Constricting Life Space and Likelihood of Neurodegenerative Disease in Community-Dwelling Older Men

Importance

Life space is a measure of the frequency, range, and independence of movement through the environment. There is increasing interest in life space as a holistic measure of function in older adults, but the association between change in life space and incident neurodegenerative disease is unknown.

Objective

To evaluate the association between change in life space and cognitive decline or incident neurodegenerative disease over 7 years among community-dwelling older men.

Design, Setting, and Participants

In this cohort study, logistic regression analyses were used to examine the association of baseline and change in life space with change in cognition unadjusted and adjusted for demographics, cardiovascular risk factors, depression, gait speed, and physical activity. Mixed linear effects models were used to evaluate the association between change in life space and change in cognition. Men were recruited from 6 US sites to participate in a prospective, community-based cohort study of aging and followed-up from 2007 to 2014. Individuals with prevalent dementia or Parkinson disease (PD) at baseline were excluded. Data were analyzed from May 2022 to September 2023.

Exposure

Life space, assessed using the University of Alabama at Birmingham Life Space Assessment and divided into tertiles.

Main Outcomes and Measures

Participants completed the Modified Mini-Mental State (3MS) Test, and Trail-Making Test Part B at baseline and 7 years later. At follow-up, participants were asked about a new physician diagnosis of dementia and PD.

Results

A total of 1684 men (mean [SD] age, 77.1 [4.2] years) were recruited and over 7 years of follow-up, 80 men (4.8%) developed dementia and 23 men (1.4%) developed PD. Mean (SD) life space score was 92.9 (18.7) points and mean (SD) change was -9.9 (22.3) points over follow up. In the adjusted model, each 1-SD decrement in life space was associated with increased odds of dementia (odds ratio [OR], 1.59; 95% CI, 1.28-1.98) but not PD (OR, 1.48; 95% CI, 0.97-2.25). For each 1-SD decrement in life space, men worsened by 20.6 (95% CI, 19.8-21.1) seconds in their Trails B score (P < .001) and declined by 1.2 (95% CI, 1.0-1.3) points in their 3MS score (P < .001) over 7 years.

Conclusions and Relevance

In this study of 1684 men followed up over 7 years, change in life space was associated with faster cognitive decline and increased likelihood of neurodegenerative illness. Future studies should examine the role of clinician assessments or wearable electronics in tracking life space in older adults at risk of cognitive decline and neurodegenerative illness.

The Association between Changes in Built Environment and Changes in Walking among Older Women in Portland, Oregon

Some cross-sectional evidence suggests that the objectively measured built environment can encourage walking among older adults. We examined the associations between objectively measured built environment with change in self-reported walking among older women by using data from the Study of Osteoporotic Fractures (SOF). We evaluated the longitudinal associations between built environment characteristics and walking among 1253 older women (median age = 71 years) in Portland, Oregon using generalized estimating equation models. Built environment characteristics included baseline values and longitudinal changes in distance to the closest bus stop, light rail station, commercial area, and park. A difference of 1 km in the baseline distance to the closest bus stop was associated with a 12% decrease in the total number of blocks walked per week during follow-up (e^β = 0.88, 95% CI: 0.78, 0.99). Our study provided limited support for an association between neighborhood transportation and changes in walking among older women. Future studies should consider examining both objective measures and perceptions of the built environment.

Impact of earlier gestational diabetes screening for pregnant people with obesity on maternal and perinatal outcomes

OBJECTIVES

Gestational diabetes (GDM) screening at 24-28 weeks' gestation reduces risk of adverse maternal and perinatal outcomes. While experts recommend first-trimester screening for high-risk patients, including those with obesity, data supporting this recommendation is limited.

METHODS

We implemented a systematic population intervention to encourage first-trimester GDM screening by oral glucose tolerance testing in a cohort of pregnant people with obesity in two integrated health systems from 2009 to 2013, and compared outcomes to the same population pre-intervention (2006-2009). Up to five years of postpartum glucose testing results (through 2018) were assessed among GDM cases in the post-intervention group. Primary outcomes were large-for-gestational-age birthweight (LGA); macrosomia; a perinatal composite outcome; gestational hypertension/preeclampsia; cesarean delivery; and medication treatment of GDM.

RESULTS

A total of 40,206 patients (9,156 with obesity) were screened for GDM; 2,672 (6.6%) were diagnosed with GDM. Overall, multivariate adjusted risk for LGA and cesarean delivery were lower following the intervention (LGA: aOR 0.89 [0.82, 0.96]; cesarean delivery: 0.89 [0.85, 0.93]). This difference was more pronounced in patients diagnosed with GDM (LGA: aOR 0.52 [0.39, 0.70]; cesarean delivery 0.78 [0.65, 0.94]); insulin/oral hypoglycemic treatment rates for GDM were also higher post-intervention than pre-intervention (22 vs. 29%; p<0.0001). There were no differences for the other primary outcomes. Only 20% of patients diagnosed with GDM early in pregnancy who had postpartum testing had results in the overt diabetes range, suggesting a spectrum of diabetes detected early in pregnancy.

CONCLUSIONS

First trimester GDM screening for pregnant people with obesity may improve GDM-associated outcomes.

First year infant weight trajectories predict overweight/obesity at age 2 in a diverse population

BACKGROUND

Obesity is emerging as early as two years of age and risk may be elucidated by differences in infant growth trajectories. We examined infant weight gain in the first year of life and association with overweight/obesity at age two.

METHODS

In a diverse, population-based cohort study we conducted growth curve analysis using Health Maintenance Organization electronic medical record data from January 1, 2012 through December 31, 2013.

RESULTS

Among 930 infants, there was a linear relationship with birth weight and initial weight gain from birth and increased odds of developing overweight/obesity at age two [Odds Ratio OR = 1.001; (95% CI: 1.000-1.002), p = 0.0274] and [OR = 1.009; (1.006-1.01), p = 0.0001) respectively. The odds of becoming overweight/obese at age 2 increased in infants who had slower weight deceleration rates (OR third quartile = 2.78, fourth quartile = 4.3) compared to the first quartile. Other factors associated with overweight/obesity risk at age two included female sex and Native Hawaiian race/ethnicity.

CONCLUSIONS

Rate of weight gain in the first year may be an important risk factor for early childhood obesity. A deeper dive into first year growth patterns and related sociocultural and nutritional factors is needed to inform targetable points for intervention.

Vitamin D deficiency and insufficiency in Hawaii: Levels and sources of serum vitamin D in older adults

OBJECTIVE

To examine the major sources of vitamin D [25-hydroxyvitamin D (25(OH)D)] and evaluate their collective role on rates of vitamin D deficiency/insufficiency among older adults.

METHODS

Cross-sectional analysis of the relationship between serum 25(OH)D levels and sources of vitamin D (self-reported and objectively validated sun exposure, supplementation, food including fortified sources). Study subjects were part of the Hawaii Longitudinal Study of Personality and Health who completed a clinic visit between 55 and 65 years (M = 59.6) and food frequency questionnaire, and provided serum to assay 25(OH)D (n = 223).

RESULTS

Although mean serum 25(OH)D levels were overall sufficient (34.3 ng/ml, [SD = 10.9]), over one-third of participants (38%) had vitamin D deficiency/insufficiency (<30 ng/ml). Asians were the most likely to be insufficient and Filipinos were the least likely (43% vs. 11%, respectively). Overall, supplement use and sun exposure were both associated with higher 25(OH)D levels and lower risk of vitamin D deficiency/insufficiency. Moreover, Vitamin D sources varied by race/ethnic groups. In multivariate models, higher body mass index, being Asian or Native Hawaiian/Pacific Islander, low supplement use, and low sun exposure were associated with higher risk for vitamin D deficiency/insufficiency (<30 ng/ml).

CONCLUSIONS

Over 1/3 of the older adult sample was vitamin D deficient/insufficient, despite most of the participants living in a tropical climate with year-round access to sun as a vitamin D source. Sun exposure and supplement use, but not food intake, explained differences in vitamin D deficiency/insufficiency in this population.

Weight Loss Prior to Pregnancy and Early Gestational Glycemia: Prepare, a Randomized Clinical Trial

CONTEXT

Women with elevated body mass index are encouraged to lose weight before pregnancy, but no trials have tested the effects of prepregnancy weight loss on risk of developing gestational diabetes.

OBJECTIVE

This work aims to determine whether prepregnancy weight loss improved the early metabolic environment as measured by early gestational diabetes diagnosis.

METHODS

This was a secondary analysis of a pragmatic randomized clinical trial conducted between May 2015 and October 2019 in an integrated health system that encouraged first-trimester gestational diabetes screening for high-risk women, including those with obesity. Women aged 18 to 40 years with a body mass index (BMI) greater than or equal to 27 who were planning pregnancy were randomly assigned to a behavioral weight loss intervention or usual care. Clinical care decisions and data collection were blind to condition assignment. We compared rates of diagnosis with gestational diabetes in early pregnancy between the groups using logistic regression.

