National treatment guidelines poorly achieved among older subjects with type 2 diabetes - call to action!

OBJECTIVE

To assess risk factors and factors associated with nonachievement of the treatment target levels among 75-year-old Finns with type 2 diabetes (T2D).

DESIGN

Cross-sectional study.

SETTING

Outpatient.

SUBJECTS

Seventy-five-year-old participants of the Turku Senior Health Clinic Study (N = 1296) with T2D (n = 247).

MAIN OUTCOME MEASURES

Nonachievement of fasting blood glucose (FBG), low-density lipoprotein (LDL-C), and blood pressure (BP) levels set by the national treatment guidelines.

RESULTS

Nonachievement rates of FBG, BP and LDL-C were 47%, 85%, and 47%, respectively. Non-usage of T2D medication was negatively (adjusted OR 0.38, 95% CI 0.16-0.88) and central obesity positively (1.88, 1.09-3.24) related to nonachievement of FBG target level; alcohol use was positively (3.71, 1.04-13.16) and decreased self-rated health negatively (0.34, 0.12-0.97) related to the nonachievement of BP target level. Nonachievement of LDL-C target level was positively related to poor financial status (3.50, 1.19-10.28) and non-use of lipid-lowering medication (7.70, 4.07-14.56).

CONCLUSIONS

Nonachievement rates of the national treatment goals were high among older T2D patients, and nonachievement was related to use of medication, obesity, alcohol use, poor health, and poor financial status. We emphasize the importance of customized target setting by risk factor levels and active treatment.

New reference limits for cardiac troponin T and N-terminal b-type natriuretic propeptide in elders

BACKGROUND AND AIMS

Our aim was to define reference limits for cardiac troponin T (cTnT) and N-terminal pro B-type natriuretic peptide (proBNP) that would better reflect their concentrations in older people. In addition, the incidence of acute myocardial infarctions (AMIs) was studied using these reference limits in an older population with and without previous heart diseases.

MATERIALS AND METHODS

A population-based study with a ten-year follow-up. The reference population was formed by 763 individuals aged over 64 years, with no diagnoses of heart or kidney diseases.

RESULTS

There was a significant increase in cTnT and proBNP concentrations with age. The 99 % reference limits for cTnT were 25 ng/L, 28 ng/l, 38 ng/l, and 71 ng/l for men in five-year-intervals starting from 64 to 69 years to 80 years and older, and 18 ng/L, 22 ng/l, 26 ng/l, and 52 ng/L for women, respectively. The 97.5 % reference limits for proBNP were 272 ng/L, 287 ng/l, 373 ng/l and 686 ng/L for men, and 341 ng/L, 377 ng/l, 471 ng/l, and 794 ng/L for women, respectively. Elevated proBNP was statistically significantly associated with future AMIs in subjects with and without a previous heart disease.

CONCLUSIONS

Age-specific reference limits for cTnT and proBNP are needed to better evaluate cardiac symptoms.

The association of previous night's sleep duration with cognitive function among older adults: a pooled analysis of three Finnish cohorts

STUDY OBJECTIVES

Sleep duration has been shown to associate with cognitive function, but little is known about the short-term effect of sleep duration on the previous night. This study examines how usual sleep duration and previous night's sleep duration are associated with cognitive function in older adults.

METHODS

The study population consisted of 2949 adults aged 59-92 years (mean 72.6, SD 5.7) derived from three Finnish cohorts. Participants' self-reported usual sleep duration was categorized into short (< 7 h, 19%), mid-range (7- < 9 h, 64%), and long (≥ 9 h, 17%). Self-reported sleep duration on the night prior to cognitive testing was categorized into shorter (59%), same (35%), and longer (5.9%) than usual sleep duration. Computerized Cambridge Neuropsychological Test Automated Battery (CANTAB®) was used to assess: (1) learning and memory, (2) working memory, (3) information processing, and (4) reaction time.

RESULTS

Participants with self-reported long, but not short, usual sleep duration had poorer learning and memory (p = .004), information processing (p = .003), and reaction time (p = .006) when compared to those with mid-range sleep duration. Those who slept more than usually the night prior to cognitive testing had poorer information processing (p = .019) than those sleeping the same as usually, while sleeping less than usually was not associated with cognitive function.

CONCLUSIONS

This study suggests that while long sleep duration was associated with worse cognitive function, sleeping more than usually the night prior to cognitive testing was only associated with information processing, and sleeping less than usually is not associated with cognitive function.

Re-examination of successful agers with lower biological than chronological age still after a 20-year follow-up period

BACKGROUND

Successful ageing is the term often used for depicting exceptional ageing but a uniform definition is lacking. The aim was to re-examine and describe the successful agers living at home at the age of 84 years or over after a 20-year follow-up. The purpose was also to identify possible factors leading to their successful ageing.

METHODS

Successful ageing was defined as the ability to live at home without daily care. Data on the participants' functional ability, objective health, self-rated health and satisfaction with life were gathered at baseline and after a 20-year follow-up period. A measurement of personal biological age (PBA) was established and the difference between the PBA and the chronological age (CA) was counted.

RESULTS

The participants' mean age was 87.6 years (Standard deviation 2.5, range 84-96). All analyzed variables depicted poorer physical ability and subjective health at re-examination than at baseline. Still, 99% of the participants were at least moderately satisfied with their lives. The PBA at baseline was 6.5 years younger than CA, and at re-examination, the difference was even more pronounced at 10.5 years.

DISCUSSION

Even though the participants were chronologically older, had poorer physical ability and subjective health, they were still satisfied with their lives indicating possible psychological resilience. The difference between the PBA and CA was greater at re-examination than at baseline indicating that they were also biologically successful agers.

