Hospital costs associated with depression in a cohort of older men living in Western Australia

BACKGROUND

There is lack of information of the hospital costs related to depression. Here, we compare the costs associated with general hospital admissions over 2 years between older men with and without a documented past history of depression.

METHODS

A community-based cohort of older men living in Perth, Western Australia, was assessed at baseline between 2001 and 2004 and followed up for 2 years by prospective data linkage. The participants were selected randomly from the Australia electoral roll. Two-year hospital costs were estimated.

RESULTS

Among 5411 patients, 75% of 339 men with depressive symptoms had at least one hospital admission compared with 61% of 5072 men without depression (P<.001). Two-year median hospital costs in the depressed group were A$4153 compared with A$1671 in participants free from depression (P<.001). In multivariate analysis, the presence of clinically significant depressive symptoms remained an independent predictor of higher cost [incident rate ratios (RR)=1.44, 95% confidence interval (CI): 1.23-1.68] and was associated with being a high-cost user of health services (RR=2.04, 95% CI: 1.43-2.92).

LIMITATIONS

The estimation of costs was solely based on the main diagnosis, potentially leading to underestimates of the real cost differences.

CONCLUSIONS

Hospital care cost was higher for older men with documented evidence of past depression than those without. The issue of depression in later life must be tackled if we want to optimize the use of limited hospital resources available.

Oral contraception does not alter typical post-exercise interleukin-6 and hepcidin levels in females

OBJECTIVES

The post-exercise interleukin-6 (IL-6) and hepcidin response was investigated during the hormone-deplete and hormone-replete phases of an estradiol and progestogen regulated oral contraceptive cycle (OCC).

DESIGN

Counterbalanced, repeated measures cross-over study.

METHODS

Ten active female monophasic oral contraceptive pill (OCP) users completed two 40 min treadmill running trials at 75% of their pre-determined peak oxygen uptake velocity (vVO2peak). These trials were randomly performed in two specific phases of the OCC: (a) Day 2-4, representing a hormone-free withdrawal period (D-0); (b) Day 12-14, representing the end of the first week of active hormone therapy (D+7). Venous blood samples were drawn pre-, post- and 3h post-exercise.

RESULTS

In both trials, serum IL-6 was significantly elevated (p<0.05) immediately post-exercise, while serum hepcidin was significantly elevated (p<0.05) 3h post-exercise, with no significant differences recorded between trials.

CONCLUSIONS

These findings suggest that exercise performed during the different phases (D-0 vs. D+7) of a monophasic OCP regulated cycle does not alter exercise induced IL-6 or hepcidin production. As such, future studies looking to investigate similar variables post-exercise, may not need to 'control' for different phases of the OCC, provided participants are current monophasic OCP users.

Lower plasma testosterone or dihydrotestosterone, but not estradiol, is associated with symptoms of intermittent claudication in older men

OBJECTIVE

In men, testosterone (T) levels decline with age, and lower T predicts all-cause and cardiovascular mortality. However, the associations of T and its metabolites, dihydrotestosterone (DHT) and estradiol (E2), with symptomatic peripheral arterial disease remain unclear. We assessed associations of T, DHT and E2 with lower limb intermittent claudication in older men.

DESIGN

Cross-sectional study.

PARTICIPANTS

Community-dwelling men aged 70-89 years resident in Perth, Western Australia.

MEASUREMENTS

Intermittent claudication was ascertained by the Edinburgh Claudication Questionnaire. Early morning, plasma T, DHT and E2 were assayed using liquid chromatography-tandem mass spectrometry.

RESULTS

There were 268 men with intermittent claudication and 2435 without claudication or any leg pain. Men with nonspecific leg pain (n = 986) were excluded. After adjusting for age, smoking, BMI, waist/hip ratio, hypertension, dyslipidaemia, diabetes, creatinine and prevalent cardiovascular disease (CVD), higher T was associated with reduced risk of having claudication (per 1 SD increase, odds ratio [OR] = 0·80, 95% confidence interval [CI] = 0·69-0·94, P = 0·006; quartiles, Q4/Q1, OR = 0·54, 95% CI = 0·36-0·81). Higher DHT was associated with reduced risk of having claudication (per 1 SD increase, OR = 0·86, 95% CI = 0·73-1·00, P = 0·048; Q4/Q1, OR = 0·64, 95% CI = 0·43-0·95). E2 was not associated with claudication (per 1 SD increase, OR = 0·96, 95% CI = 0·83-1·11, P = 0·565; Q4/Q1, OR = 0·88, 95% CI = 0·60-1·29).