RESULTS

Of 326 participants, 168 (89 in the intervention and 79 in usual care) had singleton pregnancies during the study period. At baseline, mean age was 31.3 ± 3.5 years and BMI was 34.8 ± 5.8. Fifty-nine (66%) intervention participants and 57 (72%) usual care participants underwent early screening. Among those, intervention participants were 73% less likely to be diagnosed with gestational diabetes than usual care participants (adjusted odds ratio [aOR], 0.27; 95% CI, 0.09-0.80). There was no difference in diagnosis of gestational diabetes in later pregnancy (aOR, 1.08; 95% CI, 0.41-2.81).

CONCLUSION

Participation in a prepregnancy weight loss intervention led to lower rates of gestational diabetes diagnosis in early pregnancy. This suggests positive effects of prepregnancy weight loss on the early metabolic environment, a critical factor in offspring metabolic risk.

A Pragmatic, Randomized Clinical Trial of Gestational Diabetes Screening

BACKGROUND

Gestational diabetes mellitus is common and is associated with an increased risk of adverse maternal and perinatal outcomes. Although experts recommend universal screening for gestational diabetes, consensus is lacking about which of two recommended screening approaches should be used.

METHODS

We performed a pragmatic, randomized trial comparing one-step screening (i.e., a glucose-tolerance test in which the blood glucose level was obtained after the oral administration of a 75-g glucose load in the fasting state) with two-step screening (a glucose challenge test in which the blood glucose level was obtained after the oral administration of a 50-g glucose load in the nonfasting state, followed, if positive, by an oral glucose-tolerance test with a 100-g glucose load in the fasting state) in all pregnant women who received care in two health systems. Guidelines for the treatment of gestational diabetes were consistent with the two screening approaches. The primary outcomes were a diagnosis of gestational diabetes, large-for-gestational-age infants, a perinatal composite outcome (stillbirth, neonatal death, shoulder dystocia, bone fracture, or any arm or hand nerve palsy related to birth injury), gestational hypertension or preeclampsia, and primary cesarean section.

RESULTS

A total of 23,792 women underwent randomization; women with more than one pregnancy during the trial could have been assigned to more than one type of screening. A total of 66% of the women in the one-step group and 92% of those in the two-step group adhered to the assigned screening. Gestational diabetes was diagnosed in 16.5% of the women assigned to the one-step approach and in 8.5% of those assigned to the two-step approach (unadjusted relative risk, 1.94; 97.5% confidence interval [CI], 1.79 to 2.11). In intention-to-treat analyses, the respective incidences of the other primary outcomes were as follows: large-for-gestational-age infants, 8.9% and 9.2% (relative risk, 0.95; 97.5% CI, 0.87 to 1.05); perinatal composite outcome, 3.1% and 3.0% (relative risk, 1.04; 97.5% CI, 0.88 to 1.23); gestational hypertension or preeclampsia, 13.6% and 13.5% (relative risk, 1.00; 97.5% CI, 0.93 to 1.08); and primary cesarean section, 24.0% and 24.6% (relative risk, 0.98; 97.5% CI, 0.93 to 1.02). The results were materially unchanged in intention-to-treat analyses with inverse probability weighting to account for differential adherence to the screening approaches.

CONCLUSIONS

Despite more diagnoses of gestational diabetes with the one-step approach than with the two-step approach, there were no significant between-group differences in the risks of the primary outcomes relating to perinatal and maternal complications. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ScreenR2GDM ClinicalTrials.gov number, NCT02266758.).

Timing of Gestational Diabetes Diagnosis by Maternal Obesity Status: Impact on Gestational Weight Gain in a Diverse Population

Background: We hypothesized that earlier gestational diabetes mellitus (GDM) diagnosis and treatment of high-risk women would reduce gestational weight gain (GWG) in the first trimester and overall. Materials and Methods: We evaluated timing of GDM diagnosis among 5,391 pregnant women who delivered singleton births 2010-2013 in a large diverse health maintenance organization (HMO). All GDM screening was by the same oral glucose tolerance testing protocol; GDM treatment protocols were also consistent irrespective of timing of diagnosis. Women without risk factors were universally screened at 24-28 weeks gestation (Usual). Early screening was recommended in obese and other high-risk women at the first prenatal visit; those who screened negative Early were rescreened at 24-28 weeks (Early+Usual). Results: Average GWG for all women was 12.8 kg; 10.7% of women were diagnosed with GDM. Average GWG for all women diagnosed with GDM was 10.7 kg, adjusted for gestational age. Women with EarlyGDM averaged 2.4 kg less GWG than women diagnosed with UsualGDM (p < 0.0001). Among obese women, only women diagnosed with EarlyGDM averaged overall GWG within Institute of Medicine (IOM) weight guidelines (mean 8.1 kg) and were weight neutral in the first trimester (-0.2 kg). Overall, 43% of all pregnant women exceeded IOM GWG guidelines (gained more total weight than recommended); 60% of obese women exceeded guidelines. Obese women diagnosed with GDM were less likely to exceed IOM guidelines if diagnosed earlier in pregnancy (35% EarlyGDM vs. 59% UsualGDM exceeded guidelines, p < 0.0001). Conclusion: Our results suggest that EarlyGDM diagnosis (and thus treatment) in high-risk women is beneficial for optimizing GWG.

A randomized pragmatic clinical trial of gestational diabetes screening (ScreenR2GDM): Study design, baseline characteristics, and protocol adherence

BACKGROUND

ScreenR2GDM is a pragmatic randomized clinical trial designed to investigate if one of two gestational diabetes (GDM) screening and treatment protocols results in improved outcomes in the context of standard clinical care.

METHODS

Pregnant women are randomized to one of two GDM screening strategies: 1-step: 2-h, 75 g, oral glucose tolerance test (OGTT) or 2-step: 1-h, 50 g glucose challenge test (GCT) followed by 3-h, 100 g OGTT if GCT-positive. Providers are prompted within the electronic medical record to order the assigned test but were given the option to order the alternate test. Collected data include maternal and pregnancy characteristics, GDM testing, and outcomes for mother and newborn. We describe the study design and baseline characteristics and evaluate characteristics associated with adhering to the randomized protocol.

RESULTS

Baseline characteristics of the 23,792 randomized pregnancies were comparable between the two groups. Adherence to assigned test differed between the two strategies: 66.1% for 1-step and 91.7% for 2-step (p < .0001). 27% of the women randomized to receive the 1-step completed the 2-step test vs 2% randomized to the 2-step who completed the 1-step (p < .0001). Patient characteristics related to adherence included obesity, age, prior GDM, Medicaid insurance, race and nulliparity. Clinician characteristics related to adherence included provider type, age and gender.

CONCLUSIONS

Both patient and provider characteristics were related to adherence to the randomized GDM screening protocol. Analytical techniques that incorporate these findings into the formal evaluation of the two protocols on GDM-associated outcomes will be necessary to account for potential biases introduced by non-adherence.

Glycated Peptide Levels Are Associated With Cognitive Decline Among Nondiabetic Older Women

BACKGROUND

The association between diabetes and dementia may be explained in part by elevated levels of glycated peptides; we sought to determine whether serum-glycated peptides predicted cognitive decline in nondiabetic older adults.

METHODS

We prospectively studied 525 community-dwelling nondiabetic women, mean age of 82 years, and analyzed baseline glycated peptides (serum level of fructosamine and glycated albumin). Cognitive outcomes included 5-year decline on the short Mini-Mental State Examination (sMMSE), Trails B, and performance on a battery of five other cognitive tests at the follow-up visit. Generalized linear models were adjusted for education, age, race, physical activity, body mass index, and vascular disease.

RESULTS

Women with higher level of fructosamine (upper two tertiles) had greater 5-year decline in Trails B performance compared with women in the lowest tertile (adjusted mean change = 67 vs 50 seconds, p = .046), but change in sMMSE was not different between groups. Higher fructosamine was also associated with worse cognitive function 5 years later: adjusted mean score for the California Verbal Learning Test-II Short Form was 22.7 versus 23.9 (p = .010) and for Category Fluency was 10.1 versus 11.1 (p = .003). Higher glycated albumin was also associated with worse performance on Category Fluency (10.1 vs 11.1, p = .003) but not on any other test.

CONCLUSIONS

Among older nondiabetic women, higher concentrations of glycated peptides may be associated with greater cognitive decline, especially in measures of executive function. These associations may present new opportunities for targeted prevention and therapeutic strategies in cognitive aging.

Long-Term Weight Trajectory and Risk of Hip Fracture, Falls, Impaired Physical Function, and Death

OBJECTIVES

To determine the association between weight trajectory, health status, and mortality in older women.

DESIGN

Cohort study.

SETTING

Study of Osteoporotic Fractures.

PARTICIPANTS

Older community-dwelling women (age: baseline (1986-88), mean 68, range 65-81; Year 20 (2006-08), mean 88, range 83-102 (N = 1,323)).

