Modifiable Impairments Predict Progressive Disability Among Older Persons

Simpler modified fried frailty scale as a practical tool to evaluate physical frailty: Methodological report for its cross-cultural adaptation and validation

Frailty is a common geriatric syndrome that indicates homeostenosis and increased risk of disability and mortality. It is amenable to intervention when detected. Hence, screening frailty is of utmost importance to preserve quality-of-life and function in older age. Simpler Modified Fried Frailty Scale is a very practical frailty screening tool that has recently been introduced and has rooted from the original Fried Scale. It is developed in Turkish and has been shown to predict mortality in nursing home residents. Considering the variety of languages in Europe, it seems valid to adapt and validate this tool in different European languages. Thereby, it is expected that clinicians will have the possibility to screen for frailty more quickly and easily in their practice across many countries. This report is written to explain the details of the final consensus methodology suggested for Simpler Modified Fried Frailty Scale validation in order to guide and help the research teams in their studies.

Patterns of Chronic Conditions and Their Association With Visual Impairment and Health Care Use

Importance

Visual impairment and visual disorders often co-occur with other chronic conditions. Understanding patterns of multimorbidity is important for reducing health care use and improving health outcomes.

Objective

To identify chronic condition patterns and their association with visual impairment and health care use in a nationally representative sample.

Design, Setting, and Participants

This cross-sectional study used National Health Interview Survey data for 387 780 individuals aged 18 years and older, representative of the civilian noninstitutionalized US population, from January 1, 2002, to December 31, 2014. Statistical analysis was performed from June to November 2018.

Exposures

Participants were classified in subgroups with different combinations of self-reported chronic conditions using latent class analysis.

Main Outcomes and Measures

Self-reported visual impairment, emergency department visit, and hospitalization use in the previous 12 months.

Results

Among the 387 780 individuals included in the study, 51.8% were female, 77.6% were white, and the mean (SD) age was 46.2 (18.0) years. Latent class analysis identified 5 different classes, with 70.5% of the participants belonging to the healthy group. The other 4 groups represented various degrees and patterns of multimorbidity. The hypertensive group (19.6%) had a high prevalence of hypertension (62.6%), the respiratory conditions group (4.4%) had a high prevalence of emphysema (47.7%) and asthma (45.6%), the heart disease group (3.6%) had high prevalence of coronary heart disease (69.8%), and the severely impaired group (1.8%) had higher prevalence of most conditions compared with the other groups. In the adjusted analysis, compared with the healthy group, participants in all 4 disease groups had elevated risk of visual impairment: heart condition group (odds ratio [OR], 3.19; 95% CI, 2.92-3.48), hypertensive group (OR, 3.28; 95% CI, 3.10-3.48), respiratory condition group (OR, 3.87; 95% CI, 3.56-4.20), and severely impaired group (OR, 10.19; 95% CI, 9.20-11.28). All 4 disease groups had elevated risk of reporting emergency department use and hospitalization. For the severely impaired group, the OR for emergency department use was 9.39 (95% CI, 8.53-10.34), and the OR for hospitalization was 10.80 (95% CI, 9.80-11.92).

Conclusions and Relevance

In this study, individuals in all 4 multimorbidity groups had an elevated risk of visual impairment and health care use compared with the healthy group. Characteristics of high-risk groups identified by this study may help in the development and implementation of interventions to avert the more serious consequences of having multiple chronic conditions.

Muscle mass, strength, and physical performance predicting activities of daily living: a meta-analysis

Background Activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are essential for independent living and are predictors of morbidity and mortality in older populations. Older adults who are dependent in ADLs and IADLs are also more likely to have poor muscle measures defined as low muscle mass, muscle strength, and physical performance, which further limit their ability to perform activities. The aim of this systematic review and meta-analysis was to determine if muscle measures are predictive of ADL and IADL in older populations. Methods A systematic search was conducted using four databases (MEDLINE, EMBASE, Cochrane, and CINAHL) from date of inception to 7 June 2018. Longitudinal cohorts were included that reported baseline muscle measures defined by muscle mass, muscle strength, and physical performance in conjunction with prospective ADL or IADL in participants aged 65 years and older at follow-up. Meta-analyses were conducted using a random effect model. Results Of the 7760 articles screened, 83 articles were included for the systematic review and involved a total of 108 428 (54.8% female) participants with a follow-up duration ranging from 11 days to 25 years. Low muscle mass was positively associated with ADL dependency in 5/9 articles and 5/5 for IADL dependency. Low muscle strength was associated with ADL dependency in 22/34 articles and IADL dependency in 8/9 articles. Low physical performance was associated with ADL dependency in 37/49 articles and with IADL dependency in 9/11 articles. Forty-five articles were pooled into the meta-analyses, 36 reported ADL, 11 reported IADL, and 2 reported ADL and IADL as a composite outcome. Low muscle mass was associated with worsening ADL (pooled odds ratio (95% confidence interval) 3.19 (1.29-7.92)) and worsening IADL (1.28 (1.02-1.61)). Low handgrip strength was associated with both worsening ADL and IADL (1.51 (1.34-1.70); 1.59 (1.04-2.31) respectively). Low scores on the short physical performance battery and gait speed were associated with worsening ADL (3.49 (2.47-4.92); 2.33 (1.58-3.44) respectively) and IADL (3.09 (1.06-8.98); 1.93 (1.69-2.21) respectively). Low one leg balance (2.74 (1.31-5.72)), timed up and go (3.41 (1.86-6.28)), and chair stand test time (1.90 (1.63-2.21)) were associated with worsening ADL. Conclusions Muscle measures at baseline are predictors of future ADL and IADL dependence in the older adult population.