CONCLUSIONS

Successful agers were satisfied with life despite hardships and had a lower biological than chronological age. Further research is needed to evaluate causality.

Senior Health Clinic for 75-year-old home-dwelling Finns - study design, clinic protocol and non-response analysis

BACKGROUND

In the Finnish policy on older people preventive activities, which maintain functional capacity and independent living, are emphasized. The Turku Senior Health Clinic, aimed at maintaining independent coping of all home-dwelling 75-year-old citizens in the city of Turku, was founded in the beginning of 2020. The aim of this paper is to describe design and protocol of the Turku Senior Health Clinic Study (TSHeC) and provide results of the non-response analysis.

METHODS

The non-response analysis used data from 1296 participants (71% of those eligible) and 164 non-participants of the study. Sociodemographic, health status, psychosocial and physical functional ability indicators were included in the analysis. Participants and non-participants were also compared in respect to their neighborhood socioeconomic disadvantage. Differences between participants and non-participants were tested using the Chi squared or Fisher´s exact test for categorical variables and t-test for continuous variable.

RESULTS

The proportions of women (43% vs. 61%) and of those with only satisfying, poor or very poor self-rated financial status (38% vs. 49%) were significantly lower in non-participants than in participants. Comparison of the non-participants and participants in respect to their neighborhood socioeconomic disadvantage showed no differences. The prevalence of hypertension (66% vs. 54%), chronic lung disease (20% vs. 11%), and kidney failure (6% vs. 3%) were higher among non-participants compared to participants. Feelings of loneliness were less frequent among non-participants (14%) compared to participants (32%). The proportions of those using assistive mobility devices (18% vs. 8%) as well as those having previous falls (12% vs. 5%) were higher in non-participants than in participants.

CONCLUSIONS

The participation rate of TSHeC was high. No neighborhood differences in participation were found. Health status and physical functioning of non-participants seemed to be slightly worse than those of the participants, and more women than men participated. These differences may weaken the generalizability of the findings of the study. The differences have to be taken into account when recommendation for the content and implementation of preventive nurse-managed health clinic in primary health care in Finland is going to be given.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05634239; registration date; 1st of December 2022. Retrospectively registered.

Ceramides and Phosphatidylcholines Associate with Cardiovascular Diseases in the Elderly

Background

The ceramide- and phospholipid-based cardiovascular risk score (CERT2) has been found to predict the risk for cardiovascular disease (CVD) events, especially cardiovascular mortality. In the present study, our aim was to estimate the predictive ability of CERT2 for mortality of CVD, coronary artery disease (CAD), and stroke in the elderly and to compare these results with those of conventional lipids.

Methods

We conducted a prospective study with an 18-year follow-up period that included a total of 1260 participants ages ≥64 years. Ceramides and phosphatidylcholines were analyzed using a LC-MS. Total cholesterol and triglycerides were performed by enzymatic methods and HDL cholesterol was determined by a direct enzymatic method. Concentrations of LDL-cholesterol were calculated according to the Friedewald formula.

Results

A higher score of CERT2 was significantly associated with higher CVD, CAD, and stroke mortality during the 18-year follow-up both in unadjusted and adjusted Cox regression models. The unadjusted hazard ratios (HRs) of CERT2 (95% CI) per SD for CVD, CAD, and stroke were 1.72 (1.52–1.96), 1.76 (1.52–2.04), and 1.63 (1.27–2.10), respectively, and the corresponding adjusted HRs (95% CI) per SD for CERT2 were 1.48 (1.29–1.69), 1.50 (1.28–1.75), and 1.41 (1.09–1.83). For conventional lipids, HRs per SD were lower than for CERT2.

Conclusions

The risk score CERT2 associated strongly with CVD, CAD, and stroke mortality in the elderly, while the association between these events and conventional lipids was weak.

The long-term prognostic value of serum 25(OH)D, albumin, and LL-37 levels in acute respiratory diseases among older adults

Background

Older adults are more susceptible to respiratory tract infection than healthy working age adults. The increased susceptibility of older adults is thought to be interlinked with vitamin D status, nourishment, and immunological state in general. Data are scarce whether these parameters could serve as prognostic markers.

Aim

To study whether serum 25(OH)D, albumin, and LL-37 level could give prognostic value of long-term survival in the older adults with multimorbidity and acute respiratory infection.

Methods

Consecutive episodes of hospital care of patients 65 years and older with respiratory symptoms were prospectively studied as a cohort. Standard clinical questionnaire was filled by the study physician. Laboratory markers included serum levels of 25(OH)D, albumin and LL-37, C-reactive protein (CRP), white blood cell count (WBC) and polymerase chain reaction diagnostics for 14 respiratory viruses. Pneumonia was confirmed by chest radiographs. Respiratory illness severity, death at ward, length of hospital stays, and 5-year survival were used as outcomes.

Results

In total, 289 older adult patients with mean age of 83 years were included in the study. Serum 25(OH)D deficiency (< 50 nmol/liter) was present in 59% and hypoalbuminemia (< 3.5 g/dL) in 55% of the study patients. Low serum albumin level was associated to one, two- and five-year mortality after hospital stay (all P < .05). In addition, it was associated with pneumonia, dyspnea, over 13-night long stay at ward and death at ward (all P < .05). No associations were seen between serum 25(OH)D and LL-37 levels and disease severity, short-term clinical outcome, or long-term survival. Associations between serum 25(OH)D, albumin, and LL-37 levels and respiratory virus presence were not seen.

