Association Between Real-Time Continuous Glucose Monitor Use and Diabetes-Related Medical Costs for Patients with Type 2 Diabetes

Little is known about the impact of real-time continuous glucose monitoring (rtCGM) on diabetes-related medical costs within the type 2 diabetes (T2D) population. A retrospective analysis of administrative claims data from the Optum Research Database was conducted. Changes in diabetes-related health care resource utilization costs were expressed as per-patient-per-month (PPPM) costs. A total of 571 T2D patients (90% insulin treated) met study inclusion criteria. Average PPPM for diabetes-related medical costs decreased by -$424 (95% confidence interval [CI] -$816 to -$31, P = 0.035) after initiating rtCGM. These reductions were driven, in part, by reductions in diabetes-related inpatient medical costs: -$358 (95% CI -$706 to -$10, P = 0.044). Inpatient hospital admissions were reduced on average -0.006 PPPM (P = 0.057) and total hospital days were reduced an average of -0.042 PPPM (P = 0.139). These findings provide real-world evidence that rtCGM use was associated with diabetes-related health care resource utilization cost reductions in patients with T2D.

Development of a natural language processing algorithm to detect chronic cough in electronic health records

Background

Chronic cough (CC) is difficult to identify in electronic health records (EHRs) due to the lack of specific diagnostic codes. We developed a natural language processing (NLP) model to identify cough in free-text provider notes in EHRs from multiple health care providers with the objective of using the model in a rules-based CC algorithm to identify individuals with CC from EHRs and to describe the demographic and clinical characteristics of individuals with CC.

Methods

This was a retrospective observational study of enrollees in Optum’s Integrated Clinical + Claims Database. Participants were 18–85 years of age with medical and pharmacy health insurance coverage between January 2016 and March 2017. A labeled reference standard data set was constructed by manually annotating 1000 randomly selected provider notes from the EHRs of enrollees with ≥ 1 cough mention. An NLP model was developed to extract positive or negated cough contexts. NLP, cough diagnosis and medications identified cough encounters. Patients with ≥ 3 encounters spanning at least 56 days within 120 days were defined as having CC.

Results

The positive predictive value and sensitivity of the NLP algorithm were 0.96 and 0.68, respectively, for positive cough contexts, and 0.96 and 0.84, respectively, for negated cough contexts. Among the 4818 individuals identified as having CC, 37% were identified using NLP-identified cough mentions in provider notes alone, 16% by diagnosis codes and/or written medication orders, and 47% through a combination of provider notes and diagnosis codes/medications. Chronic cough patients were, on average, 61.0 years and 67.0% were female. The most prevalent comorbidities were respiratory infections (75%) and other lower respiratory disease (82%).

Conclusions

Our EHR-based algorithm integrating NLP methodology with structured fields was able to identify a CC population. Machine learning based approaches can therefore aid in patient selection for future CC research studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02035-6.

Racial and ethnic disparity in clinical outcomes among patients with confirmed COVID-19 infection in a large US electronic health record database

BACKGROUND

Racial and ethnic minority groups have been disproportionately affected by the US coronavirus disease 2019 (COVID-19) pandemic; however, nationwide data on COVID-19 outcomes stratified by race/ethnicity and adjusted for clinical characteristics are sparse. This study analyzed the impacts of race/ethnicity on outcomes among US patients with COVID-19.

METHODS

This was a retrospective observational study of patients with a confirmed COVID-19 diagnosis in the electronic health record from 01 February 2020 through 14 September 2020. Index encounter site, hospitalization, and mortality were assessed by race/ethnicity (Hispanic, non-Hispanic Black [Black], non-Hispanic White [White], non-Hispanic Asian [Asian], or Other/unknown). Associations between racial/ethnic categories and study outcomes adjusted for patient characteristics were evaluated using logistic regression.

FINDINGS

Among 202,908 patients with confirmed COVID-19, patients from racial/ethnic minority groups were more likely than White patients to be hospitalized on initial presentation (Hispanic: adjusted odds ratio 1·690, 95% CI 1·620-1·763; Black: 1·810, 1·743-1·880; Asian: 1·503, 1·381-1·636) and during follow-up (Hispanic: 1·700, 1·638-1·764; Black: 1·578, 1·526-1·633; Asian: 1·391, 1·288-1·501). Among hospitalized patients, adjusted mortality risk was lower for Black patients (0·881, 0·809-0·959) but higher for Asian patients (1·205, 1·000-1·452).

INTERPRETATION

Racial/ethnic minority patients with COVID-19 had more severe disease on initial presentation than White patients. Increased mortality risk was attenuated by hospitalization among Black patients but not Asian patients, indicating that outcome disparities may be mediated by distinct factors for different groups. In addition to enacting policies to facilitate equitable access to COVID-19-related care, further analyses of disaggregated population-level COVID-19 data are needed.

Associations of insomnia symptoms with subsequent health services use among community-dwelling U.S. older adults

STUDY OBJECTIVES

Determine the association of insomnia symptoms with subsequent health services use, in a representative sample of U.S. older adults.

METHODS

Participants were 4,289 community-dwelling Medicare beneficiaries who had continuous fee-for-service Medicare coverage 30 days before, and 1 year after the National Health and Aging Trends Study (NHATS) Round 1 interview. Participants reported past-month insomnia symptoms (i.e. sleep onset latency >30 min, difficulty returning to sleep) which we categorized as 0, 1, or 2 symptoms. Outcomes were health services use within 1 year of interviews from linked Medicare claims: emergency department (ED) visits, hospitalizations, 30-day readmissions, home health care (all measured as yes/no), and number of hospitalizations and ED visits.

RESULTS

Overall, 18.5% of participants were hospitalized, 28.7% visited the ED, 2.5% had a 30-day readmission, and 11.3% used home health care. After adjustment for demographics, depressive and anxiety symptoms, medical comorbidities, and BMI, compared to participants with no insomnia symptoms, those with two insomnia symptoms had a higher odds of ED visits (odds ratio [OR) = 1.60, 95% confidence interval [CI] = 1.24-2.07, p < 0.001), hospitalizations (OR = 1.29, 95% CI = 1.01-1.65, p < 0.05), and 30-day readmissions (OR = 1.88, 95% CI = 1.88-3.29, p < 0.05). Reporting 2 insomnia symptoms, versus no insomnia symptoms, was associated with a greater number of ED visits and hospitalizations (incidence rate ratio (IRR) = 1.52, 95% CI = 1.23-1.87, p < 0.001; IRR = 1.21, 95% CI = 1.02-1.44, p < 0.05, respectively) after adjusting for demographic and health characteristics.

CONCLUSIONS

Among older adults, insomnia symptoms are associated with greater health services use, including emergency department use, hospitalization, and 30-day readmission. Targeting insomnia may lower health services use.

Sleep Disturbances and Risk of Hospitalization and Inpatient Days Among Older Women

Study Objectives

Determine the associations of sleep disturbances with hospitalization risk among older women.

Methods

One thousand eight hundred and twenty-seven women (mean age 83.6 years) participating in Study of Osteoporotic Fractures Year 16 (Y16) examination (2002-2004) linked with Medicare and/or HMO claims. At Y16 examination, sleep/wake parameters were measured by actigraphy (total sleep time [TST], sleep efficiency [SE], sleep latency [SL], and wake after sleep onset [WASO]) and subjective sleep measures (sleep quality [Pittsburgh Sleep Quality Index] and daytime sleepiness [Epworth Sleepiness Scale]) were assessed by questionnaire. Measures except TST were dichotomized based on clinical thresholds. Incident hospitalizations were determined from claims data.