CONCLUSIONS

Lower T or DHT levels, but not E2, are associated with symptoms of intermittent claudication in older men. Reduced exposure to androgens may represent a causal factor or biomarker for symptomatic peripheral arterial disease. Further studies are needed to examine underlying mechanisms and evaluate therapeutic options in ageing men.

Higher free thyroxine levels are associated with all-cause mortality in euthyroid older men: the Health In Men Study

OBJECTIVE

Thyroid dysfunction predicts poorer health outcomes, but the relationship between thyroid hormone levels within the reference range and mortality in older adults remains unclear. In this study, we examined the associations between the concentrations of free thyroxine (FT4) and TSH and all-cause mortality in older men without thyroid disease.

SUBJECTS AND METHODS

We performed a longitudinal study in community-dwelling men aged 70-89 years. Men with thyroid disease or taking thyroid-related medications were excluded. Baseline FT4 and TSH levels were assayed. Incident deaths were ascertained using data linkage.

RESULTS

There were 3885 men without thyroid disease followed for (means.d.) 6.41.5 years, during which time 837 had died (21.5%). men who had died had higher baseline ft4 levels (16.22.3 vs 15.82.1 pmol/l, p0.001), but comparable tsh levels (2.41.5 vs 2.31.5 miu/l, P=0.250). After accounting for age, smoking, physical factors and medical comorbidities, higher circulating ft4 levels predicted all-cause mortality (quartile Q4 vs quartiles Q1Q3: FT4 levels ≥ 17.32 vs <17.32 pmol/l: adjusted hazard ratio (HR)=1.19, 95% CI=1.02-1.39, P=0.025). TSH levels did not predict mortality. After excluding men with subclinical hyperthyroidism or hypothyroidism, there were 3442 men and 737 who had died (21.4%). In these men, higher FT4 levels remained independently associated with all-cause mortality (quartile Q4 vs quartiles Q1-Q3: adjusted HR=1.19, 95% CI=1.02-1.41, P=0.032).

CONCLUSIONS

Higher FT4 levels are associated with all-cause mortality in euthyroid older men, independently of conventional risk factors and medical comorbidities. Additional research is needed to determine whether or not this relationship is causal and to clarify the utility of thyroid function testing to stratify mortality risk in ageing men.

Low vitamin D status is an independent predictor of increased frailty and all-cause mortality in older men: the Health in Men Study

CONTEXT AND OBJECTIVE

Hypovitaminosis D and frailty are common in the older population. We aimed to determine whether 25-hydroxyvitamin D [25(OH)D] concentrations are associated with frailty and mortality.

DESIGN

We conducted a prospective cohort study.

SETTING AND PARTICIPANTS

Participants included 4203 older men aged 70-88 years in Perth, Western Australia.

MAIN OUTCOME MEASURES

25(OH)D was measured by immunoassay. Frailty was assessed with the 5-point FRAIL (fatigue, resistance, ambulation, illness, and loss of weight) scale. Mortality was determined from the death registry via the Western Australian Data Linkage System.

RESULTS

At baseline, 676 (16.1%) men were frail, as defined by having ≥3 deficits (FRAIL scale ≥ 3). In multivariate cross-sectional analysis, low vitamin D status, defined by the lowest quartile of 25(OH)D values (<52.9 nmol/L), was associated with increased prevalent frailty (odds ratio, 1.96; 95% confidence interval [CI], 1.52 to 2.52) in comparison to the highest quartile of 25(OH)D values (>81.6 nmol/L). After a mean period of 5.3 years, the adjusted odds ratio of being frail at follow-up for men with low vitamin D and having zero deficit at baseline (FRAIL scale = 0) was 1.56 (95% CI, 1.07 to 2.27). Low vitamin D also predicted all-cause mortality over a period of up to 9.2 years (hazard ratio, 1.20; 95% CI, 1.02 to 1.42), independent of baseline frailty and other covariates.

CONCLUSION

Hypovitaminosis D is associated with prevalent and incident frailty in older men. Hypovitaminosis D also predicts all-cause mortality, independent of frailty. The association between vitamin D and mortality is not solely dependent on the occurrence of frailty.