MEASUREMENTS

Body weight measured repeatedly over 20 years (mean 8 times). Logistic and Cox proportional hazard models were used to evaluate whether 20-year weight trajectory measures were associated with hip fracture, falls, physical performance, and mortality.

RESULTS

In models adjusted for age, clinic, calcium use, Year 20 weight, walking speed, comorbidity score, smoking, self-reported health, and walking for exercise, women with moderate weight loss (>9.0 kg) over 20 years had a 74% greater risk of death (hazard ratio (HR) = 1.74, 95% confidence interval (CI) = 1.37-2.20) in the 5 years after the Year 20 visit than those with no weight loss and more than twice the risk of hip fracture (HR = 2.56, 95% CI = 1.39-4.70). They were 3.6 times (odds ratio (OR) = 3.60, 95% CI = 1.86-6.95) as likely to have poor physical function at the Year 20 visit as women with no weight loss but no greater risk of 2 or more falls in the 1.5 years after the Year 20 visit. Weight variability and abrupt weight decline were not associated with adverse health oucomes (falls, fractures, mortality), but those in the highest quartile of variability were 2.3 times (OR = 2.26, 95% CI = 1.34-3.80) as likely to have poor physical function scores.

CONCLUSION

In women surviving past 80 years of age, moderate weight loss over 20 years was associated with greater risk of hip fracture, poor physical function, and mortality but not of falls. Future work should separate voluntary from involuntary weight loss.

Frailty Phenotype and Healthcare Costs and Utilization in Older Women

OBJECTIVES

To determine the association of the frailty phenotype with subsequent healthcare costs and utilization.

DESIGN

Prospective cohort study (Study of Osteoporotic Fractures (SOF)).

SETTING

Four U.S. sites.

PARTICIPANTS

Community-dwelling women (mean age 80.2) participating in SOF Year 10 (Y10) examination linked with their Medicare claims data (N=2,150).

MEASUREMENTS

At Y10, frailty phenotype defined using criteria similar to those used in the Cardiovascular Health Study frailty phenotype and categorized as robust, intermediate stage, or frail. Participant multimorbidity burden ascertained using claims data. Functional limitations assessed by asking about difficulty performing instrumental activities of daily living. Total direct healthcare costs and utilization ascertained during 12 months after Y10.

RESULTS

Mean total annualized cost±standard deviation (2014 dollars) was $3,781±6,920 for robust women, $6,632±12,452 for intermediate stage women, and $10,755 ± 16,589 for frail women. After adjustment for age, site, multimorbidity burden, and cognition, frail women had greater mean total (cost ratio (CR)=1.91, 95% confidence interval (CI)=1.59-2.31) and outpatient (CR=1.55, 95% CI=1.36-1.78) costs than robust women and greater odds of hospitalization (odds ratio (OR)=2.05, 95% CI=1.47-2.87) and a skilled nursing facility stay (OR=3.85, 95% CI=1.88-7.88). There were smaller but significant effects of the intermediate stage category on these outcomes. Individual frailty components (shrinking, poor energy, slowness, low physical activity) were also each associated with higher total costs. Functional limitations partially mediated the association between the frailty phenotype and total costs (CR further adjusted for self-reported limitations=1.32, 95% CI=1.07-1.63 for frail vs robust; CR=1.35, 95% CI=1.18-1.55 for intermediate stage vs robust women).

CONCLUSION

Intermediate stage and frail older community-dwelling women had higher subsequent total healthcare costs and utilization after accounting for multimorbidity and functional limitations. Frailty phenotype assessment may improve identification of older adults likely to require costly, extensive care.

Associations of Smoking, Moderate Alcohol Use, and Function: A 20-Year Cohort Study of Older Women

Objective: The objective of this study is to determine whether the health effects of smoking and moderate alcohol use persist with aging. Method: Smoking status, alcohol use, and measures of function and health were obtained from 9,704 women aged ≥65 years at baseline and over 10- and 20-year follow-up periods. Adjusted multiple linear and logistic regression and Cox proportional hazard models estimated associations. Results: Current versus never smokers had worse walking speed, self-reported health, difficulty with instrumental activities of daily living (IADLs), and depression at 10 years and higher death rates at 10 and 20 years. Moderate versus never drinkers had better grip strength, walking speed, self-reported health, and less difficulty with IADLs and were less likely to live in nursing homes at 10 years and die at 10 and 20 years. Discussion: Among aging women over 20 years, smoking is associated with worse physical function, including death, while moderate alcohol use is associated with better outcomes.

The Ability of a Single BMD and Fracture History Assessment to Predict Fracture Over 25 Years in Postmenopausal Women: The Study of Osteoporotic Fractures

The ability of bone mineral density (BMD) and other risk factors to predict fracture risk is well-established for as long as 5 to 10 years. However, their value to predict risk over a longer term has not been directly studied. We investigated whether a single assessment of femoral neck BMD and fracture history can predict fracture risk over 20 to 25 years. We used data from the Study of Osteoporotic Fractures (SOF) that assessed BMD and risk factors in 7959 women age ≥67 (mean = 73.4) in 1988-1990. Follow-up for fractures continued for 25 years for hip fracture, and for 20 years for any nonvertebral fracture. Using age-adjusted proportional hazards models, we analyzed the relationships between a single baseline assessment of femoral neck BMD, fracture history and age, and 20-25-year fracture incidence. The 25-year cumulative incidence of hip fracture was 17.9%; 20-year incidence of any nonvertebral fracture was 46.2%. The 25-year hip fracture incidence was highest in those ≥80 years old (22.6%) compared to 13.9% in women aged <70 years. A single femoral neck BMD measurement strongly predicted long-term hip fracture risk to 25 years: 29.6% risk in the lowest BMD quartile versus 7.6% with the highest relative hazard (RH) = 4.9 (95% CI, 4.1 to 6.0). Femoral neck BMD predicted hip fracture with little degradation over time from RH/SD = 2.6 (2.2 to 3.0) for 0 to 5 years to RH/SD = 1.8 (1.4 to 2.4) for 20 to 25 years. Lifetime hip fracture risk was similar (∼30%) regardless of age from 67 to >80 years. History of hip fracture predicted hip fractures only slightly better than history of nonvertebral fracture (RH = 1.6 [95% CI, 1.1 to 2.2] versus RH = 1.4 [95% CI, 1.2 to 1.5], respectively). Fracture history remained strongly predictive up to 25 years. We conclude that a single BMD and fracture history assessment can predict fracture risk over 20 to 25 years. Long-term risk of hip fracture remains extremely high in the oldest age groups, supporting risk assessment and consideration of treatment even in the oldest, highest-risk women.© 2017 American Society for Bone and Mineral Research.

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.

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.

Weight Trajectory over 20 Years and Likelihood of Mild Cognitive Impairment or Dementia Among Older Women

OBJECTIVES

The association between weight change and cognition is controversial. We examined the association between 20-year weight change and cognitive function in late life.

DESIGN

Cohort study.

SETTING

Study of Osteoporotic Fractures (SOF).

PARTICIPANTS

One thousand two hundred eighty-nine older, community-dwelling women (mean baseline age 68 (65-81) and 88 (82-102) at cognitive testing).

MEASUREMENTS

Study of Osteoporotic Fractures participants had body weight measured repeatedly over 20 years (mean 8 weights). Adjudicated cognitive status was classified as normal (n = 775) or mild cognitive impairment (MCI)/dementia (n = 514) at Year 20. Logistic models were used to evaluate whether absolute weight change, rate of weight loss per year, presence of abrupt, unrecovered weight loss, and weight variability were associated with MCI or dementia.

RESULTS

Women with greater rate of weight loss over 20 years had increased chance of developing MCI or dementia. In age/education/clinic-adjusted "base" models, each 0.5 kg/yr decrease resulted in 30% increased odds of MCI/dementia (OR = 1.30 [95% CI: 1.14, 1.49]). After adjustment for age, education, clinic, depression, and walking speed, there was 17% (OR = 1.17 [95% CI: 1.02, 1.35]) increased odds of MCI/dementia for each 0.5 kg/yr decrease in weight. In base models, variability in weight was significant. Each 1% average deviation from each woman's predicted weight curve was associated with 11% increased odds of MCI/dementia (OR = 1.11 [95% CI: 1.04, 1.18]). The estimate was attenuated after full adjustment (OR = 1.06 [95% CI: 0.99, 1.14]). The presence of an abrupt weight decline was not associated with MCI/dementia.

CONCLUSIONS

Rate of weight loss over 20 years was associated with development of MCI or dementia in women surviving past 80 years, suggesting that nutritional status, social-environmental factors, and/or adipose tissue function and structure may affect cognitive function with aging.

