovascular risk scores) and cognitive functioning (examined by 4 cognitive assessments). The association between higher burden of modifiable risk factors and poorer cognitive functioning can be significantly mediated by a larger BAG (multimodal: p = 0.014, 40.8% mediation proportion; white matter-based: p = 0.023, 15.7% mediation proportion), which indicated an older brain. Subgroup analysis further revealed a steeper slope (p = 0.019) of association between cognitive functioning and multimodal BAG in the group of higher modifiable risks. The results confirm that BAG can serve as a mediating indicator linking risk loadings to cognitive functioning, implicating its potential in the management of cognitive aging and dementia.