Gut microbiota disturbances in hospitalized older adults with malnutrition and clinical outcomes

OBJECTIVE

Malnutrition is one of the most threatening conditions in geriatric populations. The gut microbiota has an important role in the host's metabolic and muscular health: however, its interplay with disease-related malnutrition is not well understood. We aimed to identify the association of malnutrition with the gut microbiota and predict clinical outcomes in hospitalized acutely ill older adults.

METHODS

We performed a secondary longitudinal analysis in 108 geriatric patients from a prospective cohort evaluated at admission and 72 h of hospitalization. We collected clinical, demographic, nutritional, and 16S rRNA gene-sequenced gut microbiota data. Microbiota diversity, overall composition, and differential abundance were calculated and compared between patients with and without malnutrition. Microbiota features associated with malnutrition were used to predict clinical outcomes.

RESULTS

Patients with malnutrition (51%) had a different microbiota composition compared to those who were well-nourished during hospitalization (ANOSIM R = 0.079, P = 0.003). Patients with severe malnutrition showed poorer α-diversity at admission (Shannon P = 0.012, Simpson P = 0.018) and follow-up (Shannon P = 0.023, Chao1 P = 0.008). Differential abundance of Lachnospiraceae NK4A136 group, Subdoligranulum, and Faecalibacterium prausnitzii were significantly lower and inversely associated with malnutrition, while Corynebacterium, Ruminococcaceae Incertae Sedis, and Fusobacterium were significantly increased and positively associated with malnutrition. Corynebacterium, Ruminococcaceae Incertae Sedis, and the overall composition were important predictors of critical care in patients with malnutrition during hospitalization.

CONCLUSION

Older adults with malnutrition, especially in a severe stage, may be subject to substantial gut microbial disturbances during hospitalization. The gut microbiota profile of patients with malnutrition might help us to predict worse clinical outcomes.

1,2-BF2 Shift and Photoisomerization Induced Multichromatic Response

Adaptive materials that exhibit a multichromatic response as a function of applied stimulus are highly desirable, as they can result in applications ranging from smart surfaces to anticounterfeit devices. Here we report on such a system based on an intriguing thermal 1,2-BF2 shift that transforms a visible-light-activated azo-BF2 photoswitch into a BF2-hydrazone fluorophore (BODIHY) in both solution and the solid-state. Structure-property analysis, in conjunction with DFT calculations, reveals that the shift is catalyzed by the spatial proximity of an oxygen atom next to the BF2 group and that the activation originates from an electronic and not steric effect. Theoretical calculations also show that while the energy barrier for the trans → BODIHY transformation is accessible at room temperature (thermal half-life of 30 h), the cis → BODIHY transformation has a much higher barrier, which is why the 1,2-BF2 shift is not observed for the cis form. The photoswitching of the azo-BF2, in conjunction with the 1,2-BF2 shift, was then used in the multicolor modulation of a switch-containing cross-linked polydimethylsiloxane film using light and/or heat stimuli, elaborating the usefulness of the sophisticated reaction cascade that can be accessed from this simple system.

Relationship between chronic pain, depressive symptoms, and functional disability in community-dwelling older adults: mediating role of frailty

BACKGROUND

Borim et al. showed that older adults with chronic pain exhibited more depressive symptoms and frailty components. Depressive symptoms were associated with more frailty components, and those with more depressive symptoms and frailty faced greater limitations in IADL performance. Frailty appears to mediate the pathway from chronic pain to functional impairment Chronic pain is directly associated with depressive symptoms and frailty. Chronic pain is not directly associated with functional disability. Depression and frailty are both directly associated with functional disabilities. Frailty mediates the association between chronic pain and functional disability. Depression; Disability evaluation; Frailty; Frail elderly.

OBJECTIVE

To evaluate the direct and indirect effects of chronic pain, depressive symptoms, frailty components, and functional disability through a pathway analysis approach in a sample of community-dwelling older adults.

METHODS

Data of 419 participants were cross-sectionally evaluated for the presence of depressive symptoms (Geriatric Depression Scale [15 items]), physical frailty components (phenotype criteria), chronic pain, and limitations in performing instrumental activities of daily living (functional disability scale by Lawton and Brody). Structural equation modeling via path analysis was used to explore the direct and indirect effects among these four variables. Statistical significance was set at p<0.05.

RESULTS

Of the total participants, 69.8% were women and 59.3% had low education (1-4 years); the mean age was 80.3±4.6 years. Chronic pain and depressive symptoms were directly related and were associated to frailty. The number of frailty components and depressive symptoms were directly associated with functional disability. Frailty had an indirect effect on the association between chronic pain, depressive symptoms, and functional disabilities.

CONCLUSION

The pathway from chronic pain and depressive symptoms to functional disability is potentially mediated by the number of frailty components.

Anorexia of aging: An international assessment of healthcare providers' knowledge and practice gaps

BACKGROUND

Anorexia of aging is a common geriatric syndrome that includes loss of appetite and/or reduced food intake, with associated undernutrition, unintended weight loss, sarcopenia, functional decline, loss of independence and other adverse health outcomes. Anorexia of aging can have multiple and severe consequences and is often overlooked by healthcare professionals (HCPs). Even more concerningly, clinicians commonly accept anorexia of aging as an inevitable part of 'normal' aging. The aim of this assessment was to identify current gaps in professional knowledge and practice in identifying and managing older persons with anorexia. Results may guide educational programmes to fill the gaps identified and therefore improve patient outcomes.

METHODS

This international assessment was conducted using a mixed-methods approach, including focus group interviews with subject matter experts and an electronic survey of practicing HCPs. The assessment was led by the Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD) and was supported by in-country collaborating organizations.

RESULTS

A quantitative survey of 26 multiple-choice questions was completed by physicians, dietitians and other HCPs (n = 1545). Most HCPs (56.8%) recognize a consistent definition of anorexia of aging as a loss of appetite and/or low food intake. Cognitive changes/dementia (91%) and dysphagia (87%) are seen as the biggest risk factors. Most respondents were confident to give nutritional (62%) and physical activity (59.4%) recommendations and engaged caregivers such as family members in supporting older adults with anorexia (80.6%). Most clinicians assessed appetite at each visit (66.7%), although weight is not measured at every visit (41.5%). Apart from the Mini-Nutritional Assessment Short Form (39%), other tools to screen for appetite loss are not frequently used or no tools are used at all (29.4%). A high number of respondents (38.7%) believe that anorexia is a normal part of aging. Results show that treatment is focused on swallowing disorders (78%), dentition issues (76%) and increasing oral intake (fortified foods [75%] and oral nutritional supplements [74%]). Nevertheless, the lack of high-quality evidence is perceived as a barrier to optimal treatment (49.2%).

CONCLUSIONS

Findings from this international assessment highlight the challenges in the care of older adults with or at risk for anorexia of aging. Identifying professional practice gaps between individual HCPs and team-based gaps can provide a basis for healthcare education that is addressed at root causes, targeted to specific audiences and developed to improve individual and team practices that contribute to improving patient outcomes.