Impact of Maternal Glucose and Gestational Weight Gain on Child Obesity over the First Decade of Life in Normal Birth Weight Infants

Objective To determine, among children with normal birth weight, if maternal hyperglycemia and weight gain independently increase childhood obesity risk in a very large diverse population. Methods Study population was 24,141 individuals (mothers and their normal birth weight offspring, born 1995-2003) among a diverse population with universal GDM screening [50-g glucose-challenge test (GCT); 3 h. 100 g oral glucose tolerance test (OGTT) if GCT+]. Among the 13,037 full-term offspring with normal birth weight (2500-4000 g), annual measured height/weight was ascertained between ages 2 and 10 years to calculate gender-specific BMI-for-age percentiles using USA norms (1960-1995 standard). Results Among children who began life with normal birth weight, we found a significant trend for developing both childhood overweight (>85 %ile) and obesity (>95 %ile) during the first decade of life with both maternal hyperglycemia (normal GCT, GCT+ but no GDM, GDM) and excessive gestational weight gain [>40 pounds (18.1 kg)]; p < 0.0001 for both trends. These maternal glucose and/or weight gain effects to imprint for childhood obesity in the first decade remained after adjustment for potential confounders including maternal age, parity, as well as pre-pregnancy BMI. The attributable risk (%) for childhood obesity was 28.5 % (95 % CI 15.9-41.1) for GDM and 16.4 % (95 % CI 9.4-23.2) for excessive gestational weight gain. Conclusions for Practice Both maternal hyperglycemia and excessive weight gain have independent effects to increase childhood obesity risk. Future research should focus on prevention efforts during pregnancy as a potential window of opportunity to reduce childhood obesity.

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.

Lifetime trauma, personality traits, and health: A pathway to midlife health status

OBJECTIVE

This study investigated whether lifetime experience of trauma is related to personality through instrumental and reactive trait processes, and whether lifetime trauma is a mechanism underlying the association between childhood conscientiousness and objectively assessed adult physical health.

METHOD

Participants (N = 831) were 442 women and 389 men from the Hawaii longitudinal study of personality and health. Teacher assessments of personality were obtained when the participants were in elementary school. Self-reported adult personality assessments, lifetime histories of trauma experience, and objectively assessed physiological dysregulation were obtained between ages 45-55.

RESULTS

Women tended to report more high-betrayal trauma than men, whereas men reported more low-betrayal trauma than women. Women who were judged by their teachers to be less agreeable and less conscientious in childhood reported more lifetime trauma, suggesting instrumental trait processes. For both genders, neuroticism and openness/intellect/imagination in adulthood, but not in childhood, were associated with lifetime trauma, suggesting reactive trait processes. For both genders, trauma experience was correlated with dysregulation and with Body Mass Index (BMI). The indirect paths from childhood conscientiousness to adult dysregulation and BMI through total teen and adult trauma were significant for women, but not for men (indirect effect for women's dysregulation = -.025, p = .040, 95% confidence interval [CI] = -.048, -.001; indirect effect for women's BMI = -.037, p = .009, 95% CI = -.067, -.008).

CONCLUSION

Teen and adult trauma experience appears to be a hitherto unidentified mechanism in women underlying the association between conscientiousness and health. (PsycINFO Database Record

Measures of Sleep-Wake Patterns and Risk of Mild Cognitive Impairment or Dementia in Older Women

OBJECTIVE

Sleep disturbances are common in older adults. Little is known about the sleep of cognitively intact older adults and its relationship to subsequent cognitive impairment. The objective of this study was to examine the association between objective sleep-wake measures and risk of incident cognitive impairment.

METHODS

In this prospective cohort study encompassing four U.S. sites, 1,245 women (mean age: 82.6 years) without dementia participated in the Study of Osteoporotic Fractures and completed actigraphy at the baseline visit and comprehensive cognitive assessment at follow-up. The association between sleep-wake patterns measured by actigraphy and risk of incident mild cognitive impairment (MCI) and dementia was examined.

RESULTS

A total of 473 women (38%) developed cognitive impairment during an average (SD) follow-up of 4.9 (0.6) years; 290 (23.3%) developed MCI and 183 (14.7%) developed dementia. After controlling for multiple potential confounders, women in the lowest quartile of average sleep efficiency (<74%) had a 1.5-fold higher odds of developing MCI or dementia compared with women in the highest quartile of sleep efficiency (>86%) (odds ratio: Q1 versus Q4 1.53; 95% CI: 1.07, 2.19; Wald χ(2) [1, N = 1,223] = 5.34 for p for trend = 0.03). Longer average sleep latency, but not total sleep time, was also associated with higher odds of developing cognitive impairment. Greater variability in both sleep efficiency and total sleep time was associated with an increased odds of developing MCI or dementia.

CONCLUSION

Lower average sleep efficiency, longer average sleep latency, and greater variability in sleep efficiency and total sleep time are associated with increased odds of developing cognitive impairment. Further research is needed to explore the mechanisms underlying these associations.

Long-term Cognitive Trajectories and Mortality in Older Women

BACKGROUND

Few studies have examined whether change in cognition is linked to mortality. This study examined the relationship between cognitive trajectories in older age and risk of death.

METHODS

We studied community-dwelling, nondemented women aged 65+ (mean age = 71) enrolled in a prospective study of aging and followed up to 25 years. A modified Mini-Mental State Examination (mMMSE) and Trail Making Task Part B (TMTB) were administered at multiple visits during follow-up. We examined the association between cognitive trajectories (analyzed by quintiles) from baseline to age 80 (n = 7,477 for mMMSE and n = 6,503 for TMTB) and all-cause mortality after age 80 using Cox regression models, both unadjusted and adjusted for education, physical activity, alcohol, depression score, current smoking and history of hypertension and diabetes. Cause of death was determined from death certificates, classified as cardiovascular, cancer and other.

RESULTS

Women with greater rate of decline were older, less educated, less physically active, had higher depression score and were more likely to have a history of hypertension and diabetes (all p < .01). Participants with the greatest decline (quintile 1) had an increased risk of death (mMMSE hazard ratio [HR] = 1.28; TMTB HR = 1.43] and those with the least decline (quintile 5) had a decreased risk of death (mMMSE HR = 0.73; TMTB HR = 0.61) compared with intermediate decliners (quintiles 2-4). Cognitive trajectories were associated with cardiovascular mortality and other causes of death, but not cancer deaths.

CONCLUSIONS

Our study suggests that greater decline in general cognition or executive function is associated with higher rates of mortality in oldest-old women.

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.

A Big Five approach to self-regulation: personality traits and health trajectories in the Hawaii longitudinal study of personality and health

Self-regulatory processes influencing health outcomes may have their origins in childhood personality traits. The Big Five approach to personality was used here to investigate the associations between childhood traits, trait-related regulatory processes and changes in health across middle age. Participants (N = 1176) were members of the Hawaii longitudinal study of personality and health. Teacher assessments of the participants' traits when they were in elementary school were related to trajectories of self-rated health measured on 6 occasions over 14 years in middle age. Five trajectories of self-rated health were identified by latent class growth analysis: Stable Excellent, Stable Very Good, Good, Decreasing and Poor. Childhood Conscientiousness was the only childhood trait to predict membership in the Decreasing class vs. the combined healthy classes (Stable Excellent, Stable Very Good and Good), even after controlling for adult Conscientiousness and the other adult Big Five traits. The Decreasing class had poorer objectively assessed clinical health measured on one occasion in middle age, was less well-educated, and had a history of more lifespan health-damaging behaviors compared to the combined healthy classes. These findings suggest that higher levels of childhood Conscientiousness (i.e. greater self-discipline and goal-directedness) may prevent subsequent health decline decades later through self-regulatory processes involving the acquisition of lifelong healthful behavior patterns and higher educational attainment.

Age-related macular degeneration and mortality in older women: the study of osteoporotic fractures

OBJECTIVES

To examine the association between age-related macular degeneration (AMD) and all-cause and cause-specific mortality in a population of older women.

DESIGN

Prospective cohort study.

SETTING

Four U.S. clinical centers.

PARTICIPANTS

A random sample of 1,202 women with graded fundus photographs at the Year 10 visit of the Study of Osteoporotic Fractures (mean age 79.5).

MEASUREMENTS

Forty-five-degree stereoscopic fundus photographs were graded for presence and severity (early vs late) of AMD. Vital status was adjudicated from death certificates. Cox proportional hazards models, adjusted for appropriate confounders, were used to estimate mortality hazards ratios.

RESULTS

Prevalence of any AMD was 40.5% at baseline, with 441 (36.7%) having early AMD and 46 (3.8%) having late AMD. Cumulative mortality was 51.6% over 15 years of follow-up. Overall, there was no significant association between AMD presence or severity and all-cause or cause-specific mortality. Because there was a significant interaction between AMD and age in predicting mortality (P<.05 for each mortality type), analyses were stratified according to age group. In women younger than 80, after adjusting for covariates, late AMD was associated with cardiovascular disease (CVD) mortality (hazard ratio (HR)=2.61, 95% confidence interval (CI)=1.05-6.46). In women aged 80 and older, early AMD was associated with all-cause (HR=1.39, 95% CI=1.11-1.75) and non-CVD, noncancer (HR=1.45, 95% CI=1.05-2.00) mortality. Any AMD was associated with all-cause (HR=1.42, 95% CI=1.13-1.78) and CVD (HR=1.45, 95% CI=1.01-2.09) mortality in women aged 80 and older.