Associations of insulin-like growth factor-I and its binding proteins and testosterone with frailty in older men

OBJECTIVE

Ageing is associated with frailty and decreased anabolic hormones, insulin-like growth factor-I (IGF-I) and testosterone. We hypothesized that components of the IGF-I system, in conjunction with testosterone, modulate frailty risk in the elderly. We examined associations between IGF-I, its binding proteins IGFBP1 and IGFBP3 and testosterone with frailty in men.

DESIGN

Observational study of 3 447 community-dwelling men aged 70-89 years assessed in 2001-04, with 1 654 reassessed in 2008-09.

METHODS

Baseline total IGF-I, IGFBP1, IGFBP3 and testosterone were assayed. Frailty was assessed using the FRAIL scale, comprising 5 domains: fatigue; difficulty climbing stairs; difficulty walking >100 m; >5 illnesses; weight loss >5%. Men with ≥ 3 domains were considered frail.

RESULTS

At baseline, 527 men (15·3%) were frail. Frail men had lower IGFBP3 (3 630 ng/ml vs not frail: 3 800 ng/ml, P < 0·001) and comparable IGFBP1 (23·5 vs 21·5 ng/ml, P = 0·09). In multivariate analyses, higher IGFBP1 was associated with increased prevalence of frailty (highest vs lowest quartile Q4:Q1, adjusted odds ratio [OR] = 1·39, 95% CI = 1·03-1·88). New-onset frailty arose in 260 (17·5%) of 1 484 men. Lower baseline IGF-I predicted new-onset frailty (Q1:Q4 OR = 1·48, 95% CI = 1·00-2·20) as did higher IGFBP1 (Q4:Q1 OR = 1·59, 95% CI = 1·01-2·50). Men with both IGF-I and free testosterone in Q1 had greater odds of prevalent frailty (OR = 2·13, 95% CI = 1·54-2·95).

CONCLUSIONS

Older men with higher IGFBP1 level, or both lower IGF-I and testosterone, are more likely to be frail, while those with lower IGF-I and higher IGFBP1 are more likely to become frail. Components of the IGF-I system may be biomarkers or independent predictors of frailty.

Is hypovitaminosis D associated with abdominal aortic aneurysm, and is there a dose-response relationship?

OBJECTIVE

This study aims to investigate the association between plasma 25-hydroxyvitamin D (25(OH)D) concentrations with the presence of abdominal aortic aneurysm (AAA) and aortic diameter.

DESIGN

An observational study of 4233 community-dwelling men aged 70-88 years, who participated in a randomised controlled trial of screening for AAA.

METHODS

Infrarenal aortic diameter measured by ultrasound and 25(OH)D by immunoassay.

RESULTS

A total of 311 men (7.4%) with AAA (defined as aortic diameter ≥ 30 mm) comprised the study. Multivariable models were adjusted for age, smoking, cardiovascular disease, hypertension, diabetes, dyslipidaemia, body mass index and serum creatinine concentration. Amongst men with the lowest 25(OH)D quartile of values compared with the highest quartile, the adjusted odds ratio of having an AAA increased in a graded fashion from 1.23 (95% confidence interval (CI) 0.87-1.73) for AAA ≥ 30 mm to 5.42 (95% CI 1.85-15.88) for AAA ≥ 40 mm. Similarly, there was a dose-response relationship between 25(OH)D concentrations and the size of the AAA: every 10-nmol l(-1) decrease in 25(OH)D levels was associated with 0.49 mm (95% CI 0.11-0.87) increase in mean aortic diameter.

CONCLUSIONS

Low vitamin D status is associated with the presence of larger AAA in older men, and there is a graded inverse relationship between 25(OH)D concentrations and AAA diameter. Further research is needed to clarify the mechanisms underlying these associations.

Cardiovascular diseases do not influence the mental health outcome of older men with depression over 6 years

BACKGROUND

The concept of 'vascular depression' implies that cardiovascular disease facilitates the onset or persistence of depression in later life, and that the natural course of depression should differ according to whether or not vascular pathology is present.

METHODS

Population-based cohort of 431 older men were diagnosed with depression (prevalent cases) and followed for up to 6 years. We used the Western Australian Data Linkage System to establish the presence of cardiovascular disease (CVD, documented history of coronary heart disease or stroke) and subsequent persistence or recurrence of depression during follow up (ICD-10 codes). Other measures recorded: age, place of birth, education, social support and disadvantage, smoking history, sensory impairment, medical morbidity burden and use of antidepressants.