Functional impairment and risk of mortality in patients on chronic hemodialysis: results of the Lazio Dialysis Registry

BACKGROUND

Functional impairment is associated with adverse outcomes in older people, as well as in patients on chronic hemodialysis. The aim of this study was to evaluate if functional impairment represents a risk factor for reduced survival in patients on chronic hemodialysis.

METHODS

All incident chronic hemodialysis patients of Lazio, a large region of central Italy, registered in the Dialysis and Transplant Lazio Region Registry (DTLRR) in the period 2008-2013 were considered eligible. Inclusion criteria were: age > 18 years, resident in Lazio, still doing dialysis after 90 days from incidence date, doing hemodialysis or hemodiafiltration treatment for > 9 h/week. Patients were stratified into three classes of functional activity: total autonomy, autonomy in some activities, and not self-sufficient. Functional activity was assessed for each patient by the referring physician for the DTLRR from the ~ 90 hemodialysis units of the Lazio region. Each patient was followed from date of first dialysis treatment to the end of the study (31/12/2015) or death or renal transplant, whichever occurred first. Cox proportional hazard models were performed to obtain mortality hazard ratios (HR), 95% confidence intervals (CI), for each class of functional activity adjusting for sex, age, country of birth, city of residence, body mass index (BMI), type of nephropathy, vascular access, previous nephrology counselling, weekly hours of hemodialysis, serum albumin, hemoglobin, and presence of comorbidities (e.g. vascular diseases, coronary disease, and diabetes).

RESULTS

A total of 3356 patients were studied. In the whole follow-up period, 1622 deaths occurred (48%). Functional impairment was associated with the risk of mortality: compared to 'total autonomy', the HR for 'autonomy in some activities' was 1.30 [95% CI: 1.14-1.49] and for 'not self-sufficient' 1.71 [1.47-1.99] (p for trend < 0.05). The number of evitable deaths attributable to reduced functional activity was 237.

CONCLUSION

Functional impairment represents a risk factor for reduced survival in chronic hemodialysis patients. There is a need for early identification of patients who might benefit from interventions aimed at preventing, reversing or delaying the functional impairment.

Manual Handling in Aged Care: Impact of Environment-related Interventions on Mobility

The manual handling of people (MHP) is known to be associated with high incidence of musculoskeletal disorders for aged care staff. Environment-related MHP interventions, such as appropriate seated heights to aid sit-to-stand transfers, can reduce staff injury while improving the patient's mobility. Promoting patient mobility within the manual handling interaction is an endorsed MHP risk control intervention strategy. This article provides a narrative review of the types of MHP environmental controls that can improve mobility, as well as the extent to which these environmental controls are considered in MHP risk management and assessment tools. Although a range of possible environmental interventions exist, current tools only consider these in a limited manner. Development of an assessment tool that more comprehensively covers environmental strategies in MHP risk management could help reduce staff injury and improve resident mobility through auditing existing practices and guiding the design of new and refurbished aged care facilities.

Progressive disability in elderly population among tribals of Telangana: a cross sectional study

Background

The tribal population of Telangana, India, lives in remote and difficult conditions. This study was carried out to find out estimate, the prevalence and progression of disability in elderly population among tribals of Khammam District, Telangana state, India.

Methods

A population based cross sectional survey was conducted in villages of Tribal Sub Plan area. Elderly people who are 60 years or older were chosen with a two stage sampling procedure: (1) probability proportion to size was used to select clusters and (2) in each selected cluster households were selected by systematic random sampling. The participants were interviewed with the 36 item Telugu version of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) questionnaire. Socio- demographic information, behavioral measurements, health and social benefit indicators were also assessed. Descriptive analytical methods were used for prevalence estimation and logistic regression was used to examine the associations of progressive age over disability among elderly.

Results

A total of 506 elderly people from 1349 households in 20 villages across 31mandals of Khammam were interviewed. Majority of elderly population among tribals were illiterate (men 88.94%; women 99.33%), used tobacco (men 81.25%; women 57.72%), consumed alcohol (men 80.77%; women 47.32%) and were hypertensive (men 53.85%; women 63.42%). The prevalence of disability was higher in women. Maximum disability in the interviewed elderly population was seen in domains of performing house hold activities, and mobility. In comparison with men, women expressed more disability for majority of domains. As age progressed, the disability for self-care domain increased to a maximum of 2.6 times in men and 6.6 times in women and for mobility domain increased to a maximum of 9.7 times in men and 7.2 times in women.

Conclusions

Although present disability modifying mobility Assistive Devices (AD) can help elderly in overcoming disability, these are primarily designed for built environments. As the needs, cultural sensitivities, and living environment of elderly population in tribals are unique, newer innovative assistive devices should be designed and developed.

All-cause mortality risk in elderly individuals with disabilities: a retrospective observational study

OBJECTIVES

Disability is considered an important issue that affects the elderly population. This study aimed to explore the relationship between disability and all-cause mortality in US elderly individuals.