CONCLUSION

AMD is a predictor of poorer survival in women, especially those aged 80 and older. Determination of shared risk factors may identify novel pathways for intervention that may reduce the risk of both conditions.

A life-span behavioral mechanism relating childhood conscientiousness to adult clinical health

OBJECTIVE

To investigate a life-span health-behavior mechanism relating childhood personality to adult clinical health.

METHODS

Childhood Big Five personality traits at mean age 10, adult Big Five personality traits, adult clinically assessed dysregulation at mean age 51 (a summary of dysregulated blood glucose, blood pressure, and lipids), and a retrospective, cumulative measure of life-span health-damaging behavior (lifetime smoking, physical inactivity, and body mass index from age 20) were assessed in the Hawaii Personality and Health Cohort (N = 759). Structural equation modeling was used to test the conceptual model with direct and indirect paths from a childhood Conscientiousness factor to an adult Conscientiousness factor, life-span health-damaging behaviors, educational attainment, adult cognitive ability, and adult clinical health.

RESULTS

For both men and women, childhood Conscientiousness influenced health-damaging behaviors through educational attainment, and life-span health-damaging behaviors predicted dysregulation. Childhood Conscientiousness predicted adult Conscientiousness, which did not predict any other variables in the model. For men, childhood Conscientiousness predicted dysregulation through educational attainment and health-damaging behaviors. For women, childhood Conscientiousness predicted dysregulation through educational attainment and adult cognitive ability.

CONCLUSIONS

Assessing cumulative life-span health behaviors is a novel approach to the study of health-behavior mechanisms. Childhood Conscientiousness appears to influence health assessed more than 40 years later through complex processes involving educational attainment, cognitive ability, and the accumulated effects of health behaviors, but not adult Conscientiousness.

Hyperkyphosis, kyphosis progression, and risk of non-spine fractures in older community dwelling women: the study of osteoporotic fractures (SOF)

While accentuated kyphosis is associated with osteoporosis, it is unknown whether it increases risk of future fractures, independent of bone mineral density (BMD) and vertebral fractures. We examined the associations of baseline Cobb angle kyphosis and 15 year change in kyphosis with incident non-spine fractures using data from the Study of Osteoporotic Fractures. A total of 994 predominantly white women, aged 65 or older, were randomly sampled from 9704 original participants to have repeated Cobb angle measurements of kyphosis measured from lateral spine radiographs at baseline and an average of 15 years later. Non-spine fractures, confirmed by radiographic report, were assessed every 4 months for up to 21.3 years. Compared with women in the lower three quartiles of kyphosis, women with kyphosis greater than 53° (top quartile) had a 50% increased risk of non-spine fracture (95% CI, 1.10-2.06 after adjusting for BMD, prevalent vertebral fractures, prior history of fractures, and other fracture risk factors. Cobb angle kyphosis progressed an average of 7° (SD = 6.8) over 15 years. Per 1 SD increase in kyphosis change, there was a multivariable adjusted 28% increased risk of fracture (95% CI, 1.06-1.55) that was attenuated by further adjustment for baseline BMD (HR per SD increase in kyphosis change, 1.19; 95% CI 0.99-1.44). Greater kyphosis is associated with an elevated non-spine fracture risk independent of traditional fracture risk factors in older women. Furthermore, worsening kyphosis is also associated with increased fracture risk that is partially mediated by low baseline BMD that itself is a risk factor for kyphosis progression. These results suggest that randomized controlled fracture intervention trials should consider implementing kyphosis measures to the following: (1) further study kyphosis and kyphosis change as an additional fracture risk factor; and (2) test whether therapies may improve or delay its progression.

Inflammatory markers and risk of hip fracture in older white women: the study of osteoporotic fractures

Hip fractures are the most devastating consequence of osteoporosis and impact 1 in 6 white women leading to a two- to threefold increased mortality risk in the first year. Despite evidence of inflammatory markers in the pathogenesis of osteoporosis, few studies have examined their effect on hip fracture. To determine if high levels of inflammation increase hip fracture risk and to explore mediation pathways, a case-cohort design nested in a cohort of 4709 white women from the Study of Osteoporotic Fractures was used. A random sample of 1171 women was selected as the subcohort (mean age 80.1 ± 4.2 years) plus the first 300 women with incident hip fracture. Inflammatory markers interleukin-6 (IL-6) and soluble receptors (SR) for IL-6 (IL-6 SR) and tumor necrosis factor (TNF SR1 and TNF SR2) were measured, and participants were followed for a median (interquartile range) of 6.3 (3.7, 6.9) years. In multivariable models, the hazard ratio (HR) of hip fracture for women in the highest inflammatory marker level (quartile 4) was 1.64 (95% confidence interval [CI], 1.09-2.48, p trend = 0.03) for IL-6 and 2.05 (95% CI, 1.35-3.12, p trend <0.01) for TNF SR1 when compared with women in the lowest level (quartile 1). Among women with 2 and 3-4 inflammatory markers in the highest quartile, the HR of hip fracture was 1.51 (95% CI, 1.07-2.14) and 1.42 (95% CI, 0.87-2.31) compared with women with zero to one marker(s) in the highest quartile (p trend = 0.03). After individually adjusting for seven potential mediators, cystatin-C (a biomarker of renal function) and bone mineral density (BMD) attenuated HRs among women with the highest inflammatory burden by 64% and 50%, respectively, suggesting a potential mediating role. Older white women with high inflammatory burden are at increased risk of hip fracture in part due to poor renal function and low BMD.

Does change in the neighborhood environment prevent obesity in older women?

Neighborhood environment is consistently associated with obesity; changes to modifiable aspects of the neighborhood environment may curb the growth of obesity in the US and other developed nations. However, currently the majority of studies are cross-sectional and thus not appropriate for evaluating causality. The goal of this study was to evaluate the effect of a neighborhood-changing intervention on changes in obesity among older women. Over the past 30 years the Portland, Oregon metropolitan region has made significant investments in plans, regulatory structures, and public facilities to reduce sprawl and increase compact growth centers, transit-oriented development approaches, and green space. We used geocoded residential addresses to link data on land-use mix, public transit access, street connectivity, and access to green space from four time points between 1986 and 2004, with longitudinal data on body mass index (BMI) from a cohort of 2003 community-dwelling women aged 66 years and older. Height and weight were measured at clinic visits. Women self-reported demographics, health habits, and chronic conditions, and self-rated their health. Neighborhood socioeconomic status was assessed from census data. Neighborhood walkability and access to green space improved over the 18-year study period. On average there was a non-significant mean weight loss in the cohort between baseline (mean age 72.6 years) and the study's end (mean age 85.0 years). We observed no association between neighborhood built environment or change in built environment and BMI. Greater neighborhood socioeconomic status at baseline was independently associated with a healthier BMI at baseline, and protected against an age-related decline in BMI over time. BMI decreases with age reflect increased frailty, especially among older adults with complex morbidities. Future research should consider the influence of the neighborhood environment on additional relevant health outcomes and should include measures of the social environment in conjunction with built environment measures.

Long-term cognitive and functional effects of potentially inappropriate medications in older women

BACKGROUND

The use of potentially inappropriate medications in older adults can lead to known adverse drug events, but long-term effects are less clear. We therefore conducted a prospective cohort study of older women to determine whether PIM use is associated with risk of functional impairment or low cognitive performance.

METHODS

We followed up 1,429 community-dwelling women (≥ 75 years) for a period of 5 years at four clinical sites in the United States. The primary predictor at baseline was PIM use based on 2003 Beers Criteria. We also assessed anticholinergic load using the Anticholinergic Cognitive Burden scale. Outcomes included scores on a battery of six cognitive tests at follow-up and having one or more incident impairments in instrumental activities of daily living. Regression models were adjusted for baseline age, race, education, smoking, physical activity, a modified Charlson Comorbidity Index, and cognitive score.

RESULTS

The mean ± SD age of women at baseline was 83.2 ± 3.3. In multivariate models, baseline PIM use and higher ACB scores were significantly associated with poorer performance in category fluency (PIM: p = .01; ACB: p = .02) and immediate (PIM: p = .04; ACB: p = .03) and delayed recall (PIM: p = .04). Both PIM use (odds ratio [OR]: 1.36 [1.05-1.75]) and higher ACB scores (OR: 1.11 [1.04-1.19]) were also strongly associated with incident functional impairment.

CONCLUSIONS

The results provide suggestive evidence that PIM use and increased anticholinergic load may be associated with risk of functional impairment and low cognitive performance. More cautious selection of medications in older adults may reduce these potential risks.