RESULTS

The age of participants ranged from 69 to 86 years and CVD was present in 212 (49.2%) of them. Depressed men with and without CVD had a similar distribution of demographic, lifestyle, social and clinical factors as men without CVD, but higher medical morbidity. One hundred and twenty six (29.2%) men died and another 43 had a recorded diagnosis of depressive disorder between the baseline assessment and the 31st December 2007. Compared with participants without CVD, the adjusted hazard ratio of recurrent or persistent depression during follow up for participants with CVD was 0.78 (95% confidence interval, 95% CI=0.43-1.42). An additional 30 men were identified with depression during a new clinical assessment in 2008-09. Logistic regression showed that the adjusted odds of depression for men with compared to those without CVD was 0.98 (95% CI=0.61-1.59).

CONCLUSION

Persistence or recurrence of symptoms over 6 years in older men with depression is not influenced by the presence of CVD, which raises doubts about the usefulness and validity of the concept of vascular depression.

Association between depression and hospital outcomes among older men

BACKGROUND

Studies that have investigated the relation between depression and the type, nature, extent and outcome of general hospital admissions have been limited by their retrospective designs and focus on specific clinical populations. We explored this relation prospectively in a large, community-based sample of older men.

METHODS

A cohort of 5411 men aged 69 years and older enrolled in the Health in Men Study was assessed at baseline for depressive symptoms, defined as a score of 7 or higher on the 15-item Geriatric Depression Scale. Participants were followed for 2 years for occurrence and number of hospital admissions, type of hospital admission, length of hospital stay and inpatient death as recorded in the Western Australian Data Linkage System.

RESULTS

Of 339 men with depressive symptoms, 152 (44.8%) had at least 1 emergency hospital admission, compared with 1164 of 5072 (22.9%) nondepressed men (p < 0.001). In multivariate analyses, the presence of depressive symptoms was a significant independent predictor of hospital admission (hazard ratio 1.67, 95% confidence interval [CI] 1.38-2.01), number of hospital admissions (incidence rate ratio [IRR] 1.22, 95% CI 1.07-1.39) and total length of hospital stay (IRR 1.65, 95% CI 1.36-2.01).

INTERPRETATION

Participants with depressive symptoms were at higher risk of hospital admission for nonpsychiatric conditions and were more likely to have longer hospital stays and worse hospital outcomes, compared with nondepressed participants. These results highlight the potential to target this high-risk group to reduce the burden of health care costs in an aging population.

Higher free thyroxine levels predict increased incidence of dementia in older men: the Health in Men Study

CONTEXT

Both hypothyroidism and subclinical hyperthyroidism hinder cognitive function.

OBJECTIVE

We aimed to determine whether more subtle alterations of thyroid hormone levels predict increased incidence of dementia in aging men.

PARTICIPANTS AND DESIGN

Community-dwelling men aged 70-89 yr participated in this prospective longitudinal study.

MAIN OUTCOME MEASURES

The Standardized Mini-Mental State Examination was performed at baseline (2001-2004), and circulating TSH and free T(4) (FT(4)) were assayed. Men with known thyroid disease or dementia, or Standardized Mini-Mental State Examination scores below 24 were excluded from follow-up. New-onset dementia, defined by International Classification of Disease (ICD) codes, was ascertained using data linkage (2001-2009).

RESULTS

During follow-up, 145 of 3401 men (4.3%) were diagnosed for the first time with dementia. Men who developed dementia had higher baseline FT(4) (16.5 ± 2.2 vs. 15.9 ± 2.2 pmol/liter, P = 0.004) but similar TSH (2.2 ± 1.4 vs. 2.3 ± 1.6 mU/liter, P = 0.23) compared with men who did not receive this diagnosis. After adjusting for covariates, higher FT(4) predicted new-onset dementia (11% increased risk per 1 pmol/liter increase in FT(4), P = 0.005; quartiles Q2-4 vs. Q1: adjusted hazard ratio = 1.76, 95% confidence interval = 1.03-3.00, P = 0.04). There was no association between TSH quartiles and incident dementia. When the analysis was restricted to euthyroid men (excluding those with subclinical hyper- or hypothyroidism), higher FT(4) remained associated with incident dementia (11% increase per unit increment, P = 0.03; Q2-4 vs. Q1: adjusted hazard ratio = 2.02, 95% confidence interval = 1.10-3.71, P = 0.024).

CONCLUSIONS

Higher FT(4) levels predict new-onset dementia in older men, independently of conventional risk factors for cognitive decline. Additional studies are needed to explore potential underlying mechanisms and to clarify the utility of thyroid function testing in older men at risk of dementia.