Breaking the photoswitch speed limit

The forthcoming generation of materials, including artificial muscles, recyclable and healable systems, photochromic heterogeneous catalysts, or tailorable supercapacitors, relies on the fundamental concept of rapid switching between two or more discrete forms in the solid state. Herein, we report a breakthrough in the "speed limit" of photochromic molecules on the example of sterically-demanding spiropyran derivatives through their integration within solvent-free confined space, allowing for engineering of the photoresponsive moiety environment and tailoring their photoisomerization rates. The presented conceptual approach realized through construction of the spiropyran environment results in ~1000 times switching enhancement even in the solid state compared to its behavior in solution, setting a record in the field of photochromic compounds. Moreover, integration of two distinct photochromic moieties in the same framework provided access to a dynamic range of rates as well as complementary switching in the material's optical profile, uncovering a previously inaccessible pathway for interstate rapid photoisomerization.

Visible light activated energy storage in solid-state Azo-BF2 switches

We present here a group of Azo-BF2 photoswitches that store and release energy in response to visible light irradiation. Unmodified Azo-BF2 switches have a planar structure with a large π-conjugation system, which hinders E-Z isomerization when in a compacted state. To address this challenge, we modified the switches with one or two aliphatic groups, which altered the intermolecular interactions and arrangement of the photochromes in the solid state. The derivative with two substituents exhibited a non-planar configuration that provided particularly large conformational freedom, allowing for efficient isomerization in the solid phase. Our discovery highlights the potential of using double aliphatic functionalization as a promising approach to facilitate solid-state switching of large aromatic photoswitches. This finding opens up new possibilities for exploring various photoswitch candidates for molecular solar thermal energy storage applications.

Metal and Proton Relay-Controlled Hierarchical Multistep Switching Cascade

Transition metals play an important role in many biological processes including cellular regulation and signal transduction. Emulating such processes on the molecular level, while challenging, can help us learn how to manipulate intermolecular communication, an important requirement for the development of solution-based molecular machines. In this work, we demonstrate a transition metal-based artificial multistep switching cascade that exhibits intrinsic hierarchical level control. The process starts with Zn(II), which initiates a transition metal relay by displacing a macrocycle-encapsulated Pd(II). The latter then binds to a hydrazone switch leading to coordination-coupled deprotonation (CCD). Finally, the proton generated through CCD activates the E/Z isomerization of a second noncoordinating pH-sensitive hydrazone switch. This whole multistep process can be reset to the original state by removing the Pd(II) from the system.

Efficacy of cognitive remediation in bipolar disorder: systematic review and meta-analysis of randomized controlled trials

A significant percentage of people with bipolar disorder (BD) exhibit suboptimal functional adjustment, even when appropriately treated and after symptomatic recovery is achieved. Given that cognitive impairment is one of the strongest correlates of socio-occupational outcomes and quality of life in BD, cognitive remediation (CR) is currently acknowledged as a promising treatment that could help bridge the gap between symptomatic and full functional recovery. The aim of this review was to explore the efficacy of CR approaches in improving cognitive and functional outcomes in BD patients. PubMed, PsycINFO, and CENTRAL were searched from inception to November 2022. Randomized controlled trials exploring the effects of CR on cognition and/or functional adjustment in adult BD patients were eligible. Ten studies based on seven independent trials (n = 586) were included. Change-score effect sizes (Hedges' g) were obtained for efficacy outcome measures and combined by means of meta-analytic procedures. Small but significant overall effects were observed for working memory (g = 0.32, 95% CI 0.11-0.52), planning (g = 0.30, 95% CI 0.03-0.56), and verbal learning (g = 0.40, 95% CI 0.15-0.66). However, CR was not found to exert any significant effects on functional outcomes at treatment completion or at follow-up assessment. Although CR may modestly enhance the cognitive performance of BD patients, this effect does not translate into an improvement at the functional level. The current data do not support the inclusion of CR as a treatment recommendation in clinical practice guidelines for the management of BD.

Non-equilibrium Steady States in Catalysis, Molecular Motors, and Supramolecular Materials: Why Networks and Language Matter

All chemists are familiar with the idea that, at equilibrium steady state, the relative concentrations of species present in a system are predicted by the corresponding equilibrium constants, which are related to the free energy differences between the system components. There is also no net flux between species, no matter how complicated the reaction network. Achieving and harnessing non-equilibrium steady states, by coupling a reaction network to a second spontaneous chemical process, has been the subject of work in several disciplines, including the operation of molecular motors, the assembly of supramolecular materials, and strategies in enantioselective catalysis. We juxtapose these linked fields to highlight their common features and challenges as well as some common misconceptions that may be serving to stymie progress.

Cognitive Impairment Predicts Sarcopenia 9 Years Later Among Older Adults

OBJECTIVE

To assess the longitudinal association between cognitive impairment and sarcopenia in a sample of Brazilian community-dwelling older adults.

DESIGN

Nine-year observational prospective study.

SETTING AND PARTICIPANTS

A total of 521 community-dwelling older adults from 2 Brazilian sites of the Frailty in Brazilian Older Adults (FIBRA in Portuguese) study.

METHODS

Sarcopenia was defined as low hand-grip strength and low muscle mass. Cognitive impairment was determined at baseline using the Mini-Mental State Examination, with education-adjusted cutoff scores. The logistic regression model was used to assess the association between cognitive impairment and incident sarcopenia after adjusting for gender, age, education, morbidities, physical activity, and body mass index. Inverse probability weighting was applied to correct for sample loss at follow-up.

RESULTS

The mean age of the study population was 72.7 (±5.6) years, and 365 were women (70.1%). Being 80 years and older (odds ratio [OR], 4.62; 95% CI, 1.38-15.48; P = .013), being under- and overweight (OR, 0.29; 95% CI, 0.11-0.76; P = .012, and OR, 5.12; 95% CI, 2.18-12.01; P < .001, respectively) and having cognitive impairment (OR, 2.44; 95% CI, 1.18-5.04; P = .016) at baseline predicted sarcopenia after 9 years.

CONCLUSION AND IMPLICATIONS

Cognitive impairment may predict sarcopenia in Brazilian older adults. More studies are necessary to identify the main mechanisms shared by sarcopenia and cognitive decline, which could support the development of prevention interventions.

Association of Motoric Cognitive Risk Syndrome with Sarcopenia and Systemic Inflammation in Pre-Frail Older Adults

Motoric cognitive risk syndrome (MCR) is defined by the presence of slow gait and subjective cognitive decline. It is well recognized as a prodrome for dementia, but the biological mechanism and trajectory for MCR are still lacking. The objective of this study was to explore the association of MCR with body composition, including sarcopenia and systemic inflammation, in pre-frail older adults in a cross-sectional study of 397 pre-frail community-dwelling older adults. Data on demographics, physical function, frailty, cognition (Montreal Cognitive Assessment (MoCA)), perceived health and depression were collected. Body composition was measured using a bioelectrical impedance analyzer. Systemic inflammatory biomarkers, such as progranulin, growth differentiation factor-15 (GDF-15), interleukin-10 (IL-10), interleukin-6 and tumor necrosis factor-α (TNF-α), were collected. Univariate and multivariate logistic regression were used to analyze the association between MCR, body composition, sarcopenia and systemic inflammatory biomarkers. The prevalence of MCR was 14.9%. They were significantly older and there were more females, depression, functional impairment, lower education, physical activity and MoCA scores. Body fat percentage (BF%), fat mass index, fat to fat free mass ratio (FM/FFM) and sarcopenia prevalence were significantly higher in MCR. Serum GDF-15 and TNF-α levels were highest with progranulin/TNF-α and IL-10/TNF-α ratio lowest in MCR. Compared to healthy patients, MCR was significantly associated with sarcopenia (aOR 2.62; 95% CI 1.46-3.17), BF% (aOR 1.06; 95% CI 1.01-1.12), FMI (aOR 1.16; 95% CI 1.02-1.30) and FM/FFM (aOR 6.38; 95% CI 1.20-33.98). The association of IL-10 to TNF-α ratio (aOR 0.98, 95% CI 0.97-0.99) and IL-10 (aOR 2.22, 95% CI 0.05-0.98) with MCR were independent of sarcopenia and BF%. Longitudinal population studies are needed to understand the role of body fat indices and IL-10 in pre-frail older adults with MCR and trajectory to dementia.

