HOMEFOOD randomized trial-beneficial effects of 6-month nutrition therapy on body weight and physical function in older adults at risk for malnutrition after hospital discharge

BACKGROUND/OBJECTIVES

Malnutrition is common among older adults. Dietary intervention studies in older adults aiming to improve anthropometrics measures and physical function have been inconsistent. We aimed to investigate the effects of nutrition therapy in combination with home delivered meals and oral nutritional supplements (ONS) in community-dwelling older adults discharged from hospital.

METHODS

A total of 106 participants (>65 years) were randomized into the intervention group (n = 53) and into the control group (n = 53). The intervention group received individual nutrition therapy (five in person visits and three phone calls) and freely delivered energy- and protein- rich foods, while the control group received standard care. Dietary intake, anthropometrics, and short physical performance battery (SPPB) were assessed at baseline and at endpoint.

RESULTS

Energy intake at baseline was similar in both groups (~1500 kcal at the hospital) but there was a significant increase in energy intake and body weight in the intervention group (+919 kcal/day and 1.7 kg, P < 0.001 in both cases) during the study period, compared to a significant decrease in both measures among controls (-815 kcal/day and -3.5 kg, P < 0.001 in both cases). SPPB score increased significantly in the intervention group while no changes were observed among controls.

CONCLUSIONS

Most Icelandic older adults experience substantial weight loss after hospital discharge when receiving current standard care. However, a 6-month multi-component nutrition therapy, provided by a clinical nutritionist in combination with freely delivered supplemental energy- and protein-dense foods has beneficial effects on body weight, physical function, and nutritional status.

STUDY REGISTRATION

This study was registered at ClinicalTrials.gov ( NCT03995303 ).

HOMEFOOD Randomised Trial - Six-Month Nutrition Therapy in Discharged Older Adults Reduces Hospital Readmissions and Length of Stay at Hospital Up to 18 Months of Follow-Up

BACKGROUND

Malnutrition is frequently observed in older adults and is associated with hospital readmissions, length of stay (LOS), and mortality in discharged patients.

OBJECTIVE

The aim of this study was to investigate effects of six-month nutrition therapy on hospital readmissions, LOS, mortality and need for long-term care residence 1-, 6-, 12- and 18-months post-discharge in older Icelandic adults.

DESIGN

Secondary analysis of a randomized controlled trial.

PARTICIPANTS

Participants (>65 years) were randomised into intervention (n=53) and control (n=53) before discharge from a geriatric unit.

INTERVENTION

The intervention group received nutrition therapy based on the Nutrition Care Process, including home visits, phone calls, freely delivered energy- and protein-rich foods and supplements for six months after hospital discharge.

MEASUREMENTS

The Icelandic electronic hospital registry was accessed to gain information on emergency room visits (ER), hospital readmissions, LOS, mortality and need for long-term care residence.

RESULTS

The intervention group had a lower proportion of participants with at least one readmission compared to control (1 month: 1.9% vs 15.8%, P=0.033; 6 months: 25.0% vs 46.2%, P=0.021; 12 months: 38.5% vs 55.8%, P=0.051; and 18 months: 51.9% vs 65.4%, P=0.107). There was also a lower total number of readmissions per participant (1 month: 0.02 vs 0.19, P=0.015; 6 month: 0.33 vs 0.77, P=0.014; 0.62 vs 1.12, P=0.044) and a shorter LOS (1 month: 0.02 vs 0.92, P=0.013; 6 months: 2.44 vs 13.21; P=0.006; 12 months: 5.83 vs 19.40, P=0.034; 18 months: 10.42 vs 26.00, P=0.033) in the intervention group. However, there were no differences between groups in ER visits, mortality and need for long-term care residence.

CONCLUSION

A six-month nutrition therapy in older Icelandic adults discharged from hospital reduced hospital readmissions and shortens LOS at the hospital up to 18-months post-discharge. However, it did neither affect mortality, ER, nor need of long-term care residence in this group.

Changes in home care clients' characteristics and home care in five European countries from 2001 to 2014: comparison based on InterRAI - Home Care data

Background

Policymakers advocate extended residence in private homes as people age, rather than relocation to long-term care facilities. Consequently, it is expected that older people living in their own homes will be frailer and have more complex health problems over time. Therefore, community care for aging people is becoming increasingly important to facilitate prevention of decline in physical and cognitive abilities and unnecessary hospital admission and transfer to a nursing home. The aim of this study was to examine changes in the characteristic of home care clients and home care provided in five European countries between 2001 and 2014 and to explore whether home care clients who are most in need of care receive the care required.

Methods

This descriptive study used data from two European research projects, Aged in Home Care (AdHOC; 2001–2002) and Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of Community Care (IBenC; 2014–2016). In both projects, the InterRAI-Home Care assessment tool was used to assess a random sample of home care clients 65 years and older in five European countries. These data facilitate a comparison of physical and cognitive health and the provided home care between countries and study periods.

Results

In most participating countries, both cognitive (measured on the Cognitive Performance Scale) and functional ability (measured on the Activities of Daily Living Hierarchy scale) of home care clients deteriorated over a 10-year period. Home care provided increased between the studies. Home care clients who scored high on the physical and cognitive scales also received home care for a significantly higher duration than those who scored low.

Conclusion

Older people in several European countries remain living in their own homes despite deteriorating physical and cognitive skills. Home care services to this group have increased. This indicates that the government policy of long-term residence at own home among older people, even in increased frailty, has been realised.

The sarcopenia and physical frailty in older people: multi-component treatment strategies (SPRINTT) project: description and feasibility of a nutrition intervention in community-dwelling older Europeans

BACKGROUND

The "Sarcopenia and Physical Frailty in Older People: Multicomponent Treatment Strategies" (SPRINTT) project sponsored a multi-center randomized controlled trial (RCT) with the objective to determine the effect of physical activity and nutrition intervention for prevention of mobility disability in community-dwelling frail older Europeans. We describe here the design and feasibility of the SPRINTT nutrition intervention, including techniques used by nutrition interventionists to identify those at risk of malnutrition and to carry out the nutrition intervention.