Reference ranges and determinants of testosterone, dihydrotestosterone, and estradiol levels measured using liquid chromatography-tandem mass spectrometry in a population-based cohort of older men

CONTEXT

Testosterone (T) levels decline with increasing age. Controversy exists over the threshold for classifying T as low vs. normal in older men. The relevance of assessing dihydrotestosterone (DHT) and estradiol (E2) remains unclear.

OBJECTIVE

We assessed the associations of T, DHT, and E2 in men aged 70 yr or older and established reference ranges for these in healthy older men.

PARTICIPANTS

Community-dwelling men aged 70-89 yr residing in Perth, Western Australia, Australia, participated in the study.

MAIN OUTCOME MEASURES

Plasma T, DHT, and E2 were assayed using liquid chromatography-tandem mass spectrometry in early morning samples from 3690 men.

RESULTS

Increasing age, higher body mass index and waist to hip ratio, dyslipidemia, diabetes, and higher LH were independently associated with lower levels of T and DHT. Increasing age, diabetes, and higher LH were associated with lower E2. In a reference group of 394 men aged 76.1 ± 3.2 yr reporting excellent or very good health with no history of smoking, diabetes, cardiovascular disease, cancer, depression, or dementia, the 2.5th percentile for T was 6.4 nmol/liter (184 ng/dl); DHT, 0.49 nmol/liter; and E2, 28 pmol/liter. Applying these cutoffs to all 3690 men, those with low T or DHT had an increased odds ratio for frailty, diabetes, and cardiovascular disease. Men with both low T and DHT had a higher odds ratio for these outcomes.

CONCLUSIONS

The 2.5th percentile in a reference group of healthy older men provides age-appropriate thresholds for defining low T, DHT, and E2. Additional studies are needed to test their potential applicability and clinical utility in older men.

Do low testosterone levels contribute to ill-health during male ageing?

Testosterone regulates male sexual development and body composition. In adult men, testosterone levels exhibit a gradual decline with increasing age. Whether it is age per se or health and behaviour related factors that are responsible for this decline, and the implications thereof for subsequent health remain controversial. Observational studies report associations of lower testosterone levels with poorer health outcomes in ageing men, including frailty, reduced sexual activity, insulin resistance and cardiovascular events and mortality. However, outcome data from randomised clinical trials of testosterone are limited, and are lacking for major endpoints such as cardiovascular events. The risks and benefits of testosterone intervention in older men require further clarification. This article will review the role of testosterone in men, discuss epidemiological and interventional data illuminating its potential role to preserve health during male ageing, consider the limitations of the evidence base and implications for clinical practice, and explore future directions for research in this topical area.

Hormones and health outcomes in aging men

Increasing age is a predictor of ill-health and mortality related to cardiovascular disease and to frailty, a syndrome characterized by deterioration of multiple organ systems leading to loss of physiological reserve, diminished capacity to cope with stressors, and increased risk of disability and death. As men grow older, their levels of testosterone decline while the prevalence of ill-health increases. Observational studies have linked lower testosterone levels with cardiovascular disease and mortality in middle-aged and older men. More recently, lower testosterone has been shown to predict reduced sexual activity and frailty in aging men. Additional studies are needed to determine whether lower testosterone is a biomarker or a potentially treatable risk factor for poorer health outcomes in older men. During aging, the response of the pituitary-thyroid axis alters to manifest higher thyrotropin levels. The presences of subclinical hypo- and hyper-thyroidism predict adverse cardiovascular outcomes. Newer results indicate that in euthyroid older men, differences in free thyroxine levels within the normal range predict specific health outcomes including frailty. Clarification of the roles of endogenous testosterone and thyroxine in the genesis of ill-health during male aging offers the prospect of future intervention to preserve health and well-being in this growing population.

