Morbidity and comorbidity in relation to functional status: a community-based study of the oldest old (90+ years)

Modifiable Risk Factors and Change in Cognition of Māori and Non-Māori in Advanced Age: LiLACS NZ

OBJECTIVE

This study investigated whether previously identified modifiable risk factors for dementia were associated with cognitive change in Māori (indigenous people of New Zealand) and non-Māori octogenarians of LiLACS NZ (Life and Living in Advanced Age; a Cohort Study in New Zealand), a longitudinal study.

METHOD

Multivariable repeated-measure mixed effect regression models were used to assess the association between modifiable risk factors and sociodemographic variables at baseline, and cognitive change over 6 years, with p values of <.05 regarded as statistically significant.

RESULTS

Modifiable factors associated with cognitive change differed between ethnic groups. Depression was a negative factor in Māori only, secondary education in non-Māori was protective, and obesity predicted better cognition over time for Māori. Diabetes was associated with decreased cognition for both Māori and non-Māori.

CONCLUSION

Our results begin to address gaps in the literature and increase understanding of disparities in dementia risk by ethnicity. These findings have implications for evaluating the type and application of culturally appropriate methods to improve cognition.

Hip Fracture in Nonagenarians: Characteristics and Factors Related to 30-Day Mortality in 1177 Patients

BACKGROUND

The number of nonagenarian patients with hip fracture is increasing. The goals of this study were to describe the characteristics and in-hospital course of a cohort of 1177 nonagenarians admitted for hip fracture compared with younger patients and to identify risk factors for 30-day mortality after admission.

METHODS

This is a retrospective observational cohort study including patients aged 65 years or older admitted for hip fracture during various periods from February 1997 to December 2016. We defined 3 age groups: 65-79, 80-89, and 90 years and older. We included sociodemographic variables, baseline functional status, comorbidities, fracture and surgical characteristics, postoperative complications, length of stay, and in-hospital and 30-day mortality. Multiple logistic regression analysis was used to study risk factors for 30-day mortality in surgically treated nonagenarians.

RESULTS

Nonagenarians were more likely to be women and to have dementia and heart disease. Some 72% walked independently before the fracture. The most relevant treatable risk factor for 30-day mortality in nonagenarians (in terms of higher odds ratio [OR]) was developing respiratory infection (OR: 4.56, 95% confidence interval [CI]: 2.73-7.63). Better prefracture functional status (higher Katz score; OR: 0.83, 95% CI: 0.74-0.92) and spinal anesthesia (OR: 0.19, 95% CI: 0.05-0.68) decreased risk of 30-day mortality.

CONCLUSIONS

Nonagenarian patients with hip fracture differ significantly from younger patients concerning clinical characteristics, medical complications, and in-hospital and 30-day mortality rates. We identified several variables on which we could act to reduce 30-day mortality, such as respiratory infection, electrolyte disorders, polypharmacy, cardiac arrhythmia, and spinal anesthesia.

Cognitive, functional, physical, and nutritional status of the oldest old encountered in primary care: a systematic review

Background

The oldest old (individuals over 90 years) are a fast-growing population. Characterizing their specificity would be helpful to adapt health care. This study aimed to characterize the cognitive, functional, nutritional, and physical status of individuals over 90.

Methods

We conducted a systematic review of cross-sectional or cohort studies of individuals aged 90 years old or more, living at home or in a nursing home, in April 2018. Two reviewers selected eligible articles, extracted data, and evaluated the risk of bias (assessed by the Newcastle-Ottawa Scale).

Results

The search strategy identified 3086 references; 35 articles were included referring to 8 cross-sectional and 27 longitudinal studies. Dementia was diagnosed in 30–42.9% of study participants, cognitive impairment in 12–50%, and 31–65% had no cognitive impairment. In terms of activities of daily living, 14–72.6% of individuals had no difficulty, 35.6–38% had difficulty, and 14.4–55.5% were dependent. For instrumental activities of daily living, 20–67.9% needed help. Regarding nutritional status, the Mini Nutritional Assessment Short Form mean score ranged from 10.3 (SD: 1.8) to 11.1 (SD: 2.4). Eight to 32% of individuals could not stand up from a chair, 19–47% could stand without the use of their arms; and 12.9–15% were not able to walk 4 m.

Conclusions

These results suggest a heterogeneous population with a certain proportion of oldest old with a low level of disability. These findings suggest that a specific approach in the care of the oldest old could help prevent disability.

Trajectories of Nonagenarian Health: Sex, Age, and Period Effects

The US population aged 90 years or more is growing rapidly, and there are limited data on their health. The Cardiovascular Health Study is a prospective study of black and white adults aged ≥65 years recruited in 2 waves (1989-1990 and 1992-1993) from Medicare eligibility lists in Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Pittsburgh, Pennsylvania. We created a synthetic cohort of the 1,889 participants who had reached age 90 years at baseline or during follow-up through July 16, 2015. Participants entered the cohort at 90 years of age, and we evaluated their changes in health after age 90 years (median duration of follow-up, 3 years (interquartile range, 1.3-5)). Measures of health included cardiovascular events, cognitive function, depressive symptoms, prescription medications, self-rated health, and functional status. The mortality rate was high: 19.0 per 100 person-years (95% confidence interval : 17.8, 20.3) in women and 20.9 per 100 person-years (95% confidence interval: 19.2, 22.8) in men. Cognitive function and all measures of functional status declined with age; these changes were similar by sex. When we isolated period effects, we found that medication use increased over time. These estimates can help inform future research and can help health-care systems meet the needs of this growing population.