METHODS

SPRINTT RCT recruited older adults (≥ 70 years) from 11 European countries. Eligible participants (n = 1517) had functional limitations measured with Short Physical Performance Battery (SPPB score 3-9) and low muscle mass as determined by DXA scans, but were able to walk 400 m without assistance within 15 min. Participants were followed up for up to 3 years. The nutrition intervention was carried out mainly by individual nutrition counseling. Nutrition goals included achieving a daily protein intake of 1.0-1.2 g/kg body weight, energy intake of 25-30 kcal/kg of body weight/day, and serum vitamin D concentration ≥ 75 mmol/L. Survey on the method strategies and feasibility of the nutrition intervention was sent to all nutrition interventionists of the 16 SPRINTT study sites.

RESULTS

Nutrition interventionists from all study sites responded to the survey. All responders found that the SPRINTT nutrition intervention was feasible for the target population, and it was well received by the majority. The identification of participants at nutritional risk was accomplished by combining information from interviews, questionnaires, clinical and laboratory data. Although the nutrition intervention was mainly carried out using individual nutritional counselling, other assisting methods were used as appropriate.

CONCLUSION

The SPRINTT nutrition intervention was feasible and able to adapt flexibly to varying needs of this heterogeneous population. The procedures adopted to identify older adults at risk of malnutrition and to design the appropriate intervention may serve as a model to deliver nutrition intervention for community-dwelling older people with mobility limitations.

Lifestyle and 25-hydroxy-vitamin D among community-dwelling old adults with dementia, mild cognitive impairment, or normal cognitive function

BACKGROUND

Several studies have indicated that older adults with cognitive impairment have a poorer lifestyle than their healthy peers including lower 25-hydroxy-vitamin D levels (25OHD).

AIM

To investigate the associations between lifestyle and 25OHD depending on cognitive status among old adults.

METHODS

Community-dwelling old adults (65-96 years) participated in this cross-sectional study based on the Age-Gene/Environment-Susceptibility-Reykjavik-Study. The analytical sample included 5162 subjects who were stratified by cognitive status, i.e., dementia (n = 307), mild cognitive impairment (MCI, n = 492), and normal cognitive status (NCS, n = 4363). Lifestyle variables were assessed and 25OHD was measured. The associations between lifestyle and 25OHD were calculated using linear models correcting for potential confounders.

RESULTS

According to linear regression models, 25OHD was significantly lower in older people with dementia (53.8 ± 19.6 nmol/L) than in NCS participants (57.6 ± 17.7 nmol/L). Cod liver oil (7.1-9.2 nmol/L, P < 0.001) and dietary supplements (4.4-11.5 nmol/L, P < 0.001) were associated with higher 25OHD in all three groups. However, physical activity ≥ 3 h/week (2.82 nmol/L, P < 0.001), BMI < 30 kg/m² (5.2 nmol/L, P < 0.001), non-smoking (4.8 nmol/L, P < 0.001), alcohol consumption (2.7 nmol/L, P < 0.001), and fatty fish consumption ≥ 3x/week (2.6 nmol/L, P < 0.001) were related to higher 25OHD in NCS only, but not in participants with dementia or MCI.

DISCUSSION

Older people living in Iceland with dementia are at higher risk for 25OHD deficiency when compared to healthy individuals. Physical activity reported among participants with dementia, and MCI is low and is not significantly associated with 25OHD.

CONCLUSIONS

Lifestyle factors among NCS participants are associated with 25OHD levels. Importantly, healthy lifestyle should be promoted among individuals with MCI and dementia.

The effect of cognitive function on mobility improvement among community-living older adults: A 12-week resistance exercise intervention study

The purpose of the study was to investigate the association between baseline cognitive function and improvement in mobility after 12 weeks of resistance training (3 times/week; 3 sets, 6-8 repetitions at 75-80% of the 1-repetition maximum) among community-dwelling older adults in Iceland (N=205, 73.5±5.7 years, 57.0% female). Body composition, physical activity status, cardiovascular risk factors, 6-minute walk test (6MWT), and Mini-Mental State Examination (MMSE) were measured. The linear regression model was used to examine the association between baseline MMSE and mobility improvement. Mean distance of 6MWT was 462.8±71.6 meter at baseline and mean change after the exercise intervention was 33.7±34.9 meter. The mean MMSE score at baseline was 27.6±1.9. After adjusting for baseline covariates, we found that baseline MMSE score was significantly associated with improvement in mobility among older adults after the exercise intervention. Cognitive function strongly influences the effect of exercise intervention on mobility among older adults.

Co-Presence of Multimorbidity and Disability with Frailty: An Examination of Heterogeneity in the Frail Older Population

BACKGROUND

Frailty is often associated with multimorbidity and disability.

OBJECTIVES

We investigated heterogeneity in the frail older population by characterizing five subpopulations according to quantitative biological markers, multimorbidity and disability, and examined their association with mortality and nursing home admission.

DESIGN

Observational study.

PARTICIPANTS

Participants (n=4,414) were from the population-based Age Gene/Environment Susceptibility Reykjavik Study.

MEASUREMENTS

Frailty was defined by ≥ 3 of five characteristics: weight loss, weakness, reduced energy levels, slowness and physical inactivity. Multimorbidity was assessed using a simple disease count, based on 13 prevalent conditions. Disability was assessed by five activities of daily living; participants who had difficulty with one or more tasks were considered disabled. Differences among frail subpopulations were based on the co-presence of multimorbidity and disability. Differences among the following subpopulations were examined: 1) Non-frail (reference group); 2) Frail only; 3) Frail with disability; 4) Frailty with multimorbidity; 5) Frail with disability and multimorbidity.

RESULTS

Frailty was present in 10.7% (n=473). Frailty was associated with increased risk for mortality (OR 1.40; 95% CI 1.15-1.69) and nursing home admission (OR 1.50; 95% CI 1.16-1.93); risks differed by subpopulations. Compared to the non-frail, the frail only group had poorer cognition and increased inflammation levels but did not have increased risk for mortality (OR 1.40; 95% CI 0.84-2.33) or nursing home admission (OR 1.01; 95% CI 0.46-2.21). Compared to the non-frail, the other frail subpopulations had significantly poorer cognition, increased inflammation levels, more white matter lesions, higher levels of calcium, glucose and red cell distribution width and increased risk for mortality and nursing home admission.