Conclusions

Serum albumin level on admission seems to give valuable information about the patients’ general health and recovery potential in treating older adults with respiratory symptoms. Serum 25(OH)D and LL-37 had no associations with disease severity or long- and short-term prognosis among older adults hospitalized with respiratory symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02836-8.

Chronic conditions and multimorbidity associated with institutionalization among Finnish community-dwelling older people: an 18-year population-based follow-up study

Aim

The aim of the study is to assess the association of chronic conditions and multimorbidity with institutionalization in older people.

Findings

Having dementia, mood or neurological disorder and/or five or more chronic conditions were associated with a higher risk of institutionalization.

Message

These risk factors should be recognized in primary care when providing and targeting care and support for home-dwelling older people.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00535-y.

Purpose

The ageing population is increasingly multimorbid. This challenges health care and elderly services as multimorbidity is associated with institutionalization. Especially dementia increases with age and is the main risk factor for institutionalization. The aim of this study was to assess the association of chronic conditions and multimorbidity with institutionalization in home-dwelling older people, with and without dementia.

Methods

In this prospective study with 18-year follow-up, the data on participants’ chronic conditions were gathered at the baseline examination, and of conditions acquired during the follow-up period from the municipality’s electronic patient record system and national registers. Only participants institutionalized or deceased by the end of the follow-up period were included in this study. Different cut-off-points for multimorbidity were analyzed. Cox regression model was used in the analyses. Death was used as a competing factor.

Results

The mean age of the participants (n = 820) was 74.7 years (64.0‒97.0). During the follow-up, 328 (40%) were institutionalized. Dementia, mood disorders, neurological disorders, and multimorbidity defined as five or more chronic conditions were associated with a higher risk of institutionalization in all the participants. In people without dementia, mood disorders and neurological disorders increased the risk of institutionalization.

Conclusion

Having dementia, mood or neurological disorder and/or five or more chronic conditions were associated with a higher risk of institutionalization. These risk factors should be recognized when providing and targeting care and support for older people still living at home.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00535-y.

Subjective and objective health predicting mortality and institutionalization: an 18-year population-based follow-up study among community-dwelling Finnish older adults

BACKGROUND

Objective health measures, such as registered illnesses or frailty, predict mortality and institutionalization in older adults. Also, self-reported assessment of health by simple self-rated health (SRH) has been shown to predict mortality and institutionalization. The aim of this study was to assess the association of objective and subjective health with mortality and institutionalization in Finnish community-dwelling older adults.

METHODS

In this prospective study with 10- and 18-year follow-ups, objective health was measured by registered illnesses and subjective health was evaluated by simple SRH, self-reported walking ability (400 m) and self-reported satisfaction in life. The participants were categorized into four groups according to their objective and subjective health: 1. subjectively and objectively healthy, 2. subjectively healthy and objectively unhealthy, 3. subjectively unhealthy and objectively healthy and 4. subjectively and objectively unhealthy. Cox regression model was used in the analyses. Death was used as a competing factor in the institutionalization analyses.

RESULTS

The mean age of the participants (n = 1259) was 73.5 years (range 64.0-100.0). During the 10- and 18-year follow-ups, 466 (37%) and 877 (70%) died, respectively. In the institutionalization analyses (n = 1106), 162 (15%) and 328 (30%) participants were institutionalized during the 10- and 18-year follow-ups, respectively. In both follow-ups, being subjectively and objectively unhealthy, compared to being subjectively and objectively healthy, was significantly associated with a higher risk of institutionalization in unadjusted models and with death both in unadjusted and adjusted models.

CONCLUSIONS

The categorization of objective and subjective health into four health groups was good at predicting the risk of death during 10- and 18-year follow-ups, and seemed to also predict the risk of institutionalization in the unadjusted models during both follow-ups. Poor subjective health had an additive effect on poor objective health in predicting mortality and could therefore be used as part of an older individual's health evaluation when screening for future adverse outcomes.

The Association of the Brief Dementia Risk Index and Incident Dementia among Finnish 70-Year-Olds: A 5-Year Follow-Up Study

BACKGROUND

An accurate identification of older individuals at increased risk of developing dementia is very important. Various dementia risk prediction models have been developed, but not all models are applicable among older population.

OBJECTIVES

To examine the association of the Brief Dementia Risk Index (BDRI) and incidence of dementia among community-dwelling Finnish older adults.

METHODS

Participants were community-dwelling nondemented 70-year-olds examined in 2011 (n = 943). Cox regression model with death as a competing risk was used to analyze the association of BDRI and incident dementia (ICD-10 codes F00-03 and G30) during the 5-year follow-up (n = 883).

RESULTS

The rate of dementia incidence was 4.9% during the follow-up. Having at least moderate risk according to BDRI significantly predicted incident dementia (hazard ratio 3.18, 95% confidence interval: 1.71-5.92, p < 0.001), also after adjustment with education level (2.93, 1.52-5.64, p = 0.001). No interaction between gender and BDRI was found.

CONCLUSION

BDRI could be an applicable tool for identification of older individuals at increased risk of developing dementia in clinical settings.

Frailty, walking ability and self-rated health in predicting institutionalization: an 18-year follow-up study among Finnish community-dwelling older people

Background

In clinical practice, there is a need for an instrument to screen older people at risk of institutionalization.

Aims

To analyze the association of frailty, walking-ability and self-rated health (SRH) with institutionalization in Finnish community-dwelling older people.