DESIGN

Retrospective and longitudinal designs.

SETTING

Data from the National Health and Nutrition Examination Survey (NHANES 1999-2002) conducted by the National Center for Health Statistics of the Centers for Disease Control and Prevention.

PARTICIPANTS

A total of 1834 participants in the age range 60-84 years from NHANES 1999-2002.

MAIN OUTCOME MEASURES

We acquired five major domains of disability (activities of daily living (ADL), general physical activities (GPA), instrumental ADL (IADL), lower extremity mobility (LEM) and leisure and social activities (LSA)) through self-reporting. We applied an extended-model approach with Cox (proportional hazards) regression analysis to investigate the relationship between different features of disability and all-cause mortality risk in the study population.

RESULTS

During a mean follow-up of 5.7 years, 77 deaths occurred. An increased risk of all-cause mortality was identified in elderly individuals with disability after adjustment for potential confounders (HR 2.23; 95% CI 1.29 to 3.85; p=0.004). Participants with more than one domain of disability were associated with a higher risk of mortality (ptrend=0.047). Adjusted HRs and 95% CIs for each domain of disability were 2.53 (1.49 to 4.31), 1.99 (0.93 to 4.29), 1.74 (0.72 to 4.16), 1.57 (0.76 to 3.27) and 1.52 (0.93 to 2.48) for LEM, LSA, ADL, IADL and GPA, respectively.

CONCLUSIONS

The results of this study support an increased association between disability and all-cause mortality in the elderly in the USA. Disability in LEM may be a good predictor of high risk of all-cause mortality in elderly subjects.

Severity of Concurrent Visual and Hearing Impairment and Mortality

Purpose: Visual impairment and, to a lesser extent, hearing impairment are independent predictors of reduced survival in selected studies of community-residing adults. To date, the association of severity of concurrent impairment and mortality has not been examined. Method: The National Health Interview Survey is a continuous, multistage, area probability survey of the U.S. civilian noninstitutionalized population. Mortality linkage with the National Death Index of 116,796 adult participants from 1986 to 1994 with complete impairment data was performed through 1997. Results: Findings indicate that moderate to severe concurrent hearing and visual impairment in women is associated with significantly increased risk of mortality. More modest mortality associations are evident for men and for adults with less severe impairments, irrespective of gender. Discussion: Prevention of severe visual and hearing impairment should be a national public health priority, especially given the aging of the U.S. population.

Physical fitness is predictive for a decline in the ability to perform instrumental activities of daily living in older adults with intellectual disabilities: Results of the HA-ID study

The ability to perform instrumental activities of daily living (IADL) is important for one's level of independence. A high incidence of limitations in IADL is seen in older adults with intellectual disabilities (ID), which is an important determinant for the amount of support one needs. The aim of this study was to assess the predictive value of physical fitness for the ability to perform IADL, over a 3-year follow-up period, in 601 older adults with ID. At baseline, an extensive physical fitness assessment was performed. In addition, professional caregivers completed the Lawton IADL scale, both at baseline and at follow-up. The average ability to perform IADL declined significantly over the 3-year follow-up period. A decline in the ability to perform IADL was seen in 44.3% of the participants. The percentage of participants being completely independent in IADL declined from 2.7% to 1.3%. Manual dexterity, balance, comfortable and fast gait speed, muscular endurance, and cardiorespiratory fitness were significant predictors for a decline in IADL after correcting for baseline IADL and personal characteristics (age, gender, level of ID, and Down syndrome). This can be interpreted as representing the predictive validity of the physical tests for a decline in IADL. This study shows that even though older adults with ID experience dependency on others due to cognitive limitations, physical fitness also is an important aspect for IADL, which stresses the importance of using physical fitness tests and physical fitness enhancing programs in the care for older adults with ID.

Geriatric assessment as an aide to understanding falls in older adults with cancer

PURPOSE

In older adults, falls are a common cause of functional decline, institutionalization, and reduced quality of life. This study (1) investigates the prevalence of falls in a large sample of community-dwelling older adults with a cancer diagnosis and (2) evaluates the association of falls with domains of comprehensive geriatric assessment (CGA) that pertain to falls risk.

METHODS

Patients completed a CGA that includes a self-reported measure of number of falls in the past 6 months. Summary statistics are used to describe prevalence of falls and associations with hypothesized risk factors using Fisher's exact tests and multivariable logistic regression.

RESULTS

A total of 1172 patients were enrolled, mean age 73 (65-99), 74 % female, and 89 % Caucasian. Two hundred fifty-six (22 %) reported one or more falls within the last 6 months. Patients with at least one instrumental activities of daily living (IADL) or physical function deficit had more falls as compared those with no deficits identified (p ≤ 0.001). The number of daily medications, comorbidities, Timed Up and Go score >14 s, and poor vision were also associated with increased falls (p ≤ 0.001). Reduced physical function, poor vision, and low performance status had the highest adjusted odds ratio (3.6, 3.4, and 3.0, respectively) for falls.

CONCLUSIONS

There is a high prevalence of falls in community-dwelling older patients with a cancer diagnosis. Falls are significantly associated with several measures of geriatric assessment including IADL, physical function, comorbidities, medications, and vision. Timely identification and management of risk factors for falls are important considerations in the care of older cancer patients.

