Diabetes, inflammation, and functional decline in older adults: findings from the Health, Aging and Body Composition (ABC) study

OBJECTIVE

Age, diabetes, and elevated inflammatory markers independently increase the risk of functional decline. We examined the effect of C-reactive protein (CRP) and interleukin-6 (IL-6) on the incident mobility limitation in older adults with and without diabetes.

RESEARCH DESIGN AND METHODS

We analyzed data from a cohort of 2,895 well-functioning adults aged 70-79 years, followed for development of persistent functional limitation over 3.5 years. Participants were assessed for the presence of diabetes according to fasting glucose and/or hypoglycemic medication use and were divided into three equal groups (tertiles) according to level of CRP or IL-6. Persistent functional limitation was defined as difficulty climbing 10 steps or walking one-quarter mile on two consecutive semiannual assessments.

RESULTS

At baseline, 702 participants (24%) had diabetes. CRP values were (median +/- SD) 2.8 +/- 4.4 versus 3.7 +/- 5.4 for those with normal glucose and diabetes, respectively (P < 0.001). The unadjusted incidence of functional limitation associated with increased levels of CRP and IL-6 was greater among participants with diabetes. After adjusting for clinical and demographic covariates, persistent functional limitation for the highest tertile was greater compared with that for the lowest tertile of CRP or IL-6 for those with and without diabetes. CRP hazard ratios (HRs) were 1.7 (95% CI 1.2-2.3) versus 1.4 (1.1-1.6), respectively. IL-6 HRs were 1.8 (1.3-2.5) versus 1.6 (1.4-2.0), respectively.

CONCLUSIONS

In initially high-functioning older adults, those with diabetes and higher inflammatory burden had an increased risk of functional decline. Interventions at early stages to reduce inflammation may preserve function in these individuals.

Angiotensin-converting enzyme insertion/deletion genotype, exercise, and physical decline

CONTEXT

Physical performance in response to exercise appears to be influenced by the angiotensin-converting enzyme (ACE) insertion (I)/deletion (D) genotype in young adults, but whether this relationship could help explain variation in older individuals' response to exercise has not been well studied.

OBJECTIVE

To determine whether the ACE genotype interacts with significant physical activity to affect the incidence of mobility limitation in well-functioning older adults.

DESIGN, SETTING, AND PARTICIPANTS

The Health Aging and Body Composition (Health ABC) Cohort Study, conducted in the metropolitan areas of Memphis, Tenn, and Pittsburgh, Pa. A total of 3075 well-functioning community-dwelling adults aged 70 through 79 years were enrolled from 1997 to 1998 and had a mean of 4.1 years of follow-up.

MAIN OUTCOME MEASURE

Incident mobility limitation defined as the report of difficulty walking a quarter of a mile (0.4 km) or walking up 10 steps on 2 consecutive semiannual interviews (n = 1204).

RESULTS

Physically active participants (those reporting expending > or =1000 kcal/wk in exercise, walking, and stair climbing) were less likely to develop mobility limitation regardless of genotype. However, activity level interacted significantly with the ACE genotype (P = .002). In the inactive group, the ACE genotype was not associated with limitation (P = .46). In the active group, those with the II genotype were more likely to develop mobility limitation after adjusting for potential confounders compared with those with ID/DD genotypes (adjusted rate ratio, 1.45, 95% confidence interval, 1.08-1.94). The gene association was especially strong among participants reporting weightlifting. Exploration of possible physiological correlates revealed that among active participants, those with the II genotype had higher percentage of body fat (P = .02) and more intermuscular thigh fat (P = .02) but had similar quadriceps strength as those with ID/DD.

CONCLUSIONS

Among older individuals who exercised, those with the ACE DD or ID genotypes were less likely to develop mobility limitation than those with the II genotype. Regardless of genotype, individuals who exercised were less likely to develop mobility limitation than those who did not exercise.

Reliability of the 400-m usual-pace walk test as an assessment of mobility limitation in older adults

OBJECTIVES

To assess the test-retest reliability of the 400-m usual-pace walk test (400-MWT), and to determine whether the 4-m walk test predicts inability to walk 400 m.

DESIGN

Observational.

SETTING

Community, 20-m tract course.

PARTICIPANTS

Sixty study participants (aged>or=65) were enrolled from the community and met the following eligibility criteria: self-reported difficulty in two or more of four functional domains (mobility and exercise tolerance, upper extremity function, basic self-care, higher functional tasks of independent living) and a score of 18 or higher on the Mini-Mental State Examination.