Weight loss severity and functional decline among the oldest old in a middle-income country: The FIBRA study longitudinal findings

BACKGROUND AND AIMS

Nutritional status is a key modifiable risk factor associated with disability, and further evidence suggests that weight change is also linked to this adverse outcome. Thus, this study aims to evaluate weight loss severity and functional decline in instrumental activities of daily living (IADL) in a seven-year period among a sample of Brazilian oldest-old adults.

METHODS

Longitudinal prospective study using data from the FIBRA study (Frailty in Older Brazilians), a population-based investigation carried out in 2008/2009, with follow-up data collected in 2016/2017 from participants who were 80 years and older in the follow-up in Campinas, Brazil. Of the 167 participants with complete data in 2016-2017, 16 had improved their functional status and were excluded, so the final sample was restricted to 151 participants who maintained or declined functional status. We considered functional decline when a subject had greater IADL dependencies at follow-up than baseline. Logistic regression was performed to assess the effect of weight loss, according to severity (moderate weight loss: 5-10% of body weight; severe weight loss >10%) in increasing the number of disabilities than the group with stable weight, controlling for covariates (gender, age, education, and morbidity). An alpha level of <5% was adopted.

RESULTS

During the follow-up period, 60.3% of the participants kept stable weight, 21.8% had moderate weight loss, and 17.9% had severe weight loss. During the follow-up, only severe weight loss was associated with a higher risk of functional decline (OR = 2.74; p = 0.032).

CONCLUSIONS

Severe weight loss was associated with functional decline. This finding reinforces the importance of early identification of weight loss among older adults.

Confinement-Driven Photophysics in Hydrazone-Based Hierarchical Materials

Confinement-imposed photophysics was probed for novel stimuli-responsive hydrazone-based compounds demonstrating a conceptual difference in their behavior within 2D versus 3D porous matrices for the first time. The challenges associated with photoswitch isomerization arising from host interactions with photochromic compounds in 2D scaffolds could be overcome in 3D materials. Solution-like photoisomerization rate constants were realized for sterically demanding hydrazone derivatives in the solid state through their coordinative immobilization in 3D scaffolds. According to steady-state and time-resolved photophysical measurements and theoretical modeling, this approach provides access to hydrazone-based materials with fast photoisomerization kinetics in the solid state. Fast isomerization of integrated hydrazone derivatives allows for probing and tailoring resonance energy transfer (ET) processes as a function of excitation wavelength, providing a novel pathway for ET modulation.

Frailty and affective disorders throughout adult life: A 5-year follow-up of the Lifelines Cohort Study

BACKGROUND

Frailty is an important concept for risk stratification in clinical practice, but it is hardly acknowledged at all in mental healthcare settings. This paper aims to assess the impact of frailty on the course of depression and anxiety, and the impact of these affective disorders on the course of frailty.

METHODS

Lifelines, a prospective population-based cohort study, evaluated 167,729 people living in the northern Netherlands. Frailty was based on the deficit accumulation model, which resulted in a 60-item frailty index (FI) at baseline and a 35-item FI at baseline and 5-year follow-up. Current depressive and anxiety disorders were assessed with the Mini International Neuropsychiatric Interview according to DSM-IV criteria. Bidirectional associations between frailty and affective disorders were investigated using separate multivariable regression analyses in younger (<60 years) and older adults (≥60 years).

RESULTS

The FI was associated with the onset of a depressive disorder (younger adults: odds ratio [OR] = 1.12; 95% confidence interval [CI] 1.11-1.13; older adults: OR = 1.13; 95% CI 1.09-1.16) as well as any anxiety disorder (younger adults: OR = 1.10; 95% CI 1.09-1.10; older adults: OR = 1.07; 95% CI 1.04-1.09). The other way around, depressive disorder and anxiety disorders were associated with an accelerated increase of frailty over time (depressive disorder: younger adults: beta [β] = 0.03, p < 0.001; older adults: β = 0.04, p < 0.001; and any anxiety disorder: younger adults: β = 0.02, p < 0.001; older adults: β = 0.01, p < 0.142), although the effect of anxiety disorders was less equivocal among older adults.

CONCLUSIONS

Affective disorders are reciprocally related to frailty. Results with respect to the impact of anxiety disorders on frailty suggest most impact at lower levels of frailty. Our results might imply that interventions to slow biological aging should be broadened towards younger and middle-aged people as well as non-frail older patients. To develop targeted treatment, future clinical and epidemiologic studies on the underlying pathways of this bidirectional association are needed.

Patterns of participation restriction among older adults at risk of falls and relationship with intrinsic capacity: A latent cluster analysis

Introduction

The concept of participation restriction was first described by the World Health Organization in 2001 as a component of The International Classification of Functioning, Disability and Health Framework. Both falls and fear of falling (FOF) are associated with social isolation, depression, anxiety, poor quality of life and cognitive impairment resulting in participation restriction. Life-space mobility (LSM) is an important indicator for participation restriction which depends on multiple inter-related factors. We aimed to determine participation patterns using latent cluster analysis (LCA) in older adults at risk of falls, its relationship with intrinsic capacity (IC) and its risk prediction.

Methods

Cross-sectional study of 154 community dwelling older adults ≥ 60 years with falls or risk of falls was conducted. Questionnaires were administered on demographics, hearing, LSM, frailty (FRAIL scale), anorexia of aging (SNAQ), cognition (Montreal Cognitive Assessment, MoCA), FOF (Falls Efficacy Scale-International), physical function, and assessment for handgrip strength (HGS), gait speed, 5-times sit to stand (STS), vision and times-up-and-go (TUG) were performed. Six IC domains (vision and hearing, cognition, nutrition, mobility and depression) were measured.

Results

Three pattern of participation cluster were identified, high (n = 63, 40.9%), moderate (n = 83, 53.9%) and low (n = 8, 33 5.2%). Individuals in the high participation cluster were significantly younger, had higher LSM scores and lower FES-I scores, more robust, fewer ADL and IADL limitations, lower prevalence of low HGS, higher gait speed and shorter TUG. In the fully adjusted model compared to the high participation cluster, moderate participation was significantly associated with low MoCA scores (OR 4.2, 95% CI 1.7-10.4, p = 0.02), poor STS (OR 7.1, 95% CI 3.0-17.0, p < 0.001) whereas low participation was associated with anorexia of aging (OR 9.9, 95% CI 1.6-60.9, p = 0.014), poor STS (OR 19.1, 95% CI 2.0-187.5, p = 0.011) and hearing impairment (OR 9.8, 95% CI 1.4-70.8, p = 0.024). Participants with 3 out of 6 IC decline had a probability of greater than 80% to belong to the low/moderate participation class.

