[A randomized clinical trial of falls and malnutrition prevention in community-dwelling elders aged 85 years old. The OCTABAIX study]

Functional and Cognitive Decline Is Associated With Increased Endothelial Cell Inflammation and Platelet Activation: Liquid Biopsy of Microvesicles in Community- Dwelling Octogenarians

Increased life expectancy is usually associated with comorbidities, such as cardio and cerebrovascular disease causing impaired functionality. A common underlying cause of these comorbidities is vascular inflammation and injury. Elevated levels of circulating microvesicles (cMV), as a product of a hemostatic and inflammatory cell activation, could be direct mapping of an imbalanced hemostasis. In this manuscript, we aimed to investigate by liquid biopsy whether successful aging can be discriminated by cMV levels and phenotype. To this purpose, we included 135 community-dwelling octogenarians in a cross-sectional study. Successful aging was defined as good functional (Barthel Index > 90 points, and Lawton index score > 7/4 points for women and men, respectively) and cognitive status (Spanish version of the Mini-Mental State Examination -MEC- > 24 points) and no need for institutionalization. Total, annexin V positive (AV⁺), and AV^– cMV from different cell origins from the vascular compartment were phenotypically characterized and quantified from fasting plasma samples by flow cytometry. Successful aging was associated with lower plasma concentrations of total and AV⁺ CD141⁺/CD41⁺-CD61⁺, and PAC1⁺/AV⁺, CD141⁺/AV⁺, and CD36⁺/AV^– cMV. From these phenotypes, ROC curve analyses revealed that CD141⁺/AV⁺ and CD141⁺/CD41⁺-CD61⁺/AV⁺ endothelial- and platelet-derived cMV discriminate successful and non-successful aging with an AUC (95%CI) of 0.655 (0.551, 0.758), P = 0.005, and 0.638 (0.535, 0.741), P = 0.013, respectively. In conclusion, successful aging is associated with low levels of cMV released by endothelial cells and platelets, indicating lower endothelial cell inflammation and platelet activation. Our results contribute to the understanding of the link between unsuccessful aging, cognitive decline and vascular cell inflammatory disturbances.

Multifactorial and multiple component interventions for preventing falls in older people living in the community

BACKGROUND

Falls and fall-related injuries are common, particularly in those aged over 65, with around one-third of older people living in the community falling at least once a year. Falls prevention interventions may comprise single component interventions (e.g. exercise), or involve combinations of two or more different types of intervention (e.g. exercise and medication review). Their delivery can broadly be divided into two main groups: 1) multifactorial interventions where component interventions differ based on individual assessment of risk; or 2) multiple component interventions where the same component interventions are provided to all people.

OBJECTIVES

To assess the effects (benefits and harms) of multifactorial interventions and multiple component interventions for preventing falls in older people living in the community.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature, trial registers and reference lists. Date of search: 12 June 2017.

SELECTION CRITERIA

Randomised controlled trials, individual or cluster, that evaluated the effects of multifactorial and multiple component interventions on falls in older people living in the community, compared with control (i.e. usual care (no change in usual activities) or attention control (social visits)) or exercise as a single intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risks of bias and extracted data. We calculated the rate ratio (RaR) with 95% confidence intervals (CIs) for rate of falls. For dichotomous outcomes we used risk ratios (RRs) and 95% CIs. For continuous outcomes, we used the standardised mean difference (SMD) with 95% CIs. We pooled data using the random-effects model. We used the GRADE approach to assess the quality of the evidence.