Results

Nine hundred and seventy-six women (53%) had ≥1 hospitalization in the 3 years after the Year 16 examination. Reduced SE (odds ratio [OR] = 2.39, 95% confidence interval [CI] 1.69-3.39), prolonged SL (OR = 1.41, 95% CI 1.11-1.78), greater WASO (OR = 1.57, 95% CI 1.28-1.93), shorter TST (OR = 1.98, 95% CI 1.42-2.77) and poorer sleep quality (OR = 1.33, 95% CI 1.07-1.65) were each associated with a higher age and site-adjusted odds of hospitalization; associations were attenuated after multivariable adjustment for traditional prognostic factors with the OR for reduced SE (OR = 1.60, 95% CI 1.08-2.38) and shorter TST (OR = 1.63, 95% CI 1.12-2.37) remaining significant. Among women who were hospitalized, greater WASO (rate ratio [RR] = 1.20, 95% CI 1.04-1.37) and poorer sleep quality (RR = 1.18, 95% CI 1.02-1.35) were each associated with a greater age and site-adjusted RR of inpatient days, but associations did not persist after multivariate adjustment.

Conclusions

Older women with sleep disturbances have an increased risk of hospitalization partially attributable to demographics, poorer health status, and comorbidities.

Cystatin C and the Risk of Frailty and Mortality in Older Men

Background

This study examines the association between cystatin C (cysC) levels and risks of progression of frailty status or death in older men.

Methods

Prospective study of 2,613 men without overt frailty aged 67 years and older enrolled in the MrOS ancillary sleep study. Baseline measurements included serum cysC, serum creatinine, and frailty status. Repeat frailty status, performed an average of 3.4 years later, was assessed as an ordinal outcome of robust, intermediate stage (prefrail), frail or dead.

Results

Mean age was 75.7 years. Men with higher cysC were older and had a higher comorbidity burden. After adjusting for age, clinical site, and race, higher cysC was associated with nearly twofold greater odds of being classified as intermediate stage versus robust (OR quartile 4 vs 1; 1.82, 95% confidence interval [CI] 1.35-2.45), a threefold greater odds of frailty versus robust (OR quartile 4 vs 1; 3.13, 95% CI 2.03-4.82), and a more than fivefold greater odds of death versus robust (OR quartile 4 vs 1; 5.48, 95% CI 2.98-10.08). Results were similar for cysC-based estimated glomerular filtration rate (eGFR). This relationship was attenuated but persisted after adjusting for additional potential confounders including baseline frailty status, body mass index, smoking status, comorbidity burden, self-reported disability, and serum albumin. In contrast, neither serum creatinine nor creatinine-based eGFR was associated in a graded manner with higher risks of development of frailty or death.

Conclusions

In this cohort of older men without overt frailty, higher cysC and cysC-based eGFR, but not creatinine or creatinine-based estimates of GFR, were associated with increased risks of frailty or death. These findings suggest that higher cysC level may be a promising biomarker for unsuccessful aging as manifested by increased risks of frailty and death.

Effects of Mobility and Cognition on Hospitalization and Inpatient Days in Women in Late Life

Background

This study examines effects of mobility and cognition on hospitalization and inpatient days among women late in life.

Methods

Prospective study of 663 women (mean age 87.7 years) participating in the Study of Osteoporotic Fractures Year 20 examination (2006-2008) linked with their inpatient claims data. At Year 20, mobility ascertained by Short Physical Performance Battery categorized as poor, intermediate, or good. Cognitive status adjudicated based on neuropsychological tests and classified as normal, mild cognitive impairment, or dementia. Hospitalizations (n = 182) during 12 months following Year 20.

Results

Reduced mobility and poorer cognition were each associated in a graded manner with higher inpatient health care utilization, even after accounting for each other and traditional prognostic indicators. For example, adjusted mean inpatient days per year were 0.94 (95% confidence interval [CI] 0.52-1.45) among women with good mobility increasing to 2.80 (95% CI 1.64-3.89) among women with poor mobility and 1.59 (95% CI 1.08-2.03) among women with normal cognition increasing to 2.53 (95% CI 1.55-3.40) among women with dementia. Women with poor mobility/dementia had a nearly sixfold increase in mean inpatient days per year (4.83, 95% CI 2.73-8.54) compared with women with good mobility/normal cognition (0.84, 95% CI 0.49-1.44).

Conclusions

Among women late in life, mobility limitations and cognitive deficits were each independent predictors of higher inpatient health care utilization even after considering each other and conventional predictors. Additive effects of reduced mobility and poorer cognition may be important to consider in medical decision making and health care policy planning for the growing population of adults aged ≥85 years.

Pre-fracture individual characteristics associated with high total health care costs after hip fracture

Older women with pre-fracture slow walk speed, high body mass index, and/or a high level of multimorbidity have significantly higher health care costs after hip fracture compared to those without those characteristics. Studies to investigate if targeted health care interventions for these individuals can reduce hip fracture costs are warranted.

INTRODUCTION

The aim of this study is to estimate the associations of individual pre-fracture characteristics with total health care costs after hip fracture, using Study of Osteoporotic Fractures (SOF) cohort data linked to Medicare claims.

METHODS

Our study population was 738 women age 70 and older enrolled in Medicare Fee for Service (FFS) who experienced an incident hip fracture between January 1, 1992 and December 31, 2009. We assessed pre-fracture individual characteristics at SOF study visits and estimated costs of hospitalizations, skilled nursing facility and inpatient rehabilitation stays, home health care visits, and outpatient utilization from Medicare FFS claims. We used generalized linear models to estimate the associations of predictor variables with total health care costs (2010 US dollars) after hip fracture.

RESULTS

Median total health care costs for 1 year after hip fracture were $35,536 (inter-quartile range $24,830 to $50,903). Multivariable-adjusted total health care costs for 1 year after hip fracture were 14 % higher ($5256, 95 % CI $156 to $10,356) in those with walk speed <0.6 m/s compared to ≥1.0 m/s, 25 % higher ($9601, 95 % CI $3314 to $16,069) in those with body mass index ≥30 kg/m² compared to 20 to 24.9 mg/kg², and 21 % higher ($7936, 95 % CI $346 to $15,526) for those with seven or more compared to no comorbid medical conditions.

CONCLUSIONS

Pre-fracture poor mobility, obesity, and multiple comorbidities are associated with higher total health care costs after hip fracture in older women. Studies to investigate if targeted health care interventions for these individuals can reduce the costs of hip fractures are warranted.

Sarcopenia and Health Care Utilization in Older Women

BACKGROUND

Although there are several consensus definitions of sarcopenia, their association with health care utilization has not been studied.