Discussion

Physical function, cognition, hearing and nutrition were significantly associated with low and/or moderate participation class. Future studies are needed to evaluate improvement in participation of those with falls or at risk for falls through restoration of IC.

Cannabinoids in Late Life Parkinson's Disease and Dementia: Biological Pathways and Clinical Challenges

The use of cannabinoids as therapeutic drugs has increased among aging populations recently. Age-related changes in the endogenous cannabinoid system could influence the effects of therapies that target the cannabinoid system. At the preclinical level, cannabidiol (CBD) induces anti-amyloidogenic, antioxidative, anti-apoptotic, anti-inflammatory, and neuroprotective effects. These findings suggest a potential therapeutic role of cannabinoids to neurodegenerative disorders such as Parkinson's disease (PD) and Alzheimer. Emerging evidence suggests that CBD and tetrahydrocannabinol have neuroprotective therapeutic-like effects on dementias. In clinical practice, cannabinoids are being used off-label to relieve symptoms of PD and AD. In fact, patients are using cannabis compounds for the treatment of tremor, non-motor symptoms, anxiety, and sleep assistance in PD, and managing responsive behaviors of dementia such as agitation. However, strong evidence from clinical trials is scarce for most indications. Some clinicians consider cannabinoids an alternative for older adults bearing Parkinson's disease and Alzheimer's dementia with a poor response to first-line treatments. In our concept and experience, cannabinoids should never be considered a first-line treatment but could be regarded as an adjuvant therapy in specific situations commonly seen in clinical practice. To mitigate the risk of adverse events, the traditional dogma of geriatric medicine, starting with a low dose and proceeding with a slow titration regime, should also be employed with cannabinoids. In this review, we aimed to address preclinical evidence of cannabinoids in neurodegenerative disorders such as PD and AD and discuss potential off-label use of cannabinoids in clinical practice of these disorders.

Number of ideas in spontaneous speech predicts cognitive impairment and frailty in community-dwelling older adults nine years later

OBJECTIVE

To investigate the associations between linguistic parameters in spontaneous speech at baseline and cognitive impairment and frailty nine years later.

METHODS

A prospective analysis was carried out on data of the Frailty in Brazilian Older People Study (FIBRA) Study, a population-based study on frailty. From a probabilistic sample of 384 individuals aged 65 and older at baseline (2008-2009), 124 aged 73 years and older at follow-up were selected, as they had scored above the cutoff values of cognitive screening for dementia adjusted by years of schooling at baseline and had answered to the question What is healthy aging and had no frailty at baseline. Verbal responses were submitted to content analysis and had its ideas and words counted. Number of ideas corresponded to the frequency of meaning categories and number of words to all identified significant textual elements in the text constituted by the sample answers to that question.

RESULTS

Multivariate logistic regression analyses, controlling for the effects of age, sex, and education, showed that individuals with a high number of ideas at baseline had lower chance of having cognitive impairment (OR = 0.39; 95% CI 0.22 - 0.69) and frailty (OR 0.66; 95% CI 0.44 - 0.99) nine years later than those with low number of ideas.

CONCLUSIONS

Higher number of ideas, but not number of words, in spontaneous speech seems to be associated to a more positive prognosis in mental and physical health nine years later. Linguistic markers may be used to predict cognitive impairment and frailty in older individuals.

Management in severe dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

ABSTRACT Alzheimer’s disease (AD) and other neurodegenerative dementias have a progressive course, impairing cognition, functional capacity, and behavior. Most studies have focused on AD. Severe dementia is associated with increased age, higher morbidity-mortality, and rising costs of care. It is fundamental to recognize that severe dementia is the longest period of progression, with patients living for many years in this stage. It is the most heterogeneous phase in the process, with different abilities and life expectancies. This practice guideline focuses on severe dementia to improve management and care in this stage of dementia. As it is a long period in the continuum of dementia, clinical practice should consider non-pharmacological and pharmacological approaches. Multidisciplinary interventions (physical therapy, speech therapy, nutrition, nursing, and others) are essential, besides educational and support to caregivers.

Manejo das demências em fase avançada: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia

RESUMO A doença de Alzheimer (DA) e outras demências neurodegenerativas têm um curso progressivo com comprometimento da cognição, capacidade funcional e comportamento. A maioria dos estudos enfocou a DA. A demência grave está associada ao aumento da idade, maior morbimortalidade e aumento dos custos de cuidados. É fundamental reconhecer que a demência grave é o período mais longo de progressão, com o paciente vivendo muitos anos nesta fase. É a fase mais heterogênea do processo, com diferentes habilidades e expectativa de vida. Esta diretriz de prática concentra-se na demência grave para melhorar o manejo e o cuidado nessa fase da demência. Como um longo período no continuum da demência, as abordagens não farmacológicas e farmacológicas devem ser consideradas. Intervenções multidisciplinares (fisioterapia, fonoaudiologia, nutrição, enfermagem, entre outras) são essenciais, além de educacionais e de apoio aos cuidadores.

Decision-making executive function profile and performance in older adults with major depression: a case-control study

OBJECTIVES

Decision making (DM) is a component of executive functioning, essential for choosing appropriate decisions. Executive dysfunctioning is particularly common in late-life depression, however the literature is scarce on DM. This case-control study aimed to evaluate the DM profile and performance in participants with and without unipolar major depression.

METHOD

The DM profile and performance were assessed by the Melbourne Decision Making Questionnaire and the Iowa Gambling Task (IGT), respectively, in three groups of older adults from a university-based geriatric psychiatry clinic, i.e. current depression (n = 30), remitted depression (n = 43) and healthy controls (n = 59). The Hamilton Depression scale (HAM-D) 21 items, the Hamilton Anxiety scale, and the Mini-Mental State Examination were used to access depressive symptoms, anxiety symptoms, and cognitive impairment, respectively. Multinomial, nominal and binary logistic regression was used to evaluate the associations between depression, depressive symptomatology and DM.

RESULTS

In comparison to the control group, patients with current depression presented higher scores in buck-passing and proscratination DM profiles. In the hypervigilance profile, there was a significant difference between current and remitted depression groups. A higher value ​in the HAM-D scale increased the probability of disadvantageous DM profiles. Depressive patients showed a tendency of a higher mean score in both disadvantageous decks (A and B) of IGT. Patients with current depression showed a worse performance compared to the remitted depression group in the IGT netscore.

CONCLUSION

Older adults with current depression showed DM profiles considered maladaptive or disadvantageous compared to both remitted depression and healthy controls groups.

Photon Energy Storage in Strained Cyclic Hydrazones: Emerging Molecular Solar Thermal Energy Storage Compounds

The generally small Gibbs free energy difference between the Z and E isomers of hydrazone photoswitches has so far precluded their use in photon energy storing applications. Here, we report on a series of cyclic and acyclic hydrazones, which possess varied degrees of ring strain and, hence, stability of E isomers. The photoinduced isomerization and concurrent phase transition of the cyclic hydrazones from a crystalline to a liquid phase result in the storage of a large quantity of energy, comparable to that of azobenzene derivatives. We demonstrate that the macrocyclic photochrome design in combination with phase transition is a promising strategy for molecular solar thermal energy storage applications.