METHODS

The 400-MWT and 4-m walk test were each repeated within 7 days.

RESULTS

The mean age+/-standard deviation of the study population was 84.3+/-6.3; 88.3% were women. Nineteen participants (31.7%) failed both 400-MWTs, and 41 successfully completed both tests (kappa=1). Mean walking speed for the 4-m test was 0.87+/-0.18 m/s for those who completed the 400-MWT and 0.53+/-0.17 m/s for those who failed (P<.001). The Spearman correlation coefficient between 4-m and 400-m walking speeds was 0.93. The estimated area under the receiver operating characteristic curve between 4-m walking speed and the ability to perform the 400-MWT was 0.91. The 4-m gait speed averaged less than 0.6 m/s in 80% of subjects who failed the 400-MWT.

CONCLUSION

The test-retest reliability for inability to complete the 400-MWT is high. Four-m walking speed is highly predictive of ability to perform the 400-MWT. These findings may prove useful to future clinical trials and observational studies that involve assessment of mobility limitations in older adults.

Inflammatory markers and cognition in well-functioning African-American and white elders

BACKGROUND

Several lines of evidence suggest that inflammatory mechanisms contribute to AD.

OBJECTIVE

To examine whether several markers of inflammation are associated with cognitive decline in African-American and white well-functioning elders.

METHODS

The authors studied 3,031 African-American and white men and women (mean age 74 years) enrolled in the Health, Aging, and Body Composition Study. Serum levels of interleukin-6 (IL-6) and C-reactive protein (CRP) and plasma levels of tumor necrosis factor-alpha (TNFalpha) were measured at baseline; cognition was assessed with the Modified Mini-Mental State Examination (3MS) at baseline and at follow-up. Cognitive decline was defined as a decline of >5 points.

RESULTS

In age-adjusted analyses, participants in the highest tertile of IL-6 or CRP performed nearly 2 points lower (worse) on baseline and follow-up 3MS (p < 0.001 for all) and declined by almost 1 point over the >2 years (p = 0.01 for IL-6 and p = 0.04 for CRP) compared with those in the lowest tertile. After multivariate adjustment, 3MS scores among participants in the highest tertile of IL-6 and CRP were similar at baseline but remained significantly lower at follow-up (p < or = 0.05 for both). Those in the highest inflammatory marker tertile were also more likely to have cognitive decline compared with the lowest tertile for IL-6 (26 vs 20%; age-adjusted odds ratio [OR] = 1.34; 95% CI 1.06 to 1.69) and for CRP (24 vs 19%; OR = 1.41; 95% CI 1.10 to 1.79) but not for TNFalpha (23 vs 21%; OR = 1.12; 95% CI 0.88 to 1.43). There was no significant interaction between race and inflammatory marker or between nonsteroidal anti-inflammatory drug use and inflammatory marker on cognition.

CONCLUSIONS

Serum markers of inflammation, especially IL-6 and CRP, are prospectively associated with cognitive decline in well-functioning elders. These findings support the hypothesis that inflammation contributes to cognitive decline in the elderly.

Determinants of an incorrect inhalation technique in patients with asthma or COPD

OBJECTIVE

To determine the prevalence of an incorrect inhalation technique and to examine its determinants among primary care patients with asthma or chronic obstructive pulmonary disease (COPD).

DESIGN

Cross-sectional study.

SETTING

28 general practitioners in The Netherlands.

SUBJECTS

558 asthma and COPD patients, aged 16-75 years.

MAIN OUTCOME MEASURES

Inhalation technique was assessed using a standardised inhaler-specific checklist. Pulmonary function assessment and questionnaires were used to collect data about inhaler, patient and disease characteristics.

RESULTS

Overall, 24.2% of the patients made at least one essential mistake in their inhalation technique. The type of inhaler appeared to be the strongest independent determinant of an incorrect inhalation technique. Compared to patients using the Diskhaler, patients using the Rotahaler/Spinhaler, Turbuhaler, Metered Dose Inhaler (MDI) or Cyclohaler/Inhaler-Ingelheim were at significantly higher risk of making inhalation mistakes (odds ratios (OR) were 16.08, 13.17, 11.60 and 3.27, respectively). Other significant determinants of an incorrect inhalation technique were low emotional quality of life (OR = 1.73) and being treated in a group practice (OR = 2.26).

CONCLUSIONS

An incorrect inhalation technique is common among pulmonary disease patients in primary care. Our study suggests that especially patients using the Rotahaler/Spinhaler, Turbuhaler or MDI, patients with emotional problems and patients in a group practice are at increased risk for an incorrect inhalation technique.