Visual acuity and increased mortality: the role of allostatic load and functional status

PURPOSE

Poor vision may detrimentally impact functional status and affect allostatic load (AL), a measure of cumulative physiological wear and tear on the body's regulatory systems. We examined the direct effects of visual acuity (VA) on mortality and its indirect effect on mortality through its impact on functional status and AL in older adults.

METHODS

Data from 4981 participants (age ≥ 60 years) from the 1999-2004 National Health and Nutrition Examination Survey (NHANES) with mortality linkage through 2006 were analyzed. Functional status was assessed by activities of daily living (ADL) and instrumental activities of daily living (IADL). The AL index was composed of 10 biomarkers: systolic and diastolic blood pressures, body mass index (BMI), glycosylated hemoglobin, total cholesterol, triglycerides, albumin, C-reactive protein, homocysteine, and creatinine clearance. Visual acuity was categorized as no (20/20-20/25), mild (20/30-20/40), moderate (20/50-20/80), or severe (≥20/200) visual impairment. Structural equation modeling using three mediating variables representing ADL, IADL, and AL examined the effects of VA on all-cause and cardiovascular disease (CVD)-related mortality.

RESULTS

Adjusting for all covariates, a one-unit change in VA category increased mortality risk (hazard ratio [HR] = 1.17; 95% confidence interval [CI] 1.05, 1.32); IADL and AL predicted mortality (HR = 1.15; CI 1.10, 1.20 and HR = 1.13; CI 1.06, 1.20, respectively). Activities of daily living did not predict mortality (HR = 0.98; CI 0.91, 1.05). Worse VA was associated with increased AL (β = 0.11; P = 0.013) and worse IADL (β = 1.06; P < 0.001). Worse VA increased mortality risk indirectly through AL (HR = 1.01; CI 1.00, 1.03) and IADL (HR = 1.16; CI 1.09, 1.23). The total effect of VA on mortality including through IADL and AL was HR = 1.38 (CI 1.23, 1.54). Similar but slightly stronger patterns of association were found when examining CVD-related mortality, but not cancer-related mortality.

CONCLUSIONS

Allostatic load and particularly IADL may function as mediators between VA impairment and mortality. Older adults with VA impairment could potentially benefit from interventions designed to prevent IADL functional status decline to reduce the risk of mortality.

The Prediction of ADL and IADL Disability Using Six Physical Indicators of Frailty: A Longitudinal Study in the Netherlands

Frailty is a predictor of disability. A proper understanding of the contribution of individual indicators of frailty in the prediction of disability is a requisite for preventive interventions. The aim of this study was to determine the predictive power of the individual physical frailty indicators: gait speed, physical activity, hand grip strength, Body Mass Index (BMI), fatigue, and balance, for ADL and IADL disability. The sample consisted of 505 community-dwelling persons (≥75 years, response rate 35.1%). Respondents first participated between November 2007 and June 2008, and a subset of all respondents participated again one year later (N = 264, 52.3% response rate). ADL and IADL disability were assessed by the Groningen Activity Restriction Scale. BMI was assessed by self-report, and the other physical frailty indicators were assessed with the TUG test (gait speed), the LAPAQ (physical activity), a hand grip strength test, the SFQ (fatigue), and the Four-test balance scale. All six physical frailty indicators were associated with ADL and IADL disability. After controlling for previous disability, sociodemographic characteristics, self-perceived lifestyle, and chronic diseases, only gait speed was predictive of both ADL and IADL disability, whereas there was a small effect of fatigue on IADL disability. Hence, these physical frailty indicators should be included in frailty assessment when predicting future disability.

Do older adults with cancer fall more often? A comparative analysis of falls in those with and without cancer

PURPOSE/OBJECTIVES

To examine whether a history of cancer increased the likelihood of a fall in community-dwelling older adults, and if cancer type, stage, or time since diagnosis increased falls.

DESIGN

A longitudinal, retrospective, cohort study.

SETTING

A home- and community-based waiver program in Michigan.

SAMPLE

862 older adults aged 65 years or older with cancer compared to 8,617 older adults without cancer using data from the Minimum Data Set-Home Care and Michigan cancer registry.

METHODS

Reports of falls were examined for 90-180 days. Generalized estimating equations were used to compare differences between the groups.

MAIN RESEARCH VARIABLES

Cancer, falls, patient characteristics, comorbidities, medications, pain, weight loss, vision, memory recall, and activities, as well as cancer type, stage, and time since diagnosis.

FINDINGS

A fall occurred at a rate of 33% in older adults with cancer compared to 29% without cancer (p < 0.00). Those with a history of cancer were more likely to fall than those without cancer (adjusted odds ratio 1.16; 95% confidence interval [1.02, 1.33]; p = 0.03). No differences in fall rates were determined by cancer type or stage, and the odds of a fall did not increase when adding time since cancer diagnosis.

CONCLUSIONS

The fall rate was higher in older adults with cancer than in older adults without cancer.

IMPLICATIONS FOR NURSING

Nurses need to assess fall risk and initiate fall prevention measures for older adults at the time of cancer diagnosis.