MAIN RESULTS

We included 62 trials involving 19,935 older people living in the community. The median trial size was 248 participants. Most trials included more women than men. The mean ages in trials ranged from 62 to 85 years (median 77 years). Most trials (43 trials) reported follow-up of 12 months or over. We assessed most trials at unclear or high risk of bias in one or more domains.Forty-four trials assessed multifactorial interventions and 18 assessed multiple component interventions. (I² not reported if = 0%).Multifactorial interventions versus usual care or attention controlThis comparison was made in 43 trials. Commonly-applied or recommended interventions after assessment of each participant's risk profile were exercise, environment or assistive technologies, medication review and psychological interventions. Multifactorial interventions may reduce the rate of falls compared with control: rate ratio (RaR) 0.77, 95% CI 0.67 to 0.87; 19 trials; 5853 participants; I² = 88%; low-quality evidence. Thus if 1000 people were followed over one year, the number of falls may be 1784 (95% CI 1553 to 2016) after multifactorial intervention versus 2317 after usual care or attention control. There was low-quality evidence of little or no difference in the risks of: falling (i.e. people sustaining one or more fall) (RR 0.96, 95% CI 0.90 to 1.03; 29 trials; 9637 participants; I² = 60%); recurrent falls (RR 0.87, 95% CI 0.74 to 1.03; 12 trials; 3368 participants; I² = 53%); fall-related hospital admission (RR 1.00, 95% CI 0.92 to 1.07; 15 trials; 5227 participants); requiring medical attention (RR 0.91, 95% CI 0.75 to 1.10; 8 trials; 3078 participants). There is low-quality evidence that multifactorial interventions may reduce the risk of fall-related fractures (RR 0.73, 95% CI 0.53 to 1.01; 9 trials; 2850 participants) and may slightly improve health-related quality of life but not noticeably (SMD 0.19, 95% CI 0.03 to 0.35; 9 trials; 2373 participants; I² = 70%). Of three trials reporting on adverse events, one found none, and two reported 12 participants with self-limiting musculoskeletal symptoms in total.Multifactorial interventions versus exerciseVery low-quality evidence from one small trial of 51 recently-discharged orthopaedic patients means that we are uncertain of the effects on rate of falls or risk of falling of multifactorial interventions versus exercise alone. Other fall-related outcomes were not assessed.Multiple component interventions versus usual care or attention controlThe 17 trials that make this comparison usually included exercise and another component, commonly education or home-hazard assessment. There is moderate-quality evidence that multiple interventions probably reduce the rate of falls (RaR 0.74, 95% CI 0.60 to 0.91; 6 trials; 1085 participants; I² = 45%) and risk of falls (RR 0.82, 95% CI 0.74 to 0.90; 11 trials; 1980 participants). There is low-quality evidence that multiple interventions may reduce the risk of recurrent falls, although a small increase cannot be ruled out (RR 0.81, 95% CI 0.63 to 1.05; 4 trials; 662 participants). Very low-quality evidence means that we are uncertain of the effects of multiple component interventions on the risk of fall-related fractures (2 trials) or fall-related hospital admission (1 trial). There is low-quality evidence that multiple interventions may have little or no effect on the risk of requiring medical attention (RR 0.95, 95% CI 0.67 to 1.35; 1 trial; 291 participants); conversely they may slightly improve health-related quality of life (SMD 0.77, 95% CI 0.16 to 1.39; 4 trials; 391 participants; I² = 88%). Of seven trials reporting on adverse events, five found none, and six minor adverse events were reported in two.Multiple component interventions versus exerciseThis comparison was tested in five trials. There is low-quality evidence of little or no difference between the two interventions in rate of falls (1 trial) and risk of falling (RR 0.93, 95% CI 0.78 to 1.10; 3 trials; 863 participants) and very low-quality evidence, meaning we are uncertain of the effects on hospital admission (1 trial). One trial reported two cases of minor joint pain. Other falls outcomes were not reported.

AUTHORS' CONCLUSIONS

Multifactorial interventions may reduce the rate of falls compared with usual care or attention control. However, there may be little or no effect on other fall-related outcomes. Multiple component interventions, usually including exercise, may reduce the rate of falls and risk of falling compared with usual care or attention control.

Inflammation and hemostasis in older octogenarians: implication in 5-year survival

Social changes and medical advances have increased longevity, but the conditions governing healthy vs unhealthy cardiovascular (CV) aging are not fully known. Factors beyond classical CV risk factors may have an important unrecognized value. We sought to identify proteins differentially expressed in healthy octogenarians (HOs) without a history of cardiovascular disease (CVD) and preserved functional and cognitive state compared with octogenarians with a history of CVD and cognitive decline (UHOs) using a systems biology approach, and investigated how these proteins relate to CV mortality at 5-year follow-up. Plasmas obtained from older octogenarians (87 ± 0 years) were analyzed by 2-DE + MS and bioinformatic pathway analysis in HOs (N = 38) and UHOs with cognitive (MEC<25) and functional (Barthel<90) decline and a previous ischemic event (acute myocardial infarction and/or stroke; N = 27). Results were validated by ELISA in HOs and UHOs and in an additional group of older octogenarians without cognitive impairment but with a previous CVD manifestation (HO-CVD; N = 35). UHOs showed a coordinated change in several inflammation-related proteins (AMBP, RBP4, and ITIH4; P < 0.05), together with a significant increase in the major inducer of the acute-phase reaction, interleukin-6 (P = 0.03). UHOs also showed a coordinated increase in hemostatic proteins that was associated with an impairment of fibrinolysis and an increased 5-year CV mortality (P = 0.003). The combination of inflammation (ITIH4 and interleukin-6) and hemostatic markers (D-dimer, A2AP, and coagulation factor XIII) was able to discriminate the presence of an unhealthy phenotype in the elderly (AUC = 0.750; P = 0.001). Unhealthy older octogenarians show increased levels of several plasma proteins of inflammation and coagulation. In older octogenarians, the increase in hemostatic markers indicated an increase in 5-year CV mortality at follow-up.