Methods

In this prospective study with 10- and 18-year follow-ups, frailty was assessed using FRAIL Scale (FS) (n = 1087), Frailty Index (FI) (n = 1061) and PRISMA-7 (n = 1055). Walking ability was assessed as self-reported ability to walk 400 m (n = 1101). SRH was assessed by a question of general SRH (n = 1105). Cox regression model was used to analyze the association of the explanatory variables with institutionalization.

Results

The mean age of the participants was 73.0 (range 64.0‒97.0) years. Prevalence of institutionalization was 40.8%. In unadjusted models, frailty was associated with a higher risk of institutionalization by FS in 10-year follow-up, and FI in both follow-ups. Associations by FI persisted after age- and gender-adjustments in both follow-ups. By PRISMA-7, frailty predicted a higher risk of institutionalization in both follow-ups. In unadjusted models, inability to walk 400 m predicted a higher risk of institutionalization in both follow-ups and after adjustments in 10-year follow-up. Poor SRH predicted a higher risk of institutionalization in unadjusted models in both follow-ups and after adjustments in 10-year follow-up.

Discussion

Simple self-reported items of walking ability and SRH seemed to be comparable with frailty indexes in predicting institutionalization among community-dwelling older people in 10-year follow-up.

Conclusions

In clinical practice, self-reported walking ability and SRH could be used to screen those at risk.

Electronic supplementary material

The online version of this article (10.1007/s40520-020-01551-x) contains supplementary material, which is available to authorized users.

A practical laboratory index to predict institutionalization and mortality - an 18-year population-based follow-up study

Background

Previously, several indexes based on a large number of clinical and laboratory tests to predict mortality and frailty have been produced. However, there is still a need for an easily applicable screening tool for every-day clinical practice.

Methods

A prospective study with 10- and 18-year follow-ups. Fourteen common laboratory tests were combined to an index. Cox regression model was used to analyse the association of the laboratory index with institutionalization and mortality.

Results

The mean age of the participants (n = 1153) was 73.6 (SD 6.8, range 64.0–100.0) years. Altogether, 151 (14.8%) and 305 (29.9%) subjects were institutionalized and 422 (36.6%) and 806 (69.9%) subjects deceased during the 10- and 18-year follow-ups, respectively. Higher LI (laboratory index) scores predicted increased mortality. Mortality rates increased as LI scores increased both in unadjusted and in age- and gender-adjusted models during both follow-ups. The LI did not significantly predict institutionalization either during the 10- or 18-year follow-ups.

Conclusions

A practical index based on routine laboratory tests can be used to predict mortality among older people. An LI could be automatically counted from routine laboratory results and thus an easily applicable screening instrument in clinical settings.

Frailty and mortality: an 18-year follow-up study among Finnish community-dwelling older people

BACKGROUND

There is a lack of agreement about applicable instrument to screen frailty in clinical settings.

AIMS

To analyze the association between frailty and mortality in Finnish community-dwelling older people.

METHODS

This was a prospective study with 10- and 18-year follow-ups. Frailty was assessed using FRAIL scale (FS) (n = 1152), Rockwood's frailty index (FI) (n = 1126), and PRISMA-7 (n = 1124). To analyze the association between frailty and mortality, Cox regression model was used.

RESULTS

Prevalence of frailty varied from 2 to 24% based on the index used. In unadjusted models, frailty was associated with higher mortality according to FS (hazard ratio 7.96 [95% confidence interval 5.10-12.41] in 10-year follow-up, and 6.32 [4.17-9.57] in 18-year follow-up) and FI (5.97 [4.13-8.64], and 3.95 [3.16-4.94], respectively) in both follow-ups. Also being pre-frail was associated with higher mortality according to both indexes in both follow-ups (FS 2.19 [1.78-2.69], and 1.69 [1.46-1.96]; FI 1.81[1.25-2.62], and 1.31 [1.07-1.61], respectively). Associations persisted even after adjustments. Also according to PRISMA-7, a binary index (robust or frail), frailty was associated with higher mortality in 10- (4.41 [3.55-5.34]) and 18-year follow-ups (3.78 [3.19-4.49]).

DISCUSSION

Frailty was associated with higher mortality risk according to all three frailty screening instrument used. Simple and fast frailty indexes, FS and PRISMA-7, seemed to be comparable with a multidimensional time-consuming FI in predicting mortality among community-dwelling Finnish older people.

CONCLUSIONS

FS and PRISMA-7 are applicable frailty screening instruments in clinical setting among community-dwelling Finnish older people.

Factors associated with institutionalization among home-dwelling patients of Urgent Geriatric Outpatient Clinic: a 3-year follow-up study

Aim

To examine the effect of predictive factors on institutionalization among home-dwelling patients of Urgent Geriatric Outpatient Clinic during a 3-year follow-up.

Findings

The rates of institutionalization and mortality were 29.9% and 46.1%, respectively. The use of home care, dementia, higher age and falls during the previous 12 months significantly predicted institutionalization during the follow-up.

Message

Cognitive and/or functional impairment mainly predicted institutionalization among older patients of UrGeriC having health problems and acute difficulties in managing at home.

Purpose

To examine the effect of predictive factors on institutionalization among older patients.

Methods

The participants were older (aged 75 years or older) home-dwelling citizens evaluated at Urgent Geriatric Outpatient Clinic (UrGeriC) for the first time between the 1st of September 2013 and the 1st of September 2014 (n = 1300). They were followed up for institutionalization for 3 years. Death was used as a competing risk in Cox regression analyses.