Physical exercise and the prevention of disability in activities of daily living in older persons with osteoarthritis

BACKGROUND

The prevention of disability in activities of daily living (ADL) may prolong older persons' autonomy (older persons are defined in this study as those aged > or =60 years). However, proved preventive strategies for ADL disability are lacking. A sedentary lifestyle is an important cause of disability. This study examines whether an exercise program can prevent ADL disability.

METHODS

A 2-center, randomized, single-blind, controlled trial was conducted in which participants were assigned to an aerobic exercise program, a resistance exercise program, or an attention control group. Of the 439 community-dwelling persons aged 60 years or older with knee osteoarthritis originally recruited, the 250 participants initially free of ADL disability were used for this study. Incident ADL disability, defined as developing difficulty in transferring from a bed to a chair, eating, dressing, using the toilet, or bathing, was assessed quarterly during 18 months of follow-up.

RESULTS

The cumulative incidence of ADL disability was lower in the exercise groups (37.1%) than in the attention control group (52.5%) (P =.02). After adjustment for demographics and baseline physical function, the relative risk of incident ADL disability for assignment to exercise was 0.57 (95% confidence interval, 0.38-0.85; P =.006). Both exercise programs prevented ADL disability; the relative risks were 0.60 (95% confidence interval, 0.38-0.97; P =.04) for resistance exercise and 0.53 (95% confidence interval, 0.33-0.85; P =.009) for aerobic exercise. The lowest ADL disability risks were found for participants with the highest compliance to exercise.

CONCLUSIONS

Aerobic and resistance exercise may reduce the incidence of ADL disability in older persons with knee osteoarthritis. Exercise may be an effective strategy for preventing ADL disability and, consequently, may prolong older persons' autonomy.

Treatment of isolated systolic hypertension is most effective in older patients with high-risk profile

BACKGROUND

Although present guidelines suggest that treatment of hypertension is more effective in patients with multiple risk factors and higher risk of cardiovascular events, this hypothesis was never verified in older patients with systolic hypertension.

METHODS AND RESULTS

Using data from the Systolic Hypertension in the Elderly Program, we calculated the global cardiovascular risk score according to the American Heart Association Multiple Risk Factor Assessment Equation in 4,189 participants free of cardiovascular disease (CVD) and in 264 participants with CVD at baseline. In the placebo group, rates of cardiovascular events over 4.5 years were progressively higher according to higher quartiles of CVD risk. The protection conferred by treatment was similar across quartiles of risk. However, the numbers needed to treat (NNTs) to prevent one cardiovascular event were progressively smaller according to higher cardiovascular risk quartiles. In participants with baseline CVD, the NNTs to prevent one cardiovascular event were similar to those estimated for CVD-free participants in the highest-risk quartile.

CONCLUSIONS

Treatment of systolic hypertension is most effective in older patients who, because of additional risk factors or prevalent CVD, are at higher risk of developing a cardiovascular event. These patients are prime candidates for antihypertensive treatment.

Determinants of different dimensions of disease severity in asthma and COPD : pulmonary function and health-related quality of life

OBJECTIVE

To identify determinants of pulmonary function and health-related quality of life (HRQOL) to better understand disease severity in patients with asthma and COPD.

DESIGN

Observational study.

SETTING

Dutch general practice.

PATIENTS

We studied 837 asthma patients and 231 COPD patients.

RESULTS

The association between pulmonary function and HRQOL was poor for asthma (beta = 0.10) and COPD (beta = 0.19). Multivariately, in asthma, lower pulmonary function was associated with male gender, region of living, current smoking, use of inhaled short-acting bronchodilators, longer duration of disease, and higher diurnal variation in peak expiratory flow. In COPD, lower pulmonary function was associated with male gender, use of inhaled bronchodilators, more days and nights disturbed by respiratory complaints, not wheezing, and bronchial hyperresponsiveness. Reduced HRQOL was associated most strongly with more days and nights disturbed by respiratory complaints and dyspnea in both asthma and COPD. In asthma, additional associations were found with younger age, lower educational level, region of living, comorbidity, use of inhaled bronchodilators and corticosteroids, wheezing, chronic cough, sputum production, and bronchial hyperresponsiveness. In COPD, lower age, not smoking, chronic cough, and sputum production were associated with reduced HRQOL.

CONCLUSIONS

Pulmonary function and HRQOL appear to highlight different aspects of disease severity in asthma and COPD. Therefore, both measures should be taken into account in order to get a complete picture of severity of disease.