Resource use and its association to cognitive impairment, ADL functions, and behavior in residents of Swedish nursing homes: Results from the U-Age program (SWENIS study)

OBJECTIVES

We aimed to investigate resource use and its association to cognitive impairment, activities of daily living, and neuropsychiatric symptoms in residents of Swedish nursing homes.

METHODS

Data were collected in 2014 from a Swedish national sample of nursing home residents (n = 4831) and were collected by staff in the facility. The sample consists of all nursing homes in 35 of 60 randomly selected Swedish municipalities. Demographic data and data on resource use, cognitive and physical function as well as neuropsychiatric symptoms were collected through proxies. Descriptive statistics and regression modeling were used to investigate this association.

RESULTS

We found that cognitive impairment, activities of daily living, and neuropsychiatric symptoms were associated with 23 hours per week increase in total resource use versus cognitively intact persons. This was also the case for being dependent in activities of daily living. Being totally dependent increased the amount of resource use by 25 hours per week. The sex of a resident did not influence the resource use. Annual costs of resource use with no functional dependency were 359 685 SEK, and in severely cognitive impaired resident, the cost was 825 081 SEK.

CONCLUSION

Being cognitively impaired as well as functionally dependent increases the resource use significantly in nursing homes. This has implications for differentiation of costs in institutional settings in health economic evaluations.

Factors associated with low levels of physical activity among elderly residents in a small urban area in the interior of the Brazilian Amazon

The aim of the present study was to investigate levels of physical activity and risk factors for inactivity in older adults living in an urban area in the interior of the Amazonas state, Brazil. Data were collected between 2013 and 2015 from 274 individuals 60 years of age or older who resided in the interior of the Brazilian Amazon. Sociodemographic, general health, functional capacity and physical performance were associated with self-referred physical activity level. A multivariate analysis, after adjustment, showed that being a man, having a body mass index above 27kg/m², never having lived in riverside communities and having less than three associated chronic diseases were independent risk factors for low levels of physical activity among elderly residing in the interior of the Brazilian Amazon. Few studies have been conducted about the characteristics that are singular to this population. Our results suggest that the physical activity level and, consequently, the aging process of the elderly is influenced by where they have resided throughout their lives. Additionally, the results showed particular risk factors associated with low physical activity level among older adults residing in the interior of the state of Amazonas.

Incidence of ADL Disability in Older Persons, Physical Activities as a Protective Factor and the Need for Informal and Formal Care--Results from the SNAC-N Project

Background

The aim of the study was to examine 1) the incidence of disability in Activities of Daily Living (ADL), in persons 78 years and older 2) explore whether being physical active earlier is a significant predictor of being disability free at follow-up and 3) describe the amount of informal and formal care in relation to ADL-disability.

Methods

Data were used from a longitudinal community-based study in Nordanstig (SNAC-N), a part of the Swedish National Study on Aging and Care (SNAC). To study objectives 1) and 2) all ADL-independent participants at baseline (N = 307) were included; for objective 3) all participants 78 years and older were included (N = 316). Data were collected at baseline and at 3- and 6-year follow-ups. ADL-disability was defined as a need for assistance in one or more activities. Informal and formal care were measured using the Resource utilization in Dementia (RUD)-instrument.

Results

The incidence rates for men were similar in the age groups 78-81and 84 years and older, 42.3 vs. 42.5/1000 person-years. For women the incidence rate for ADL-disability increased significantly from the age group 78–81 to the age group 84 years and older, 20.8 vs.118.3/1000 person-years. In the age group 78–81 years, being physically active earlier (aOR 6.2) and during the past 12 month (aOR 2.9) were both significant preventive factors for ADL-disability. Both informal and formal care increased with ADL-disability and the amount of informal care was greater than formal care. The incidence rate for ADL-disability increases with age for women and being physically active is a protective factor for ADL-disability.

Conclusion

The incidence rate for ADL-disability increases with age for women, and being physical active is a protective factor for ADL-disability.

[The NonaSantfeliu study. Baseline assessment and ten years of follow-up]

NonaSantfeliu study: A review is presented of the studies that are part of the initial overall assessment and the studies performed during the 10 years of follow-up of a cohort of nonagenarians. It is a population-based study of 186 subjects, 76.5% women, mean age at baseline of 93.06 years, a quarter (26%) being institutionalized. The mean of baseline Barthel index was 60.8, and the mean for the Lobo's cognitive minimental was 21. Nonagenarian males with low comorbidity had more successful aging criteria than women with high comorbidity quantified with the Charlson Index. The survival rate at 10 years follow-up was very low, and 95.6% of the population had died. This represented an annual mortality rate of 9.5%. A common denominator on assessing all different annual cuts, is that the most important factors associated with mortality are those related to geriatric assessment, such as a function, cognition, dementia, and cumulative comorbidity and multiple medications, compared to more traditional risk factors described in younger populations.