Changes in physical performance in older women according to presence and treatment of diabetes mellitus

OBJECTIVES

To determine whether older women with diabetes mellitus have a greater longitudinal decline in physical performance than those without and whether any decline differs according to insulin sensitizer use.

DESIGN

Prospective cohort study.

SETTING

Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela, Pennsylvania.

PARTICIPANTS

Community-dwelling women (mean age 78.5 ± 3.6) enrolled in the Study of Osteoporotic Fractures in 1997-98 and restudied 4.9 ± 0.6 years later (N = 2,864).

MEASUREMENTS

Women were categorized as having no diabetes mellitus (n = 2,680) or having diabetes mellitus (n = 184). A prescription medication inventory was used to determine use of insulin sensitizers (metformin and thiazolidinedione). The outcomes were longitudinal changes in physical performance measures, including grip strength, usual walk speed, and rapid walk speed.

RESULTS

Estimates from fully adjusted models showed that women with diabetes mellitus had greater declines in usual walk speed (-0.16 m/s, 95% confidence interval (CI) = -0.19 to -0.14) and rapid walk speed (-0.21 m/s, 95% CI = -0.24 to -0.17) than those without (usual walk speed -0.11 m/s, 95% CI = -0.12 to -0.11, P < .001; rapid walk speed -0.15 m/s, 95% CI = -0.16 to -0.14; P = .005). Women with diabetes mellitus taking insulin sensitizers had less decline in usual walk speed than those not taking insulin sensitizers (P < .001). Declines in grip strength did not differ significantly by diabetes mellitus status or insulin sensitizer use.

CONCLUSION

Older women with diabetes mellitus have a greater decline in walk speed, but not grip strength, than older women without diabetes mellitus. Clinical studies in older adults to determine whether diabetes mellitus treatments such as insulin sensitizers can prevent loss in walk speed and mobility are needed.

Cystatin C and risk of hip fractures in older women

To test the hypothesis that older women with higher cystatin C are at increased risk of hip fracture independent of traditional risk factors including hip bone mineral density (BMD), we performed a case-cohort analysis nested in a cohort of 4709 white women attending a Year 10 (1997-1998) examination of the Study of Osteoporotic Fractures that included a random sample of 1170 women and the first 300 women with incident hip fracture occurring after Year 10 examination. Serum cystatin C and creatinine were measured in Year 10 sera. In a model adjusted for age, clinical site, body mass index, and total hip BMD, higher cystatin C was associated with an increased risk of hip fracture (p for linear trend 0.008) with women in quartile 4 having a 1.9-fold higher risk (hazard ratio [HR] 1.91; 95% confidence interval [CI], 1.24-2.95) compared with those in quartile 1 (referent group). Further adjustment for additional risk factors only slightly attenuated the association; the risk for hip fracture was 1.7-fold higher (HR 1.74; 95% CI, 1.11-2.72) in women in quartile 4 compared with those in quartile 1. In contrast, neither serum creatinine nor creatinine-based estimated glomerular filtration rate (eGFRCr ) were associated with risk of hip fracture. Older women with higher cystatin C, but not higher serum creatinine or lower eGFRCr , have an increased risk of hip fracture independent of traditional risk factors. These findings suggest that cystatin C may be a promising biomarker for identification of older adults at high risk of hip fracture.

Childhood conscientiousness relates to objectively measured adult physical health four decades later

OBJECTIVE

Many life span personality-and-health models assume that childhood personality traits result in life-course pathways leading through morbidity to mortality. Although childhood conscientiousness in particular predicts mortality, there are few prospective studies that have investigated the associations between childhood personality and objective health status in adulthood. The present study tested this crucial assumption of life span models of personality and health using a comprehensive assessment of the Big Five traits in childhood (M age = 10 years) and biomarkers of health over 40 years later (M age = 51 years).

METHODS

Members of the Hawaii Personality and Health Cohort (N = 753; 368 men, 385 women) underwent a medical examination at mean age 51. Their global health status was evaluated by well-established clinical indicators that were objectively measured using standard protocols, including blood pressure, lipid profile, fasting blood glucose, and body mass index. These indicators were combined to evaluate overall physiological dysregulation and grouped into five more homogeneous subcomponents (glucose intolerance, blood pressure, lipids, obesity, and medications).

RESULTS

Lower levels of childhood conscientiousness predicted more physiological dysregulation (β = -.11, p < .05), greater obesity (β = -.10, p < .05), and worse lipid profiles (β = -.10, p < .05), after controlling for the other Big Five childhood personality traits, gender, ethnicity, parental home ownership, and adult conscientiousness.

CONCLUSIONS

These findings are consistent with a key assumption in life span models that childhood conscientiousness is associated with objective health status in older adults. They open the way for testing mechanisms by which childhood personality may influence mortality through morbidity; mechanisms that could then be targeted for intervention.

Ten-year trajectory of potentially inappropriate medications in very old women: importance of cognitive status

OBJECTIVES

To determine which older adults tend to receive potentially inappropriate medications (PIMs), how this may differ according to cognitive status, and how the trajectories of PIM use change over time.

DESIGN

Ten-year longitudinal cohort study.

SETTING

Three clinical sites in the United States.

PARTICIPANTS

One thousand four hundred eighty-four community-dwelling women aged 75 and older.

MEASUREMENTS

At follow-up, cognitive status was ascertained and classified as normal, mild cognitive impairment (MCI), or dementia. Beers 2003 criteria and other literature were used to identify PIMs from detailed medication inventory performed at three time points. Anticholinergic load was measured using the Anticholinergic Cognitive Burden Scale (ACB), which assigns medications a value from 0 to 3 depending on anticholinergic properties.

RESULTS

At baseline, 23.9% of women were taking at least one PIM and the mean ± SD ACB score was 1.41 ± 1.69. The most frequently reported PIMs were anticholinergics (15.2%), benzodiazepines (8.6%), and antispasmodics (8.0%). Over 10 years, PIM use increased for women with dementia (24.9-33.1%; P = .02) but remained fairly constant for women with MCI (23.9-23.0%; P = .84) and normal cognitive status (22.2-19.8%; P = .17). Mean ACB score increased significantly (P < .001) over time for all groups (dementia: 1.28-2.05; MCI: 0.98-1.66; normal: 0.99-1.48).

CONCLUSION

PIM use and anticholinergic load in a community-dwelling population of older women was high, especially in women who later developed dementia. Future guidelines should limit PIM use and seek safer alternatives.

Factors associated with kyphosis progression in older women: 15 years' experience in the study of osteoporotic fractures

Age-related hyperkyphosis is thought to be a result of underlying vertebral fractures, but studies suggest that among the most hyperkyphotic women, only one in three have underlying radiographic vertebral fractures. Although commonly observed, there is no widely accepted definition of hyperkyphosis in older persons, and other than vertebral fracture, no major causes have been identified. To identify important correlates of kyphosis and risk factors for its progression over time, we conducted a 15-year retrospective cohort study of 1196 women, aged 65 years and older at baseline (1986 to 1988), from four communities across the United States: Baltimore County, MD; Minneapolis, MN; Portland, OR; and the Monongahela Valley, PA. Cobb angle kyphosis was measured from radiographs obtained at baseline and an average of 3.7 and 15 years later. Repeated measures, mixed effects analyses were performed. At baseline, the mean kyphosis angle was 44.7 degrees (SE = 0.4, SD = 11.9) and significant correlates included a family history of hyperkyphosis, prevalent vertebral fracture, low bone mineral density, greater body weight, degenerative disc disease, and smoking. Over an average of 15 years, the mean increase in kyphosis was 7.1 degrees (SE = 0.25). Independent determinants of greater kyphosis progression were prevalent and incident vertebral fractures, low bone mineral density and concurrent bone density loss, low body weight, and concurrent weight loss. Thus, age-related kyphosis progression may be best prevented by slowing bone density loss and avoiding weight loss.

Diabetes and change in bone mineral density at the hip, calcaneus, spine, and radius in older women

Older women with type 2 diabetes mellitus (DM) have higher bone mineral density (BMD) but also have higher rates of fracture compared to those without DM. Limited evidence suggests that DM may also be associated with more rapid bone loss. To determine if bone loss rates differ by DM status in older women, we analyzed BMD data in the Study of Osteoporotic Fractures (SOF) between 1986 and 1998. SOF participants were women ≥65 years at baseline who were recruited from four regions in the U.S. DM was ascertained by self-report. BMD was measured with dual-energy x-ray absorptiometry (DXA) at baseline and at least one follow-up visit at the hip (N = 6624) and calcaneus (N = 6700) and, on a subset of women, at the spine (N = 396) and distal radius (N = 306). Annualized percent change in BMD was compared by DM status, using random effects models. Of 6,867 women with at least one follow-up DXA scan, 409 had DM at baseline. Mean age was 70.8 (SD 4.7) years. Baseline BMD was higher in women with DM at all measured sites. In models adjusted for age and clinic, women with prevalent DM lost bone more rapidly than those without DM at the femoral neck (-0.96 vs. -0.59%/year, p < 0.001), total hip (-0.98 vs. -0.70%/year, p < 0.001), calcaneus (-1.64 vs. -1.40%/year, p = 0.005), and spine (-0.33 vs. +0.33%/year, p = 0.033), but not at the distal radius (-0.97 vs. -0.90%/year, p = 0.91). These findings suggest that despite higher baseline BMD, older women with DM experience more rapid bone loss than those without DM at the hip, spine, and calcaneus, but not the radius. Higher rates of bone loss may partially explain higher fracture rates in older women with DM.