Heparanase 1 Upregulation Promotes Tumor Progression and Is a Predictor of Low Survival for Oral Cancer

Background: Oral cavity cancer is still an important public health problem throughout the world. Oral squamous cell carcinomas (OSCCs) can be quite aggressive and metastatic, with a low survival rate and poor prognosis. However, this is usually related to the clinical stage and histological grade, and molecular prognostic markers for clinical practice are yet to be defined. Heparanase (HPSE1) is an endoglycosidase associated with extracellular matrix remodeling, and although involved in several malignancies, the clinical implications of HPSE1 expression in OSCCs are still unknown.

Methods: We sought to investigate HPSE1 expression in a series of primary OSCCs and further explore whether its overexpression plays a relevant role in OSCC tumorigenesis. mRNA and protein expression analyses were performed in OSCC tissue samples and cell lines. A loss-of-function strategy using shRNA and a gain-of-function strategy using an ORF vector targeting HPSE1 were employed to investigate the endogenous modulation of HPSE1 and its effects on proliferation, apoptosis, adhesion, epithelial–mesenchymal transition (EMT), angiogenesis, migration, and invasion of oral cancer in vitro.

Results: We demonstrated that HPSE1 is frequently upregulated in OSCC samples and cell lines and is an unfavorable prognostic indicator of disease-specific survival when combined with advanced pT stages. Moreover, abrogation of HPSE1 in OSCC cells significantly promoted apoptosis and inhibited proliferation, migration, invasion, and epithelial–mesenchymal transition by significantly decreasing the expression of N-cadherin and vimentin. Furthermore, a conditioned medium of HPSE1-downregulated cells resulted in reduced vascular endothelial growth.

Conclusion: Our results confirm the overexpression of HPSE1 in OSCCs, suggest that HPSE1 expression correlates with disease progression as it is associated with several important biological processes for oral tumorigenesis, and can be managed as a prognostic marker for patients with OSCC.

The Frail Depressed Patient: A Narrative Review on Treatment Challenges

Although the public importance of frailty is widely acknowledged by the World Health Organization, physical frailty is still largely neglected in geriatric mental health care. Firstly in this narrative review, we summarize the knowledge on the epidemiology of the association between depression and frailty, whereafter implications for treatment will be discussed. Even though frailty and depression have overlapping diagnostic criteria, epidemiological studies provide evidence for distinct constructs which are bidirectionally associated. Among depressed patients, frailty has predictive validity being associated with increased mortality rates and an exponentially higher fall risk due to antidepressants. Nonetheless, guidelines on the treatment of depression neither consider frailty for risk stratification nor for treatment selection. We argue that frailty assessment enables clinicians to better target the pharmacological and psychological treatment of depression as well as the need for interventions targeting primarily frailty, for instance, lifestyle interventions and reduction of polypharmacy. Applying a frailty informed framework of depression treatment studies included in a meta-analysis reveals that the benefit–harm ratio of antidepressants given to frail depressed patients can be questioned. Nonetheless, frail-depressed patients should not withhold antidepressants as formal studies are not available yet, but potential adverse effects should be closely monitored. Dopaminergic antidepressants might be preferable when slowness is a prominent clinical feature. Psychotherapy is an important alternative for pharmacological treatment, especially psychotherapeutic approaches within the movement of positive psychology, but this approach needs further study. Finally, geriatric rehabilitation, including physical exercise and nutritional advice, should also be considered. In this regard, targeting ageing-related abnormalities underlying frailty that may also be involved in late-life depression such as low-grade inflammation might be a promising target for future studies. The lack of treatment studies precludes firm recommendations, but more awareness for frailty in mental health care will open a plethora of alternative treatment options to be considered.

The impact of a history of child abuse on cognitive performance: a cross-sectional study in older patients with a depressive, anxiety, or somatic symptom disorder

BACKGROUND

Child abuse is a major global burden with an enduring negative impact on mental and physical health. A history of child abuse is consistently associated with worse cognitive performance among adults; data in older age groups are inconclusive. Since affective symptoms and cognitive functioning are interrelated among older persons, a synergistic effect can be assumed in patients with affective symptoms who also have suffered from child abuse. This study examines the association between a history of child abuse and cognitive performance in such patients.

METHODS

Cross-sectional data were collected from the 'Routine Outcome Monitoring for Geriatric Psychiatry & Science' project, including 179 older adults (age 60-88 years) with either a unipolar depressive, any anxiety, or somatic symptom disorder referred to specialized geriatric mental health care. A history of physical, sexual, and psychological abuse, and emotional neglect was assessed with a structured interview. Cognitive functioning was measured with three paper and pencils tests (10-words verbal memory test, Stroop Colour-Word test, Digit Span) and four tests from the computerized Cogstate Test Battery (Detection Test, Identification Test, One Card Learning Test, One Back Test). The association between a history of child abuse and cognitive performance was examined by multiple linear regression analyses adjusted for covariates.

RESULTS

Principal component analyses of nine cognitive parameters revealed four cognitive domains, i.e., visual-verbal memory, psychomotor speed, working memory and interference control. A history of child abuse was not associated with any of these cognitive domains. However, when looking at the specific types of child abuse separately, a history of physical abuse and emotional neglect were associated with poorer interference control. A history of physical abuse was additionally associated with better visual-verbal memory.

CONCLUSIONS

The association between a history of child abuse and cognitive performance differs between the different types of abuse. A history of physical abuse might particularly be a key determinant of cognitive performance in older adults with a depressive, anxiety, or somatic symptom disorder. Future studies on the impact of these disorders on the onset of dementia should take child abuse into account.

TRIAL REGISTRATION

ROM-GPS is registered at the Dutch Trial Register ( NL6704 at www.trialregister.nl ).

Interplay between Inflammaging, Frailty and Nutrition in Covid-19: Preventive and Adjuvant Treatment Perspectives

As humans age, their immune system undergoes modifications, including a low-grade inflammatory status called inflammaging. These changes are associated with a loss of physical and immune resilience, amplifying the risk of being malnourished and frail. Under the COVID-19 scenario, inflammaging increases the susceptibility to poor prognostics. We aimed to bring the current concepts of inflammaging and its relationship with frailty and COVID-19 prognostic; highlight the importance of evaluating the nutritional risk together with frailty aiming to monitor older adults in COVID-19 scenario; explore some compounds with potential to modulate inflammaging in perspective to manage the COVID-19 infection. Substances such as probiotics and senolytics can help reduce the high inflammatory status. Also, the periodic evaluation of nutrition risk and frailty will allow interventions, assuring the appropriate care.

Frailty, depression and mortality in a cohort of community-dwelling older adults

Abstract Objective To estimate the risk represented by the combined conditions of frailty and depression in relation to mortality in a cohort of older adults in a prospective measure. Method Prospective cohort study derived from baseline (2008/2009) and follow-up (2016/2017) measurements of the FIBRA Study - Polo Unicamp. Data from 739 older adults (67,2% female; 73,1+5.87 years) living in two urban centers in the state of São Paulo (Brazil) were analyzed to examine survival curves and to estimate mortality risk. The analyzes included four conditions resulting from the combination of depression (presence x absence of symptoms) and frailty (frail x robust) and the covariates sex, age, education, cognitive performance and comorbidities. Results The percentage of deaths was 25.7%. There were significant differences between the survival curves regarding the combinations between frailty and depression. Male sex, age over 75 years, low education, low cognitive performance and the combinations “depression-robust”, “depression-frail” and “no depression-frail” presented independent risks for mortality. In the multivariate model, the highest risks were given, respectively, by older ages, the combinations “depression-robust”, “depression-frail”, “no depression-frail”, male sex and lower cognitive performance. Conclusion Combinations between frailty and depression can result in differences in survival and mortality among older adults. In the nine-year period, depression proved to be the ordering variable of the groups in relation to risk estimates, even in the presence of important covariates. Investments in the prevention of both syndromes and their associations may result in a decrease in mortality in older people from general causes.