METHODS

We included women from the prospective Study of Osteoporotic Fractures with complete assessment of sarcopenia by several definitions at the Study of Osteoporotic Fractures Year 10 (Y10) exam (1997-1998) who also had available data from Medicare Fee- For-Service Claims (N = 566) or Kaiser Encounter data (N = 194). Sarcopenia definitions evaluated were: International Working Group, European Working Group for Sarcopenia in Older Persons, Foundation for the NIH Sarcopenia Project, Baumgartner, and Newman. Hurdle models and logistic regression were used to assess the relation between sarcopenia status (the summary definition and the components of slowness, weakness and/or lean mass) and outcomes that included hospitalizations, cumulative inpatient days/year, short-term (part A paid) skilled nursing facility stay in the 3 years following the Y10 visit.

RESULTS

None of the consensus definitions, nor the definition components of weakness or low lean mass, was associated with increased risk of hospitalization or greater likelihood of short-term skilled nursing facility stay. Women with slowness by any criterion definition were about 50% more likely to be hospitalized; had a greater rate of hospitalization days amongst those hospitalized; and had 1.8 to 2.1 times greater likelihood of a short-term skilled nursing facility stay than women without slowness. There was the suggestion of a protective association of low lean mass by the various criterion definitions on short-term skilled nursing facility stay.

CONCLUSION

Estimated effects of sarcopenia on health care utilization were negligible. However, slowness was associated with greater health care utilization.

Impact of radiographic vertebral fractures on inpatient healthcare utilization in older women

BACKGROUND

Vertebral fractures (VFx) are the most common osteoporotic fracture and are associated with higher risk of impaired function, additional fractures and death. The purpose of this analysis was to test the hypotheses that VFx are also associated with greater inpatient healthcare utilization.

METHODS

We studied 4709 Caucasian women enrolled in the Study of Osteoporotic Fractures (SOF) and merged SOF cohort data with Medicare claims or Kaiser encounter data. To be included in this analysis, women had to be enrolled in Medicare Fee for Service or Kaiser as of 1/1/1991 and have radiographic information on VFx status at SOF Visit 3 (1991-92). VFx status was assessed using quantitative morphometry on lateral thoracic and lumbar spine radiographs. Prevalent VFx were defined as any height ratio>3 standard deviations below normal. Women were considered to have a clinical VFx if they reported a new diagnosis of VFx and a clinical radiographic report that confirmed that a VFx was present. Any hospitalization and the number of annualized days of hospitalization were identified through inpatient claims or encounter data. Specific hospitalizations for 5 major common reasons for hospitalizations were also examined.

RESULTS

Over 5-years, 2632 (55.9%) women were hospitalized. In multivariate adjusted models, women with a prevalent radiographic VFx were 21% (95% CI, 2-44%) more likely to be hospitalized for any reason. This association was independent of a number of risk factors including smoking. The annualized rate of inpatient day was, however, similar, 1.67 and 1.48 among women with and without a VFx, respectively, p=0.49. Women with an incident clinical VFx were more likely to be hospitalized including women without evidence of a prevalent radiographic VFx (odds ratio (OR)=5.33; 95% confidence interval (CI)=1.81-15.71) and women with a prevalent radiographic VFx (OR=2.13; 95% CI, 1.05-4.33). Women with a VFx were more likely to be hospitalized specifically for hip fracture or chronic obstructive pulmonary disease (COPD) but not stroke, myocardial infarction or congestive heart failure. The association with COPD was attenuated to non-significance after adjusting for smoking.

CONCLUSION

Our results extend the potential public health impact of radiographic and clinical VFx to include an increased risk of any hospitalization.

Effects of Mobility and Cognition on Risk of Mortality in Women in Late Life: A Prospective Study

BACKGROUND

This study examines the effects of mobility and cognition on mortality risk in women late in life.

METHODS

A prospective study was conducted among 1,495 women (mean age 87.6 years) participating in the Study of Osteoporotic Fractures Year 20 examination (2006-2008). Mobility (ascertained by Short Physical Performance Battery [SPPB]) was categorized as poor (SPPB 0-3, n = 312), intermediate (SPPB 4-9, n = 799), or good (SPPB 10-12, n = 384). Cognitive status (adjudicated based on neuropsychological tests) was classified as normal (n = 873), mild cognitive impairment (n = 354), or dementia (n = 268). Deaths (n = 749) were identified from Year 20 through July 31, 2014 (average follow-up 4.9 years).

RESULTS

There was not strong evidence of an interaction between mobility and cognition for prediction of mortality risk (p interaction term .16). Compared to women with good mobility, mortality risks were increased among women with intermediate mobility (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.02-1.57) and those with poor mobility (HR 1.64, 95% CI 1.24-2.16) after consideration of cognition and other mortality risk factors. Similarly, mortality risks were higher among women with mild cognitive impairment (HR 1.46, 95% CI 1.21-1.76) and those with dementia (HR 1.88, 95% CI 1.54-2.31) compared to women with normal cognition after consideration of mobility and other mortality risk factors.

CONCLUSIONS

Among women late in life, 5-year mortality risk was substantially increased among women with deficits in mobility even after accounting for cognition and traditional prognostic indicators. Similarly, deficits in cognition were associated with increased 5-year mortality despite consideration of mobility and conventional risk factors.

Confirmatory factor analysis of the Pittsburgh Sleep Quality Index in women with hot flashes

OBJECTIVE

Women, especially those with hot flashes, report poor sleep quality during various stages of the menopausal transition and postmenopause. Sleep measurements vary widely because of the copious instruments available. The Pittsburgh Sleep Quality Index (PSQI) is a frequently used questionnaire that produces a single score for sleep quality. This one-factor structure has not received consistent support in the literature. The goal of this analysis was to determine the best factor structure of the PSQI in women with hot flashes.

METHODS

A confirmatory factor analysis was conducted on PSQI baseline data from three randomized controlled clinical trials enrolling perimenopausal and postmenopausal women with hot flashes (N = 849) from the Menopause Strategies: Finding Lasting Answers for Symptoms and Health network. Several a priori factor models were compared.

RESULTS

One-factor and two-factor models did not fit the data. A three-factor model comprising sleep efficiency, perceived sleep quality, and daily disturbance showed good fit; however, the sleep medication item was dropped because of poor fit and low rates of sleep medication use. The three-factor model was examined in African-American and white subsamples and was found to be similar in both groups; however, two items showed small group differences in strength as indicators.

CONCLUSIONS

Sleep quality in midlife women with hot flashes, as measured by the PSQI, seems to comprise three correlated factors. Minor measurement differences detected between groups are of research interest but do not necessitate different scoring practices. Additional research is needed to further define sleep quality and its associations with health-related outcomes.

Estimating True Resource Costs of Outpatient Care for Medicare Beneficiaries: Standardized Costs versus Medicare Payments and Charges

OBJECTIVE

To compare standardized estimates of the true resource costs of outpatient health care to the allowable and billed charges for that care among Medicare Fee for Service (FFS) beneficiaries.

DATA SOURCES/STUDY SETTING

Medicare Carrier and Outpatient Standard Analytic (SAF) files linked to participant data in the Study of Osteoporotic Fractures from 2004 through 2010. Participants were 3,435 female Medicare Fee for Service enrollees age 80 and older recruited in one rural and three metropolitan areas of the United States.

STUDY DESIGN

We estimated standardized costs for Carrier and OP-SAF claims using Medicare payment weights, and compared them to allowable and billed charges for those claims. We used semilog linear regression to estimate the associations of age, race, bone mineral density, prior fracture, and geriatric depression scale score with allowable charges, billed charges, and standardized costs.