Time trends in prevalence of activities of daily living (ADL) disability and survival: comparing two populations (aged 78+ years) living in a rural area in Sweden

The aim was to study time trends in prevalence of disability in ADL and survival among men and women 78 years and older comparing two cohorts. The study was a time trend study based on two population-based community cohorts, the Nordanstig Project (NP), collected 1995-1998 and the Swedish National Study on Aging and Care in Nordanstig (SNAC-N), collected 2001-2003. The participants were people aged 78 years and older from the NP cohort (N=303) and from the SNAC-N cohort (N=406). All were clinically examined by physicians and nurses using standardized protocols. Disability was defined as a need for assistance in one or more ADL activities. The prevalence of disability and survival were compared using logistic and Cox models. The prevalence of ADL disability was stable for men, while women became more disabled in ADL during the time period, OR 2.36 (1.12-4.94). There was no significant difference in survival time between the cohorts in either ADL disabled persons or non-disabled persons. There was a tendency for increased survival for non-disabled persons in SNAC-N compared with NP, although not significant; this was particularly true for women. In general, women survived longer than men did regardless of whether they were ADL disabled or not. The time trends for ADL disability found in the study show that ADL disability had increased in women but not in men. More studies are needed to identify risk factors for ADL disability with a view to preventing it in time.

In nonagenarians, acute kidney injury predicts in-hospital mortality, while heart failure predicts hospital length of stay

BACKGROUND/AIMS

The elderly constitute an increasing proportion of admitted patients worldwide. We investigate the determinants of hospital length of stay and outcomes in patients aged 90 years and older.

METHODS

We retrospectively analyzed all admitted patients aged >90 years from the general medical wards in a tertiary referral medical center between August 31, 2009 and August 31, 2012. Patients' clinical characteristics, admission diagnosis, concomitant illnesses at admission, and discharge diagnosis were collected. Each patient was followed until discharge or death. Multivariate logistic regression analysis was utilized to study factors associated with longer hospital length of stay (>7 days) and in-hospital mortality.

RESULTS

A total of 283 nonagenarian in-patients were recruited, with 118 (41.7%) hospitalized longer than one week. Nonagenarians admitted with pneumonia (p = 0.04) and those with lower Barthel Index (p = 0.012) were more likely to be hospitalized longer than one week. Multivariate logistic regression analysis revealed that patients with lower Barthel Index (odds ratio [OR] 0.98; p = 0.021) and those with heart failure (OR 3.05; p = 0.046) had hospital stays >7 days, while patients with lower Barthel Index (OR 0.93; p = 0.005), main admission nephrologic diagnosis (OR 4.83; p = 0.016) or acute kidney injury (OR 30.7; p = 0.007) had higher in-hospital mortality.

CONCLUSION

In nonagenarians, presence of heart failure at admission was associated with longer hospital length of stay, while acute kidney injury at admission predicted higher hospitalization mortality. Poorer functional status was associated with both prolonged admission and higher in-hospital mortality.

Dementia in the oldest old: a multi-factorial and growing public health issue

The population of oldest old, or people aged 85 and older, is growing rapidly. A better understanding of dementia in this population is thus of increasing national and global importance. In this review, we describe the major epidemiological studies, prevalence, clinical presentation, neuropathological and imaging features, risk factors, and treatment of dementia in the oldest old. Prevalence estimates for dementia among those aged 85+ ranges from 18 to 38%. The most common clinical syndromes are Alzheimer's dementia, vascular dementia, and mixed dementia from multiple etiologies. The rate of progression appears to be slower than in the younger old. Single neuropathological entities such as Alzheimer's dementia and Lewy body pathology appear to have declining relevance to cognitive decline, while mixed pathology with Alzheimer's disease, vascular disease (especially cortical microinfarcts), and hippocampal sclerosis appear to have increasing relevance. Neuroimaging data are sparse. Risk factors for dementia in the oldest old include a low level of education, poor mid-life general health, low level of physical activity, depression, and delirium, whereas apolipoprotein E genotype, late-life hypertension, hyperlipidemia, and elevated peripheral inflammatory markers appear to have less relevance. Treatment approaches require further study, but the oldest old may be more prone to negative side effects compared with younger patients and targeted therapies may be less efficacious since single pathologies are less frequent. We also highlight the limitations and challenges of research in this area, including the difficulty of defining functional decline, a necessary component for a dementia diagnosis, the lack of normative neuropsychological data, and other shortcomings inherent in existing diagnostic criteria. In summary, our understanding of dementia in the oldest old has advanced dramatically in recent years, but more research is needed, particularly among varied racial, ethnic, and socioeconomic groups, and with respect to biomarkers such as neuroimaging, modifiable risk factors, and therapy.

Self-reported activities of daily living and performance-based functional ability: a study of congruence among the oldest old

Although researchers and clinicians tend to use subjective evaluations of functioning and objective assessments interchangeably, there may be important differences between how people view their own abilities and objective indicators. This study aims to examine the relation between self-reported evaluations of function and health and performance-based (PB) measures of functional ability and objective health indicators in a sample of the oldest old. The study is based on data from a sample of 349 individuals aged 80 and older from the OCTO-Twin Study. One member of each twin pair was randomly selected for this study. The result demonstrates that subjective evaluations of functional ability are significantly associated with objective measures of health and PB measures of function although considerable variance remained unexplained. The association of PB measures to the self-report evaluations differed by measure. PB measures had stronger associations with self-reported functioning than objective health indicators such as diseases and medications. PB balance was related to self-reported function in instrumental activities in daily life (IADL) and self-reported mobility, whereas PB upper body strength and flexibility was associated with all three self-reports of function but not to perceived health. The strength of these associations did not differ from one another suggesting that PB balance and upper body strength and flexibility have comparable effects on self-reports of daily life function. From a practical perspective, our findings confirm that self-reported ADL reflects objective measures of functioning, but probably also has subjective components that need further exploration. The result also indicates a need for multiple measures in evaluating functional ability in the oldest old.