Results

The mean age of the participants was 85.1 years (standard deviation [SD] 5.5, range 75–103 years), and 74% were female. The rates of institutionalization and mortality were 29.9% and 46.1%, respectively. The mean age for institutionalization was 86.1 (SD 5.6) years. According to multivariate Cox regression analyses, the use of home care (hazard ratio 2.43, 95% confidence interval 1.80–3.27, p < 0.001), dementia (2.38, 1.90–2.99, p < 0.001), higher age (≥ 95 vs. 75–84; 1.65, 1.03–2.62, p = 0.036), and falls during the previous 12 months (≥ 2 vs. no falls; 1.54, 1.10–2.16, p = 0.012) significantly predicted institutionalization during the 3-year follow-up.

Conclusion

Cognitive and/or functional impairment mainly predicted institutionalization among older patients of UrGeriC having health problems and acute difficulties in managing at home.

Self-rated health and objective health status as predictors of all-cause mortality among older people: a prospective study with a 5-, 10-, and 27-year follow-up

Background

Despite a non-specific nature of self-rated health (SRH), it seems to be a strong predictor of mortality. The aim of this study is to assess the association of SRH and objective health status (OH) with all-cause mortality in 70-year-old community-dwelling older people in Finland.

Methods

A prospective study with 5-, 10- and 27-year follow-ups. SRH (n = 1008) was assessed with a single question and OH (n = 962) by the Rockwood’s Frailty Index (FI). To assess the association of SRH and OH with mortality, Cox regression model was used.

Results

Of the 1008 participants, 138 (13.7%), 319 (31.6%), and 932 deceased (86.3%) during the 5-, 10- and 27-year follow-ups, respectively. In unadjusted models, subjects with poor SRH had almost eightfold risk for mortality compared to those with good SRH during the 5-year follow-up; among those with poor OH, the risk was fourfold compared to those with good OH. In the 10-year-follow up, both poor SRH and poor OH predicted about fourfold risk for mortality compared to those with good health. During the 27-year follow-up, OH was a stronger predictor of mortality than SRH. Poor SRH, compared to good SRH, showed 95% sensitivity and 34% specificity for 5-year mortality; corresponding figures for OH were 54 and 80%, respectively.

Conclusions

Single-item SRH seems to be able to capture almost the same as OH in predicting a short-term (less than 10 years) mortality risk among older adults in clinical settings. The use of SHR may also enhance the focus on patient-centered care.

Respiratory tract virus infections in the elderly with pneumonia

BACKGROUND

In children suffering from severe lower airway illnesses, respiratory virus detection has given good prognostic information, but such reports in the elderly are scarce. Therefore, our aim was to study whether the detection of nasopharyngeal viral pathogens and conventional inflammatory markers in the frail elderly correlate to the presence, signs and symptoms or prognosis of radiographically-verified pneumonia.

METHODS

Consecutive episodes of hospital care of patients 65 years and older with respiratory symptoms (N = 382) were prospectively studied as a cohort. Standard clinical questionnaire was filled by the study physician. Laboratory analyses included PCR diagnostics of nasopharyngeal swab samples for 14 respiratory viruses, C-reactive protein (CRP) and white blood cell count (WBC). Chest radiographs were systematically analysed by a study radiologist. The length of hospital stay, hospital revisit and death at ward were used as clinical endpoints.

RESULTS

Median age of the patients was 83 years (range 76-90). Pneumonia was diagnosed in 112/382 (29%) of the studied episodes. One or more respiratory viruses were detected in 141/382 (37%) episodes and in 34/112 (30%) episodes also diagnosed with pneumonia. Pneumonia was associated with a WBC over 15 × 10⁹/L (P = .006) and a CRP value over 80 mg/l (P < .05). A virus was detected in 30% of pneumonia episodes and in 40% of non-pneumonia episodes, but this difference was not significant (P = 0.09). The presence of a respiratory virus was associated with fewer revisits to the hospital (P < .05), whereas a CRP value over 100 mg/l was associated with death during hospital stay (P < .05). Respiratory virus detections did not correlate to WBC or CRP values, signs and symptoms or prognosis of radiographically-verified pneumonia episodes.

CONCLUSION

Among the elderly with respiratory symptoms, respiratory virus detection was not associated with an increased risk of pneumonia or with a more severe clinical course of the illness. CRP and WBC remain important indicators of pneumonia, and according to our findings, pneumonia should be treated as a bacterial disease regardless of the virus findings. Our data does not support routine virus diagnostics for the elderly patients with pneumonia outside the epidemic seasons.

Prediction of the Future Need for Institutional Care in Finnish Older People: A Comparison of Two Birth Cohorts

BACKGROUND

More recent birth cohorts of older people have better physical and cognitive status than earlier cohorts. As such, this could be expected to diminish the need for institutional care. The prediction of the future need for institutional care provides essential information for the planning and delivery of future care and social services as well as the resources needed.

OBJECTIVE

To predict the future need for institutional care among older Finnish people born in 1940.

METHODS

Representative samples of home-dwelling 70-year-olds from Turku, Finland were examined with similar methods in 1991 (those born in 1920) (n = 1,032) and in 2011 (those born in 1940) (n = 956). Predictors of institutionalization rates from the earlier 1920 cohort, together with data of sociodemographic factors, health, psychosocial and physical status, the need for help, and health behavior, were used to predict the future institutionalization rate among the 1940 cohort in this study using Cox regression models.