RESULTS

Estimated associations of patient characteristics with standardized costs were not statistically different than the associations with allowable charges (chi-squared [χ(2)]: 8.6, p = .13) but were different from associations with billed charges (χ(2): 25.5, p < .001).

CONCLUSION

Allowable charges for outpatient utilization in the Carrier file and OP-SAF may be good surrogates for standardized costs that reflect patient medical and surgical acuity.

Circadian rest-activity rhythms predict future increases in depressive symptoms among community-dwelling older men

OBJECTIVE

Circadian rest-activity rhythms (CARs) have been cross-sectionally associated with depressive symptoms, although no longitudinal research has examined whether CARs are a risk factor for developing depressive symptoms.

METHODS

We examined associations of CARs (measured with actigraphy over a mean of 4.8 days) with depressive symptoms (measured with the Geriatric Depression Scale) among 2,892 community-dwelling older men (mean age: 76.2 ± 5.5 years) from the MrOS Sleep Study who were without cognitive impairment. Among 2,124 men with minimal (0-2) symptoms at baseline, we assessed associations between CAR parameters and increases to mild (3-5) or clinically significant (≥6) symptoms after an average of 1.2 (±0.32) years.

RESULTS

Cross-sectional associations between rhythm height parameters were independent of chronic diseases, lifestyle, sleep, and self-reported physical activity covariates. For example, men in the lowest mesor quartile had twice the adjusted odds (adjusted odds ratio [AOR]: 2.04, 95% confidence interval [CI]: 1.36-3.04, p = 0.0005) of having prevalent clinically significant symptoms (compared to minimal). Longitudinally, low CAR robustness (being in the lowest quartile of the pseudo-F statistic) was independently associated with increasing odds of developing symptoms (i.e., AOR for having clinically significant depressive symptoms at follow-up = 2.58, 95% CI: 1.11-5.99, p = 0.03).

CONCLUSION

CAR disturbances are indicative of depressive symptomology. Low CAR robustness may independently contribute to the risk of worsening depression symptomology.

Subjective and objective sleep disturbance and longitudinal risk of depression in a cohort of older women

OBJECTIVE

To investigate the longitudinal relationship between subjective and objective sleep disturbance and depressive symptoms.

DESIGN

Longitudinal.

SETTING

Three US clinical centers.

PARTICIPANTS

Nine hundred fifty-two community-dwelling older women (70 y or older).

MEASUREMENTS

At baseline, subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and objective sleep measures were assessed with wrist actigraphy. Depressive symptoms were assessed with the Geriatric Depression Scale (GDS) at baseline and approximately 5 y later. The analysis was restricted to women with few (GDS 0-2) depressive symptoms at baseline.

RESULTS

There was an independent association between greater PSQI score (per standard deviation increase, indicating worse subjective sleep quality) at baseline and greater odds of worsening depressive symptoms (≥ 2-point increase in GDS) (Multivariate Odds Ratio [MOR] 1.19, confidence interval [CI] 1.01-1.40, P = 0.036). Higher scores specifically on the sleep quality (MOR 1.41, CI 1.13-1.77, P < 0.003) and sleep latency (MOR 1.21, CI 1.03-1.41, P = 0.018) PSQI subscales were also associated with greater odds for worsening depressive symptoms. Objective assessments revealed an association between baseline prolonged wake after sleep onset (WASO ≥ 60 min) and worsening depressive symptoms at follow-up (MOR 1.36, CI 1.01-1.84, P = 0.046). There were no associations between other objectively assessed sleep measures and worsening depressive symptoms.

CONCLUSIONS

In older women with few or no depressive symptoms at baseline, those with more subjectively reported sleep disturbance and more objectively assessed fragmentation of sleep at baseline had greater odds of worsening depressive symptoms 5 y later. Future studies investigating this relationship in more detail are indicated.

CITATION

Maglione JE, Ancoli-Israel S, Peters KW, Paudel ML, Yaffe K, Ensrud KE, Stone KL, Study of Osteoporotic Fractures Research Group. Subjective and objective sleep disturbance and longitudinal risk of depression in a cohort of older women.

Estimation of standardized hospital costs from Medicare claims that reflect resource requirements for care: impact for cohort studies linked to Medicare claims

OBJECTIVE

To compare cost estimates for hospital stays calculated using diagnosis-related group (DRG) weights to actual Medicare payments.

DATA SOURCES/STUDY SETTING

Medicare MedPAR files and DRG tables linked to participant data from the Study of Osteoporotic Fractures (SOF) from 1992 through 2010. Participants were women age 65 and older recruited in three metropolitan and one rural area of the United States.

STUDY DESIGN

Costs were estimated using DRG payment weights for 1,397 hospital stays for 795 SOF participants for 1 year following a hip fracture. Medicare cost estimates included Medicare and secondary insurer payments, and copay and deductible amounts.

PRINCIPAL FINDINGS

The mean (SD) of inpatient DRG-based cost estimates per person-year were $16,268 ($10,058) compared with $19,937 ($15,531) for MedPAR payments. The correlation between DRG-based estimates and MedPAR payments was 0.71, and 51 percent of hospital stays were in different quintiles when costs were calculated based on DRG weights compared with MedPAR payments.

CONCLUSIONS

DRG-based cost estimates of hospital stays differ significantly from Medicare payments, which are adjusted by Medicare for facility and local geographic characteristics. DRG-based cost estimates may be preferable for analyses when facility and local geographic variation could bias assessment of associations between patient characteristics and costs.

Cystatin C and frailty in older men

OBJECTIVES

To determine whether higher cystatin C would be associated with greater frailty in men aged 65 and older.

DESIGN

Cross-sectional cohort study.

SETTING

Six U.S. sites.

PARTICIPANTS

A random sample of community-dwelling men aged 65 and older enrolled in the Osteoporotic Fractures in Men (MrOS) Study (mean age 73.8; 9.8% frail and 47.2% intermediate frailty; N = 1,602).

MEASUREMENTS

Serum cystatin C, creatinine, and frailty were measured. Frailty was analyzed as an ordinal outcome of robust, intermediate frailty, and frail using a multinomial logistic regression model, and the base model was adjusted for age, race, and clinical site.

RESULTS

Higher cystatin C was associated with seven times greater odds of being frail than being robust (odds ratio (OR) quartile 4 vs 1 = 7.12, 95% confidence interval (CI) = 3.76-13.46) and 2.4 times greater odds of intermediate frailty than robust (OR quartile 4 vs 1 = 2.38, 95% CI = 1.70-3.32). The association was attenuated but persisted after adjusting for multiple possible confounders. In contrast, neither higher serum creatinine (OR quartile 4 vs 1 = 1.36, 95% CI = 0.78-2.40) nor lower creatinine-based estimated glomerular filtration rate (OR quartile 4 vs 1 = 1.01, 95% CI = 0.54-1.87) was associated in a graded manner with greater odds of frailty.

CONCLUSION

Higher cystatin C, but not creatinine-based measures, was associated with greater odds of frailty in this cohort of older men.

Association between body size and composition and erectile dysfunction in older men: Osteoporotic Fractures in Men Study

OBJECTIVES

To examine the association between body size and composition and erectile dysfunction (ED) in older men.

DESIGN

Cross-sectional analysis of the Osteoporotic Fractures in Men study.