Aspirin decreases the risk of depression in older men with high plasma homocysteine

High total plasma homocysteine (tHcy) is associated with increased risk of cardiovascular events and depression. Consumption of B-vitamins (B6, B9 and B12) reduces tHcy by about 15%, but has equivocal effects on these health outcomes, suggesting that this relationship is either not causal or is confounded by other factors. The results of recent randomized trials suggest that antiplatelet therapy may confound these associations. This cross-sectional study assessed 3687 men aged 69-87 years for history of clinically significant depression (Geriatric Depression Scale 15 items 7) or a recorded diagnosis of depression in the Western Australian Data Linkage System, and collected information on the use of aspirin, B-vitamins and antidepressant medication, along with age, education, living arrangements, smoking history and medical comorbidity as assessed by the Charlson index. Participants donated a blood sample for the measurement of tHcy, and concentrations15 μmol l(-1) were considered high. Five hundred and thirteen (13.9%) men showed evidence of depression, and of those 31.4% had high tHcy, 41.5% were using aspirin, 6.8% were consuming B-vitamins. Multivariate logistic regression showed that high tHcy was associated with increased odds of depression (odds ratio (OR)=1.60, 95% confidence interval (CI)=1.20-2.14), as was the use of B-vitamins (OR=1.95, 95% CI=1.21-3.13). There was a significant interaction between high tHcy and aspirin use (OR=0.57, 95% CI=0.36-0.91), but not between high tHcy and B-vitamin use (OR=0.80, 95% CI=0.26-2.46). The analyses were adjusted for smoking status, Charlson index and use of antidepressants. The results of this study indicate that older men with high tHcy who use aspirin have lower risk of depression, and suggest that antiplatelet therapy may be an effective preventive or management strategy for these cases. Randomized trials are required to confirm the antidepressant effect of aspirin in people with high tHcy.

Elevated homocysteine is associated with poorer self-perceived physical health in older men: the Health in Men Study

OBJECTIVES

To determine the relationship between high total homocysteine (tHcy) and self-perceived physical health, by investigating the associations between tHcy, the methylenetetrahydrofolate reductase (MTHFR) 677T polymorphism and physical health-related quality of life (HRQOL).

STUDY DESIGN

We conducted a cross-sectional study using a cohort of 4248 community-dwelling men aged 70-88 years.

MAIN OUTCOME MEASURES

In addition to clinical determinants of physical health, tHcy was measured by immunoassay, the MTHFR 677T polymorphism was detected by a polymerase chain reaction (PCR)-based method, and physical HRQOL were assessed with the SF-36 Health Survey.

RESULTS

In multiple regression analyses, the odds of being in the lowest quartile of the physical component summary (PCS) scores (i.e. <35) was 1.47 (95% CI 1.21-1.78) for men with high tHcy (≥15 μmol/l), after adjusting for age, smoking, history of hazardous alcohol use, polypharmacy, prevalent falls and weighted Charlson co-morbidity index. When history of hypertension, heart disease, stroke, arthritis and osteoporosis were included in place of the Charlson's index, the result was unchanged (OR 1.45, 95% CI 1.20-1.75). Men with the MTHFR TT homozygosity had significantly higher tHcy concentration than those with the CC genotype (mean difference of 1.38 μmol/l, 95% CI 0.77-1.99). However, there was no apparent association between the MTHFR polymorphism and PCS.

CONCLUSION

Elevated tHcy is associated with poorer self-perceived physical health in community-dwelling older men. The results of this study support further longitudinal investigations to assess this relationship prospectively.

Higher free thyroxine levels are associated with frailty in older men: the Health In Men Study

OBJECTIVE

Frailty is common in the elderly and predisposes to ill-health. Some symptoms of frailty overlap those of thyroid dysfunction, but it is unclear whether differences in thyroid status influence risk of frailty. We evaluated associations between thyroid status and frailty in older men.

DESIGN

Cross-sectional epidemiological study.

PARTICIPANTS

Community-dwelling men aged 70-89 years.

MEASUREMENTS

Circulating thyrotropin (TSH) and free thyroxine (FT(4) ) were assayed. Frailty was assessed as ≥3 of the Fatigue, Resistance, Ambulation, Illnesses and Loss (FRAIL) scale's 5 domains: fatigue; resistance (difficulty climbing flight of stairs); ambulation (difficulty walking 100 m); illness (>5); or weight loss (>5%), blinded to hormone results.

RESULTS

Of 3943 men, 27 had subclinical hyperthyroidism, 431 subclinical hypothyroidism and 608 were classified as being frail (15·4%). There was an inverse log-linear association of TSH with FT(4). There was no association between TSH and frailty. After adjusting for covariates, men with FT(4) in the highest two quartiles had increased odds of being frail (Q3:Q1, odds ratio [OR] = 1·32, 95% confidence interval [CI] = 1·01-1·73 and Q4:Q1, OR = 1·36, 95% CI = 1·04-1·79, P = 0·010 for trend). Higher FT(4) was associated with fatigue (P = 0·038) and weight loss (P < 0·001). The association between FT(4) and frailty remained significant when the analysis was restricted to euthyroid men.