RESULTS

Health as well as psychosocial and physical status were significantly better in the 1940 cohort compared to the earlier cohort. In the 1940 cohort, the predicted rates of institutionalization were 1.8, 10.4, and 26.0% at the ages of 80 (year 2020), 85 (year 2025), and 90 years (year 2030), respectively. At every age (80, 85, and 90 years), the predicted rates of institutionalization by Mini-Mental State Examination (MMSE) were about two-fold among those with MMSE scores 18-26 (3.0-38.8%) compared to those with scores 27-30 (1.6-23.7%) and those with a body mass index (BMI) <25 (2.5-34.3%) compared to those with a BMI of 25-29.9 (1.4-20.9%), and about three-fold among participants with several falls (5.3-57.0%) compared to participants with no falls (1.5-23.1%).

CONCLUSIONS

The 1940 cohort performed better in health as well as psychosocial and physical status than the 1920 cohort. Nevertheless, the predicted rates of future need for institutional care were high, especially at the ages of 85 and 90 years, among those with a lowered cognitive or physical status.

Predictors of institutionalization among home-dwelling older Finnish people: a 22-year follow-up study

BACKGROUND

Identification of predictive factors on institutionalization provides the basis for the development and application of preadmission assessment. There is a lack of evidence for predictors of institutionalization for older people.

AIMS

To examine the effect of predictive factors on institutionalization in home-dwelling 70-year-old people.

METHODS

The data were collected in 1991 by the clinical examinations, a postal questionnaire, and an interview from the residents of Turku, Finland, born in 1920 (n = 1032). Institutionalization was defined as entry into a nursing home or sheltered housing at any time during a 22-year follow-up.

RESULTS

A rate of institutionalization was 22.0%. In multivariable Cox regression analysis, impaired cognitive function (MMSE 18-26) (hazard ratio 1.71, confidence interval 1.24-2.36) and low BMI (<25 kg/m²) (compared to both BMI of 25-29.9 and that of ≥30, respectively, 1.88, 1.32-2.67, and 1.66, 1.05-2.60), having several falls during the previous year (2.50, 1.28-4.90).

CONCLUSIONS

We conclude that impaired cognitive function, low BMI, and frequent falling predicted institutionalization during the 22-year follow-up. To reduce or postpone institutionalization, interventions should target risk factors, such as frailty, physical limitations, and falling. In addition, community-based services according to the needs and functional ability of the home-dwelling older people should be developed.

Enzymatic accessibility of fiber hemp is enhanced by enzymatic or chemical removal of pectin

Pectinolytic enzymes, steam explosion and alkaline treatment were used to assess the role of pectin for the accessibility of hydrolytic enzymes in the enzymatic hydrolysis of biomass. Hemp (Cannabis sativa L.), a potential energy crop especially in boreal climate with a low need of fertilizers, was used in the study either as untreated or anaerobically preserved raw material. Addition of pectinases increased the hydrolysis yield by 26%, 54%, and 64% from the theoretical carbohydrates of untreated, acid, and alkali-preserved materials, respectively. Steam explosion and hot alkali treatment increased the conversion of the total carbohydrates by 78% and 60%, respectively, compared to the untreated hemp. Elevated separation of cells within the hemp stalk tissues and an increased surface area was revealed after hot alkali or pectinase treatments, contributing to the increased conversion to sugars by commercial enzymes.

Oxidation of milled wood lignin with laccase, tyrosinase and horseradish peroxidase

In this paper the oxidation of milled wood lignin (MWL), catalysed by three enzymes, i.e. laccase, tyrosinase and horseradish peroxidase (HRP) was studied. The oxidation was followed by measuring the consumption of O(2) during laccase and tyrosinase treatment and of H(2)O(2) during HRP treatment. Both laccase and HRP were found to oxidise lignin effectively, whereas the effect of tyrosinase was negligible. The changes in MWL molecular-weight distributions caused in the reactions were analysed by gel permeation chromatography. Both laccase and HRP treatments were found to polymerise MWL. Peroxidase treatment was found to decrease the amount of phenolic hydroxyls in MWL, whereas no such effect could be detected in the laccase-treated sample. Both laccase and HRP treatments were, however, found to increase the amount of conjugated structures in MWL. The formation of phenoxy radicals during the treatments was studied by electron paramagnetic resonance spectroscopy. Phenoxy radicals were detected in both laccase and HRP-treated samples. The amount of the formed phenoxy radicals was found to be essentially constant during the detected time (i.e. 20-120 min after the addition of enzyme).

Purification and characterisation of a novel laccase from the ascomycete Melanocarpus albomyces

A novel laccase from the ascomycete Melanocarpus albomyces was purified and characterised. The enzyme was purified using anion exchange chromatography, hydrophobic interaction chromatography and gel filtration, and the purified laccase was biochemically characterised. It had activity towards typical substrates of laccases including 2,2'-azinobis-(3-ethylbenzthiazoline-6-sulphonate), dimethoxyphenol, guaiacol, and syringaldazine. The laccase showed good thermostability and it had a pH optimum at neutral pH, both unusual properties for most known fungal laccases. The activity of the laccase from M. albomyces was highest at 60-70 degrees C. With guaiacol and syringaldazine the pH optima were rather broad: 5-7.5 and 6-7, respectively. It retained 50% of its activity after 5 h incubation at 60 degrees C. The molecular weight of the laccase was about 80 kDa and the isoelectric point 4.0. The ultraviolet-visible absorption and electron paramagnetic resonance spectra of the purified laccase indicated that the typical three types of copper were present.

Screening of micro-organisms for decolorization of melanins produced by bluestain fungi

A total of 17 fungi and four bacteria were screened for their ability to decolorize melanin, using isolated extracellular melanin of the bluestain fungus Aureobasidium pullulans as substrate. On agar media, decolorization was observed by four fungal strains: Bjerkandera adusta VTT-D-99746, Galactomyces geotrichum VTT-D-84228, Trametes hirsuta VTT-D-95443 and Trametes versicolor VTT-D-99747. The four fungi were more efficient on nitrogen-limited medium than on complete medium. The melanin-decolorizing activity of G. geotrichum appeared to be located on the mycelium and could be liberated into the medium enzymatically.