SETTING

Six U.S. clinical sites.

PARTICIPANTS

Community-dwelling men aged 65 and older.

MEASUREMENTS

Body composition measures using anthropometry (body weight, body mass index (BMI)) and dual X-ray absorptiometry (total body fat percentage, trunk fat percentage, ratio of trunk and total body fat). ED was assessed using the single-item Massachusetts Male Aging Study (MMAS) scale and the five-item International Index of Erectile Function questionnaire (IIEF-5).

RESULTS

In men completing the MMAS scale (n = 4,108), prevalence of complete ED was 42%. In sexually active men completing the IIEF-5 questionnaire (n = 1,659), prevalence of moderate to severe ED was 56%. In multivariate-adjusted analyses reporting prevalence ratios (PRs) and 95% confidence intervals (CIs), the prevalence of MMAS-defined complete ED was significantly greater in men in the highest quartile of body weight (PR = 1.24, 95% CI = 1.16-1.34), total body fat percentage (PR = 1.25, 95% CI = 1.13-1.40), and trunk fat percentage (PR = 1.24, 95% CI = 1.15-1.38), and was greater in men with a BMI greater than 30.0 kg/m(2) than in those with BMI of 22.0 to 24.9 kg/m(2) (PR = 1.17, 95% CI = 1.05-1.31). Associations appeared similar for IIEF-5-defined moderate to severe ED in analyses adjusted for age and study site.

CONCLUSION

In a cohort of older men, high body weight, BMI, and total body fat percentage were independently associated with greater prevalence of moderate to severe and complete ED. Future studies should investigate whether interventions to promote weight loss and fat loss will improve erectile function in older men.

Magnitude and consequences of misclassification of incident hip fractures in large cohort studies: the Study of Osteoporotic Fractures and Medicare claims data

In the Study of Osteoporotic Fractures (SOF), 18.5 % of incident hip fractures identified in Medicare Fee-for-Service claims data were not reported to or confirmed by the cohort. Cognitive impairment was a modest risk factor for false-negative hip fracture ascertainment via self-report.

INTRODUCTION

Prospective cohort studies of fractures that rely on participant self-report to be the initial signal of an incident fracture could be prone to bias if a significant proportion of fractures are not self-reported.

METHODS

We used data from the SOF merged with Medicare Fee-for-Service claims data to estimate the proportion of participants who had an incident hip fracture identified in Medicare claims that was either not self-reported or confirmed (by review of radiographic reports) in SOF.

RESULTS

Between 1/1/1991 and 12/31/2007, 647 SOF participants had a hip fracture identified in Medicare claims, but 120 (18.5 %) were either not reported to or confirmed by the cohort. False-negative hip fracture ascertainment was associated with a reduced modified Mini-Mental State Exam (MMSE) score (odds ratio 1.31 per SD decrease, 95 % C.I. 1.06-1.63). Point estimates of associations of predictors of incident hip fracture were changed minimally when the misclassification of incident hip fracture status was corrected with use of claims data.

CONCLUSIONS

A substantial minority of incident hip fractures were not reported to or confirmed in the SOF. Cognitive impairment was modestly associated with false-negative hip fracture ascertainment. While there was no evidence to suggest that misclassification of incident hip fracture status resulted in biased associations of potential predictors with hip fracture in this study, false-negative incident fracture ascertainment in smaller cohort studies with limited power may increase the risk of type 2 error (not finding significant associations of predictors with incident fractures).

Sleep disturbances and risk of frailty and mortality in older men

OBJECTIVE

To test the hypothesis that non-frail older men with poorer sleep at baseline are at increased risk of frailty and death at follow-up.

METHODS

In this prospective cohort study, subjective (questionnaires) and objective sleep parameters (actigraphy, in-home overnight polysomnography) were measured at baseline in 2505 non-frail men aged ≥67years. Repeat frailty status assessment performed an average of 3.4 years later; vital status assessed every four months. Sleep parameters expressed as dichotomized predictors using clinical cut-points. Status at follow-up exam classified as robust, intermediate (pre-frail) stage, frail, or died in interim.

RESULTS

None of the sleep disturbances were associated with the odds of being intermediate/frail/dead (vs. robust) at follow-up. Poor subjective sleep quality (multivariable odds ratio [MOR] 1.26, 95% CI 1.01-1.58), greater nighttime wakefulness (MOR 1.31, 95% CI 1.04-1.66), and greater nocturnal hypoxemia (MOR 1.47, 95% CI 1.02-2.10) were associated with a higher odds of frailty/death at follow-up (vs. robust/intermediate). Excessive daytime sleepiness (MOR 1.60, 95% CI 1.03-2.47), greater nighttime wakefulness (MOR 1.57, 95% CI 1.12-2.20), severe sleep apnea (MOR 1.74, 95% CI 1.04-2.89), and nocturnal hypoxemia (MOR 2.28, 95% CI 1.45-3.58) were associated with higher odds of death (vs. robust/intermediate/frail at follow-up). The association between poor sleep efficiency and mortality nearly reached significance (MOR 1.48, 95% CI 0.99-2.22). Short sleep duration and prolonged sleep latency were not associated with frailty/death or death at follow-up.

CONCLUSIONS

Among non-frail older men, poor subjective sleep quality, greater nighttime wakefulness, and greater nocturnal hypoxemia were independently associated with higher odds of frailty or death at follow-up, while excessive daytime sleepiness, greater nighttime wakefulness, severe sleep apnea and greater nocturnal hypoxemia were independently associated with an increased risk of mortality.

Depressive symptoms and subjective and objective sleep in community-dwelling older women

OBJECTIVES

To examine the relationship between depressive symptoms and subjective and objective sleep in older women.

DESIGN

Cross-sectional.

SETTING

Four U.S. clinical centers.

PARTICIPANTS

Three thousand forty-five community-dwelling women aged 70 and older.

MEASUREMENTS

Depressive symptoms were assessed using the Geriatric Depression Scale, categorizing participants as normal (0-2, reference), some depressive symptoms (3-5), or depressed (≥ 6). Subjective sleep quality and daytime sleepiness were assessed using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). Objective sleep measures were assessed using wrist actigraphy.

RESULTS

In multivariable-adjusted models, there were graded associations between greater level of depressive symptoms and worse subjective sleep quality and more subjective daytime sleepiness (P-trends < .001). Women with some depressive symptoms (odds ratio (OR) = 1.82, 95% confidence interval (CI) = 1.48-2.24) and depressed (OR = 2.84, 95% CI = 2.08-3.86) women had greater odds of reporting poor sleep (PSQI>5). Women with some depressive symptoms (OR = 1.97, 95% CI = 1.47-2.64) and depressed women (OR = 1.70, 95% CI = 1.12-2.58) had greater odds of reporting excessive daytime sleepiness (ESS>10). There were also graded associations between greater level of depressive symptoms and objectively measured wake after sleep onset (WASO) (P-trend = .03) and wake episodes longer than 5 minutes (P-trend = .006). Depressed women had modestly higher odds of WASO of 1 hour or longer (OR = 1.37, 95% CI = 1.03-1.83). Women with some depressive symptoms (OR = 1.49, 95% CI = 1.19-1.86) and depressed women (OR = 2.04, 95% CI = 1.52-2.74) had greater odds of being in the highest quartile for number of nap episodes longer than 5 minutes. No associations between depressive symptom level and prolonged sleep latency, poor sleep efficiency, or short or long total sleep time were found.