Twenty-year depressive trajectories among older women

CONTEXT

Despite the frequent occurrence of depressive symptoms among older adults, especially women, little is known about the long-term course of late-life depressive symptoms.

OBJECTIVE

To characterize the natural course of depressive symptoms among older women (from the young old to the oldest old) followed up for almost 20 years.

DESIGN

Using latent-class growth-curve analysis, we analyzed women enrolled in an ongoing prospective cohort study (1988 through 2009).

SETTING

Clinic sites in Baltimore, Maryland; Minneapolis, Minnesota; the Monongahela Valley near Pittsburgh, Pennsylvania; and Portland, Oregon.

PARTICIPANTS

We studied 7240 community-dwelling women 65 years or older.

MAIN OUTCOME MEASURE

The Geriatric Depression Scale short form (score range, 0-15) was used to routinely assess depressive symptoms during the follow-up period.

RESULTS

Among older women, we identified 4 latent classes during 20 years, with the predicted probabilities of group membership totaling 27.8% with minimal depressive symptoms, 54.0% with persistently low depressive symptoms, 14.8% with increasing depressive symptoms, and 3.4% with persistently high depressive symptoms. In an adjusted model for latent class membership, odds ratios (ORs) for belonging in the increasing depressive symptoms and persistently high depressive symptoms classes, respectively, compared with a group having minimal depressive symptoms were substantially and significantly (P < .05) elevated for the following variables: baseline smoking (ORs, 4.69 and 7.97), physical inactivity (ORs, 2.11 and 2.78), small social network (ORs, 3.24 and 6.75), physical impairment (ORs, 8.11 and 16.43), myocardial infarction (ORs, 2.09 and 2.41), diabetes mellitus (ORs, 2.98 and 3.03), and obesity (ORs, 1.86 and 2.90).

CONCLUSIONS

During 20 years, almost 20% of older women experienced persistently high depressive symptoms or increasing depressive symptoms. In addition, these women had more comorbidities, physical impairment, and negative lifestyle factors at baseline. These associations support the need for intervention and prevention strategies to reduce depressive symptoms into the oldest-old years.

Hip pain while using lower extremity joints and sleep disturbances in elderly white women: results from a cross-sectional analysis

OBJECTIVE

To evaluate sleep quality in women with hip pain due to daily activities involving the lower extremity joints.

METHODS

We evaluated the association of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) hip pain severity score with objective sleep measures obtained by wrist actigraphy in 2,225 white women ≥ 65 years of age enrolled in the Study of Osteoporotic Fractures.

RESULTS

Women had an increased odds of spending ≥ 90 minutes awake after sleep onset (odds ratio [OR] 1.28, 95% confidence interval [95% CI] 1.11-1.50) for every 5-point increase in hip pain score after adjustment for all covariates. Hip pain when sitting or lying was the strongest predictor of sleep fragmentation (OR 2.0, 95% CI 1.47-2.73); however, standing pain was associated with a higher number of awake minutes in bed scored from sleep onset to the end of the last sleep episode, independent of pain while in bed (OR 1.41, 95% CI 1.07-2.01). Sleep disturbances increased significantly after the first 2 hours of sleep in women with severe hip pain compared to those without hip pain (mean ± SD 1.4 ± 0.47 minutes per hour of sleep; P < 0.003). Similar associations were observed for long wake episodes >5 minutes. There were no associations between daytime napping, sleep latency, sleep efficiency, and total sleep minutes and WOMAC hip pain.

CONCLUSION

Fragmented sleep was greater in women with hip pain compared to those without hip pain; however, fragmented sleep in women with severe hip pain compared to those without hip pain was unchanged until after the first 2 hours of sleep. Further investigations into pain medications wearing off over time or the prolonged periods of inactivity decreasing the pain threshold are warranted.

Associations between 25-hydroxyvitamin D and weight gain in elderly women

BACKGROUND

25-Hydroxyvitamin D [25(OH)D] levels are lower in obese individuals. Determining whether low vitamin D status can predispose weight gain requires a longitudinal study.

METHODS

From a community-based multicenter U.S. prospective cohort of 9704 (Study of Osteoporotic Fractures [SOF]), 4659 women aged ≥65 with baseline 25(OH)D measurement were followed for 4.5 years. They were weighed at baseline and follow-up visits, and a subset (n=1054) had 25(OH)D levels remeasured at follow-up.

RESULTS

Women with 25(OH)D levels ≥30 ng/mL had lower baseline weight (141.6 pounds) compared to women with 25(OH)D levels <30 ng/mL (148.6 pounds) (p<0.001). Overall, 25(OH)D status was not associated with weight change over 4.5 years, although there was a significant interaction between 25(OH)D status and weight change category (loss, gain, stable) (p<0.0001). In women who gained ≥5% weight, those with baseline 25(OH)D levels ≥30 ng/mL gained 16.4 pounds (12.2% of baseline weight) over 4.5 years compared to 18.5 pounds (13.9% of baseline weight) in women with levels <30 ng/mL (p=0.04). In women who lost ≥5% weight or remained stable (<5% weight change), there was no association between 25(OH)D status at baseline and weight change. Among women who gained weight and had 25(OH)D measured at both visits, having sustained or developing 25(OH)D levels ≥30 ng/mL was associated with less weight gain between visits (14.81 vs. 16.34 pounds, p=0.04).

CONCLUSIONS

Higher 25(OH)D levels are associated with lower weight gains, suggesting low vitamin D status may predispose to fat accumulation.

Poor sleep quality and functional decline in older women

OBJECTIVES

To determine whether objectively measured sleep quality predicts 5-year incident instrumental activity of daily living (IADL) impairment and decline in grip strength and gait speed in older women.

DESIGN

Prospective cohort.

SETTING

Participants' homes, Study of Osteoporotic Fractures sites.

PARTICIPANTS

Eight hundred seventeen women with a mean age of 82.4 at baseline.

MEASUREMENTS

Participants completed 4.1 ± 0.7 nights of wrist actigraphy at baseline and measures of IADL impairment, grip strength, and gait speed at baseline and 5-year follow-up.

RESULTS

After 5 years of follow-up, approximately 41% of participants had incident impairment in one or more IADLs. The quartile of women with the shortest total sleep time (TST) had 93% greater odds of incident IADL impairment than the longest sleepers (adjusted odds ratio (AOR) = 1.93, 95% confidence interval (CI) = 1.25-2.97). Similarly, the quartile of women with the lowest sleep efficiency (SE) had 65% greater odds of impairment than those with the highest (AOR = 1.65, 95% CI = 1.06-2.57). Women in the shortest TST quartile had twice the odds of declining grip strength as those with the longest TST (AOR = 1.97, 95% CI = 1.17-3.32). Finally, women in the quartiles with the most wake after sleep onset (WASO) and the lowest SE had approximately 90% greater odds of grip strength decline than those with the least WASO (AOR = 1.90, 95% CI = 1.11-3.24) and SE (AOR = 1.92, 95% CI = 1.12-3.29).

CONCLUSION

Findings indicate that shorter sleep duration, greater WASO, and lower SE are risk factors for functional or physical decline in older women.

Surgical menopause and nonvertebral fracture risk among older US women

OBJECTIVE

The aim of this study was to determine whether older postmenopausal women with a history of bilateral oophorectomy before natural menopause (surgical menopause) have a higher risk of nonvertebral postmenopausal fracture than women with natural menopause.

METHODS

We used 21 years of prospectively collected incident fracture data from the ongoing Study of Osteoporotic Fractures, a cohort study of community-dwelling women without previous bilateral hip fracture who were 65 years or older at enrollment, to determine the risk of hip, wrist, and any nonvertebral fracture. χ(2) and t tests were used to compare the two groups on important characteristics. Multivariable Cox proportional hazards regression models stratified by baseline oral estrogen use status were used to estimate the risk of fracture.

RESULTS

Baseline characteristics differed significantly among the 6,616 women within the Study of Osteoporotic Fractures who underwent either surgical (1,157) or natural (5,459) menopause, including mean age at menopause (44.3 ± 7.4 vs 48.9 ± 4.9 y, P < 0.001) and current use of oral estrogen (30.2% vs 6.5%, P < 0.001). Fracture rates were not significantly increased for surgical versus natural menopause, even among women who had never used oral estrogen (hip fracture: hazard ratio [HR], 0.87; 95% CI, 0.63-1.21; wrist fracture: HR, 1.10; 95% CI, 0.78-1.57; any nonvertebral fracture: HR, 1.11; 95% CI, 0.93-1.32).