Fragilidade, depressão e mortalidade em uma coorte de pessoas idosas residentes na comunidade

Resumo Objetivo Estimar o risco representado por condições combinadas de fragilidade e depressão em relação à mortalidade de uma coorte de idosos em medida prospectiva. Método Estudo de coorte prospectivo derivado das medidas de linha de base (2008/2009) e seguimento (2016/2017) do Estudo Fibra - Polo Unicamp. Foram analisados dados de 739 idosos (67,2% feminino; 73,1+5,87 anos) residentes em dois centros urbanos do estado de São Paulo (Brasil) para o exame de curvas de sobrevida e para estimar risco de mortalidade. As análises incluíram quatro condições resultantes da combinação entre depressão (presença x ausência de sintomas) e de fragilidade (frágil x robusto) e as covariáveis sexo, idade, escolaridade, desempenho cognitivo e comorbidades. Resultados A porcentagem de óbitos foi de 25,7%. Houve diferenças significativas entre as curvas de sobrevida referentes às combinações entre fragilidade e depressão. Sexo masculino, idade acima de 75 anos, baixa escolaridade, baixo desempenho cognitivo e as combinações “depressão-robusto”, “depressão-frágil” e “sem depressão-frágil” apresentaram riscos independentes para mortalidade. No modelo multivariado, os maiores riscos foram dados, respectivamente, por idades mais avançadas, as combinações “depressão-robusto”, “depressão-frágil”, “sem depressão-frágil”, sexo masculino e menor desempenho cognitivo. Conclusão Combinações entre fragilidade e depressão podem resultar em diferenças em sobrevida e mortalidade entre idosos. No período de nove anos, depressão revelou ser a variável de ordenação dos grupos em relação às estimativas de risco, mesmo na presença de covariáveis importantes. Investimentos na prevenção de ambas as síndromes e de suas associações podem resultar diminuição na mortalidade de idosos por causas gerais.

Association of Cognitive Performance with Frailty in Older Individuals with Cognitive Complaints

OBJECTIVES

Frailty is a risk factor for poor cognitive performance in older adults. However, few studies have evaluated the association of cognitive performance with frailty in a low- to middle-income country (LMIC). This study aimed to investigate an association between cognitive performance and frailty in older adults with memory complaints in Brazil. Secondarily, we aim to assess an association of cognitive performance with gait speed and grip strength.

DESIGN

Cross-sectional study.

SETTING

Outpatient service from a LMIC.

PARTICIPANTS

Older adults with memory complaints reported by the participants, their proxies, or their physicians.

MEASUREMENTS

Frailty was evaluated using the Cardiovascular Health Study criteria. A neuropsychological battery evaluated memory, attention, language, visuospatial function, executive function. Linear regression analysis with adjustment for age, sex, and education was used. We also evaluated the interaction of education with frailty, grip strength, and gait speed.

RESULTS

Prefrailty was associated with poor performance in the memory domain, as well as slower gait speed was associated with worse performance in memory, attention, language, and executive function. Frailty and grip strength were not associated with cognitive performance. Interactions of education with gait speed were significant for global performance, as well as for attention and visuospatial ability.

CONCLUSION

In elderly patients with memory complaints, prefrailty was associated with poor memory performance. Slowness was associated with poorer performance in some cognitive domains, mainly in participants with low education.

The long-term course of cognition in bipolar disorder: a systematic review and meta-analysis of patient-control differences in test-score changes

Neuropsychological impairment represents a key aspect of bipolar disorder (BD) that is evident even in early-course patients and is a strong predictor of functional outcomes among those affected. Previous meta-analyses of longitudinal studies suggest that BD-related cognitive deficits may not progress along the course of the disorder. However, short test-retest periods were used in most primary studies and comparisons with healthy controls were limited. The aim of this review was to synthesize the findings of research reports comparing long-term neurocognitive trajectories between BD patients and healthy individuals. PubMed, PsycINFO, and Scopus databases were searched from inception through July 2021. Publications were considered for inclusion if they reported cognitive test scores of BD patients and healthy controls at two different time points, with a minimum test-retest interval of 5 years. Fifteen studies compared the long-term course of cognition in BD patients with that of healthy controls. Ten of these were included in the quantitative analysis and involved 540 BD patients and 644 healthy individuals (mean follow-up period: 8.9 years). Patient-control effect sizes (standardized mean differences) were calculated for test-score changes in 24 neuropsychological variables and combined by means of meta-analytic procedures. No significant differences were found between patients and controls regarding long-term cognitive outcomes. These findings are consistent with previous shorter-term longitudinal meta-analyses and do not provide evidence for progressive cognitive deterioration in most bipolar individuals. Future studies should address the longitudinal course of cognition in different subgroups of BD patients and its prognostic and therapeutic value.

Association of coronary calcification with prognosis of Covid-19 patients without known heart disease

Risk factors that determine the severity of Covid-19 have not been fully elucidated. The aim of this study was to evaluate the role of coronary artery calcification (CAC) as a risk factor for death or mechanical ventilation (MV) of patients without known heart disease infected with Covid-19. We analyzed 283 consecutive in-patients with acute respiratory symptoms with chest computed tomography (chest-CT), without previous heart disease, and criteria for Covid-19 (RT-PCR positive and/or typical clinical and chest-CT findings). CAC was classified by the number of coronary segments affected as absent (0), mild (1-3), and severe calcification (more than 3). The association between CAC, CAC severity, and death or MV due to severe respiratory failure was assessed by logistic regression. The mean age was 58.7±15.7 years and 54.1% were men. Patients with CAC were older, more likely to have hypertension, and less likely to be obese. CAC was present in 75 patients (26.5%), of which 42 had a mild calcification and 33 had severe calcification, and was associated with death (OR=2.35, 95%CI: 1.01-5.48) or MV (OR=2.72, 95%CI: 1.20-6.20) adjusted for multiple confounders, with significant and increased odds ratio for the severe form of CAC (death: OR=3.70, 95%CI: 1.20-11.42; MV: OR=3.30, 95%CI: 1.09-9.95). We concluded that CAC was an independent risk factor for death or MV in Covid-19 patients without previous heart disease, particularly for those with severe calcification. CAC can be easily visualized on common chest-CT, widely used in evaluation of moderate to severe Covid-19.

Depression as a determinant of frailty in late life

OBJECTIVES

Accumulating evidence shows depression as a risk factor for frailty, but studies are mainly population-based and widely differ in their assessment of either depression or frailty. We investigated the association between depression and frailty among geriatric outpatients using different assessment instruments for both conditions.

METHOD

Among 315 geriatric outpatients (mean age 72.1 years, 68.3% female sex) participating the MiMiCS-FRAIL cohort study, major and subthreshold depression were measured with psychiatric diagnostic interview according to DSM-5 criteria (SCID-5) as well as with instruments to screen and measure severity of depressive symptoms (GDS-15 and PHQ-9). Frailty was assessed according to a screening instrument (FRAIL-BR) and a multidimensional Frailty Index (FI-36 items). Multiple logistic and linear regression were performed to assess the association between depression (independent variable) and frailty (dependent variable) adjusted for confounders.