Treatment of recycled kraft pulps with Trichoderma reesei hemicellulases and cellulases

Effects of recycling ECF-bleached softwood kraft pulp on pulp properties were evaluated in the laboratory. The tensile strength, fiber flexibility and WRV lost during drying of the pulp were recovered by refining between the cycles which, however, resulted in deteriorated drainage properties. The recycled pulps were treated with purified Trichoderma reesei cellulases and hemicellulases and the changes in fiber properties due to enzymatic treatments were characterized. The endoglucanases (EG I and EG II) significantly improved pulp drainage already at low dosage levels, and EG II was found to be more effective at a given level of carbohydrate solubilization. Combining hemicellulases with the endoglucanase treatments increased the positive effects of the endoglucanases on pulp drainage. However, as a result of the endoglucanase treatments a slight loss in strength was observed. Combining mannanase with endoglucanase treatments appeared to increase this negative effect, whereas the impact of xylanase was not significant. Although the drainage properties of the pulps could be improved by selected enzymes, the water retention capacity of the dried hornified fibers could not be recovered by any of the enzymes tested.

Adsorption and activity of Trichoderma reesei cellobiohydrolase I, endoglucanase II, and the corresponding core proteins on steam pretreated willow

The adsorption and the hydrolytic action of purified cellulases of Trichoderma reesei, namely, cellobiohydrolase I (CBH I), endoglucanase II (EG II), and their core proteins, on steam-pretreated willow were compared. The two enzymes differed clearly in their adsorption and hydrolytic behavior. CBH I required the cellulose-binding domain (CBD) for efficient adsorption and hydrolysis, whereas EG II was able to adsorb to steam pretreated willow without its CBD. Absence of the CBD decreased the hydrolysis of cellulose by EG II, but the decrease was less pronounced than with CBH I. A linear relationship was observed between the amount of enzyme adsorbed and the degree of hydrolysis of cellulose only for CBH I. EG II and EG II core appeared to be able to hydrolyze only 1 to 2% of the substrate regardless of the amount of protein adsorbed.

Substrate specificities of Penicillium simplicissimum alpha-galactosidases

The substrate specificities of three Penicillium simplicissimum alpha-galactosidases, AGLI, AGLII, and AGLIII, were determined by using various isolated galactose-containing oligosaccharides and polymeric galacto(gluco)mannans. AGLI released galactose from melibiose and raffinose-family oligosaccharides but the amount of galactose released was decreased from 96% to 35% by the increasing chain length of the substrate from raffinose to verbascose. It was able to release galactose linked to the nonreducing end and less efficiently to the internal residues of the galactomanno-oligomers. AGLI was able to hydrolyze 60-92% of galactose from polymeric galacto(gluco)mannans alone but its action was facilitated by mannanase and beta-mannosidase. In addition, it was able to release about 10% of the galactose from softwood kraft pulp alone and about 22% in combination with mannanase. AGLII was highly specific toward small galactose-containing oligosaccharides in which the galactose is linked to the nonreducing end of the substrate. It released 90-100% of galactose present in melibiose, raffinose, stachyose, and verbascose; however, it was able to degrade polymeric substrates only in combination with mannanase and beta-mannosidase. AGLIII had only low activity toward the oligomeric substrates tested. It was able to release some galactose from the polymeric galacto(gluco)mannans alone, but its action was clearly enhanced by the backbone degrading enzymes.

Action of Trichoderma reesei mannanase on galactoglucomannan in pine kraft pulp

The di-, tri- and tetrasaccharides formed during Trichoderma reesei endo-beta-D-mannanase treatment of pine kraft pulp were studied. The oligosaccharides in the hydrolysate were fractionated using size-exclusion, anion exchange and activated carbon chromatography. The primary sequence of the purified oligomers was determined by two-dimensional NMR techniques. The T. reesei mannanase cleaves the beta-1,4-glycosidic linkage of D-mannosyl residues attached either to D-mannose or D-glucose. The D-mannosyl residue may also be substituted by a D-galactosyl group. The main disaccharide produced was mannobiose, but a significant amount of 4-O-beta-D-glucopyranosyl-D-mannopyranose (GlcMan) was also produced. After extensive hydrolysis the main trisaccharides produced were 4-O-beta-D-mannopyranosyl-[6-O-alpha-galactopyranosyl]-D-mannopyranose (Gal1Man2) and 4-O-beta-D-glucopyranosyl-4-O-beta-D-glucopyranosyl-D-mannopyranose (Glc2Man). Some mannotriose 4-O-beta-D-glucopyranosyl-4-O-beta-D-mannopyra-nosyl-D-manno pyranose (GlcMan2) and 4-O-beta-D-glucopyranosyl-[6-O-alpha-galactopyranosyl]-D-mannopyranose (Gal1GlcMan) were also detected in the hydrolysate. The structures of two tetrasaccharides were studied. They appeared to be 4-O-beta-D-glucopyranosyl-4-O-beta-D-glucopyranosyl-4-O-beta-D- glucopyranosyl-D-mannopyranose (Glc3Man) and 4-O-beta-D-glucopyranosyl-4-O-beta-D-mannopyranosyl-4-O-beta-D -glucopyranosyl-D-mannopyranose (GlcManGlcMan). According to the results obtained, the galactoglucomannan in pine contains regions in which two or three glucose units are linked together, which further means that it may contain regions with several successive mannose residues. The galactose side groups were found to be attached only to mannose.