CONCLUSIONS

The adverse health risks associated with frailty in the general older adult population may primarily be driven by increased disease burden and disability.

Insulin-Like Growth Factor-1 and Resistance Exercise in Community Dwelling Old Adults

BACKGROUND

Insulin-like growth factor-1 (IGF-1) is related to the preservation of lean body mass. Its decline during ageing is thought to make old adults more susceptible to sarcopenia and functional dependency. The aim of the present study was to investigate circulating total IGF-1 in old adults who engaged in a 12-weeks of progressive resistance training.

DESIGN

Intervention study.

SETTING

Community.

PARTICIPANTS

Old Icelandic adults (N = 235, 73.7 ± 5.7 years, 58.2% female).

INTERVENTION

Twelve-week resistance exercise program (3 times/week; 3 sets, 6-8 repetitions at 75-80% of the 1-repetition maximum) designed to increase strength and muscle mass of major muscle groups.

MEASUREMENTS

IGF-1.

RESULTS

At baseline IGF-1 was significantly associated with lean body mass and appendicular muscle mass (also when corrected for age, gender and various covariates). After the training IGF-1 decreased significantly from 112.1 ± 35.6 to 106.1 ± 35.2 µg/L during the course of the study. On and individual level, IGF-1 decreased in 59% and increased in 39% of the participants. Changes in IGF-1 were inversely related to changes in lean body mass (rho = -0.176, P = 0.013 ) and appendicular muscle mass (rho = -0.162, P = 0.019) also when corrected for protein intake, age, gender, and other covariates.

CONCLUSION

Serum total IGF-1 decreases after 12 weeks of resistance exercise in community dwelling old adults. When looked at IGF-1 changes for participants individually it becomes clear that IGF-1 response to resistances exercise is highly variable. Changes in IGF-1 are negatively related to changes in lean body mass during training, which supports the hypothesis that IGF-1 is redistributed from circulation into tissue during periods of active muscle building.

C-Reactive Protein and Resistance Exercise in Community Dwelling Old Adults

OBJECTIVES

C-reactive protein (CRP), an acute phase reactant, has been associated with atherosclerosis and has also been discussed as a target for intervention. The effects of resistance exercise on CRP are currently not clear. The present analysis investigated the response of CRP to resistance exercise in old adults.

DESIGN

Intervention study.

SETTING

Community.

PARTICIPANTS

Old Icelandic adults (N = 235, 73.7 ± 5.7 years, 58.2% female).

INTERVENTION

Twelve-week resistance exercise program (3 times/week; 3 sets, 6-8 repetitions at 75-80% of the 1-repetition maximum) designed to increase strength and muscle mass of major muscle groups.

MEASUREMENTS

C-reactive protein (CRP).

RESULTS

Mean CRP levels were 7.1 ± 4.6 mg/dL at baseline, thirty-six (15.6%) subjects had abnormally high CRP (>10 mg/L) values at baseline. After the resistance exercise program the overall changes in CRP were minor and not significant. However, CRP decreased considerably in participants with high CRP at baseline (-4.28 ± 9.41 mg/L; P = 0.015) but increased slightly in participants with normal CRP (0.81 ± 4.58 mg/L, P = 0.021).

CONCLUSIONS

Our study shows that the concentrations of circulating CRP decreased considerably after a 12-week resistance exercise program in participants with abnormally high CRP at baseline, possibly reducing thus risk for future disease. CRP changed little in participants with normal CRP at the start of the study.

Polyunsaturated fatty acids in relation to incident mobility disability and decline in gait speed; the Age, Gene/Environment Susceptibility-Reykjavik Study

BACKGROUND/OBJECTIVES

Low intake of long chain polyunsaturated fatty acids (PUFAs) are associated with physical disability; however, prospective studies of circulating PUFAs are scarce. We examined associations between plasma phospholipid n-3 and n-6 PUFAs with risk of incident mobility disability and gait speed decline.

SUBJECTS/METHODS

Data are from a subgroup of the Age, Gene/Environment Susceptibility-Reykjavik Study, a population-based study of risk factors for disease and disability in old age. In this subgroup (n = 556, mean age 75.1 ± 5.0 years, 47.5% men), plasma phospholipid PUFAs were assessed at baseline using gas chromatography. Mobility disability and usual gait speed were assessed at baseline and after 5.2 ± 0.2 years. Mobility disability was defined as the following: having much difficulty, or being unable to walk 500 m or climb up 10 steps; decline in gait speed was defined as change ⩾ 0.10 m/s. Logistic regression analyses were performed to determine associations between sex-specific s.d. increments in PUFAs with risk of incident mobility disability and gait speed decline. Odds ratios (95% confidence intervals) adjusted for demographics, follow-up time, risk factors and serum vitamin D were reported.

RESULTS

In women, but not men, every s.d. increment increase of total n-3 PUFAs and docosahexaenoic acid (DHA) was associated with lower mobility disability risk, odds ratio 0.48 (0.25; 0.93) and odds ratio 0.45 (0.24; 0.83), respectively. There was no association between n-6 PUFAs and the risk of incident mobility disability or gait speed decline.

CONCLUSIONS

Higher concentrations of n-3 PUFAs and, particularly, DHA may protect women from impaired mobility but does not appear to have such an effect in men.

Changes in body composition and use of blood cholesterol lowering drugs predict changes in blood lipids during 12 weeks of resistance exercise training in old adults

PURPOSE

Aging is associated with an impairment of blood lipids. The present study investigated the response of blood lipids to resistance exercise in old adults. The particular aim was to investigate whether the response of blood lipids is associated with changes in body composition of blood lipid medication.

METHODS

Subjects (N = 236, 73.7 ± 5.7 years, 58.2 % female) participated in a 12-week resistance exercise program (3 times/week; 3 sets, 6-8 repetitions at 75-80 % of the 1-repetition maximum), designed to increase strength and muscle mass of major muscle groups. Body composition, drug use, triglycerides (TG), total cholesterol (TC), low-density lipoprotein (LDL) and high-density lipoprotein (HDL) were assessed at baseline and endpoint.