KNOWLEDGE TRANSLATION

When caring for older adults with cancer, nurses should be aware of an increased risk for falls. Healthcare staff also should be aware of an increased risk for falls in that population during cancer treatment. Evidence-based fall prevention measures should be included in care plans for older adult cancer survivors.

Polypharmacy in the elderly from the clinical toxicologist perspective

INTRODUCTION

Polypharmacy is closely associated with multimorbidity in the elderly and can lead to problems and drug interactions.

AIM

This study assessed polypharmacy in the elderly, tracking inquiries to the Poison Information Centre Nuremberg (PICN) and patients needing toxicological intensive care therapy.

METHODS

From 2006-2009, all PICN inquiries involving individuals > 70 years were tracked, as were cases at the Toxicological Intensive Care Unit (T-ICU) regarding adverse drug reactions (ADRs) and drug poisoning.

RESULTS

Of 11,683 PICN calls about pharmaceuticals, 175 (1.5%) were from people > 70 years; 156 (4.8%) of 3,272 T-ICU patients were > 70 years. Calls about psychopharmaceuticals (46.9%) and analgesics (25.7%) were most frequent. Among the T-ICU patients, psychopharmaceuticals like sedatives and hypnotics were frequently involved (20.5%), as were tricyclic antidepressants (17.9%) and analgesics (29.5%). Ethanol was co-ingested by 18.3%.

CONCLUSION

Population-specific poison prevention strategies are needed to reduce toxic exposures. Such strategies could include pharmacist intervention, improved prescriber communication and education regarding the geriatric population, and computerized drug databases.

Self-reported vision impairment and its contribution to disability among older adults

OBJECTIVE

To examine contributions of self-reported vision impairment to disability by persons 65 years and older.

METHOD

We used data from the National Health and Nutrition Examination Survey (NHANES IV; 1999-2008; weighted N = 6,550). The four-staged Nagi model of the disability process, incorporating biomarkers, disease, and physical functioning, was used as a framework to guide variable selection. An unadjusted ordinal logistic regression model testing effects of vision on daily-life activities was compared with models that controlled covariates associated with each stage of the disability model.

RESULTS

Where significant effects of poor vision remained, the strongest effect was found for doing leisure activities at home (OR = 5.29; 95% CI [3.14, 8.90]).

DISCUSSION

Results suggest the importance of considering multiple health factors when formulating comprehensive vision rehabilitation interventions.

Fall Prevention in Hospitals

This article summarizes research and draws overall conclusions from the body of literature on fall prevention interventions to provide nurse administrators with a basis for developing evidence-based fall prevention programs in the hospital setting. Data are obtained from published studies. Thirteen articles are retrieved that focused on fall interventions in the hospital setting. An analysis is performed based on levels of evidence using an integrative review process. Multifactoral fall prevention intervention programs that included fall-risk assessments, door/bed/patient fall-risk alerts, environmental and equipment modifications, staff and patient safety education, medication management targeted to specific types, and additional assistance with transfer and toileting demonstrate reduction in both falls and fall injuries in hospitalized patients. Hospitals need to reduce falls by using multifactoral fall prevention programs using evidence-based interventions to reduce falls and injuries.

Physical performance characteristics related to disability in older persons: a systematic review

BACKGROUND

Progressive disability develops with older age in association with underlying disease, comorbidity and frailty. Physical performance characteristics are important to improve the physical condition of older persons and therefore may be able to prevent or delay the onset of (progressive) disability. However lack of understanding of the physiology and etiology of functional decline leading to disability causes a problem in the development of effective preventive interventions. The aim of the present review is to determine which physical performance characteristics are determinants of disability in the older general population.

METHODS

We searched systematically the electronic databases of PubMed (MEDLINE), CINAHL, Cochrane Library, Psychlit and Embase for cohort studies and randomized controlled trials assessing disability in the older general population. Outcomes of interest were handgrip strength, upper and lower extremity function, balance gait and physical activity. The searching strategy resulted in 22 studies included in the present systematic review.

RESULTS

Although heterogeneity was present in the measurements of disability, consistent findings were shown for physical performance characteristics and disability. In general, a lower score of the physical performance characteristics was associated with a higher probability of (the development of) disability. The association for other aspects of gait (e.g. gait-step continuity, gait-step symmetry, path deviation and turning) and disability seems to be present, though the number of studies is limited.

CONCLUSION

In the present systematic review, associations were found for hand grip strength, upper and lower body strength, gait speed, physical activity and the probability of disability.

[Polypharmacy is of major concern in cardiology]

Quality improvement in cardiology over the past decade focused on management of acute coronary syndrome with invasive and innovative medical therapies, optimizing treatment of congestive heart failure and the development of repair procedures in valvular heart disease. On the other hand cardiologist and the attendant physicians are confronted with changes in the characteristics of patients in the light of demographic facts. Comorbidity and polypharmacy raise the need for clear concepts. Therapeutic and diagnostic tools of geriatric medicine may help in that context.

Associations between hearing impairment and mortality risk in older persons: the Blue Mountains Hearing Study

PURPOSE

To assess whether hearing loss predicts an increased risk of mortality.

METHODS

The Blue Mountains Hearing Study examined 2956 persons (49+ years) during 1997 to 2000. The Australian National Death Index was used to identify deaths until 2005. Hearing loss was defined as the pure-tone average (0.5-4 kHz) of air-conduction hearing thresholds greater than 25 dB HL. Associations between hearing loss and mortality risk were estimated using Cox regression and structural equation modeling (SEM).