CONCLUSIONS

High-normal FT(4) level is an independent predictor of frailty among ageing men. This suggests that even within the euthyroid range, circulating thyroxine may contribute to reduced physical capability. Further studies are needed to clarify the utility of thyroid function testing and the feasibility of preventing or reversing frailty in older men.

Associations of total osteocalcin with all-cause and cardiovascular mortality in older men. The Health In Men Study

SUMMARY

In older men, both lower and higher total osteocalcin levels predict increased all-cause mortality, with comparable associations for cardiovascular and non-cardiovascular deaths. Differences in osteocalcin levels might influence glucose metabolism and thereby cardiovascular risk, or reflect changes in bone turnover thus representing a marker for poorer health outcomes.

INTRODUCTION

Reduced levels of total osteocalcin (TOC) are associated with adiposity, insulin resistance and type 2 diabetes, implying this bone-derived peptide might modulate cardiovascular risk. However, there are few longitudinal data relating TOC levels to survival. We examined associations of TOC level with all-cause and cardiovascular mortality in older men.

METHODS

We conducted a prospective cohort study of community-dwelling men aged 70-89 years. Aliquots of plasma collected at baseline (2001-2004) were assayed for TOC. Incidence and causes of death to 31 December 2008 were ascertained using data linkage. Cox regression analyses were performed with adjustment for conventional cardiovascular risk factors.

RESULTS

From 3,542 men followed for median 5.2 years there were 572 deaths (16.1%). Mortality was lowest in men with TOC levels in the second quintile (12.6%). In multivariate analyses, men with TOC in the lowest and highest quintiles of values had increased all-cause mortality (Q1 vs Q2: hazard ratio [HR], 1.36; 95% confidence interval 1.02-1.80 and Q5 vs Q2: HR, 1.53, 95% CI 1.18-1.98). Men with low TOC levels had similar HR for cardiovascular and non-cardiovascular deaths (Q1 vs Q2: HR, 1.35 and 1.30 respectively). Higher TOC levels predicted cardiovascular disease (CVD)-related mortality (Q5 vs Q2, HR, 1.69, 95% CI 1.09-2.64).

CONCLUSIONS

TOC predicts all-cause and CVD-related mortality in community-dwelling older men. However, the relationship is U shaped with men at both ends of the distribution at increased risk. Further investigation is required to clarify whether the underlying mechanisms involve altered bone turnover or relate specifically to the biological activity of osteocalcin.

Associations of IGF1 and its binding proteins with abdominal aortic aneurysm and aortic diameter in older men

OBJECTIVE

Abdominal aortic aneurysm (AAA) is most prevalent in older men. GH secretion declines with age resulting in reduced IGF1 levels. IGF1 and its binding proteins (IGFBPs) are expressed in vasculature, and lower IGF1 levels have been associated with cardiovascular risk factors and disease. However, the relationship of the IGF1 system with aortic dilation and AAA is unclear. We tested the hypothesis that circulating IGF1 and IGFBPs are associated with AAA and aortic diameter in older men.

DESIGN

A cross-sectional analysis involving 3981 community-dwelling men aged 70-89 years was performed.

METHODS

Abdominal aortic diameter was measured by ultrasound. Plasma total IGF1, IGFBP1 and IGFBP3 were measured by immunoassays.

RESULTS

After adjustment for age, body mass index, waist:hip ratio, smoking, hypertension, dyslipidemia, diabetes, coronary heart disease and serum creatinine, a higher IGF1 level was associated with AAA (odds ratio (OR)/1 s.d. increase 1.18, 95% confidence interval (CI) 1.05-1.33, P=0.006), as was the ratio of IGF1/IGFBP3 (OR=1.22, 95% CI 1.10-1.35, P<0.001). Highest IGF1 concentrations compared with lowest quintile were significantly associated with AAA (quintile (Q) 5 vs Q1: OR=1.80, 95% CI 1.20-2.70, P=0.004) as were IGF1/IGFBP3 ratios (Q5 vs Q1: OR=2.52, 95% CI 1.59-4.02, P<0.001). IGF1 and IGFBP1 were independently associated with aortic diameter (β=0.200, 95% CI 0.043-0.357, P=0.012 and β=0.274, 95% CI 0.098-0.449, P=0.002 respectively).