CONCLUSION

Greater depressive symptom levels were associated with more subjective sleep disturbance and objective evidence of sleep fragmentation and napping.

Circadian activity rhythms and risk of incident dementia and mild cognitive impairment in older women

OBJECTIVE

Previous cross-sectional studies have observed alterations in activity rhythms in dementia patients but the direction of causation is unclear. We determined whether circadian activity rhythms measured in community-dwelling older women are prospectively associated with incident dementia or mild cognitive impairment (MCI).

METHODS

Activity rhythm data were collected from 1,282 healthy community-dwelling women from the Study of Osteoporotic Fractures (SOF) cohort (mean age 83 years) with wrist actigraphy for a minimum of three 24-hour periods. Each participant completed a neuropsychological test battery and had clinical cognitive status (dementia, MCI, normal) adjudicated by an expert panel approximately 5 years later. All analyses were adjusted for demographics, body mass index (BMI), functional status, depression, medications, alcohol, caffeine, smoking, health status, and comorbidities.

RESULTS

After 4.9 years of follow-up, 195 (15%) women had developed dementia and 302 (24%) had developed MCI. Older women with decreased activity rhythms had a higher likelihood of developing dementia or MCI when comparing those in the lowest quartiles of amplitude (odds ratio [OR] = 1.57; 95% CI, 1.09-2.25) or rhythm robustness (OR = 1.57; 95% CI, 1.10-2.26) to women in the highest quartiles. An increased risk of dementia or MCI (OR = 1.83; 95% CI, 1.29-2.61) was found for women whose timing of peak activity occurred later in the day (after 3:51 PM) when compared to those with average timing (1:34 PM-3:51 PM).

INTERPRETATION

Older, healthy women with decreased circadian activity rhythm amplitude and robustness, and delayed rhythms have increased odds of developing dementia and MCI. If confirmed, future studies should examine whether interventions (physical activity, bright light exposure) that influence activity rhythms will reduce the risk of cognitive deterioration in the elderly.

Rest/activity rhythms and cardiovascular disease in older men

Prior studies have suggested an increased risk of cardiovascular disease (CVD)-related mortality in older adults with disturbed circadian rest/activity rhythms (RARs). The objective goal of this study was to examine the association between disrupted RARs and risk of CVD events in older men. A total of 2968 men aged 67 yrs and older wore wrist actigraphs for 115 ± 18 consecutive hours. RAR parameters were computed from wrist actigraphy data and expressed as quartiles (Q). CVD events consisted of a composite outcome of coronary heart disease (CHD), stroke, and peripheral vascular disease (PVD) events. Secondary analyses examined associations between RARs and individual components of the composite outcome (CHD, stroke, and PVD). There were 490 CVD events over an average of 4.0 ± 1.2 yrs. Overall, reduced amplitude (HR = 1.31, 95% confidence interval [CI] 1.01-1.71 for Q2 vs. Q4) and greater minimum (HR = 1.33, 95% CI 1.01-1.73 for Q4 vs. Q1) were associated with an increased risk of CVD events in multivariable-adjusted models. In secondary analyses, there was an independent association between reduced amplitude (HR = 1.36, 95% CI 1.00-1.86) and greater minimum activity counts (HR = 1.39, 95% CI 1.02-1.91) with increased risk of CHD events. Reduced F value (HR = 2.88, 95% CI 1.41-5.87 for Q1 vs. Q4 and HR = 2.71, 95% CI 1.34-5.48 for Q2 vs. Q4) and later occurring acrophase of the RAR (HR = 1.65, 95% CI 1.04-2.63 for Q4 vs. Q2-3) were associated with an increased risk of PVD events. Results were similar in men without a history of CVD events. The findings revealed that among older men, measures of decreased circadian activity rhythm robustness (reduced amplitude and greater minimum activity) were associated with an increased risk of CVD events, primarily through increased risk of CHD or stroke events, whereas measures of reduced circadian activity rhythmicity were not associated with risk of CVD events overall, but were associated with an increased risk of PVD events. These results should be confirmed in other populations.

Muscle power and physical activity are associated with bone strength in older men: The osteoporotic fractures in men study

The purpose of these analyses was to explore whether physical activity score, leg power or grip strength were associated with tibia and radius estimates of bone strength, cortical density, or total bone area. Peripheral quantitative computed tomography (pQCT) was used to compare tibial and radial bone volumetric density (vBMD, mg/cm(3)), total (ToA, mm(2)) and cortical (CoA, mm(2)) bone area, and estimates of bone compressive strength (bone strength index, BSI) and bending strength (polar strength strain index, SSIp) in a subset (n=1171) of men (> or = 65 years) who participated in the multi-site Osteoporotic Fractures in Men (MrOS) study. Physical activity was assessed by questionnaire (PASE), leg power by Nottingham Power Rig, and grip strength by a hand-held Dynamometer. Participants were categorized into quartiles of PASE, grip strength or leg power. The model was adjusted for age, race, clinic, weight, and limb length. In the tibia, BSI (+7%) and SSIp (+4%) were highest in the most active physically quartile compared to the least active (p<0.05). At the 4% site of the tibia, men with the greatest leg power had both greater ToA (+5%, p<0.001) and BSI (+5.3%, p=0.086) compared to men with the least leg power. At the 66% site of the tibia, the men with the highest leg power, compared to the men with the lowest leg power, had greater ToA (+3%, p=0.045) SSIp (+5%, p=0.008). Similar results were found at both the distal and midshaft of the radius. The findings of this study suggest the importance of maintaining levels of physical activity and muscle strength in older men to prevent bone fragility.

Rest/activity rhythms and mortality rates in older men: MrOS Sleep Study

An association between increased risk of mortality and disruptions in rest/activity circadian rhythms (RAR) has been shown among adults with dementia and with metastatic colorectal cancer. However, the association among a more general population of older adults has not been studied. Our study population consisted of 2964 men aged > or = 67 yrs of age enrolled in the Outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. Rest/activity patterns were measured with wrist actigraphy. RAR parameters were computed and expressed as quintiles, and included acrophase (time of peak activity level), amplitude (peak-to-nadir difference), mesor (middle of the peak), pseudo F-value (overall circadian rhythmicity), beta (steepness), and alpha (peak-to-trough width). After adjustment for multiple potential confounders, men in the lowest quintile of pseudo F-value had a 57% higher mortality rate (hazard ratio [HR] = 1.57, 95% CI, 1.03-2.39) than men in the highest quintile. This association was even stronger with increased risk of cardiovascular disease-related mortality (CVD) (HR = 2.32, 95% CI, 1.04-5.22). Additionally, men in the lowest quintile of acrophase had a 2.8-fold higher rate of CVD-related mortality (HR = 2.84, 95% CI, 1.29-6.24). There was no evidence of independent associations with amplitude, mesor, alpha, beta, and mortality risk. Older men with less robust RAR and earlier acrophase timing have modestly higher all-cause and CVD-related mortality rates. Further research should examine potential biological mechanisms underlying this association.