RESULTS

Frailty prevalence in patients with no, subthreshold or major depressive disorder increases from either 14.5%, 46.5% to 65.1% when using the FRAIL-BR questionnaire, and from 10.2%, 20.9%, to 30.2% when using the FI-36 index. These association remain nearly the same when adjusted for covariates. Both the FRAIL-BR and the FI-36 were strongly associated with major depressive disorder, subthreshold depression, and depressive symptoms by PHQ-9 and GDS-15.

CONCLUSION

Late life depression and frailty are associated in a dose-dependent manner, irrespective of the used definitions. Nonetheless, to avoid residual confounding, future research on underlying biological mechanisms should preferably be based on formal psychiatric diagnoses and objectively assessment frailty status.

A 6-year prospective clinical cohort study on the bidirectional association between frailty and depressive disorder

INTRODUCTION

Depressive disorder has been conceptualised as a condition of accelerated biological ageing. We operationalised a frailty index (FI) as marker for biological ageing aimed to explore the bidirectional, longitudinal association between frailty and either depressive symptoms or depressive disorder.

METHODS

A cohort study with 6-year follow-up including 377 older (≥60 years) outpatients with a DSM-IV-defined depressive disorder and 132 never-depressed controls. Site visits at baseline, 2 and 6-year follow-up were conducted and included the CIDI 2.0 to assess depressive disorder and relevant covariates. Depressive symptom severity and mortality were assessed every 6 months by mail and telephone. A 41-item FI was operationalised and validated against the 6-year morality rate by Cox regression (HR_FI  = 1.04 [95% CI: 1.02-1.06]).

RESULTS

Cox regression showed that a higher FI was associated with a lower chance of remission among depressed patients (HR_FI  = 0.98 [95% CI: 0.97-0.99]). Nonetheless, this latter effect disappeared after adjustment for baseline depressive symptom severity. Linear mixed models showed that the FI increased over time in the whole sample (B[SE] = 0.94 (0.12), p < .001) with a differential impact of depressive symptom severity and depressive disorder. Higher baseline depressive symptom severity was associated with an attenuated and depressive disorder with an accelerated increase of the FI over time.

CONCLUSIONS

The sum score of depression rating scales is likely confounded by frailty. Depressive disorder, according to DSM-IV criteria, is associated with accelerated biological ageing. This argues for the development of multidisciplinary geriatric care models incorporating frailty to improve the overall outcome of late-life depression.

Brief version of the CAMCOG for illiterate older adults with Alzheimer's dementia

BACKGROUND

The Cambridge Cognition Examination (CAMCOG) is one of the most used cognitive assessment batteries for older adults.

OBJECTIVE

To evaluate a brief version of the CAMCOG for illiterate older adults (CAMCOG-BILL) with Alzheimer's dementia (AD) and healthy controls (CG).

METHODS

Cross-sectional case-control study with 246 illiterate older adults (AD [n=159] and CG [n=87], composed by healthy seniors without cognitive complaints) who never attended school or took reading or writing lessons. Diagnosis of AD was established based on the NIA-AA and DSM-5 criteria. All participants were assessed with the CAMCOG by a researcher blinded for diagnosis. To assess the consistency of the chosen CAMCOG-BILL sub-items, we performed a binary logistic regression analysis.

RESULTS

Both the CAMCOG and the CAMCOG-BILL had satisfactory psychometric properties. The area under the curve (AUC) was 0.932 (p<0.001) for the original version of CAMCOG and 0.936 for the CAMCOG-BILL. Using a cut-off score of ≥60 (CAMCOG) and ≥44 (CAMCOG-BILL), both instruments had the same sensitivity and specificity (89 and 96%, respectively).

CONCLUSION

The CAMCOG-BILL may be a preferred tool because of the reduced test burden for this vulnerable subgroup of illiterate patients with dementia.

Applicability of the GLIM criteria for the diagnosis of malnutrition in older adults in the emergency ward: A pilot validation study

BACKGROUND & AIMS

Acutely ill older adults are at higher risk of malnutrition. This study aimed to explore the applicability and accuracy of the GLIM criteria to diagnose malnutrition in acutely ill older adults in the emergency ward (EW).

METHODS

We performed a retrospective secondary analysis, of an ongoing cohort study, in 165 participants over 65 years of age admitted to the EW of a Brazilian university hospital. Nutrition assessment included anthropometry, the Simplified Nutritional Assessment Questionnaire (SNAQ), the Malnutrition Screening Tool (MST), and the Mini-Nutritional Assessment (MNA). We diagnosed malnutrition using GLIM criteria, defined by the parallel presence of at least one phenotypic [nonvolitional weight loss (WL), low BMI, low muscle mass (MM)] and one etiologic criterion [reduced food intake or assimilation (RFI), disease burden/inflammation]. We used the receiver operating characteristic (ROC) curves and Cox and logistic regression for data analyses.

RESULTS

GLIM criteria, following the MNA-SF screening, classified 50.3% of participants as malnourished, 29.1% of them in a severe stage. Validation of the diagnosis using MNA-FF as a reference showed good accuracy (AUC = 0.84), and moderate sensitivity (76%) and specificity (75.1%). All phenotypic criteria combined with RFI showed the best metrics. Malnutrition showed a trend for an increased risk of transference to intensive care unit (OR = 2.08, 95% CI 0.99, 4.35), and severe malnutrition for in-hospital mortality (HR = 4.23, 95% CI 1.2, 14.9).

CONCLUSION

GLIM criteria, following MNA-SF screening, appear to be a feasible approach to diagnose malnutrition in acutely ill older adults in the EW. Nonvolitional WL combined with RFI or acute inflammation were the best components identified and are easily accessible, allowing their potential use in clinical practice.

Multistage Reversible Tg Photomodulation and Hardening of Hydrazone-Containing Polymers

The glass transition temperature (T_g) of a series of polyacrylate- and polymethacrylate-based polymers having bistable hydrazone photoswitches as pendants increases upon photoisomerization. The ensuing photohardening of the polymeric network was corroborated using nanoindentation measurements. The bistability of the switch allowed us to lock-in and sustain multiple T_g values in the same polymeric material as a function of the hydrazone switch's Z/E isomer ratio, even at elevated temperatures.

On Schrödinger's Cat and Evaluation of Trials Disrupted by the Covid19 Pandemic: A Critical Appraisal

From the beginning of 2020, the world has been fighting the SARS-Cov-2 outbreak. The life of each one of us has profoundly changed. Unavoidably, our clinical routine has drastically modified in its priorities and methodologies (1). The COVID-19 pandemic has also raised significant issues in the field of research. The investigators’ responsibility has increased with the need to thoughtfully weigh the risk-benefit ratio for each protocol in an emergency and evolving scenario (2).

Excess mortality in depressive and anxiety disorders: The Lifelines Cohort Study

Background

To examine the mortality risk of current and life-time depressive as well as anxiety disorders, whether this risk is moderated by sex or age, and whether this risk can be explained by lifestyle and/or somatic health status.