Brain aging in the oldest-old

Nonagenarians and centenarians represent a quickly growing age group worldwide. In parallel, the prevalence of dementia increases substantially, but how to define dementia in this oldest-old age segment remains unclear. Although the idea that the risk of Alzheimer's disease (AD) decreases after age 90 has now been questioned, the oldest-old still represent a population relatively resistant to degenerative brain processes. Brain aging is characterised by the formation of neurofibrillary tangles (NFTs) and senile plaques (SPs) as well as neuronal and synaptic loss in both cognitively intact individuals and patients with AD. In nondemented cases NFTs are usually restricted to the hippocampal formation, whereas the progressive involvement of the association areas in the temporal neocortex parallels the development of overt clinical signs of dementia. In contrast, there is little correlation between the quantitative distribution of SP and AD severity. The pattern of lesion distribution and neuronal loss changes in extreme aging relative to the younger-old. In contrast to younger cases where dementia is mainly related to severe NFT formation within adjacent components of the medial and inferior aspects of the temporal cortex, oldest-old individuals display a preferential involvement of the anterior part of the CA1 field of the hippocampus whereas the inferior temporal and frontal association areas are relatively spared. This pattern suggests that both the extent of NFT development in the hippocampus as well as a displacement of subregional NFT distribution within the Cornu ammonis (CA) fields may be key determinants of dementia in the very old. Cortical association areas are relatively preserved. The progression of NFT formation across increasing cognitive impairment was significantly slower in nonagenarians and centenarians compared to younger cases in the CA1 field and entorhinal cortex. The total amount of amyloid and the neuronal loss in these regions were also significantly lower than those reported in younger AD cases. Overall, there is evidence that pathological substrates of cognitive deterioration in the oldest-old are different from those observed in the younger-old. Microvascular parameters such as mean capillary diameters may be key factors to consider for the prediction of cognitive decline in the oldest-old. Neuropathological particularities of the oldest-old may be related to "longevity-enabling" genes although little or nothing is known in this promising field of future research.

Functional capacity of elder elderly: comparative study in three regions of Rio Grande do Sul

Study conducted with secondary data from cross-sectional population-based studies developed in three regions of the state of Rio Grande do Sul (RS), which aimed to compare the level of dependency for activities of daily living (ADL) of 155 older persons aged 80 years and over. Demographic data and the ADL scale from the 3 studies were used and a multinomial multivariate logistic regression analysis was carried out. The older persons from the urban region of Porto Alegre/RS and from the Northern region of this state presented significantly higher severe dependency than people from the countryside. The results illustrate the heterogeneity of the aging process. Health policies and actions should be planned for the elder elderly in this state.

The prevalence of disability in the oldest-old is high and continues to increase with age: findings from The 90+ Study

OBJECTIVES

To examine the prevalence and type of disability in the oldest-old (90+), the fastest growing age group in the United States.

METHODS

The current study included functional data on 697 participants from The 90+ Study, a population-based longitudinal study of aging and dementia in people aged 90 and older. Data were obtained by participant's informants via a written questionnaire. The prevalence of disability was calculated for two definitions using activities of daily living (ADLs). ADL difficulty was defined as difficulty with one or more ADLs whereas ADL dependency was defined as needing help on one or more ADLs.

RESULTS

ADL difficulty was present in 71% in 90-94 year olds, 89% in 95-99 year olds, and 97% in centenarians. ADL dependency was present in 44% of 90-94 year olds, 66% of 95-99 year olds, and 92% of centenarians. The ADL most commonly causing difficulty was walking (70%) whereas the ADL most commonly causing dependency was bathing (51%). Age, gender, and institutionalization were significantly associated with both ADL difficulty and ADL dependency.

CONCLUSIONS

Similar to studies in younger individuals, the current study suggests that the prevalence of disability continues to increase rapidly in people aged 90 and older. With the rapid growth in the number of people in this age group, disability in the oldest-old has major public health implications.

A health profile of community-living nonagenarians in Canada

Due to increasing life expectancy over time, persons who live into their ninety, known as nonagenarians, are an important and growing segment of the Canadian population. In 2001, there were 130,325 nonagenarians (compared to 3,795 centenarians), and it is estimated that they will top 400,000 by 2026. This paper provides a health profile and an exploratory analysis of selected social determinants of health for community-living nonagenarians, using the 2001 Canadian Community Health Survey (Statistics Canada, 2003). Perceived health, selection of prevalent chronic illnesses, and several health behaviours are examined. One dominant pattern is the tendency for male nonagenarians to be in better health than their female counterparts. This finding is consistent with research on centenarians and is discussed in terms of a mortality selection effect. Other key findings include the strength of sense of belonging, income, and physical activity as potential social determinants of health, connected to particular dimensions of health status.