Postmenopausal hormones and sleep quality in the elderly: a population based study

Background

Sleep disturbance and insomnia are commonly reported by postmenopausal women. However, the relationship between hormone therapy (HT) and sleep disturbances in postmenopausal community-dwelling adults is understudied. Using data from the multicenter Study of Osteoporotic Fractures (SOF), we tested the relationship between HT and sleep-wake estimated from actigraphy.

Methods

Sleep-wake was ascertained by wrist actigraphy in 3,123 women aged 84 ± 4 years (range 77-99) from the Study of Osteoporotic Fractures (SOF). This sample represents 30% of the original SOF study and 64% of participants seen at this visit. Data were collected for a mean of 4 consecutive 24-hour periods. Sleep parameters measured objectively included total sleep time, sleep efficiency (SE), sleep latency, wake after sleep onset (WASO), and nap time. All analyses were adjusted for potential confounders (age, clinic site, race, BMI, cognitive function, physical activity, depression, anxiety, education, marital status, age at menopause, alcohol use, prior hysterectomy, and medical conditions).

Results

Actigraphy measurements were available for 424 current, 1,289 past, and 1,410 never users of HT. Women currently using HT had a shorter WASO time (76 vs. 82 minutes, P = 0.03) and fewer long-wake (≥ 5 minutes) episodes (6.5 vs. 7.1, P = 0.004) than never users. Past HT users had longer total sleep time than never users (413 vs. 403 minutes, P = 0.002). Women who never used HT had elevated odds of SE <70% (OR,1.37;95%CI,0.98-1.92) and significantly higher odds of WASO ≥ 90 minutes (OR,1.37;95%CI,1.02-1.83) and ≥ 8 long-wake episodes (OR,1.58;95%CI,1.18-2.12) when compared to current HT users.

Conclusions

Postmenopausal women currently using HT had improved sleep quality for two out of five objective measures: shorter WASO and fewer long-wake episodes. The mechanism behind these associations is not clear. For postmenopausal women, starting HT use should be considered carefully in balance with other risks since the vascular side-effects of hormone replacement may exceed its beneficial effects on sleep.

Sleep-disordered breathing and urinary albumin excretion in older men

PURPOSE

Sleep-disordered breathing (SDB) may be deleterious to the cardiovascular system and other organs, including the kidney. Although older men are at increased risk for both kidney disease and SDB, it is unknown whether SDB is associated with higher urinary albumin excretion in this population.

METHODS

We examined 507 community-dwelling men age ≥ 67 years (mean 76.0 ± 5.3) enrolled in the MrOS Sleep study who underwent overnight polysomnography and gave a spot urine sample. SDB severity was categorized using the respiratory disturbance index and percent total sleep time <90% oxygen saturation (%time O2<90). Urinary albumin excretion was expressed using the albumin-to-creatinine ratio (ACR).

RESULTS

There was a graded association between respiratory disturbance index and ACR (age- and race-adjusted mean ACR = 9.35 mg/gCr for respiratory disturbance index ≥ 30 versus 6.72 mg/gCr for respiratory disturbance index < 5, p = 0.007). This association was attenuated after further adjustment for body mass index (BMI), hypertension and diabetes and no longer reached significance (p = 0.129). However, even after adjustment for age, race, BMI, hypertension, and diabetes, greater %time O2<90 was associated with higher ACR (10.35 mg/gCr for ≥10%time O2<90 versus 7.45 mg/gCr for <1%time O2<90, p = 0.046).

CONCLUSION

SDB, measured by elevated respiratory disturbance index or nocturnal hypoxemia, was associated with higher ACR. The relationship between respiratory disturbance index and ACR was partially explained by higher BMI and greater prevalence of hypertension and diabetes among men with SDB. However, greater nocturnal hypoxemia was independently associated with higher ACR, suggesting that the hypoxia component of SDB may mediate any detrimental effect of SDB on the kidney.

Circadian activity rhythms and mortality: the study of osteoporotic fractures

OBJECTIVES

To determine whether circadian activity rhythms are associated with mortality in community-dwelling older women.

DESIGN

Prospective study of mortality.

SETTING

A cohort study of health and aging.

PARTICIPANTS

Three thousand twenty-seven community-dwelling women from the Study of Osteoporotic Fractures cohort (mean age 84).

MEASUREMENTS

Activity data were collected using wrist actigraphy for a minimum of three 24-hour periods, and circadian activity rhythms were computed. Parameters of interest included height of activity peak (amplitude), midline estimating statistic of rhythm (mesor), strength of activity rhythm (robustness), and time of peak activity (acrophase). Vital status, with cause of death adjudicated through death certificates, was prospectively ascertained.

RESULTS

Over an average of 4.1 years of follow-up, there were 444 (14.7%) deaths. There was an inverse association between peak activity height and all-cause mortality rates, with higher mortality rates observed in the lowest activity quartile (hazard ratio (HR)=2.18, 95% confidence interval (CI)=1.63-2.92) than in the highest quartile after adjusting for age, clinic site, race, body mass index, cognitive function, exercise, instrumental activity of daily living impairments, depression, medications, alcohol, smoking, self-reported health status, married status, and comorbidities. A greater risk of mortality from all causes was observed for those in the lowest quartiles of mesor (HR=1.71, 95% CI=1.29-2.27) and rhythm robustness (HR=1.97, 95% CI=1.50-2.60) than for those in the highest quartiles. Greater mortality from cancer (HR=2.09, 95% CI=1.04-4.22) and stroke (HR=2.64, 95% CI=1.11-6.30) was observed for later peak activity (after 4:33 p.m.; >1.5 SD from mean) than for the mean peak range (2:50-4:33 p.m.).

CONCLUSION

Older women with weak circadian activity rhythms have higher mortality risk. If confirmed in other cohorts, studies will be needed to test whether interventions (e.g., physical activity, bright light exposure) that regulate circadian activity rhythms will improve health outcomes in older adults.

25-Hydroxyvitamin D levels and cognitive performance and decline in elderly men

OBJECTIVE

To test the hypothesis that lower 25-hydroxyvitamin D [25(OH)D] levels are associated with a greater likelihood of cognitive impairment and risk of cognitive decline.

METHODS

We measured 25(OH)D and assessed cognitive function using the Modified Mini-Mental State Examination (3MS) and Trail Making Test Part B (Trails B) in a cohort of 1,604 men enrolled in the Osteoporotic Fractures in Men Study and followed them for an average of 4.6 years for changes in cognitive function.

RESULTS

In a model adjusted for age, season, and site, men with lower 25(OH)D levels seemed to have a higher odds of cognitive impairment, but the test for trend did not reach significance (impairment by 3MS: odds ratio [OR] 1.84, 95% confidence interval [CI] 0.81-4.19 for quartile [Q] 1; 1.41, 0.61-3.28 for Q2; and 1.18, 0.50-2.81 for Q3, compared with Q4 [referent group; p trend = 0.12]; and impairment by Trails B: OR 1.66, 95% CI 0.98-2.82 for Q1; 0.96, 0.54-1.69 for Q2; and 1.30, 0.76-2.22 for Q3, compared with Q4 [p trend = 0.12]). Adjustment for age and education further attenuated the relationships. There was a trend for an independent association between lower 25(OH)D levels and odds of cognitive decline by 3MS performance (multivariable OR 1.41, 95% CI 0.89-2.23 for Q1; 1.28, 0.84-1.95 for Q2; and 1.06, 0.70-1.62 for Q3, compared with Q4 [p = 0.10]), but no association with cognitive decline by Trails B.