RESULTS

The concentrations of HDL (-6 mg/dl), LDL (-18 mg/dl), TC (-26 mg/dl) and TG (-12 mg/g) decreased significantly during the study period. A reduction in fat mass by 1 kg predicted a reduction in TG (5.0 mg/dl, P = 0.017) and a gain in lean body mass by 1 kg predicted also a reduction in TG (-4.5 mg/dl, P = 0.023). The use of blood cholesterol lowering drugs predicted greater reductions in TC (-16.9 mg/dl, P = 0.032) and LDL (-11.8 mg/dl, P = 0.038) during training.

CONCLUSIONS

TG, TC, LDL and HDL decreased significantly after 12 weeks of progressive resistance exercise in old adults. Changes in body composition, i.e., reduction in fat mass and gain in lean body mass improved the blood lipid profile. Use of blood lipid lowering drugs was associated with greater reductions in TC and LDL after the training.

Meta-analysis of 74,046 individuals identifies 11 new susceptibility loci for Alzheimer's disease

Eleven susceptibility loci for late-onset Alzheimer's disease (LOAD) were identified by previous studies; however, a large portion of the genetic risk for this disease remains unexplained. We conducted a large, two-stage meta-analysis of genome-wide association studies (GWAS) in individuals of European ancestry. In stage 1, we used genotyped and imputed data (7,055,881 SNPs) to perform meta-analysis on 4 previously published GWAS data sets consisting of 17,008 Alzheimer's disease cases and 37,154 controls. In stage 2, 11,632 SNPs were genotyped and tested for association in an independent set of 8,572 Alzheimer's disease cases and 11,312 controls. In addition to the APOE locus (encoding apolipoprotein E), 19 loci reached genome-wide significance (P < 5 × 10(-8)) in the combined stage 1 and stage 2 analysis, of which 11 are newly associated with Alzheimer's disease.

Effect of 12-week resistance exercise program on body composition, muscle strength, physical function, and glucose metabolism in healthy, insulin-resistant, and diabetic elderly Icelanders

BACKGROUND

Insulin is a stimulator of skeletal muscle protein anabolism and insulin resistance might therefore negatively affect muscle protein metabolism. We investigated muscle mass and physical function before and after a resistance exercise program in participants with prediabetes or type 2 diabetes mellitus (T2DM) in comparison to healthy controls.

METHODS

This was a secondary analysis of a randomized controlled intervention designed to investigate resistance training among older adults. Glucose metabolism status was not a selection criteria for the trial, and group designation was done retrospectively. Participants (N = 237, 73.7 ± 5.7 y, 58.2% women) participated in a 12-week resistance exercise program (3 times/week; three sets, six to eight repetitions at 75%-80% of the one-repetition maximum), designed to increase strength and muscle mass of major muscle groups. Body composition, muscular strength, timed up and go test, 6-minute walk for distance, and blood chemical variables were measured at baseline and endpoint.

RESULTS

Participants completing the study (n = 213) experienced significant changes in muscle strength or muscle function, which did not differ significantly between healthy (n = 198), prediabetic (n = 20), and T2DM participants (n = 17). Changes in serum glucose during the intervention differed by group: only glucose improved significantly in the prediabetic group, glucose and triacylglycerol improved significantly in the healthy group, whereas no serum parameter improved significantly in the T2DM group.

CONCLUSIONS

A 12-week resistance exercise program improves muscle strength and muscle function to a similar extent in healthy, prediabetic, and T2DM elderly people. However, according to our data, T2DM participants do not experience favorable changes in fasting glucose or HbA(1C).

Physical function predicts improvement in quality of life in elderly Icelanders after 12 weeks of resistance exercise

BACKGROUND

Little is known about the effects of resistance training on health related quality of life (HRQL) in the elderly.

AIM

The main purpose of the study was to investigate the effects of resistance training on strength, body composition, functional capacity and HRQL in independent living elderly people. We hypothesised that resistance training would improve lean mass, muscle strength, physical function and HRQL.

METHODS

Subjects (N = 237, 73.7±5.7 yrs, 58.2% female) participated in a 12-week resistance exercise program (3 times/week; 3 sets, 6-8 repetitions at 75-80% of the 1-repetition maximum) designed to increase strength and muscle mass of major muscle groups. Body composition, quadriceps- and grip strength, timed up and go test (TUG), six minute walk for distance (6MW) and HRQL were measured at baseline and endpoint.

RESULTS

Two hundred-and-four participants completed the study. Although the increase in lean mass was small (+0.8 kg, P<0.01), quadriceps strength (+53.5 N), grip strength (+3.0 lb), TUG (-0.6 sec), 6MW (+33.6 m) and HRQL (+1.2 t-score) improved significantly (all P<0.01). Changes in 6MW predicted improvement in HRQL after 12 weeks.

CONCLUSIONS

Our study shows that a 12-week resistance exercise program significantly improves lean mass, muscle strength, physical function and HRQL in elderly individuals, and that improvements in physical function predict improvements in HRQL. Our study indicates that resistance training should be promoted for the elderly as it has the potential to improve physical performance, thereby prolonging healthy, independent aging.

Cerebral microbleeds, retinopathy, and dementia: the AGES-Reykjavik Study

OBJECTIVE

To determine whether microvascular damage, indicated by cerebral microbleeds (CMBs) and retinal microvascular signs, is associated with cognitive function and dementia in older persons.

METHODS

This is a cross-sectional study of 3,906 participants (mean age 76 years; 58% women) in the AGES-Reykjavik Study (2002-2006). We assessed CMBs on MRI and retinal microvascular signs on digital retinal images. Composite Z scores of memory, processing speed, and executive function were derived from a battery of neurocognitive tests. Dementia and subtypes were diagnosed following international criteria. Regression models were used to relate cognitive Z scores and dementia to CMBs and retinal microvascular signs, adjusting for demographics, cardiovascular factors, and brain ischemic lesions.