Clinicopathologic correlates in the oldest-old: Commentary on "No disease in the brain of a 115-year-old woman"

den Dunnen et al. [den Dunnen, W.F.A., Brouwer, W.H., Bijlard, E., Kamphuis, J., van Linschoten, K., Eggens-Meijer, E., Holstege, G., 2008. No disease in the brain of a 115-year-old woman. Neurobiol. Aging] had the opportunity to follow up the cognitive functioning of one of the world's oldest woman during the last 3 years of her life. They performed two neuropsychological evaluations at age 112 and 115 that revealed a striking preservation of immediate recall abilities and orientation. In contrast, working memory, retrieval from semantic memory and mental arithmetic performances declined after age 112. Overall, only a one-point decrease of MMSE score occurred (from 27 to 26) reflecting the remarkable preservation of cognitive abilities. The neuropathological assessment showed few neurofibrillary tangles (NFT) in the hippocampal formation compatible with Braak staging II, absence of amyloid deposits and other types of neurodegenerative lesions as well as preservation of neuron numbers in locus coeruleus. This finding was related to a striking paucity of Alzheimer disease (AD)-related lesions in the hippocampal formation. The present report parallels the early descriptions of rare "supernormal" centenarians supporting the dissociation between brain aging and AD processes. In conjunction with recent stereological analyses in cases aged from 90 to 102 years, it also points to the marked resistance of the hippocampal formation to the degenerative process in this age group and possible dissociation between the occurrence of slight cognitive deficits and development of AD-related pathologic changes in neocortical areas. This work is discussed in the context of current efforts to identify the biological and genetic parameters of human longevity.

Risk factors for functional decline in nonagenarians: a one-year follow-up. The NonaSantfeliu study

BACKGROUND

Disability and a decline in functional capacity are common in old age.

OBJECTIVE

To determine predictors of functional decline in nonagenarians' basic activities of daily living (ADL) after 1 year of follow-up.

METHODS

A sample of 97 nonagenarians subjects not previously severely dependent (Barthel Index >59) was evaluated. This sample included 72 women (74.2%) and the mean (SD) age was 93.4 +/- 2.7 years. The following data were collected: sociodemographic data, Barthel Index (BI), Lawton-Brody Index (LI), Mental State Examination (MEC), a short version of the Mini-Nutritional Assessment, comorbidity (Charlson Index), lower-extremity function, Gait Rating Scale from the Tinetti Performance-Oriented Mobility Scale and prevalent chronic diseases. Subjects who had a 10-point or higher decline in the BI in 1 year were compared to subjects who had no decline or a maximum decline of 9 points. In addition, subjects whose total BI score fell below 60 were compared to the group of subjects who maintained scores between 60 and 100. The Student's t test, the chi(2) or the Fisher's exact test, and a multiple logistic regression analysis (with the identified risk factors of age and gender) were performed.

RESULTS

39 nonagenarians experienced a 10-point or higher decline in the BI in 1 year. A lower LI score (p = 0.003) and visual impairment (p = 0.01) were associated with functional decline. The multiple regression analysis showed that there was a significant association with LI (odds ratio (OR) 0.74, confidence interval 95% 0.60-0.91, p < 0.005). The 18 nonagenarians who had a BI <60 had a BI >60 at baseline. Lower scores on the LI (p = 0.004) and on the MEC (p = 0.01), a history of a previous stroke (p = 0.009) and higher Charlson Index scores (p = 0.03) were associated with recently acquired, severe dependency. A multiple regression analysis showed a significant association between LI (OR 0.65, 0.47-0.89, p < 0.008) and a history of previous strokes (OR 3.39, 1.01-11.34, p < 0.04).

CONCLUSIONS

According to the definition used to describe functional basic ADL decline, poor performance in instrumental ADL at baseline and a history of a stroke appear to be independent risk factors. Prevention strategies could be intensified in this subgroup of nonagenarians.

Morphological substrates of cognitive decline in nonagenarians and centenarians: a new paradigm?

Brain aging is characterized by the formation of neurofibrillary tangles (NFT) and senile plaques (SP) in both cognitively intact individuals and patients with Alzheimer's disease (AD). The ubiquitous presence of these lesions and the steady increase of the prevalence of dementia up to 85 years have strongly supported a continuum between normal brain aging and AD. In this context, the study of nonagenarians and centenarians could provide key informations about the characteristics of extreme aging. We provide here a detailed review of currently available neuropathological data in very old individuals and critically discuss the patterns of NFT, SP and neuronal loss distribution as a function of age. In younger cohorts, NFTs are usually restricted to hippocampal formation, whereas clinical signs of dementia appear when temporal neocortex is involved. SPs would not be a specific marker of cognitive impairment as no correlation was found between their quantitative distribution and AD severity. The low rate of AD lesions even in severe AD as well as the weakness of clinicopathological correlations reported in the oldest-old indicate that AD pathology is not a mandatory phenomenon of increasing chronological age. Our recent stereological observations of hippocampal microvasculature in oldest-old cases challenge the traditional lesional model by revealing that mean capillary diameters is an important structural determinant of cognition in this age group.