CONCLUSION

We found little evidence of independent associations between lower 25-hydroxyvitamin D level and baseline global and executive cognitive function or incident cognitive decline.

Sleep disturbances and frailty status in older community-dwelling men

OBJECTIVES

To test the hypothesis that sleep disturbances are independently associated with frailty status in older men.

DESIGN

Cross-sectional analysis of prospective cohort study.

SETTING

Six U.S. centers.

PARTICIPANTS

Three thousand one hundred thirty-three men aged 67 and older.

MEASUREMENTS

Self-reported sleep parameters (questionnaire); objective parameters of sleep-wake patterns (actigraphy data collected for an average of 5.2 nights); and objective parameters of sleep-disordered breathing, nocturnal hypoxemia, and periodic leg movements with arousals (PLMAs) (in-home overnight polysomnography). Frailty status was classified as robust, intermediate stage, or frail using criteria similar to those used in the Cardiovascular Health Study frailty index.

RESULTS

The prevalence of sleep disturbances, including poor sleep quality, excessive daytime sleepiness, short sleep duration, lower sleep efficiency, prolonged sleep latency, sleep fragmentation (greater nighttime wakefulness and frequent, long wake episodes), sleep-disordered breathing, nocturnal hypoxemia, and frequent PLMAs, was lowest in robust men, intermediate in men in the intermediate-stage group, and highest in frail men (P-for-trend < or =.002 for all sleep parameters). After adjusting for multiple potential confounders, self-reported poor sleep quality (Pittsburgh Sleep Quality Index > 5, multivariable odds ratio (MOR)=1.28, 95% confidence interval (CI)=1.09-1.50), sleep efficiency less than 70% (MOR=1.37, 95% CI=1.12-1.67), sleep latency of 60 minutes or longer (MOR=1.42, 95% CI=1.10-1.82), and sleep-disordered breathing (respiratory disturbance index > or =15, MOR=1.38, 95% CI=1.15-1.65) were each independently associated with higher odds of greater frailty status.

CONCLUSION

Sleep disturbances, including poor self-reported sleep quality, lower sleep efficiency, prolonged sleep latency, and sleep-disordered breathing, are independently associated with greater evidence of frailty.

Serum 25-hydroxyvitamin D levels and rate of hip bone loss in older men

CONTEXT

Vitamin D deficiency is common among older adults, but the association between 25-hydroxyvitamin D [25(OH)D] levels and rates of bone loss is uncertain.

OBJECTIVE

Our aim was to test the hypothesis that lower 25(OH)D levels are associated with higher rates of hip bone loss in older men.

DESIGN AND SETTING

We conducted a prospective cohort study in six U.S. centers.

PARTICIPANTS

A total of 1279 community-dwelling men aged 65 yr or older with 25(OH)D levels (liquid chromatography-tandem mass spectroscopy) and hip bone mineral density (BMD) (dual-energy x-ray absorptiometry) at baseline and repeat hip BMD an average of 4.4 yr later participated in the study.

MAIN OUTCOME MEASURE(S)

We measured the annualized percentage rate of change in hip BMD.

RESULTS

After adjustment for multiple potential confounders, the average rate of decline in total hip BMD was -0.59%/yr among men with 25(OH)D levels below 15.0 ng/ml, -0.54%/yr among men with 25(OH)D levels 15.0-19.9 ng/ml, -0.35%/yr among men with 25(OH)D levels 20.0-29.9 ng/ml, and -0.37%/yr among men with 25(OH)D levels of at least 30 ng/ml (P trend = 0.008 for multivariable model). Evidence was strong to support an association among men aged 75 yr and older (P trend <0.001), but not among younger men (P trend = 0.55). Findings were similar when 25(OH)D level was expressed in quintiles and when BMD at hip subregions was substituted for total hip BMD.

CONCLUSIONS

In this cohort of community-dwelling older men, men with 25(OH)D levels below 20 ng/ml had greater subsequent rates of hip bone loss, but rates of loss were similar among men with higher levels. These results lend support to the view that low 25(OH)D levels are detrimental to BMD in older men.

Kidney function and cognitive performance and decline in older men

OBJECTIVES

To examine the association between kidney function and cognitive impairment and decline in elderly men.

DESIGN

Observational prospective cohort.

SETTING

Community based.

PARTICIPANTS

Five thousand five hundred twenty-nine community dwelling men aged 65 and older (mean age 73.6 +/- 5.9).

MEASUREMENTS

Estimated glomerular filtration rate (eGFR) calculated using the standardized Modification of Diet in Renal Disease (MDRD) equation; cognitive function assessed using the Modified Mini-Mental State Examination (3MS) and Trail Making Test B (Trails B).

RESULTS

At baseline, 148 (2.7%) and 494 (9.1%) men were classified as cognitively impaired and, in the 5-year prospective analysis, 931 (23%) and 432 (11.6%) met the criteria for cognitive decline at follow-up defined according to 3MS and Trails B performance, respectively. In unadjusted analysis, the odds of prevalent cognitive impairment and risk of cognitive decline were significantly higher in men with an eGFR less than 45 and 45 to 59 mL/min per 1.73 m(2) than in men with an eGFR 60 mL/min per 1.73 m(2) or greater. Differences in age, race, and education between eGFR categories largely explained these associations, with the exception of the association between poorer renal function and higher odds of impairment based on Trails B test score, which persisted despite adjustment for multiple potential confounders.

CONCLUSION

This study found evidence of an independent association between mild to moderate reductions in kidney function and poor executive function at baseline but not with global cognitive impairment or risk of cognitive decline in older men.

Association between depressive symptoms and sleep disturbances in community-dwelling older men

OBJECTIVES

To examine the association between depressive symptoms and subjective and objective measures of sleep in community-dwelling older men.

DESIGN

Cross-sectional.

SETTING

Six U.S. clinical centers.

PARTICIPANTS

Three thousand fifty-one men aged 67 and older.

MEASUREMENTS

Depressive symptoms assessed using the 15-item Geriatric Depression Scale and categorized as 0 to 2 (normal, referent group), 3 to 5 (some depressive symptoms), and 6 to 15 (depressed); objective sleep measures ascertained using wrist actigraphy (mean duration 5.2 nights); and subjective sleep measures assessed using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale.

RESULTS

There was a strong multivariable-adjusted association between level of depressive symptoms and subjective sleep disturbances (P-trend <.001). For example, the odds of reporting poor sleep quality were 3.7 times (95% confidence interval (CI)=2.5-5.3) higher for depressed men as for normal men, and 2.1 times (95% CI=1.7-2.6) higher for men with some depressive symptoms. For objectively measured sleep disturbances, men with more depressive symptoms had greater odds of sleep latency of 1 hour or more (P-trend=.006). There was no association between level of depressive symptoms and sleep efficiency, awakening after sleep onset, multiple long-wake episodes, or total sleep time. Excluding 384 men taking antidepressants, benzodiazepines, or other anxiolytic or hypnotics did not alter the results.

CONCLUSION

Depressive symptoms have a strong, graded association with subjective sleep disturbances and are moderately associated with objectively measured prolonged sleep latency. Future studies should address temporality of depression and sleep disturbances.