RESULTS

People with multiple (≥ 2) CMBs had lower Z scores on tests of processing speed (β-coefficient -0.16; 95% confidence interval -0.26 to -0.05) and executive function (-0.14; -0.24 to -0.04); results were strongest for having multiple CMBs located in the deep hemispheric or infratentorial areas. The odds ratio of vascular dementia was 2.32 (95% confidence interval 1.02 to 5.25) for multiple CMBs and 1.95 (1.04 to 3.62) for retinopathy. Having both CMBs and retinopathy, compared to having neither, was significantly associated with markedly slower processing speed (-0.25; -0.37 to -0.12), poorer executive function (-0.19; -0.31 to -0.07), and an increased odds ratio of vascular dementia (3.10; 1.11 to 8.62).

CONCLUSION

Having multiple CMBs or concomitant CMBs and retinopathy is associated with a profile of vascular cognitive impairment. These findings suggest that microvascular damage, as indicated by CMBs and retinopathy lesions, has functional consequences in older men and women living in the community.

Cerebral microbleeds in the population based AGES-Reykjavik study: prevalence and location

BACKGROUND AND PURPOSE

Incidental foci of signal loss suggestive of cerebral microbleeds (CMBs) are frequent findings on gradient echo T2* weighted MRI (T2* MRI) of patients with haemorrhagic or ischaemic stroke. There are few prevalence data on older populations. This paper reports on the prevalence and location of CMBs in a community based cohort of older men and women (born 1907-1935) who participated in the Age Gene/Environment Susceptibility (AGES)-Reykjavik Study, a population based cohort study that followed the Reykjavik Study

METHODS

As part of the examination, all eligible and consenting cohort members underwent a full brain MRI, and blood was drawn for genotyping. Results are based on the first 1962 men (n = 820) and women (n = 1142), mean age 76 years, with complete MRI and demographic information available.

RESULTS

Evidence of CMBs was found in 218 participants (11.1% (95% CI 9.8% to 12.6%)); men had significantly more CMBs than women (14.4% vs 8.8%; p = 0.0002, age adjusted). The prevalence of CMBs increased with age (p = 0.0001) in both men (p = 0.006) and women (p = 0.007). CMBs were located in the cerebral lobes (70%), the basal ganglia region (10.5%) and infratentorium (18.6%). Having a CMB was significantly associated with a homozygote Apo E epsilon4epsilon4 genotype (p = 0.01).

CONCLUSION

Cerebral microbleeds are common in older persons. The association with homozygote Apo E epsilon4 genotype and finding a relative predominance in the parietal lobes might indicate an association with amyloid angiopathy.

Unintended weight loss in the elderly living at home: the aged in Home Care Project (AdHOC)

OBJECTIVE

To describe associations between unintended weight loss (UWL) and characteristics of nutritional status.

DESIGN

A comparative cross-sectional assessment study at 11 sites in Europe. The target population was a stratified random sample of 4,455 recipients of home care (405 in each random sample from 11 urban areas) aged 65 years and older.

MEASUREMENTS

the Resident Assessment Instrument for Home Care, version 2.0. Epidemiological and medical characteristics of clients and service utilisation were recorded in a standardized, comparative manner. UWL was defined as information of 5% or more weight loss in the last 30 days (or 10% or more in the last 180 days).

RESULTS

The final sample consisted of 4,010 persons; 74% were female. The mean ages were 80.9 +/- 7.5 years (males) and 82.8 +/- 7.3 years (females). No associations were found between single diagnoses and UWL, except for cancer. Cancer patients were excluded from further analyses. Persons with a Cognitive Performance Scale value (CPS) superior 3 (impaired) had increased risk of UWL (OR = 2.0) compared with those scoring inferior or egal 3 (less impaired). Only in the oldest group did we find a significant association between UWL and reduction in ADL and IADL functions, comparing those who scored 3 or less with those who scored more than 3 (disabled). A binary logistic regression model explained 26% of UWL: less than one meal/day, reduced appetite, malnutrition, reduced social activity, experiencing a flare-up of a recurrent or chronic problem, and hospitalisation were important indicators.

CONCLUSION

We recommend a regular comprehensive assessment in home care to identify clients with potential risk factors for weight loss and malnutrition, in particular those discharged from hospital, and those with physical dependency or cognitive problems. This study may provide incentives to create tailored preventive strategies.

Increased work-load associated with faecal incontinence among home care patients in 11 European countries

The plurality of definition of faecal incontinence (FI) complicates the cross-national comparisons between studies conducted in the area. The aim of the study was to investigate work-load and subjective care-giver burden associated with FI, among home-care patients, in Europe.

DESIGN AND METHODS

In this cross-sectional retrospective study, a random sample of 4010 RAI-HC assessments were collected during 2001-02 from home care patients aged 65 years and over (74% females; age 82.8 +/- 7.2 years) in Czech Republic, Denmark, Finland, France, Germany, Iceland, Italy, The Netherlands, Norway, Sweden and United Kingdom.

RESULTS

Of the 4010 individuals, 411 (10.3%) suffered from FI (range 1.1-30.8% from site to site). The factors significantly associated with faecal incontinence were diarrhoea [odds ratio (OR) 10.3, 95% confidence interval (CI) 6.590-15.96], urinary incontinence (OR 3.99, 95% CI 2.991-5.309) and pressure ulcers (OR 3.15, 95% CI 2.196-4.512) together with severe impairments in physical (OR 4.25, 95% CI 2.872-6.295) and cognitive (OR 3.76, 95% CI 2.663-5.304) functions. High use of working hours of the visiting nurses (OR 2.04, 95% CI 1.221-3.414) and home health carers (OR 2.40, 95% CI 1.289-4.470) were additionally associated with faecal incontinence. Use of five or more medications was an inversely associated with FI (OR 0.62, 95% CI 0.473-0.820).

CONCLUSIONS

The additional work load associated with faecal incontinence comprises considerable numbers of formal health care hours and should be taken into account when planning home health services for the older in home care patients.

Fast and simple screening for nutritional status in hospitalized, elderly people

BACKGROUND

Undernutrition has been frequently reported among hospitalized elderly patients. The aim of this study was to evaluate the mini nutrition assessment (MNA) and a screening sheet for malnutrition (SSM) by full nutritional assessment (FNA) in elderly people, and to construct a shorter screening method by combining important questions from MNA and SSM. Having a screening tool as fast and simple as possible could increase its use in clinical routines.