RESULTS

When we used Cox regression, we discovered that hearing loss was associated with increased risk of cardiovascular (hazard ratio [HR] 1.36, 95% confidence interval [CI] 1.08-1.84) and all-cause (AC) mortality (HR 1.39, 95% CI 1.11-1.79) after adjustment for age and sex but not after multivariable adjustment. SEM pathway analysis, however, revealed a greater AC mortality risk (HR 2.58, 95% CI 1.64-4.05) in persons with hearing loss, which was mediated: cognitive impairment (HR 1.45, 95% CI 1.08-1.94) and walking disability (HR 1.63, 95% CI 1.24-2.15). These variables increased mortality both directly and indirectly through effects on self-rated health.

CONCLUSIONS

Hearing loss was associated with increased AC mortality via three mediating variables: disability in walking, cognitive impairment, and self-rated health. It is important to recognize that persons with combined disabilities are at increased risk of cardiovascular and AC mortality.

Falls in the community-dwelling elderly with a history of cancer

BACKGROUND

Falls place older adults at risk for injuries, resulting in functional decline, hospitalization, institutionalization, higher healthcare costs, and decreased quality of life.

OBJECTIVE

This study examined community-dwelling elderly to identify if individuals with a history of cancer fall at a higher rate than those without cancer, and if the occurrence of falls was influenced by individual characteristics, symptoms, or function.

METHODS

This was a retrospective, cross-sectional study, in 2007, examining 7,448 community-dwelling elderly 65 years or older in a state in the Midwest. Fallers were identified based on a diagnosis of cancer, age, sex, race and ethnicity, poor vision, reduced activities of daily living (ADLs), instrumental ADLs, cognition, incontinence, pain, or depression.

RESULTS

Findings indicated that 2,125 (28.5%) had at least 1 fall. Of those who fell, 967 (13.0%) had cancer, and 363 (4.9%) with cancer had a fall.

CONCLUSION

Predictors of falls in this population included race, sex, ADLs, incontinence, depression, and pain, all with P <.05. Cancer was not a predictor of falls in this study.

IMPLICATIONS FOR PRACTICE

This study found a high frequency of falls and suggests a predictive model for fall risk in the vulnerable, community-dwelling elderly and will be used to inform future studies.

Role of frailty in patients with cardiovascular disease

Frailty is a geriatric syndrome of increased vulnerability to stressors that has been implicated as a causative and prognostic factor in patients with cardiovascular disease (CVD). The American Heart Association and the Society of Geriatric Cardiology have called for a better understanding of frailty as it pertains to cardiac care in the elderly. The aim of this study was to systematically review studies of frailty in patients with CVD. A search was conducted of Ovid MEDLINE, EMBASE, the Cochrane Database, and unpublished sources. Inclusion criteria were an assessment of frailty using systematically defined criteria and a study population with prevalent or incident CVD. Nine studies were included, encompassing 54,250 elderly patients with a mean weighted follow-up of 6.2 years. In community-dwelling elders, CVD was associated with an odds ratio (OR) of 2.7 to 4.1 for prevalent frailty and an OR of 1.5 for incident frailty in those who were not frail at baseline. Gait velocity (a measure of frailty) was associated with an OR of 1.6 for incident CVD. In elderly patients with documented severe coronary artery disease or heart failure, the prevalence of frailty was 50% to 54%, and this was associated with an OR of 1.6 to 4.0 for all-cause mortality after adjusting for potential confounders. In conclusion, there exists a relation between frailty and CVD; frailty may lead to CVD, just as CVD may lead to frailty. The presence of frailty confers an incremental increase in mortality. The role of frailty assessment in clinical practice may be to refine estimates of cardiovascular risk, which tend to be less accurate in the heterogenous elderly patient population.

Fibromyalgia is associated with impaired balance and falls

BACKGROUND/OBJECTIVE

The purpose of this study was to determine whether fibromyalgia (FM) patients differ from matched healthy controls in clinical tests of balance ability and fall frequency.

METHODS

Thirty-four FM patients and 32 age-matched controls were administered the Balance Evaluation-Systems Test (BESTest), rated their balance confidence with the Activities-Specific Balance Confidence (ABC) Scale, and reported the number of falls in the last 6 months. The Fibromyalgia Impact Questionnaire was used to assess FM severity.

RESULTS

FM patients had significantly impaired balance in all components of the BESTest compared with controls. They also scored more poorly on balance confidence. Overall FM severity (Fibromyalgia Impact Questionnaire) correlated significantly with the BESTest and the ABC scale. The BESTest and ABC correlated significantly with 6 commonly reported FM symptoms (excluding pain). FM patients reported a total of 37 falls over the last 6-months compared with 6 falls in healthy controls.

CONCLUSION

FM is associated with balance problems and increased fall frequency. Patients were aware of their balance problems. These results suggest that FM may affect peripheral and/or central mechanisms of postural control. Further objective study is needed to identify the relative contributions of various neural and musculoskeletal and other impairments to postural stability in FM to provide clinicians with methods to maximize postural stability and help fall prevention.