Methods

A cohort study (Lifelines) including 141,377 participants (18–93 years) which were followed-up regarding mortality for 8.6 years (range 3.0–13.7). Baseline depressive and anxiety disorders according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria were assessed with the Mini International Neuropsychiatric Interview and lifetime diagnoses by self-report. All-cause mortality was retrieved from Statistics Netherlands. Cox-regression was applied to calculate proportional hazard ratios, adjusted for lifestyle (physical activity, alcohol use, smoking, and body mass index) and somatic health status (multimorbidity and frailty) in different models.

Results

The mortality rate of depressive and anxiety disorders was conditional upon age but not on sex. Only in people below 60 years, current depressive and anxiety disorders were associated with mortality. Only depressive disorder and panic disorder independently predicted mortality when all mental disorders were included simultaneously in one overall model (hazard ratio [HR] = 2.18 [95% confidence intervals (CI): 1.56–3.05], p < 0.001 and HR = 2.39 [95% CI: 1.15–4.98], p = 0.020). Life-time depressive and anxiety disorders, however, were independent of each other associated with mortality. Associations hardly changed when adjusted for lifestyle characteristics but decreased substantially when adjusted for somatic health status (in particular physical frailty).

Conclusions

In particular, depressive disorder is associated with excess mortality in people below 60 years, independent of their lifestyle. This effect seems partly explained by multimorbidity and frailty, which suggest that chronic disease management of depression-associated somatic morbidity needs to be (further) improved.

A Heteromeric Carboxylic-acid-based Single Crystalline Crosslinked Organic Framework

The development of large pore single-crystalline covalently linked organic frameworks is critical in revealing the detailed structure-property relationship with substrates. One emergent approach is to photo-crosslink hydrogen-bonded molecular crystals. Introducing complementary hydrogen-bonded carboxylic acid building blocks is promising to construct large pore networks, but these molecules often form interpenetrated networks or non-porous solids. Herein, we introduced heteromeric carboxylic acid dimers to construct a non-interpenetrated molecular crystal. Crosslinking this crystal precursor with dithiols afforded a large pore single-crystalline hydrogen-bonded crosslinked organic framework HCOF-101. X-ray diffraction analysis revealed HCOF-101 as an interlayer connected hexagonal network, which possesses flexible linkages and large porous channels to host a hydrazone photoswitch. Multicycle Z/E-isomerization of the hydrazone took place reversibly within HCOF-101, showcasing the potential use of HCOF-101 for optical information storage.

Subtypes of Late-Life Depression: A Data-Driven Approach on Cognitive Domains and Physical Frailty

BACKGROUND

With increasing age, symptoms of depression may increasingly overlap with age-related physical frailty and cognitive decline. We aim to identify late-life-related subtypes of depression based on measures of depressive symptom dimensions, cognitive performance, and physical frailty.

METHODS

A clinical cohort study of 375 depressed older patients with a DSM-IV depressive disorder (acronym NESDO). A latent profile analysis was applied on the three subscales of the Inventory of Depressive Symptomatology, as well as performance in five cognitive domains and two proxies for physical frailty. For each class, we investigated remission, dropout, and mortality at 2-year follow-up as well as change over time of depressive symptom severity, cognitive performance, and physical frailty.

RESULTS

A latent profile analysis model with five classes best described the data, yielding two subgroups suffering from pure depression ("mild" and "severe" depression, 55% of all patients) and three subgroups characterized by a specific profile of cognitive and physical frailty features, labeled as "amnestic depression," "frail-depressed, physically dominated," and "frail-depressed, cognitively dominated." The prospective analyses showed that patients in the subgroup of "mild depression" and "amnestic depression" had the highest remission rates, whereas patients in both frail-depressed subgroups had the highest mortality rates.

CONCLUSIONS

Late-life depression can be subtyped by specific combinations of age-related clinical features, which seems to have prospective relevance. Subtyping according to the cognitive profile and physical frailty may be relevant for studies examining underlying disease processes as well as to stratify treatment studies on the effectiveness of antidepressants, psychotherapy, and augmentation with geriatric rehabilitation.

A multidimensional program including standing exercises, health education, and telephone support to reduce sedentary behavior in frail older adults: Randomized clinical trial

OBJECTIVES

The primary aim of this study was to evaluate the effect of a multidimensional program including home-based standing exercises, health education, and telephone support for the reduction of sedentary behavior in community-dwelling frail older adults. The secondary aim of this study was to evaluate the safety and adherence of the program.

STUDY DESIGN

A single-blind, randomized controlled trial.

METHODS

A total of 43 frail older adults were randomly assigned to the intervention and control groups. The intervention consisted of combined strategies including home-based standing exercises, health education, and telephone support for 16 weeks for frail older adults. The control group received orientation regarding the harmful effects of a sedentary lifestyle. Sedentary behavior was evaluated by total sedentary time, accumulated sedentary time in bouts of at least 10 min, and by the break in sedentary time, measured by an accelerometer used for at least 600 min/day for 4 days. Safety was assessed by self-reporting of possible adverse events. Adherence was assessed based on the number of days in which standing exercises were performed by the participants. Repeated measures ANOVA and Tukeys post hoc test were used to analyze the collected data.

RESULTS

The intervention group reduced the sedentary time by 30 min/day (p= 0.048), but without significant maintenance after 30 days of the program. Of the total number of participants, 82% (n = 14) of the intervention group participants showed more than 70% adherence to the program. The main adverse effects faced by the intervention group participants were tiredness (53%; n = 9) and lower limb pain (47%; n = 8).

CONCLUSIONS

The multidimensional program reduced sedentary behavior, was safe, and showed satisfactory adherence in frail older adults.

The association between cardiovascular risk factors and major cardiovascular diseases decreases with increasing frailty levels in geriatric outpatients

BACKGROUND

Frailty marks a process of increasing dysregulation of physiological systems which increases the risk of adverse health outcomes. This study examines the hypothesis that the association between multiple cardiovascular risk factors (CVRF) and cardiovascular diseases (CVD) becomes stronger with increasing frailty severity.

METHODS

Cross-sectional analysis of 339 older adults (55.2% women; aged 75.2 ± 9.1 years) from an outpatient geriatric clinic from a middle-income country. The frailty index (FI) was calculated as the proportion of 30 possible health deficits. We assessed hypertension, diabetes, obesity, dyslipidemia, sedentarism and smoking as CVRF (determinants) and myocardial infarction, stroke, heart failure as CVD. Poisson regression models adjusted for age, sex, and education was applied to estimate the association between frailty as well as CVRF (independent variables) with CVD (dependent variable).

RESULTS

Of the 339 patients, 18,3% were frail (FI ≥ 0.25) and 32.7% had at least one CVD. Both frailty and CVRF were significantly associated with CVD (PR = 1.03, 95% CI 1.01 to 1.05; p = 0.001, and PR = 1.46, 95% 1.24 to 1.71; p < 0.001, respectively) adjusted for covariates. The strength of the association between CVRF and CVD decreased with increasing frailty levels, as indicated by a significant interaction term of frailty and CVRF (p < 0.001).

CONCLUSION

Frailty and CVRF are both associated with CVD, but the impact of CVRF decreases in the presence of frailty. When confirmed in longitudinal studies, randomized controlled trials or causal inference methods like Mendelian randomization should be applied to assess whether a shift from traditional CVRF to frailty would improve cardiovascular outcome in the oldest old.