METHODS

FNA, MNA and SSM were carried out on 60 hospitalized patients (>65 years). Sensitivity and specificity for MNA and SSM were calculated in comparison with FNA. In order to construct a short and simple screening tool, questions from the two screening tools, which differed significantly between mal- and well-nourished patients, were used in a multivariate, stepwise linear regression. The regression model was simplified to be suitable in clinical routines.

RESULTS

Malnourishment was diagnosed by FNA in 58.3% of the elderly patients, with no gender difference. Body mass index, unintended weight loss, recent surgery and loss of appetite were predictors of malnutrition in the regression model (R(2) = 60.1%). The sensitivity and specificity of the simplified regression model were 89 and 88%, respectively, which was more precise than MNA (77 and 36%) and SSM (89 and 60%).

CONCLUSION

According to FNA, malnutrition is frequent in elderly hospitalized patients. Four questions are sufficient to conduct precise nutritional screening for malnutrition in elderly hospitalized patients. This new screening tool should be verified in other samples.

A new assessment for elders admitted to acute care: reliability of the MDS-AC

Assessment of older people rarely includes functional domains critical for ensuring optimum outcome of treatment in acute hospital care. We report the development of a new assessment instrument, and illustrate how differences between pre-hospital and hospital admission status can be systematically evaluated using the Minimum Data Set for Acute Care (MDS-AC). Content was developed by literature review and consultation with professionals working in acute areas. Dual independent assessments were conducted on hospital in-patients in 4 countries. Inter-assessor reliability coefficients were calculated for each item. Kappa was calculated for all binary and multi-level nominal variables. Quadratically weighted Kappa was estimated for all ordinal multi-level variables. Where one level of the variable contained 90% or more of the subjects, total observed agreement is reported. Separate reliability estimates were calculated for pre-hospitalization and inpatient items. Subjects had a mean age of 78. Completion of pre-hospitalization and hospital period assessment (combined) required 20 and 30 minutes. Excluding items for which 90% or more of subjects were classified into a single scoring level, average inter-assessor reliability coefficient for the pre-hospital period items was 0.57 and for in hospital 0.58. Overall exact agreement was 83% for pre-hospitalization assessment items, and 79% for the in-hospital items. The reliability achieved in the highly unstable situation of the acute admission phase is sufficient for use in clinical care and research. Differences in pre-hospital and admission status necessary for case-mix adjusted comparison of outcomes were illustrated. Development of a means for systematically comparing changes in older people during the course of illness is of increasing importance when addressing questions of the appropriate and inappropriate use of medical technology.

[Psychotropic use in nursing and residential homes in the Greater Reykjavík area in 1996.]

INTRODUCTION

Psychiatric symptoms, with or without dementia, are very common among institutionalized elderly and often treated with medications. Because of age-related changes in pharmacokinetics and polypharmacy in this age group, such treatment is precarious. A recent study showed that use of psychotropics in Icelandic nursing homes is two to three times more common than in Sweden and Denmark. The goal of this study was to register psychiatric symptoms, indications for treatment, psychotropic drug use, dosages and treatment efficacy with quality in mind.

MATERIAL AND METHODS

One hundred and fifteen individuals in five residential and nursing homes in the Greater Reykjavík area were evaluated. Fifty were on three specialized dementia units, and 65 on two residential units. Information on the number of psychotropic medications, types, dosages and treatment duration were collected. Nurses, familiar with the residents, evaluated the symptoms and treatment efficiacy.

RESULTS

Only 16% were without psychotropic medications, 39% on one type, 36% on two types and 9% on three types. On the dementia and residential units there was similar use of antidepressants (30% vs 38%), and hypnotics and tranquilizers (66% vs 71%). On specialized dementia units 62% took neuroleptic medications but only 15% on residential units. On residential units the most common symptoms were sleep disturbances and depression. Symptoms improved during treatment in 60-98% of cases according to the caring nurses. In the antidepressant drug group dosages or medications had been chanced in 65% of cases over six months. For the other groups a change of dose had been made in 45% of cases over six months. Half of those using antidepressant medications received newer types of antidepressants. Of those who received hypnotics or tranquilizers, 46 individuals received medications with t1/2 >20 hours.

DISCUSSION

The use of psychotrophic medications in the institutionalized elderly is prevalent. The greater use of antidepressants in Iceland compared to Sweden and Denmark might suggest better treatment of depression in Iceland, as many foreign studies have suggested that depression among the elderly is underdiagnosed and undertreated. The high use of hypnotics and tranquilizers, the choice and dosages however evoke concern considering possible side effects, such as falls, and raises the question if there are any alternative non-pharmacologic forms of treatment.

[Assessment of health and caring needs in nursing homes. The Resident Assessment Instrument, its development and some pilot study results.]

Those elderly living in institutions have multiple social, health and mental problems, in addition to loss of function. The Resident Assessment Instrument assesses the individual in detail and his caring needs. Resident Assessment Protocols come with the instrument and a handbook that describes how to evaluate specific problems further. Quality indicators allow comparisons between institutions and thus the quality of care can be assessed in comparable groups of residents. The elderly can be put into defined resource utilisation groups and an average cost calculated per unit or nursing home. A pilot study was conducted in Iceland in 1994 to examine the utility of the instrument. It was shown that most of the residents were viewed as competent according to documents, even if about half of them had considerable cognitive dysfunction. Dementia was the most common diagnosis. One fourth of the residents took antidepressant medications and 54-62% took sedatives or hypnotic drugs. Eight out of 10 had dentures and one third had difficulty chewing. Many more interesting findings showed up that are described in a special report.