[The Octabaix study. Baseline assessment and 5 years of follow-up]

This is a review of a prospective, community-based study with a follow-up period of 5years. It is a study of 328 participants aged 85 at baseline, of which 62% were female, 53% widows, and a third of them living alone. High blood pressure was observed in 75.9%, dyslipidaemia in 51.2%, and diabetes in 17.7%. At baseline the median Barthel Index was 95, the Spanish version of the Mini-Mental State Examination was 28, the Charlson index 1, the Mini Nutritional Assessment 25, the Gijón test 10, the visual analogue scale of the Quality of Life Test was 60, and with a mean of 6.1 prescription drugs. A lower quality of life was also associated with female gender, a phenotype of frailty, heart failure, and a high level of social risk. At 5years of follow-up, the mortality rate was high, with 138 (42.1%) of the population sample dying at the end of the period. It represents an annual mortality rate of 8.4%. Thus, a common denominator of this review has been the high importance of functionality and overall comorbidity factors associated with mortality in this very old age group, compared to other more traditional factors in younger populations. Several studies of frailty have also been assessed in this group, as well as falls, nutritional risk, diabetes and successful aging, including important aspects to better understand this population group.

High rate of mortality in Spanish community-dwelling population aged 85 with atrial fibrillation after three years of follow-up: The Octabaix study

AIM

To assess the possible association between three-year global mortality and atrial fibrillation (AF) in 328 community-dwelling participants aged 85 at baseline.

METHODS

Sociodemographic data, comorbidity and geriatric assessment tools, thromboembolic risk, and AF therapy were assessed. We compared the patients who survived with those who died.

RESULTS

At baseline, 41 (12.5%) of participants had permanent AF, and 13 of them died (31.7%) after the three-year follow-up period compared with 44 (15.3%) of the rest of cohort (P = 0.01). Cox regression analysis identified two significant clinical variables as independent predictors of three-year risk of global mortality: Lawton Index (hazard ratio 0.82, 95% confidence interval 0.75-0.91) and AF (hazard ratio 1.90, 95% confidence interval 1.01-3.56). None of the other of variables evaluated showed predictive value of global mortality in the AF patients.

CONCLUSION

In oldest old community-dwelling participants, AF is an independent risk factor for global mortality after a three-year follow-up period.

[Impact of a multidimensional intervention in elderly patients with community-acquired pneumonia: IMIEPCAP clinical trial]

INTRODUCTION

The main objective of this study is to determine whether a multidimensional intervention applied to elderly patients admitted to hospital due to pneumonia reduces re-admissions and emergency department visits in the year after the intervention.

METHODOLOGY

This is a single-centre non-pharmacological randomised clinical trial with a parallel design. Three hundred and fourteen patients will be included (157 in each arm). Eligible patients will be ≥65 years old and with a Barthel index ≥60 that are admitted to hospital due to pneumonia. Participants will be randomised to multidimensional intervention or to control group. Two months after hospital discharge the intervention group will receive a geriatric intervention, carried out by a nurse and a physician. It will include assessment of co-morbidities, nutritional, functional and cognitive status, and immunisation. The control group will receive conventional follow-up. The number of re-admissions, visits to the emergency department, functional status, survival, and institutionalisation will be evaluated one year after intervention. If the intervention shows an improvement in the studied outcomes, it would allow us to improve individual outcomes, and indirectly reduce healthcare costs using a relatively simple, standardised tool.

[The NonaSantfeliu study. Baseline assessment and ten years of follow-up]

NonaSantfeliu study: A review is presented of the studies that are part of the initial overall assessment and the studies performed during the 10 years of follow-up of a cohort of nonagenarians. It is a population-based study of 186 subjects, 76.5% women, mean age at baseline of 93.06 years, a quarter (26%) being institutionalized. The mean of baseline Barthel index was 60.8, and the mean for the Lobo's cognitive minimental was 21. Nonagenarian males with low comorbidity had more successful aging criteria than women with high comorbidity quantified with the Charlson Index. The survival rate at 10 years follow-up was very low, and 95.6% of the population had died. This represented an annual mortality rate of 9.5%. A common denominator on assessing all different annual cuts, is that the most important factors associated with mortality are those related to geriatric assessment, such as a function, cognition, dementia, and cumulative comorbidity and multiple medications, compared to more traditional risk factors described in younger populations.