Depression and cardiac mortality: results from a community-based longitudinal study

BACKGROUND

Depression may be a potential risk factor for subsequent cardiac death. The impact of depression on cardiac mortality has been suggested to depend on cardiac disease status, and to be stronger among cardiac patients. This study examined and compared the effect of depression on cardiac mortality in community-dwelling persons with and without cardiac disease.

METHODS

A cohort of 2847 men and women aged 55 to 85 years was evaluated for 4 years. Major depression was defined according to psychiatric DSM-III criteria. Minor depression was defined by Center for Epidemiologic Studies-Depression Scale scores of 16 or higher. Effects of minor and major depression on cardiac mortality were examined separately in 450 subjects with a diagnosis of cardiac disease and in 2397 subjects without cardiac disease after adjusting for demographics, smoking, alcohol use, blood pressure, body mass index, and comorbidity.

RESULTS

Compared with nondepressed cardiac patients, the relative risk of subsequent cardiac mortality was 1.6 (95% confidence interval [CI], 1.0-2.7) for cardiac patients with minor depression and 3.0 (95% CI, 1.1-7.8) for cardiac patients with major depression, after adjustment for confounding variables. Among subjects without cardiac disease at baseline, similar increased cardiac mortality risks were found for minor depression (1.5 [95% CI, 0.9-2.6]) and major depression (3.9 [95% CI, 1.4-10.9]).

CONCLUSION

Depression increases the risk for cardiac mortality in subjects with and without cardiac disease at baseline. The excess cardiac mortality risk was more than twice as high for major depression as for minor depression.

Coimpairments as predictors of severe walking disability in older women

OBJECTIVE

Severe disabilities are common among older people who have impairments in a range of physiologic systems. It is not known, however, whether the presence of multiple impairments, or coimpairments, is associated with increased risk of developing new disability. The aim of this study was to determine the combined effects of two impairments, decreased knee-extension strength and poor standing balance, on the risk of developing severe walking disability among older, moderately-to-severely disabled women who did not have severe walking disability at baseline.

DESIGN

The Women's Health and Aging Study is a 3-year prospective study with 6 semi-annual follow-up data-collection rounds following the baseline.

SETTING

At baseline, knee-extension strength and standing balance tests took place in the participants' homes.

PARTICIPANTS

758 women who were not severely walking disabled at baseline.

MEASUREMENTS

Severe walking disability was defined as customary walking speed of < 0.4 meters/second and inability to walk one quarter of a mile, or being unable to walk.

RESULTS

Over the course of the study, 173 women became severely disabled in walking. The cumulative incidence of severe walking disability from the first to the sixth follow-up was: 7.8%, 12.0%, 15.1% 19.5% 21.2%, and 22.8%. In Cox proportional hazards models, both strength and balance were significant predictors of new walking disability. In the best balance category, the rates of developing severe walking disability expressed per 100 person years were 3.1, 6.1, and 5.3 in the highest- to lowest-strength tertiles. In the middle balance category, the rates were 9.6, 13.2, and 14.7, and in the poorest balance category 21.6, 12.7, and 37.1, correspondingly. The relative risk (RR) of onset of severe walking disability adjusted for age, height, weight, and race was more than five times greater in the group with poorest balance and strength (RR 5.12, 95% confidence limit [95% CI] 2.68-9.80) compared with the group with best balance and strength (the reference group). Among those who had poorest balance and best strength, the RR of severe walking disability was 3.08 (95% CI 1.33-7.14). Among those with best balance and poorest strength, the RR was 0.97 (95% CI 0.49-1.93), as compared with the reference group.

CONCLUSION

The presence of coimpairments is a powerful predictor of new, severe walking disability, an underlying cause of dependence in older people. Substantial reduction in the risk of walking disability could be achieved even if interventions were successful in correcting only one of the impairments because a deficit in only one physiologic system may be compensated for by good capacity in another system.

Changes in depression and physical decline in older adults: a longitudinal perspective

BACKGROUND

The impact of chronicity and changes in depression on physical decline over time in older persons has not been elucidated.

METHODS

This prospective cohort study of 2121 community-dwelling persons aged 55-85 years uses two measurement occasions of depression (CES-D scale) over 3 years to distinguish persons with chronic, remitted, or emerging depression and persons who were never depressed. Physical function is assessed by self-reported physical ability as well as by observed performance on a short battery of tests.