Using the Resident Assessment Instrument for quality enhancement in nursing homes

BACKGROUND

in some current policy discussions concerning long-term care, the emphasis has been almost solely on the costs of care. This dialogue must be replaced with a discussion of value, which emphasizes both the costs of care and quality of care. While the Resident Assessment Instrument (RAI) was originally designed as a multidimensional assessment tool aimed at improving clinical practice, it can also provide the foundation for a comprehensive data base that can be used to assess and monitor the quality of care. AIMS and

CONCLUSIONS

using data from four sites (in Denmark, Iceland, Italy and the USA) and eight indicators of quality that could be derived from single assessments, we demonstrate how quality might be measured and compared using the RAI. Although this is for illustrative purposes only it does show how this data base can provide invaluable information to providers about the quality of care within their facilities. It can also allow consumers and purchasers to evaluate the relative performance of different providers.

[Views of Icelandic physicians and nurses towards limitation of treatment at the end of life.]

With increasingly advanced life-prolonging technology, the issue of when and how treatment should be limited becomes ever more important. To shed a light on the views of Icelandic physicians and registered nurses a survey was conducted at the Reykjavik Hospital and the National University Hospital. A questionnaire was sent to 184 doctors and 239 nurses. They were asked to respond to several ethical dilemmas regarding limitation of treatment at the end of life. Special emphasis was placed on respect for the patient's autonomy and communication. There were 234 (55%) answers retrieved. The general view was that one should respect patient's autonomy and honor the wish to deny life-prolonging measures. Cost could be an issue in such decisions according to 35% of physicians and 15% of nurses. Under certain conditions, euthanasia could be justified according to five (5%) physicians and 11 (9%) nurses, although only four (2%) could consider themselves as participating in such an act. The majority, 201/230 (87%), supported using written guidelines within hospitals regarding decision-making process in limiting treatment at the end of life. In a case of a dispute between patients or families and health care professionals, 49% of physicians and 84% of nurses were willing to take it to a multidisciplinary ethical committee at the hospital. In a case of a dispute between health care professionals 62% of physicians and 50% of nurses were willing to take it to the Director General of Health.

[Systolic murmurs of the elderly in an Icelandic acute care hospital: prevalence, etiology by 2D- and Doppler echocardiography and sensitivity and specificity of clinical assessment.]

Acutely hospitalised elderly patients, from February 1993 to February 1994, excluding those with known valvular heart diseases, were examined by a resident. Those who had a systolic murmur were also auscultated by a cardiologist and a geriatrician and studied with 2D- and Doppler echocardiography. Of 213 potential study participants the resident auscultated 153 patients, 79-101 years old, with the mean age of 85+/-4 years, 61% of whom were women. Systolic murmurs were diagnosed in 80 of 153 patients or 53% of over the age of 80, 61% of women and 40% of men adjusted for sex (p<0,025). Fifty seven patients with systolic murmurs were evaluated with 2D- and Doppler echocardiography. Maximal Doppler gradients 3=30 mmHg, representing significant aortic stenosis were found in 8/57 subjects (14%), aortic sclerosis in 44 (77%), and mitral regurgitation in 25/57 (44%); 1 degrees on the scale of 1-4 in 19 of 25. The sensitivity and specificity of clinical examination for the detection of aortic stenosis was 62-100% and 71-77%, aortic sclerosis 54-56% and 85-92% and mitral regurgitation 24-52% and 69-97%, respectively. Systolic murmurs are prevalent in the aged and more so in women than men. 2D- and Doppler echocardiography is of value since the clinical diagnosis of aortic stenosis is difficult in light of the high prevalence of systolic murmurs most of which are due to aortic sclerosis or clinically nonsignificant mitral regurgitation. The results are comparable with other reported studies.

[Urinary incontinence and urinary tract infections in 70-89 years old women.]

OBJECTIVES

The purpose of the study was to investigate the prevalence and presentation of urinary incontinence (UI) and urinary tract infection (UTI) among elderly women.

MATERIAL AND METHODS

A total of 120 women, aged 70-89 years, were randomly selected and asked about urogenital complaints in a structured interview. Seventy were living in homes for the elderly and 50 living at home. Medical records provided information about urinary tract infections and the use of estrogens.

MAIN OUTCOME MEASURES

Types and frequency of urinary incontinence and urogenital complaints and estrogen use.

RESULTS

Urinary incontinence affexted 47.5%, half of them daily. Urge incontinence was most common (39%), then mixed incontinence (32%) and stress incontinence (26%). Urge and mixed incontinence caused significantly more discomfort than stress incontinence. During the past two years 35% of the women had experienced UTI and 11% had five or more infections. A total of 27 women were receiving estron treatment, the mahority in homes for the elderly (p<0.001). They had a high prevalence of UI, UTI , and other complaints compared to women not receiving estrogens. Considerable or great discomfort from the urogenital tract was reported by 21% of the women. A third of the women had discussed urogenital complaints with a physician.

CONCLUSION

In view of the prevalence of urogenital complaints, it is likely that more elderly women could benefit from medical assessement and treatment. Indications for estrogen treatment need to be more clearly defined. Physicians might improve management by using preventive measures, affirmative questioning and more diagnostic work-up and thus improve the quality of life of elderly women.

[The preadmission nursing home assessment (PNHA) in Reykjavik 1992.]

No-one can be admitted to a nursing home in Iceland without a prior assessment of need, that is standardized in content and method. In 1992 there were 546 individuals in Reykjavik assessed in a need for nursing home placement, 304 (55.7%) in an unskilled (UNH) and 242 (44.3%) in a skilled nursing home (SNH). The mean age was 81.6 (+/-0.4) and 81.8 (+/- 0.5) years, respectively, with the same female: male ratio of 2:1. On January 1st 1993, 19.4 per 1000 inhabitants in Reykjavik 65 years of age or older were waiting for admission to an UNH, where notas 14.1 per 1000 waited for a SNH admission. Those who were waiting for an UNH had mostly social difficulties along with affective symtoms, but those who were waiting for a SNH, had in addition to social difficulties, impaired physical and mental capacity with greater functional deficits. The PNHA was simplified with each of the twelve variables divided into a lower and higher level of difficulty. A logistic regressions analysis found seven independent variables predicting SNH placement: physical health, use of medications, dementia, mobility, abil notity to eat, ability to dress and groom, control of urine and stools. Of those assessed in a need for SNH 78.5% had dementia of some degree. Physical function and mobility appear to be relatively preserved until late in the dementia. These analyses confirm the validity of a PNHA, which is based on disabilities in four domains: social, physical, mental and functional health.