CONCLUSIONS

In older men, higher IGF1 and an increased ratio of IGF1/IGFBP3 are associated with AAA, while IGFBP1 is independently associated with increased aortic diameter. Components of the IGF1 system may contribute to, or be a marker for, aortic dilation in ageing men.

Low free testosterone predicts mortality from cardiovascular disease but not other causes: the Health in Men Study

CONTEXT

Low testosterone is associated with all-cause mortality, but the relationship with cause-specific mortality is uncertain.

OBJECTIVE

Our objective was to explore associations between testosterone and its related hormones and cause-specific mortality.

DESIGN

This was a population-based cohort study.

SETTING AND PARTICIPANTS

Demographic and clinical predictors of mortality, and testosterone, SHBG, and LH were measured from 2001-2004 in 3637 community-dwelling men aged 70-88 yr (mean, 77 yr).

MAIN OUTCOME MEASURE

Cause of death was obtained via electronic record linkage until December 31, 2008.

RESULTS

During a mean follow-up period of 5.1 yr, there were 605 deaths. Of these, 207 [34.2%; 95% confidence interval (CI) = 30.4-38.1%] were due to cardiovascular disease (CVD), 231 to cancer (38.2%; 95% CI = 34.3-42.1%), 130 to respiratory diseases (21.5%; 95% CI = 18.2-24.8%), and 76 to other causes (12.6%; 95% CI = 9.9-15.2%). There were 39 deaths attributable to both cancer and respiratory diseases. Lower free testosterone (hazard ratio = 1.62; 95% CI = 1.20-2.19, for 100 vs. 280 pmol/liter), and higher SHBG and LH levels were associated with all-cause mortality. In cause-specific analyses, lower free testosterone (sub-hazard ratio = 1.71; 95% CI = 1.12-2.62, for 100 vs. 280 pmol/liter) and higher LH predicted CVD mortality, while higher SHBG predicted non-CVD mortality. Higher total testosterone and free testosterone levels (sub-hazard ratio = 1.96; 95% CI = 1.14-3.36, for 400 vs. 280 pmol/liter) were associated with mortality from lung cancer.

CONCLUSIONS

Low testosterone predicts mortality from CVD but is not associated with death from other causes. Prevention of androgen deficiency might improve cardiovascular outcomes but is unlikely to affect longevity otherwise.

Complaints of difficulty to fall asleep increase the risk of depression in later life: the health in men study

OBJECTIVES

To determine if complaints of poor sleep are associated with incident depression in older men.

METHODS

Cohort study with an average follow up period of 6 years (range 3 months to 8.5 years). Participants were 5127 community-dwelling Western Australian older men aged 70-90 years who provided information about sleep problems. The primary outcome of interest of the study was a recorded diagnosis of depressive episode, recurrent depressive disorder or dysthymia in the Western Australian Data Linkage System. Participants completed a health questionnaire that included questions assessing difficulty falling asleep, remaining awake, as well as early morning awakening. Other measured factors included age, education, country of birth, living arrangements, social support, smoking, body mass index, and prevalent diabetes, hypertension, arthritis, chronic respiratory diseases, coronary artery disease, stroke, and cancer. Biochemical measurement of C-reactive protein, testosterone and plasma homocysteine were available for 3800 men.

RESULTS

We found that 60% of men reported at least one sleep problem and that the unadjusted hazard ratio (HR) of depression was higher in men who complained of difficulties to initiate sleep (HR = 2.19, 95% confidence interval--95% CI = 1.47-3.27) or who remained awake most of the night (HR = 1.94, 95% CI = 1.15-3.27). There was no association between early morning awakening and incident depression. The association between incident depression and subjective difficulty falling asleep remained after the analyses were adjusted for other measured factors (HR = 1.83, 95% CI = 1.20-2.79). The association between depression and remaining awake was no longer significant once the analyses were adjusted for confounding (HR = 1.43, 95% CI = 0.81-2.53). A sensitivity analysis confirmed these results.

LIMITATIONS

The evaluation of the exposure (sleep disturbance) was limited to self-rating questions that were not externally validated. The diagnosis of depression was based on administrative record linkage rather than structure clinical interviews. The observational nature of the study limits our ability to ascribe a causal relationship between complaints of poor sleep and incident depression.

CONCLUSIONS

Complaints of difficulty falling asleep increase the risk of incident depression in older men. Clarifying the mechanisms that underlie this association should become an international research priority, as they may contribute to guide interventions designed to decrease the burden of depression in later life.