RESULTS

After adjustment for baseline physical function, health status and sociodemographic factors, chronic depression was associated with significantly greater decline in self-reported physical ability over 3 years when compared to never depressed persons (odds ratio (OR)=2.83, 95% confidence interval (CI)=1.86-4. 30). In the oldest old, but not in the youngest old, chronic depression was also significantly predictive of greater decline in observed physical performance over 3 years (OR=2.22, 95% CI=1.43-3. 79). Comparable effects were found for older persons with emerging depression. Persons with remitted depression did not have greater decline in reported physical ability or observed performance than persons who were never depressed.

CONCLUSIONS

Our findings among community-dwelling older persons show that chronicity of depression has a large impact on physical decline over time. Since persons with remitted depression did not have greater physical decline than never depressed persons, these findings suggest that early recognition and treatment of depression in older persons could be protective for subsequent physical decline.

Lower extremity performance in nondisabled older persons as a predictor of subsequent hospitalization

BACKGROUND

This study examines, in initially nondisabled older persons, the impact of reduced lower extremity performance on subsequent hospitalizations.

METHODS

A 4-year prospective cohort study was conducted among 3381 persons, aged 71 years and older, who initially reported no disability. At baseline, lower extremity performance was measured by an assessment of standing balance, a timed 2.4-m walk, and a timed test of rising from a chair five times. Data on subsequent hospital admissions and discharge diagnoses over 4 years were obtained from the Medicare database.

RESULTS

During the follow-up period, nondisabled persons with poor lower extremity performance spent significantly more days in the hospital (17.7 days) than those with intermediate and high performance (11.6 and 9.7 days, respectively). Poor lower extremity performance in nondisabled persons significantly predicted subsequent hospitalization over 4 years (relative risk for hospitalization in those with poor vs high performance: 1.78; 95% confidence interval, 1.45-2.17). This increased hospitalization risk could not be explained by several indicators of baseline health status. Increased hospitalization risks were especially found for geriatric conditions, such as dementia, decubitus ulcer, hip fractures, other fractures, pneumonia, dehydration, and acute infections.

CONCLUSIONS

Even in persons who are currently nondisabled, a simple measure of lower extremity performance is predictive of subsequent hospitalization, especially for geriatric conditions.

The protective effect of emotional vitality on adverse health outcomes in disabled older women

OBJECTIVE

Although the adverse physical health consequences of negative emotions have been studied extensively, much less is known about the potential impact of positive emotions. This study examines whether emotional vitality protects against progression of disability and mortality in disabled older women.

DESIGN

A community-based study, The Women's Health and Aging Study.

PARTICIPANTS

A total of 1002 moderately to severely disabled women aged 65 years and older living in the community.

MEASUREMENTS

Emotional vitality was defined as having a high sense of personal mastery, being happy, and having low depressive symptomatology and anxiety. The onset of new disability was determined by semiannual assessments of disability in performing activities of daily living (ADLs), walking across a room, walking 1/4 mile, and lifting/carrying 10 pounds. Mortality status was determined by proxy interviews and linkage with death certificates. Survival analyses with time to onset of specific disabilities (among those not disabled at baseline) and time to mortality were performed and adjusted for age, baseline level of difficulty, physical performance, and chronic conditions.

RESULTS

Three hundred fifty-one of the 1002 older disabled women studied were emotionally vital. Among women without the specific disability at baseline, emotional vitality was associated with a significantly decreased risk for incident disability performing ADLs (RR = 0.81, 95% CI = 0.66-0.99), for incident disability walking one-quarter mile (RR = 0.73, 95% CI = 0.59-0.92), and for incident disability lifting/carrying 10 pounds (RR = 0.77, 95% CI = 0.63-0.95). Emotional vitality was also associated with a lower risk of dying (RR = 0.56, 95% CI = 0.39-0.80). These results were not simply caused by the absence of depression since protective health effects remained when emotionally vital women were compared with 334 women who were not emotionally vital and not depressed.

CONCLUSIONS

Emotional vitality in older disabled women reduces the risk for subsequent new disability and mortality. Our findings suggest that positive emotions can protect older persons against adverse health outcomes.

[Effects of depression on physical health and mortality in the elderly. Longitudinal results of the LASA research]

This longitudinal study examines the physical health consequences of depression among 3107 older persons (55-85 years). Major depression was defined according to DSM-III criteria in a psychiatric interview. Minor depression was defined by a Center for Epidemiologic Studies Depression score > or = 16. Health consequences were assessed by 3-year change in self-reported functional status, 3-year change in performance on objective tests, and risk of death over 4.5 years. At baseline, 12.8% of the older persons had minor depression and 2.0% major depression. Minor depression was associated with a significantly greater decline in functional status and performance and, only in men but not in women, with an increased risk of death. Major depression also increases decline in functional status and the risk of death (irrespective of sex), but was not associated with decline in physical performance. These results show that late-life depression has strong unfavorable physical health consequences. The consequences of minor depression are comparable with those of major depression.