Causes and correlates of recurrent falls in ambulatory frail elderly

To determine causes and clinical correlates of recurrent falls in ambulatory frail elderly people, we evaluated 70 recurrent fallers and 56 nonfallers (mean age = 87 years) from two long-term care facilities. Evaluations included a detailed history, physical examination, performance-oriented mobility assessment, and laboratory studies. Primary causes including stroke, parkinsonism, blindness, drug-related hypotension, and arthritis were established for the most recent fall in 51 (73%) fallers. Eighteen fallers (26%) had multiple conditions that could not be prioritized for their contribution to the fall. Fallers were more often women, were functionally more impaired, and were taking more medications than nonfallers. Specific diseases did not distinguish fallers from nonfallers. Fallers of both sexes took more steps to turn 360 degrees, could not stand up from a chair without pushing off, had a higher prevalence of antidepressant use, and had impaired position sensation. These easily obtained clinical variables characterized nearly three-quarters of ambulatory elderly nursing home residents with a history of recurrent falls.

Hypotensive responses to common daily activities in institutionalized elderly. A potential risk for recurrent falls

Transient hypotension may be one of many factors contributing to the high prevalence of falls among elderly people. To determine the frequency and magnitude of hypotensive responses to common daily activities, and their potential relationship to falls in the elderly, we examined blood pressure (BP) and heart rate during a standardized series of activities in 38 institutionalized recurrent fallers (age, 87 +/- 6 years), 20 institutionalized nonfallers (age, 85 +/- 5 years), and 10 healthy young control subjects (age, 24 +/- 3 years). The coefficient of variation for systolic BP during all activities was higher in elderly subjects (fallers, 14% +/- 5%; nonfallers, 12% +/- 3%) than in young control subjects (8% +/- 1%). In contrast, the coefficient of variation for heart rate during all activities was higher in young subjects than in the elderly subjects. Elderly subjects had marked BP reduction following meals and nitroglycerin, which was significantly greater in fallers than in nonfallers, independent of the cause of the fall. Thus, institutionalized elderly have marked BP variability and hypotensive responses to meals and nitroglycerin. A decline in BP during common preload-reducing stresses may predispose some elderly people to falls.

Reduced supine cardiac volumes and diastolic filling rates in elderly patients with chronic medical conditions. Implications for postural blood pressure homeostasis

Very elderly individuals with multiple chronic illnesses are at high risk of orthostatic hypotension, falls, and associated morbidity and mortality. Alterations in cardiac volumes and filling characteristics may contribute in part to an increased prevalence of orthostatic hypotension and falls in these people. In this study cardiac function was evaluated with gated radionuclide ventriculography in eight healthy young subjects (19-38 years) and 25 elderly persons with stable chronic illnesses (73-96 years), 14 of whom had a history of recurrent falls. Blood pressure was measured supine during the radionuclide ventriculography, then after one minute of standing. Supine stroke volume index, end diastolic volume index, cardiac index, and peak filling rates were significantly lower in elderly subjects compared to young, and ejection fraction and end systolic volume index (measures of systolic function) were the same in young and old. Compared to the young, elderly subjects had a reduction in ventricular filling during the first third of diastole, but an augmentation in the last third, during atrial contraction. Within the group of elderly subjects, the directional change in systolic blood pressure during orthostasis was significantly correlated with basal supine systolic blood pressure (R = 0.81, P less than .0001) and supine cardiac index (R = 0.66, P = .002). Thus, very old people representative of those seen in clinical practice have reduced cardiac volumes and impaired early diastolic filling, a result possibly related to elevations in systolic blood pressure. These changes in cardiac structure and function may contribute, in part, to orthostatic hypotension in advanced age.

Reduced susceptibility to syncope during postural tilt in old age. Is beta-blockade protective?

Clinical studies of syncope suggest a decreased prevalence of vasovagal syncope in old age. To examine this possibility and its pathophysiologic implications, we report the results of two studies. The first evaluated responses to head-up tilt in young and old subjects. Presyncopal vasovagal symptoms occurred in 4 of 9 young subjects and only 1 of 22 old subjects. The second study asked whether decreased beta-adrenergic responsiveness protected the old during tilt via unopposed alpha-adrenergic-mediated vasoconstriction. Blood pressure, heart rate, and forearm vascular resistance responses to tilt in 11 healthy young subjects randomized to receive intravenous propranolol hydrochloride or saline were compared with those of 10 healthy elderly. Propranolol attenuated heart rate and forearm vascular resistance responses. Vasovagal symptoms occurred in 4 young and no old subjects; 2 were symptomatic during propranolol administration. Thus, presyncopal vasovagal symptoms are less common during tilt in old age. Propranolol did not prevent the vasovagal reaction or enhance forearm vasoconstriction. Propranolol's attenuation of vasoconstriction may be due to decreased activation of cardiopulmonary baroreceptors during beta-blockade.

The 'Do not resuscitate' order. A profile of its changing use

The "do not resuscitate" (DNR) order has wide-ranging ethical, legal, and economic implications. We reviewed the course of 244 patients who died during two three-month periods, in 1982 and 1986. We found that 68% of patients who died had a DNR order written, including 94% with malignancy and half of patients with cardiovascular disease. Most orders (61%) were written within three days of death, with 64% written on medical-surgical floors and 34% in critical care units. Even among patients under the age of 60 years, 57% had a DNR order written by the time of death. Ninety-one percent of DNR orders were written by attending physicians, with accompanying explanatory note in 84%. Documentation showed only 14% of patients but 77% of families being consulted. In 1983 a new two-level DNR order system defined two levels of intensity: "all but cardiopulmonary resuscitation" and "comfort measures only." Equal numbers of patients received each order in the 1986 sample. No patient was transferred to the critical care units after a DNR order had been written. The prevalence of DNR orders written for patients dying of cardiovascular disease increased from 27% to 64% over the four years. We conclude, from study of deaths in this representative community hospital, that an explicit DNR order is now the rule rather than the exception, but decisions are made late and involve family far more than the patient.