Alzheimer's and dementia in the oldest-old: a century of challenges

Alzheimer's disease (AD) is the most common type of dementia in the US and much of the world with rates increasing exponentially from age 65. Increases in life expectancy in the last century have resulted in a large number of people living to old ages and will result in a quadrupling of AD cases by the middle of the century. Preventing or delaying the onset of AD could have a huge impact in the number of cases expected to develop. The oldest-old are the fastest growing segment of the population and are estimated to account for 12% of the population over 65. Establishing accurate estimates of dementia and AD rates in this group is crucial for public health planning. Prevalence and incidence estimates above age 85 are imprecise and inconsistent because of the lack of very old individuals in most studies. Moreover, risk and protective factors in our oldest citizens have been studied little, and clinical-pathological correlations appear to be poor. We introduce The 90+ Study, established to address some of the unanswered questions about AD and dementia in the oldest-old. Our preliminary results show that close to half of demented oldest-old do not have known cerebral pathology to account for their cognitive deficits. Furthermore, the APOE-e4 allele appears to be a risk factor for AD only in the women in our study. In addition to the challenge of preventing and treating AD, the oldest-old will require major investigative energy to better understand the concomitants of longevity, the causes of dementia, and the factors that promote successful aging in oldest citizens.

Dementia-free survival among centenarians: an evidence-based review

BACKGROUND

The 2000 U.S. census identified 50,454 Americans older than 100 years (18 per 100,000). Increased longevity is only of benefit if accompanied by the maintenance of physical, social, and cognitive function into advanced age. The goal of this review was to identify research describing centenarians to find the prevalence of dementia-free survival.

METHODS

We reviewed 650 publications to find studies that described the prevalence of dementia in centenarians, were community-based, had data that were specific to persons older than 100 years, and were published in peer-reviewed journals. For each study, we identified the prevalence of dementia, the completeness of the sample, the number of study participants, the method used to diagnose dementia, and the duration of the study.

RESULTS

We identified 20 research groups from 14 countries with publications meeting our search criteria. The studies showed substantial variation in methods of assessing cognitive status, assuring a complete cohort, and sample size. Few studies reported longitudinal data or attempted diagnosis of the cause of dementia. The prevalence of dementia-free survival past 100 years of age varied between 0 and 50 percent.

CONCLUSIONS

The methodology used in studies regarding dementia prevalence among centenarians is sufficiently varied that combination of existing studies into a meta-analysis is not possible. Suggestions for assuring quality in future centenarian research are presented.

Health status in the oldest old. Age and sex differences in the Umeå 85+ Study

BACKGROUND AND AIMS

With an increasing population aged 85 years and over, the aim of this study was to describe health status and living conditions in the oldest old and to estimate age and sex differences in a Northern European population.

METHODS

A population-based cross-sectional study, The Umeå 85+ Study, was carried out in the municipality of Umeå in northern Sweden. Out of 319 eligible participants aged 85, 90 and 95 years and over, 253 participated. Structured interviews and assessments were conducted with the participants in their homes, and data were also collected from relatives, caregivers and medical charts. Cognition was screened with the Mini-Mental State Examination (MMSE), depressive symptoms with the Geriatric Depression Scale-15 (GDS-15) and nutritional status with the Mini Nutritional Assessment (MNA). Activities of daily living (ADL) were assessed applying the Staircase of ADL (including Katz' Index of ADL) and morale with the Philadelphia Geriatric Center Morale Scale (PGCMS). Participants also rated their own health.

RESULTS

Over half of the participants had hypertension, one out of four was depressed, and the same proportion had had a hip fracture; the mean number of drugs taken was 6.4+/-4.0. Younger participants had lower rates of diagnoses and prescribed drugs, and were less dependent in ADL and other functional variables; men had lower rates of diagnoses and reported symptoms. The majority of participants rated their general health and morale as good.

CONCLUSIONS

There were large variations in social, medical and functional variables within and between age and sex groups. This northern population of the oldest old seems to have a very high prevalence of hypertension, depression, hip fractures, and many prescribed drugs.

Mayo's Older African Americans Normative Studies: normative data for commonly used clinical neuropsychological measures

This report describes the methodology and sample characteristics of Mayo's Older African Americans Normative Studies (MOAANS). These studies reflect a multidisciplinary, collaborative effort by investigators at Mayo Clinic to provide age-appropriate normative data for African American elders on commonly used neuropsychological tests. A sample of 309 community-dwelling individuals over age 55 contributed to the MOAANS sample. Norms were calculated for midpoint age groups, based on percentile scores derived from cumulative frequencies of raw test scores. Demographic, medical, and sociocultural data were also collected, and are summarized to assist clinicians in making determinations regarding the appropriateness of these norms for individual patients. In most cases, the use of MOAANS norms should improve diagnostic accuracy in dementia evaluations of African American elders.

Comprehensive Health Status Assessment of Centenarians: Results From the 1999 Large Health Survey of Veteran Enrollees

BACKGROUND

Information on the health status of centenarians provides a means for understanding the health care needs of this growing population. Therefore, we examined the health status of a national cohort of centenarian veteran enrollees.

METHODS

Ninety-three centenarian veteran enrollees returned a complete health history questionnaire, which included questions about sociodemographic information, age-associated conditions, health behaviors, health-related quality of life as measured by the Veterans SF-36, and change in health status.