Relationship between conditions addressed by hemodialysis guidelines and non-ESRD-specific conditions affecting quality of life

BACKGROUND AND OBJECTIVES

Persons with ESRD identify non-disease-specific conditions as negatively affecting their quality of life. It is unknown how these non-ESRD-specific conditions correlate with each other and with ESRD-specific conditions such as anemia, renal osteodystrophy, dialysis access, and dialysis adequacy. The objectives of this study were to determine the prevalence and inter-relatedness of selected conditions among persons receiving hemodialysis and to analyze the relationship between non-ESRD-specific and ESRD-specific conditions.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This was an observational cohort study of persons with ESRD that included standardized assessments for pain, fatigue, depression, cognitive impairment, and impaired physical performance. The study was conducted at three dialysis clinics in one urban geographic area. Of the 134 persons who met exclusion criteria, 25 declined participation, yielding a sample size of 109.

RESULTS

Pain was present in >81% of participants, fatigue and impaired physical performance in >60% participants, and cognitive impairment and depression in >25% of participants. Pain, fatigue, and depression were highly correlated, but had no correlation with use of a catheter for access, hemoglobin (Hgb), intact parathyroid hormone (iPTH), phosphorous, or Kt/V values outside of the range of guidelines. There was a modest correlation between cognitive function and both Hgb and iPTH.

CONCLUSIONS

Non-ESRD-specific conditions such as fatigue, pain, and depression are as prevalent as ESRD-specific conditions, and the magnitude of the correlations between the non-ESRD-specific conditions is greater than the correlations between non-ESRD-specific and ESRD-specific conditions. Current guidelines may be failing to address a substantial component of the disease burden for persons with ESRD.

Successful Aging: The Role of Physical Activity

Although no amount of physical activity can stop the aging process, a moderate amount of regular exercise can minimize the physiological effects of an otherwise sedentary lifestyle and increase active life expectancy by limiting the development and progression of chronic disease and disabling conditions. Ideally, exercise prescription for older adults should include aerobic, muscle strengthening, and flexibility exercises. In addition, individuals at risk for falling or mobility impairment should also perform specific exercises to improve balance. The intensity and duration of physical activity should be low at the outset for those who are highly deconditioned, are functionally limited, or have chronic conditions affecting their ability to perform physical tasks. Furthermore, the progression of activities should be individualized and tailored to tolerance and preference. Incorporating principles of behavioral change into the design and application of exercise and physical activity programs will increase the likelihood of an individual initiating and maintaining a regular program of exercise and/ or physical activity. Strategies for maintaining physical function and improving overall health of older adults with chronic conditions and disability are discussed. All older adults with and without disabilities should be encouraged to develop a personalized physical activity plan that meets their needs and personal preferences.

Self-reported lack of energy (anergia) among elders in a multiethnic community

BACKGROUND

Lack of energy, "anergia," is a possible central feature for identifying, evaluating, and treating elders with health-related problems in quality of life.

METHODS

A survey was conducted on a randomly selected stratified sample (N = 2130) of three ethnic groups of community-residing elders in a defined urban geographic area: the Northern Manhattan Aging Project (NMAP). The participants were Medicare beneficiaries living north of 150(th) Street in Manhattan. The criteria for anergia were based on the presence of the major criterion "sits around a lot for lack of energy" and any two of six minor criteria. Self-reports were gathered using a computer-assisted, rater-administered interview (the Comprehensive Assessment and Referral Interview; CARE) covering: function (basic activities of daily living [ADL] and instrumental ADL [IADL]); features of geriatric syndromes such as self-rated physical health, depression, pain, respiratory distress, trouble sleeping, cognitive impairment, and cardiovascular syndromes; social isolation; and healthcare utilization. Short-term (18-month) and long-term (6-year) mortality were derived from the National Death Index.

RESULTS

Three hundred eighty-six people (18% of the sample) met criteria for anergia. Anergia was more common in women than men (22% vs 12%, p <.01), in unmarried than in married persons (21% vs 13%, p <.001), and with advancing age. People with anergia used more hospitalizations, office visits, emergency room visits, and home care services and, had higher mortality rates. In multivariate analyses, the following factors had independent associations with anergia: female gender, impaired physical function and IADL, depression, pain, respiratory symptoms, urinary incontinence, hearing difficulty, feeling dizzy or weak, and social isolation and disengagement. These factors could be the initial candidates for clinical investigation of anergia of undetermined origin. Among people with anergia at baseline, 31.3% (n = 121) had persistent anergia and 33.9% (n = 131) recovered over a follow-up period of 18 months.

CONCLUSIONS

Anergia in multiethnic older adults is associated with a range of clinical symptoms and diseases, with extensive health services use, and with increased mortality.

An examination of effect estimation in factorial and standardly-tailored designs

BACKGROUND

Many clinical trials are designed to test an intervention arm against a control arm wherein all subjects are equally eligible for all interventional components. Factorial designs have extended this to test multiple intervention components and their interactions. A newer design referred to as a ;standardly-tailored' design, is a multicomponent interventional trial that applies individual interventional components to modify risk factors identified a priori and tests whether health outcomes differ between treatment arms. Standardly-tailored designs do not require that all subjects be eligible for every interventional component. Although standardly-tailored designs yield an estimate for the net effect of the multicomponent intervention, it has not yet been shown if they permit separate, unbiased estimation of individual component effects. The ability to estimate the most potent interventional components has direct bearing on conducting second stage translational research.