Multifactorial assessment and targeted intervention in nutritional status among the older adults: a randomized controlled trial: the Octabaix study

Background

Malnutrition is frequent among older people and is associated with morbi-mortality.

The aim of the study is to assess the effectiveness of a multifactorial and multidisciplinary intervention in the nutritional status among the elderly.

Methods

Randomized, single-blind, parallel-group, clinical trial conducted from January 2009 to December 2010 in seven primary health care centers in Baix Llobregat (Barcelona). Of 696 referred people, born in 1924, 328 subjects were randomized to an intervention group or a control group. The intervention model used an algorithm and was multifaceted for both the patients and their primary care providers. The main outcome was improvement in nutritional status assessed by Mini Nutritional Assessment (MNA). Data analyses were done by intention-to-treat.

Results

Two-year assessment was completed for 127 patients (77.4%) in the intervention group and 98 patients (59.7%) in the control group. In the adjusted linear mixed models for MNA, intervention showed no significant effect during all follow-up period with −0.21 (CI: − 0.96; 0.26). In subjects with nutritional risk (MNA ≤ 23.5 / 30) existed a tendency towards improvement in MNA score 1.13 (95% CI −0.48; 2.74) after 2 years.

Conclusion

A universal multifactorial assessment and target intervention over a two year period in subjects at nutritional risk showed a tendency to improve nutrition but not in the rest of community-dwelling studied subjects. Cognitive impairment was an independent factor strongly associated with a decline in nutritional status.

Trial registration

The clinical trial is registered as part of a US National Institutes of Health Clinical Trial: NCT01141166.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0033-0) contains supplementary material, which is available to authorized users.

[Profile and prognosis of patients over 85 years old with anemia living in the community. Octabaix Study]

OBJECTIVES

To analyze the prevalence of anemia in a sample of patients over 85 years old. To explore possible differentiating features in the groups of people with and without anemia, and to evaluate the relationship of anemia with mortality after a follow-up of 3 years.

MATERIAL AND METHODS

An observational multicenter study was conducted on a cohort of people born in 1924 and who lived in the community. Socio-demographic variables, comorbidity, functionality, cognitive status, social risk, perceived quality of life, nutritional status, drug consumption and laboratory parameters were collected. Multivariate logistic regression analysis was performed.

RESULTS

A total of 328 inhabitants were included, of whom 61.6% were women. The prevalence of anemia was 24%. Statistically significant differences in the Charlson index were found, showing higher values in anemic patients (P=0001) and in the Barthel index (BI) and in the Lawton index (LI), with lower levels in anemic patients (P=002 for both). Patients with anemia had a poorer perception of their quality of life (P=015). The presence of anemia was associated with more dependence according the BI values (OR 0.985; 95% CI: 0973-0997) and with higher comorbidity according the Charlson index (OR 1.314; 95% CI: 1124-1536). Mortality was higher in the group of patients with anemia, reaching statistically significant differences in the third year P=005).

CONCLUSIONS

In our cohort anemia is a fairly prevalent feature in the population over 85 years old, and is associated with higher mortality at three years of follow up. Patients with anemia had worse physical functioning and greater comorbidity.

[Successful aging and indicators of frailty in the elderly. Octabaix Study]

El envejecimiento satisfactorio como estado óptimo de un proceso de adaptación es poco conocido en las personas más mayores.

Objetivo

Describir envejecimiento satisfactorio y analizar su asociación con indicadores de fragilidad en personas de 86 años.

Diseño

Estudio descriptivo transversal al segundo año de seguimiento de un ensayo clínico (estudio Octabaix).

Emplazamiento

Siete centros de atención primaria.

Participantes

Personas nacidas en 1924, no institucionalizadas.

Medidas principales

Se recogieron datos sociodemográficos, comorbilidad y escalas de valoración geriátrica. La fragilidad se definió por presencia de 3 o más de los siguientes criterios: debilidad muscular, lentitud en la marcha, pérdida de peso, agotamiento y escasa actividad física. El envejecimiento satisfactorio se definió según: índice de Barthel > 90/100 y test de Lobo ≥ 24/35. Se realizó un análisis descriptivo bivariante y multivariante mediante regresión logística.

Resultados

Se evaluaron 273 pacientes, 39,2% hombres. La prevalencia de envejecimiento satisfactorio fue del 47,2% (129). En el grupo sin envejecimineto satisfactorio existía una proporción de fragilidad del 34,7% (50). Se hallaron como criterios de fragilidad asociados a envejecimiento no satisfactorio la escasa actividad (OR: 7,56; IC 95%: 3,8-14,9), la debilidad (OR: 6,08; IC 95%: 2,5-14, 7), la lentitud (OR: 5,1; IC 95%: 2,8-9,5) y el agotamiento (OR: 3,6; IC 95%: 1,6-8,3).