Hemicellulases in the bleaching of chemical pulps

Hemicellulase-aided bleaching is the first full-scale biotechnical application in the pulp and paper industry which truly exploits the unique specificity and safety of biocatalysts. Hemicellulases are used to modify the structure of xylan and glucomannan in pulp fibers in order to enhance the chemical delignification. This technology can be combined with various types of kraft pulping processes and bleaching sequences. The aims of the enzymatic treatment depend on the actual mill conditions, and may be related to environmental demands, reduction of chemical costs, or maintenance or even improvement of product quality. The technology is applied on the mill scale in several countries. This review describes the principles of the enzyme-aided bleaching, the composition of the fiber substrates, the basic enzymology involved, and the present knowledge of the mechanisms of the action of enzymes, as well as the practical results and advantages obtained on the laboratory and industrial scale.

An acetylglucomannan esterase of Aspergillus oryzae; purification, characterization and role in the hydrolysis of O-acetyl-galactoglucomannan

An acetyl glucomannan esterase (AGME) was purified to electrophoretic homogeneity from the culture supernatant of Aspergillus oryzae. This new enzyme had a molecular mass of 36 kDa and an isoelectric point of 4.6. It was most active in the pH range 5.0-5.5 and was stable for 24 h at 40 degrees C at pH 5.0-6.0. The purified esterase liberated acetic acid from O-acetyl-galactoglucomannan, O-acetyl-4-O- methylglucuronoxylan and alpha-naphtyl acetate. The specific activity was 10-times higher for acetylated mannan than for acetylated xylan. The enzyme was able to act on polymeric substrate but activity was clearly enhanced by addition of mannanase from Trichoderma reesei and alpha-galactosidase from guar seeds. Presence of mannanase also increased the liberation of acetic acid in long-term hydrolysis (24 h), while the addition of alpha-galactosidase had no effect. No significant synergism between these two glycanases and the previously characterized esterase of A. oryzae (FE), which is also able to deacetylate galactoglucomannan, was observed. Even though the AGME had 8-times higher specific galactomannan deacetylating activity than the FE, the maximum amount of acetic acid liberated from the polymeric galactoglucomannan by AGME was only 80% of that of FE. Both esterases clearly enhanced the action of mannanase and alpha-galactosidase in the degradation of O-acetyl-galactoglucomannan isolated from Norway spruce.

Large-scale applicable purification and characterization of a membrane-bound PQQ-dependent aldose dehydrogenase

A membrane-bound xylose oxidizing PQQ-dependent dehydrogenase from Gluconobacter oxydans was purified with a simple large-scale applicable purification procedure. The activity recovery from membrane extract was 33% with 130-fold purification. Important characteristic with respect to the application of the dehydrogenase in biosensor technology were studied. The purified enzyme was most stable in the pH range 3.5-6.5. The pH optimum for xylose oxidation was in the range 7.5-8 for the solubilized enzyme. Optimal pH for the electrochemical detection of xylose oxidation was 6.5. Dimethyl and carboxylic acid derivatives of ferrocene were able to mediate electrons transferred in xylose oxidation from the enzyme immobilized on graphite electrode to the electrode. Hence the purified enzyme appeared to be suitable for biosensor applications.

Pilot scale production of a Trichoderma reesei endo-beta-glucanase by brewer's yeast

Endo-beta-glucanase I (EGI) of Trichoderma reesei was produced in laboratory and pilot scale using recombinant strains of "bottom-fermenting" Saccharomyces cerevisiae. The gene eg/1 was integrated in the chromosome or an expression cassette was inserted on a multicopy plasmid. Expression levels were compared in a laboratory scale bioreactor. The best EGI-producing strain was cultivated in pilot scale. Adsorbent treatment was used to remove endogenous yeast proteins and other impurities from the culture filtrate during concentration. Effective pilot scale one-step purification of the EGI protein was obtained using DEAE-Sepharose, on which EGI was weakly bound. The purified enzyme reacted with antibodies prepared against T. reesei EGI and catalyzed the hydrolysis of both insoluble and soluble substrates.

A novel combination of prosthetic groups in a fungal laccase; PQQ and two copper atoms

Extracellular laccase (benzenediol: oxygen oxidoreductase EC 1.10.3.2) from the lignin-degrading fungus, Phlebia radiata, was shown to contain a novel combination of electron carriers as its prosthetic groups. In addition to two copper atoms per enzyme molecule, one molecule of PQQ was included as a cofactor. The EPR spectrum exhibits features of type 1 and type 2 copper atoms. In the enzymatic reaction 4 molecules of lignin model compound, coniferyl alcohol, are oxidized per molecule of oxygen reduced to water. During the reaction coniferyl alcohol is transformed to dilignols.

Hydrolysis of xylan and fermentation of xylose to ethanol

The focus in the development of pulping processes has usually been exclusively on cellulose. However, hemicellulose could serve as a valuable source of hexose and pentose sugars. Consequently, it should not be destroyed in a process designed for very high cellulose fibre yields. Novel procedures developed for production of ethanol by the fermentation of pentoses as well as hexoses provide new possibilities of hemicellulose utilization. Many fungi produce extracellular hemicellulases. In the present work the production of xylanase and beta-xylosidase with strains of Aspergillus and Trichoderma was studied. The enzymes were used for the hydrolysis of xylan. Xylose was fermented to ethanol by the mold Fusarium oxysporum.