PURPOSE

We present statistical issues related to the estimation of individual component effects in trials of geriatric conditions using factorial and standardly-tailored designs. The medical community is interested in second stage translational research involving the transfer of results from a randomized clinical trial to a community setting. Before such research is undertaken, main effects and synergistic and or antagonistic interactions between them should be identified. Knowledge of the relative strength and direction of the effects of the individual components and their interactions facilitates the successful transfer of clinically significant findings and may potentially reduce the number of interventional components needed. Therefore the current inability of the standardly-tailored design to provide unbiased estimates of individual interventional components is a serious limitation in their applicability to second stage translational research.

METHODS

We discuss estimation of individual component effects from the family of factorial designs and this limitation for standardly-tailored designs. We use the phrase ;factorial designs' to describe full-factorial designs and their derivatives including the fractional factorial, partial factorial, incomplete factorial and modified reciprocal designs. We suggest two potential directions for designing multicomponent interventions to facilitate unbiased estimates of individual interventional components.

RESULTS

Full factorial designs and their variants are the most common multicomponent trial design described in the literature and differ meaningfully from standardly-tailored designs. Factorial and standardly-tailored designs result in similar estimates of net effect with different levels of precision. Unbiased estimation of individual component effects from a standardly-tailored design will require new methodology.

LIMITATIONS

Although clinically relevant in geriatrics, previous applications of standardly-tailored designs have not provided unbiased estimates of the effects of individual interventional components.

DISCUSSION

Future directions to estimate individual component effects from standardly-tailored designs include applying D-optimal designs and creating independent linear combinations of risk factors analogous to factor analysis.

CONCLUSION

Methods are needed to extract unbiased estimates of the effects of individual interventional components from standardly-tailored designs.

Reported visual impairment and risk of suicide: the 1986-1996 national health interview surveys

OBJECTIVE

To examine the relationship between reported visual impairment and suicide mortality.

METHODS

From 1986 through 1996, annual cross-sectional multistage area probability surveys of the US civilian noninstitutionalized population living at addressed dwellings were conducted by the National Center for Health Statistics. We performed mortality linkage through 2002 with the National Death Index of 137,479 adults 18 years and older. The relationships between reported visual impairment and suicide were examined using structural equation modeling.

RESULTS

The mean duration of follow-up was 11.0 years, and 200 suicide deaths were identified. After controlling for survey design, age, sex, race, marital status, number of nonocular health conditions, and self-rated health, the direct effect of visual impairment on death from suicide was elevated but not significant (hazard ratio, 1.50; 95% confidence interval, 0.90-2.49). The approximate indirect effect of visual impairment on death from suicide via poorer self-rated health (1.05; 1.02-1.08) or number of nonocular health conditions (1.12; 1.01-1.24) was significant. The total effect of visual impairment on death from suicide was elevated but not significant (1.64; 0.99-2.72).

CONCLUSIONS

Visual impairment may be associated with an increased risk of suicide through its effect on poor health. This suggests that improved treatment of visual impairment and factors causing poor health may potentially reduce suicide risk.

Self-Reported Health and Driving Cessation in Community-Dwelling Older Drivers

BACKGROUND

Stopping driving has significant negative consequences for older adults, but there is no simple, reliable screening tool to predict driving cessation. We sought to determine if self-rated health (SRH) was an independent predictor of driving cessation among older adults.

METHODS

Data on SRH (poor, fair, good, very good, or excellent), medical diagnoses, physical performance, visual acuity, driving status, and other relevant covariates were collected from 649 community-dwelling older Alabama drivers during in-home interviews. Using multivariable logistic regression analyses, we estimated the association of SRH with driving cessation 2 years later.

RESULTS

Participants had a mean age of 74 years; 43% were women, 41% African American, and 48% rural. Overall, 36% reported poor to fair SRH at baseline, and 11% had stopped driving after 2 years. Compared to 8% of drivers with good to excellent SRH, 17% with poor to fair health stopped driving (adjusted odds ratio [OR], 1.93; 95% confidence interval [CI], 1.09-3.41; p=.025). Lower Short Physical Performance Battery (SPPB) scores (adjusted OR, 0.86; 95% CI, 0.78-0.95; p=.001) and older age (adjusted OR, 1.06 per year; 95% CI, 1.01-1.11; p=.010) were also associated with driving cessation. Receiver operating characteristics curves documented similar predictive discrimination (c statistics) for SRH (0.72), the SPPB (0.70), and a count of comorbidities based on the Charlson Comorbidity Index (0.73).

CONCLUSIONS

Poor to fair SRH predicted incident driving cessation after 2 years in a cohort of older adults. SRH can be easily obtained during clinic visits to identify at-risk drivers.

Correlates of Life Space in a Volunteer Cohort of Older Adults

The authors measured the spatial extent of movement of older persons (i.e., life space) and examined factors that are related to life space. A larger life space was positively correlated with self-report measures of disability. In generalized logit models adjusted for demographics and time of year, a larger life space was associated with less visual impairment, higher levels of lower extremity motor performance, global cognition, and social involvement, and with personality and purpose in life. The results suggest that the range of environmental movement in older adults is a useful indicator of health in old age and may complement measures of disability.