Association of depression and gender with mortality in old age. Results from the Amsterdam Study of the Elderly (AMSTEL)

BACKGROUND

The association between depression and increased mortality risk in older persons may depend on the severity of the depressive disorder and gender.

AIMS

To investigate the association between major and mild depressive syndromes and excess mortality in community-living elderly men and women.

METHOD

Depression (Geriatric Mental State AGECAT) was assessed in 4051 older persons, with a 6-year follow-up of community death registers. The mortality risk of neurotic and psychotic depression was calculated after adjustment for demographic variables, physical illness, cognitive decline and functional disabilities.

RESULTS

A total of 75% of men and 41% of women with psychotic depression had diet at follow-up. Psychotic depression was associated with significant excess mortality in both men and women. Neurotic depression was associated with a 1.67-fold higher mortality risk in men only.

CONCLUSIONS

In the elderly, major depressive syndromes increase the risk of death in both men and women, but mild depression increases the risk of death only in men.

Characteristics of nondisabled older persons who perform poorly in objective tests of lower extremity function

OBJECTIVES

It has been suggested that nondisabled older persons with poor performance of lower extremity function are ideal targets for interventions of disability prevention. However, health-related factors associated with poor performance are largely unknown. Using data from a representative sample of nondisabled older persons, this study identifies the diseases and biological markers that characterize this group of the population.

DESIGN AND PARTICIPANTS

A total of 3,381 persons aged 71 or older, interviewed and administered a battery of physical performance tests at the sixth annual follow-up of the Established Populations for Epidemiologic Studies of the Elderly (EPESE), who reported no need for help in walking 1/4 mile or climbing stairs.

MEASUREMENTS

Lower extremity performance was measured using a short battery of tests including assessment of standing balance, a timed 2.4-m walk, and timed test of rising 5 times from a chair. Chronic conditions were ascertained as self-report of a physician diagnosis. Data on previous hospitalizations were obtained from the Medicare database. Nonfasting blood samples were obtained and processed with standard methods.

RESULTS

In a multivariate analysis, older age, female gender, higher BMI, history of hip fracture and diabetes, one or more hospital admissions for acute infection in the last 3 years, lower levels of hemoglobin and albumin, and higher leukocytes and gamma-glutamyl transferase were all associated independently with poor performance.

CONCLUSIONS

Screening for older patients who are not disabled but have poor lower extremity performance selects a subgroup of the population with a high percentage of women, high prevalence of diabetes and hip fracture, and high levels of biological markers of inflammation. This group represents about 10% of the US population 70 to 90 years old. These findings should be considered in planning specifically tailored interventions for disability prevention in this subgroup.

Depressed mood and body mass index as predictors of muscle strength decline in old men

OBJECTIVE

To study depressed mood as a predictor of strength decline within body weight categories over a 3-year follow-up period.

DESIGN

A prospective cohort study over 3 years.

SETTING

Honolulu, Hawaii.

PARTICIPANTS

The subjects were 2275 men participating in the Honolulu Heart Program with an average age of 77.1 years (range 71-92 years), who were not cognitively impaired at baseline (Exam 4), and who participated in maximal hand grip strength measurements at baseline and 3 years later (Exam 5).

MEASUREMENTS

Hand grip strength was measured using a dynamometer. Depressive symptoms were studied using an 11-item version of Center for Epidemiologic Studies Depression Scale with 9 as a cutoff. Body weight categories were formed on the basis of body mass index (BMI) (BMI = weight/height2; underweight: BMI < 20; normal weight: BMI 20-24.99, overweight: BMI > or = 25).

MAIN RESULTS

At baseline, 9.4% of the participants were rated as having depressed mood. The mean individual strength change over 3 years was - 6.9% (standard deviation 14.0). Steep strength decline was determined as losing > or = 14% (lowest quartile). The proportions of those with steep strength decline in the groups based on combined distributions of BMI and depressed mood were: underweight/ depressed (n = 22) 41%, underweight/not depressed (n = 200) 28%, normal weight/depressed (n = 127) 30%, normal weight/not depressed (n = 1181) 25%, overweight/depressed (n = 55) 31%, overweight/not depressed (n = 675, referent) 21%. After adjusting for baseline strength, age, height, sociodemographic variables and diseases, the odds ratio for steep strength decline was more than four times greater among those who were depressed and underweight, and twice as great among people who were depressed and normal weight compared with those who were nondepressed and overweight. The risks of nondepressed under- and normal weight people and depressed overweight people did not differ from the reference group.