RESULTS

Centenarian veteran enrollees are a group with major impairment across multiple dimensions of health-related quality of life despite having a relatively low prevalence of diseases. They had considerable physical limitations as reflected by their physical health summary scores (26.2 +/- 8.3). However, their mental health was comparatively good (mental health summary score 44.1 +/- 12.5). Compared to younger elderly veterans (ages 85-99), centenarians had a lower prevalence of hypertension, angina or myocardial infarction, diabetes, and chronic low back pain (p <.05). Centenarians had significantly worse physical functioning, role physical, vitality, and social functioning scores than did younger elderly veterans. The two groups did not differ in their general health, bodily pain, role emotional, and mental health scores. Centenarians did not perceive much decline in their physical or mental health during the preceding year.

CONCLUSIONS

Centenarian veteran enrollees are a group with a low number of age-associated diseases and good mental health despite substantial physical limitations. These results support future studies of services directed toward improvement of function as opposed to those focused solely on the treatment of diseases.

Influence of acute exacerbation of chronic obstructive pulmonary disease or congestive heart failure on functional decline after hospitalization in nonagenarian patients

BACKGROUND: The functional decline that follows hospitalization may be especially important in frail populations such as nonagenarians. The present study examined the functional decline among nonagenarians admitted because of exacerbations of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF). METHODS: A prospective cohort study was performed on two groups of patients who were distinguished by diagnosis in two tertiary academic medical hospitals. Sixty nonagenarian patients, admitted because of exacerbation of COPD (n=30) or CHF (n=30), were evaluated at admission, upon discharge, and 3 months post-hospitalization. The Barthel Index (BI) was used to assess functionality. The outcome we were interested in was functional decline 3 months after hospital discharge. RESULTS: The inpatient mortality rate was 10%. Overall functional status at discharge, as compared with that before admission, declined in all 54 surviving patients (p<0.001). At the 3-month follow-up, 37 patients were evaluated; a decline in their BI persisted in 60% of them. We did not find significant differences, either upon discharge or at 3 months post-hospitalization, in the decrease in BI rate between COPD patients and CHF patients. CONCLUSIONS: The fact that the underlying disease does not induce differences in the functional outcome of nonagenarians reinforces the importance of using a comprehensive approach at admission and after discharge for all frail patients.

Homocysteine and disability in hospitalized geriatric patients

Elevated total homocysteine (tHcy) concentrations have been found to be associated with cardiovascular disease and dementia in old age. The present study was performed to identify the prevalence of hyperhomocysteinemia (HHcy) and to analyze the association between tHcy concentration and sociodemographic characteristics, nutritional parameters, and cognitive and functional status in this sample of hospitalized geriatric patients. A total of 214 patients (77% females) 65+ years old admitted into an acute care geriatric ward of an internal medical department in the Northern Italy were studied. tHcy concentration was measured using a high-performance liquid chromatography with fluorescence detection (HPLC-F). Information about nutrition (body mass index [BMI], serum albumin, cholesterol, and transferrin) was collected on admission. Functional status was investigated with the Basic Activities of Daily Living scale (ADL) and the Instrumental Activities of Daily Living scale (IADL); cognitive and affective status were assessed by the Mini-Mental State Evaluation (MMSE) and the Geriatric Depression Scale (GDS). The mean tHcy concentration was 18.4 +/- 13.1 micromol/L; 74.2% of males and 68.9% of females had HHcy (> 12 micromol/L). Sixty-four percent of patients with normal serum vitamin B12 and folate concentrations had HHcy. Elevated tHcy concentrations were associated with older age, male gender, increasing serum creatinine, lower MMSE score, and disability. The mean tHcy concentration depended on the occurrence of different diseases. Patients affected by atherosclerotic diseases, such as ischemic heart diseases, cerebrovascular diseases, and dementia had higher mean tHcy concentration than those without diagnosed vascular diseases. In multivariate analysis, vitamin B12, folate, serum albumin, creatinine, and disability emerged as factors associated with tHcy, adjusted for age, gender, education, MMSE score, and atherosclerotic diseases. Our results suggest that the prevalence of HHcy in hospitalized patients is very high, even in subjects with normal cobalamin and folate concentrations. High Hcy concentration can be associated with functional impairment.

Women are more disabled in basic activities of daily living than men only in very advanced ages: a study on disability, morbidity, and mortality from the Kungsholmen Project

OBJECTIVE

We explored the effect of morbidity, mortality, and occurrence of new disability on gender differences in activities of daily living (ADL) functioning in different age groups in the elderly population.

METHODS

All 77+-year-old members of a community-based cohort were clinically examined by physicians, assessed by psychologists, and interviewed by nurses at baseline and after a 3-year interval. Diseases were diagnosed according to ICD-9 and the DSM-III-R criteria for dementia. The Katz index of ADL was used to measure basic functional status.

RESULTS

After adjustment for socio-demographic characteristics, the oldest women (90+ years) had higher disability prevalence and a tendency for higher long-term disability incidence. Women aged 85+ years also had higher morbidity prevalence. Mortality among disabled subjects was similar for both genders, whereas higher mortality was found in younger nondisabled men (77-84 years).