CONCLUSIONS

These data provide some reassurance that the long-term risk of nonvertebral fracture is not substantially increased for postmenopausal women who experienced premenopausal bilateral oophorectomy, compared with postmenopausal women with intact ovaries, even in the absence of postmenopausal estrogen therapy.

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.

Height loss in older women: risk of hip fracture and mortality independent of vertebral fractures

We examined if height loss in older women predicts risk of hip fractures, other nonspine fractures, and mortality, and whether this risk is independent of both vertebral fractures (VFx) and bone mineral density (BMD) by dual-energy X-ray absorptiometry. Among 3124 women age 65 and older in the Study of Osteoporotic Fractures, we assessed the association with measured height change between year 0 (1986-1988) and year 15 (2002-2004) and subsequent risk of radiologically confirmed hip fractures, other nonspine fractures, and mortality assessed via death certificates. Follow-up occurred every 4 months for fractures and vital status (>95% contacts complete). Cox proportional hazards models assessed risk of hip fracture, nonspine fracture, and mortality over a mean of 5 years after height change was assessed (ie, after final height measurement). After adjustment for VFx, BMD, and other potential covariates, height loss >5 cm was associated with a marked increased risk of hip fracture [hazard ratio (HR) 1.50, 95% confidence interval (CI) 1.06, 2.12], nonspine fracture (HR 1.48; 95% CI 1.20, 1.83), and mortality (1.45; 95% CI 1.21, 1.73). Although primary analyses were a subset of 3124 survivors healthy enough to return for a year 15 height measurement, a sensitivity analysis in the entire cohort (n = 9677) using initial height in earlier adulthood [self-reported height at age 25 (-40 years) to measured height age >65 years (Year 0)] demonstrated consistent results. Height loss >5 cm (2″) in older women was associated with a nearly 50% increased risk of hip fracture, nonspine fracture, and mortality-independent of incident VFx and BMD.

Hip fracture and increased short-term but not long-term mortality in healthy older women

BACKGROUND

Fractures have been associated with subsequent increases in mortality, but it is unknown how long that increase persists.

METHODS

A total of 5580 women from a large community-based, multicenter US prospective cohort of 9704 (Study of Osteoporotic Fractures) were observed prospectively for almost 20 years. We age-matched 1116 hip fracture cases with 4 control participants (n = 4464). To examine the effect of health status, we examined a healthy older subset (n = 960) 80 years or older who attended the 10-year follow-up examination and reported good or excellent health. Incident hip fractures were adjudicated from radiology reports by study physicians. Death was confirmed by death certificates.

RESULTS

Hip fracture cases had 2-fold increased mortality in the year after fracture compared with controls (16.9% vs 8.4%; multivariable adjusted odds ratio [OR], 2.4; 95% CI, 1.9-3.1]. When examined by age and health status, short-term mortality was increased in those aged 65 to 69 years (16.3% vs 3.7%; OR, 5.0; 95% CI, 2.6-9.5), 70 to 79 years (16.5% vs 8.9%; OR, 2.4; 95% CI, 1.8-3.3), and only in those 80 years or older with good or excellent health (15.1% vs 7.2%; multivariable adjusted OR, 2.8; 95% CI, 1.5-5.2). After the first year, survival of hip fracture cases and controls was similar except in those aged 65 to 69 years, who continued to have increased mortality.

CONCLUSIONS

Short-term mortality is increased after hip fracture in women aged 65 to 79 years and in exceptionally healthy women 80 years or older. Women 70 years or older return to previous risk levels after a year. Interventions are needed to decrease mortality in the year after hip fracture, when mortality risk is highest.

Risk factors for nonvertebral fracture in obese older women

CONTEXT

A high prevalence of obesity has recently been reported in postmenopausal women with low trauma fracture, suggesting that higher bone mineral density (BMD) in obese individuals may not be protective against fracture.

OBJECTIVE

The aim of this study was to compare BMD and other risk factors for nonvertebral fracture in 1377 obese postmenopausal women.

DESIGN

Characteristics of obese women with and without incident nonvertebral fracture were investigated among the prospective cohort in the Study of Osteoporotic Fractures.

SETTING

The Study of Osteoporotic Fractures is a multicenter study of 9704 women (>99% Caucasian) aged 65 yr and over who were recruited between September 1986 and October 1988 from population-based listings at four U.S. clinical centers.

MAIN OUTCOME MEASURE

The main outcome measure was nonvertebral fracture.

RESULTS

BMD T-scores in the spine, femoral neck, and total hip were significantly lower in obese women who experienced fractures than in obese women without fracture: mean differences, -0.56 [95% confidence interval (CI) = -0.73 to -0.39], -0.46 (95% CI = -0.57 to -0.36), and -0.51 (95% CI = -0.62 to -0.39), respectively (P < 0.0001 for all). A previous history of fracture [odds ratio = 1.69 (95% CI = 1.33-2.14); P < 0.0001] and femoral neck BMD [1.62 (95% CI = 1.42-1.85) per sd decrease in BMD; P < 0.0001] were independently associated with incident nonvertebral fracture.

CONCLUSIONS

Obese postmenopausal women who sustain nonvertebral fractures have significantly lower BMD on average than obese women without fracture and are more likely to have a past history of fracture. Fractures in obese postmenopausal women thus exhibit some characteristics of fragility fractures.

WHO absolute fracture risk models (FRAX): do clinical risk factors improve fracture prediction in older women without osteoporosis?

Bone mineral density (BMD) is a strong predictor of fracture, yet most fractures occur in women without osteoporosis by BMD criteria. To improve fracture risk prediction, the World Health Organization recently developed a country-specific fracture risk index of clinical risk factors (FRAX) that estimates 10-year probabilities of hip and major osteoporotic fracture. Within differing baseline BMD categories, we evaluated 6252 women aged 65 or older in the Study of Osteoporotic Fractures using FRAX 10-year probabilities of hip and major osteoporotic fracture (ie, hip, clinical spine, wrist, and humerus) compared with incidence of fractures over 10 years of follow-up. Overall ability of FRAX to predict fracture risk based on initial BMD T-score categories (normal, low bone mass, and osteoporosis) was evaluated with receiver-operating-characteristic (ROC) analyses using area under the curve (AUC). Over 10 years of follow-up, 368 women incurred a hip fracture, and 1011 a major osteoporotic fracture. Women with low bone mass represented the majority (n = 3791, 61%); they developed many hip (n = 176, 48%) and major osteoporotic fractures (n = 569, 56%). Among women with normal and low bone mass, FRAX (including BMD) was an overall better predictor of hip fracture risk (AUC = 0.78 and 0.70, respectively) than major osteoporotic fractures (AUC = 0.64 and 0.62). Simpler models (eg, age + prior fracture) had similar AUCs to FRAX, including among women for whom primary prevention is sought (no prior fracture or osteoporosis by BMD). The FRAX and simpler models predict 10-year risk of incident hip and major osteoporotic fractures in older US women with normal or low bone mass.

Higher cord C-peptide concentrations are associated with slower growth rate in the 1st year of life in girls but not in boys

OBJECTIVE

To understand the relationships between maternal glycemia during pregnancy and prenatal and early postnatal growth by evaluating cord C-peptide and IGF-I as mediating biomarkers in boys and girls separately.

RESEARCH DESIGN AND METHODS

We evaluated 342 neonates within the EDEN mother-child cohort study born to mothers without diabetes diagnosis before pregnancy. We measured maternal glycemia at 24-28 weeks of gestation and neonates' cord blood C-peptide (used as a proxy for fetal insulin) and IGF-I at birth. Reported maternal prepregnancy BMI and all measured infant weights and lengths in the 1st year were recorded. Growth modeling was used to obtain an individual growth curve for each infant in the 1st year. Path models, a type of structural equation modeling, were used for statistical analysis. Path analysis is a multivariate method associated with a graphical display that allows evaluation of mediating factors and distinguishes direct, indirect, and total effects.

RESULTS

Cord C-peptide at birth was positively correlated with maternal prepregnancy BMI and maternal glycemia and was higher in girls. In a path model that represented prenatal growth, there was no significant direct effect of maternal glycemia on birth weight, but the effect of maternal glycemia on birth weight was mediated by fetal insulin and IGF-I in both girls and boys. However, in girls only, higher concentrations of cord C-peptide (but not cord IGF-I or maternal glucose) were associated with slower weight growth in the first 3 months of life.

CONCLUSIONS

Our study underlines the role of the fetal insulin-IGF-I axis in the relationship between maternal glycemia during pregnancy and birth weight. We also show for the first time that high insulin concentration in female fetuses is associated with slower early postnatal growth. This slow, early growth pattern may be programmed by fetal hyperinsulinemia, and girls may be more susceptible than boys to its consequences.