CONCLUSIONS

Depressed mood was associated with increased risk of steep strength decline, in particular in older men with low body weight. Low body weight in combination with depressed mood may be an indicator of frailty or severe disease status that leads to accelerated strength loss and disability.

Vitamin B(12) deficiency and depression in physically disabled older women: epidemiologic evidence from the Women's Health and Aging Study

OBJECTIVE

It has been hypothesized that adequate concentrations of vitamin B(12) and folate are essential to maintain the integrity of the neurological systems involved in mood regulation, but epidemiologic evidence for such a link in the general population is unavailable. This study examined whether community-dwelling older women with metabolically significant vitamin B(12) or folate deficiency are particularly prone to depression.

METHOD

Serum levels of vitamin B(12), folate, methylmalonic acid, and total homocysteine were assayed in 700 disabled, nondemented women aged 65 years and over living in the community. Depressive symptoms were measured by means of the Geriatric Depression Scale and categorized as no depression, mild depression, and severe depression.

RESULTS

Serum homocysteine levels, serum folate levels, and the prevalences of folate deficiency and anemia were not associated with depression status. The depressed subjects, especially those with severe depression, had a significantly higher serum methylmalonic acid level and a nonsignificantly lower serum vitamin B(12) level than the nondepressed subjects. Metabolically significant vitamin B(12) deficiency was present in 14.9% of the 478 nondepressed subjects, 17. 0% of the 100 mildly depressed subjects, and 27.0% of the 122 severely depressed women. After adjustment for sociodemographic characteristics and health status, the subjects with vitamin B(12) deficiency were 2.05 times as likely to be severely depressed as were nondeficient subjects.

CONCLUSIONS

In community-dwelling older women, metabolically significant vitamin B(12)deficiency is associated with a twofold risk of severe depression.

Caregiving arrangements of older disabled women, caregiving preferences, and views on adequacy of care

The role of women in caregiving to elderly people has focused primarily on their involvement as givers of care. In contrast, this article focuses on older women as recipients of caregiving. Data from the WHAS and the WHAS Caregiving Study are used to describe: the relationship of caregiving arrangements among moderately to severely disabled older women to sociodemographic, health and functional status; the characteristics of primary family caregivers and the assistance they provide; preferences for caregiving arrangements among both care recipients and caregivers; and views on adequacy of caregiving among older women cared for by family. Overall, about one quarter of these women had no caregiver, reflecting the inclusion in the WHAS of women with only moderate functional difficulty, but close to two-thirds relied on family members, and 15% on paid help only. Greater reliance on family was associated with being age 80 or older, black, and living with others. Women with poorer functioning--more ADL and IADL difficulties, difficulty taking medications without help, low cognitive functioning, not emotionally vital--also were significantly more likely to be cared for by family. Caregiving preferences varied among older women and their husband and daughter caregivers. Husbands consistently viewed in-home family help as the best caregiving arrangement regardless of levels of need. Older women and daughter caregivers both saw nursing homes as the best option for people with dementia and substantial care needs. One-quarter of elderly women chose in-home paid help as the best arrangement for meeting ADL/IADL needs. Older women generally held positive views of the assistance they received from family members. Younger women and lower income women were more likely to indicate they received less help than needed.

Sex differences in the prevalence of mobility disability in old age: the dynamics of incidence, recovery, and mortality

OBJECTIVES

This study examined sex differences in the prevalence of mobility disability in older adults according to the influences of three components of prevalence: disability incidence, recovery from disability, and mortality.

METHODS

Participants in a population-based study of older adults from three communities in the United States (N = 10,263) were studied for up to 7 years. Life table methods were used to estimate the influence of each of the three components of disability prevalence in women and men. Sex differences in probabilities for transition states were measured by relative risks derived from a single model using a Markov chain approach.

RESULTS

The proportion of disabled women increased from 22% of women aged 70 years to 81% of those aged 90 years. In men, comparable figures were 15% and 57%. Incidence had the greatest impact on the sex differences in disability prevalence until age 90 and older when recovery rates had a greater impact on differences in prevalence. Mortality differences in men and women had only a modest impact on sex differences in disability prevalence. These findings initially seemed to contradict striking sex differences observed in the relative risks for mortality in men compared with women. Subsequent graphical analyses showed that incidence rather than recovery or mortality largely accounted for sex differences in disability prevalence in old age.