CONCLUSION

We conclude that gender differences in disability, morbidity, and mortality vary with age in the elderly population. Gender differences in morbidity and basic functional dependence were evident only in the oldest old. Based on current and previous findings, we speculate that more women may be at higher risk of developing severe disability than men in the advanced ages due to longer survival with slight disability earlier in adult life.

Positive and negative affect in very old age

The current study examined two issues involving the relationship between age and affect in very old age using data from men and women (aged 70 to 100+ years, M = 85 years) in the Berlin Aging Study (BASE). The first issue was whether unique effects of age on positive and negative affect remained after we controlled for other variables that would be expected to relate to affect in late life. We found no unique effects of age after we controlled for demographic, personality, and health and cognitive functioning variables. Personality and general intelligence emerged as the strongest predictors of positive and negative affect. Second, we evaluated patterns within meaningful subgroups: young old versus oldest old and men versus women. Subgroup differences in predictor patterns were minimal. Although we accounted for much of the age-related variance in positive and negative affect, a significant amount of variance in the affect of older adults remained unexplained.

Medical history, cognitive status and mobility at the age of 90. A population-based study in Tampere, Finland

BACKGROUND AND AIMS

The oldest-old population is expanding rapidly. There is a new need for clinical information about this group, which is actively using social and health care. We studied the population of people born in 1907-1910 and living in the city of Tampere (Finland) at the age 90 (N=916, 79.4% women, 20.6% men); 71.7% of the population lived in the community and 28.3% in institutions.

METHODS

Medical records of 832 (90.8%) nonagenarians were obtained. We registered diagnoses of chronic diseases or diseases that required hospitalization at any time of their lives, as well as physicians' notes on their memory and mobility. Diseases were coded and grouped according to ICD-10.

RESULTS

The most common diagnosis groups were cardiovascular diseases (78.3%), gastrointestinal diseases (58.6%), infections (53.6%) and trauma (49.6%). There was an average of 8 chronic or severe diseases mentioned in patient records. The diagnosis of dementia was mentioned in 26.7% of cases, most of them living in institutions; a problem with memory--from forgetfulness to dementia--was mentioned in 35.9% of cases; 37.5% were able to move using no or a light support, 8.3% were bedridden.

CONCLUSIONS

We conclude that this age group suffers from numerous chronic diseases influencing mobility and cognition. Dementia seems to be the most important symptom leading to institutionalization.

Relation of dietary quality, physical activity, and smoking habits to 10-year changes in health status in older Europeans in the SENECA study

OBJECTIVES

This study investigated the effect of healthy lifestyle behaviors on self-rated health and self-care ability over a 10-year follow-up period in older persons in the SENECA study.

METHODS

Health status and lifestyle behaviors were examined in 1988/1989, 1993, and 1999 in 216 men and 264 women, born between 1913 and 1918, from 7 European countries.

RESULTS

Self-rated health and self-care ability declined in men and women with healthy and unhealthy lifestyle habits over the 10-year follow-up period. Inactive and smoking persons had an increased risk for a decline in health status as compared with active and nonsmoking people. No effect of a healthy, Mediterranean-like diet on the deterioration in health status was observed.

CONCLUSIONS

Being physically active and nonsmoking delayed deterioration in health status in older participants aged 70 to 75 years in the SENECA study.

Loneliness, health and social network among elderly people—a follow-up study

The purpose of this study is to describe and follow up the existence of experienced loneliness, subjective health and social network among elderly people during a period of 10 years. The study is based on interviews (with structured questions) with persons, aged 75 years and over, performed by trained nurses at a baseline (in 1987) and three follow-ups. Descriptive statistics (frequency) and chi2 tests were used to study significant differences of the variables experienced loneliness, subjective health, housing, satisfaction with friend contacts and having a good friend to talk to, over time. The results showed that most elderly people tended to report high satisfaction with friend contacts over the study time, despite the decrease in having a good friend to talk to. The satisfaction with social contacts was very close connected with feelings of loneliness. Therefore, a greater understanding for the meaning of having a good friend/friends to talk to (meaningful contacts) seems to be important in caring for elderly people.

The impact of somatic and cognitive disorders on the functional status of the elderly

To estimate the relative effects of coexisting nondementia illnesses on the probability of functional disability, depending on the presence of cognitive impairment or dementia, we used data from the baseline case-control assessment of a longitudinal study of aging and dementia. Our study included 668 subjects (345 nondemented, 98 cognitively impaired, and 225 demented), aged 75 and older. Demented subjects had greater disability prevalence on all specific instrumental activities of daily living (IADL) and activities of daily living (ADL) items than cognitively impaired subjects who, in turn, had greater disability than nondemented subjects. Somatic illnesses were found to be associated with particular tasks in item specific models; decreasing MMSE was strongly associated with the probability of IADL and ADL disability, which increased dramatically in the presence of somatic illnesses among cognitively impaired as well as demented subjects. Attention to illnesses among cognitively impaired and demented people may shed light on remediable factors crucial to their daily functioning.

Dementia: when is it not Alzheimer disease?

The advent of symptomatic therapies for Alzheimer disease has placed increasing emphasis on early diagnosis of the dementia syndrome and its various types. This article reviews the definition and epidemiology of the condition that affects up to 50% of all Americans over the age of 80. Also discussed are the main causes of dementia, focusing on those that are not Alzheimer disease and a diagnostic approach that is based on guidelines recently published by the American Academy of Neurology.