CONCLUSION

Disability incidence, recovery from disability, and mortality dynamically influence the sex differences in the prevalence of mobility disability. However, incidence has the greatest impact overall on the higher prevalence of disability in women compared with men.

Racial differences in prevalence of cobalamin and folate deficiencies in disabled elderly women

BACKGROUND

Many previous investigations of cobalamin and folate status were performed in white populations.

OBJECTIVE

Our objective was to determine whether there are racial differences in the prevalence of cobalamin and folate deficiency.

DESIGN

The study was a cross-sectional comparison of baseline serum cobalamin, folate, methylmalonic acid (MMA), total homocysteine (tHcy), and creatinine concentrations, complete blood count, and vitamin supplementation in 550 white and 212 African American subjects from a cohort of physically disabled older women.

RESULTS

The mean (+/-SD) serum MMA concentration was significantly higher in whites than in African Americans: 284 +/- 229 compared with 218 +/- 158 nmol/L (P = 0.0001). tHcy concentration was higher in African Americans than in whites: 12.4 +/- 7.0 compared with 10.9 +/- 4.6 micromol/L (P = 0.001). Serum cobalamin was lower in whites (P = 0.0002). Cobalamin deficiency (serum cobalamin <258 pmol/L and MMA >271 nmol/L) was more frequent in the white women (19% compared with 8%; P < 0.0003). Folate deficiency (serum folate <11.4 nmol/L, tHcy >13.9 micromol/L, and MMA <271 nmol/L) was more prevalent in African Americans than in whites (5% compared with 2%; P = 0.01). Multivitamin use was associated with lower tHcy but not with MMA concentrations. Regression models showed that age >85 y, African American race, serum creatinine >90 micromol/L, and high MMA concentration were all significantly correlated with higher tHcy. Creatinine > 90 micromol/L, white race, and folate concentration were positively associated with MMA concentration.

CONCLUSIONS

Cobalamin deficiency with elevated serum MMA concentration is more prevalent in elderly white than in African American women and elevated serum tHcy and folate deficiency are more prevalent in elderly African American than in white women.

Minor and major depression and the risk of death in older persons

BACKGROUND

The association between depression and mortality in older community-dwelling populations is still unresolved. This study determined the effect of both minor and major depression on mortality and examined the role of confounding and explanatory variables on this relationship.

METHODS

A cohort of 3056 men and women from the Netherlands aged 55 to 85 years were followed up for 4 years. Major depression was defined according to DSM-III criteria by means of the Diagnostic Interview Schedule. Minor depression was defined as clinically relevant depression (defined by a Center for Epidemiologic Studies Depression score > or = 16) not fulfilling diagnostic criteria for major depression.

RESULTS

After adjustment for confounding variables (sociodemographics, health status), men with minor depression had a 1.80-fold higher risk of death (95% confidence interval, 1.35-2.39) during follow-up than nondepressed men. In women, minor depression did not significantly increase the mortality risk. Irrespective of sex, major depression was associated with a 1.83-fold higher mortality risk (95% confidence interval, 1.09-3.10) after adjustment for sociodemographics and health status. Health behaviors such as smoking and physical inactivity explained only a small part of the excess mortality risk associated with depression.

CONCLUSION

Even after adjustment for sociodemographics, health status, and health behaviors, minor depression in older men and major depression in both older men and women increase the risk of dying.

Exploring the effect of depression on physical disability: longitudinal evidence from the established populations for epidemiologic studies of the elderly

OBJECTIVES

This study examined the effect of depression on the incidence of physical disability and the role of confounding and explanatory variables in this relationship.

METHODS

A cohort of 6247 subjects 65 years and older who were initially free of disability was followed up for 6 years. Baseline depression was assessed by the Center for Epidemiological Studies Depression Scale. Disability in mobility and disability in activities of daily living were measured annually.

RESULTS

Compared with the 5751 nondepressed subjects, the 496 depressed subjects had a relative risk (95% confidence interval) of 1.67 (1.44, 1.95) and 1.73 (1.54, 1.94) for incident disability in activities of daily living and mobility, respectively. Adjustment for sociodemographic characteristics and baseline chronic conditions reduced the risks to 1.39 (1.18, 1.63) and 1.45 (1.29, 1.93), respectively. Less physical activity and fewer social contacts among depressed persons further explained part of their increased disability risk.

CONCLUSIONS

Depression in older persons may increase the risk for incident disability. This excess risk is partly explained by depressed persons' decreased physical activity and social interaction. The role of other factors (e.g., biological mechanisms) should be examined.