La prevalencia de envejecimiento satisfactorio es elevada en personas de 86 años en la comunidad. La escasa actividad física multiplica por 7 la asociación a envejecimiento no satisfactorio, y la debilidad muscular por 6. Por ello, incorporar el cribado dirigido a detectar estos 2 factores podría mejorar intervenciones posteriores hacia un envejecimiento más óptimo, si estos resultados se confirman en futuros estudios.

Inverted CD4:CD8 ratio is not associated with three-year mortality in a sample of community-dwelling oldest old: the OCTABAIX immune study

BACKGROUND

The presence of an immune risk phenotype (IRP) has been correlated with survival rates in elderly people.

OBJECTIVE

To determine whether an inverted CD4:CD8 ratio might be a marker of IRP in a sample of oldest old by assessing its relationship with mortality.

DESIGN

Prospective cohort study.

SETTING

Community-based survey study of seven primary healthcare centres.

PARTICIPANTS

328 people born in 1924 and registered with primary healthcare centres.

MEASUREMENTS

Chronic drug prescription, functional status (Barthel and Lawton indexes) and cognitive status (Spanish version of the Mini-Mental State Examination) were recorded. CD4:CD8 ratios were determined, with a ratio of 1.00 or less being used to define IRP.

RESULTS

The CD4:CD8 ratio was 1.00 or less in 47 subjects (15.6%). After three years, 51 subjects had died (16.3%); 9 were from among the 47 (19.1%) with an inverted CD4:CD8 ratio and 42 (15.8%) from the remainder (P=0.52). Multivariate analysis identified two significant clinical variables (Lawton Index scores and the number of chronic drugs prescribed) as being independent predictors of three-year mortality risk in this cohort of octogenarians. This risk profile did not change when introducing the CD4:CD8 ratio into the calculation.

CONCLUSION

In this community-dwelling population of oldest old (85 years old at baseline) an inverted CD4:CD8 ratio was not associated with three-year mortality.

Preventive home visits for mortality, morbidity, and institutionalization in older adults: a systematic review and meta-analysis

BACKGROUND

Home visits for older adults aim to prevent cognitive and functional impairment, thus reducing institutionalization and mortality. Visitors may provide information, investigate untreated problems, encourage medication compliance, and provide referrals to services.

METHODS AND FINDINGS

DATA SOURCES

Ten databases including CENTRAL and Medline searched through December 2012.

STUDY SELECTION

Randomized controlled trials enrolling community-dwelling persons without dementia aged over 65 years. Interventions included visits at home by a health or social care professional that were not related to hospital discharge.

DATA EXTRACTION AND SYNTHESIS

Two authors independently extracted data. Outcomes were pooled using random effects.

MAIN OUTCOMES AND MEASURES

Mortality, institutionalization, hospitalization, falls, injuries, physical functioning, cognitive functioning, quality of life, and psychiatric illness.

RESULTS

Sixty-four studies with 28642 participants were included. Home visits were not associated with absolute reductions in mortality at longest follow-up, but some programs may have small relative effects (relative risk = 0.93 [0.87 to 0.99]; absolute risk = 0.00 [-0.01 to 0.00]). There was moderate quality evidence of no overall effect on the number of people institutionalized (RR = 1.02 [0.88 to 1.18]) or hospitalized (RR = 0.96 [0.91 to 1.01]). There was high quality evidence for number of people who fell, which is consistent with no effect or a small effect (odds ratio = 0.86 [0.73 to 1.01]), but there was no evidence that these interventions increased independent living. There was low and very low quality evidence of effects for quality of life (standardised mean difference = -0.06 [-0.11 to -0.01]) and physical functioning (SMD = -0.10 [-0.17 to -0.03]) respectively, but these may not be clinically important.

CONCLUSIONS

Home visiting is not consistently associated with differences in mortality or independent living, and investigations of heterogeneity did not identify any programs that are associated with consistent benefits. Due to poor reporting of intervention components and delivery, we cannot exclude the possibility that some programs may be effective.

Multifactorial assessment and targeted intervention to reduce falls among the oldest-old: a randomized controlled trial

Background

The purpose of this study was to assess the effectiveness of a multifactorial intervention to reduce falls among the oldest-old people, including individuals with cognitive impairment or comorbidities.

Methods

A randomized, single-blind, parallel-group clinical trial was conducted from January 2009 to December 2010 in seven primary health care centers in Baix Llobregat (Barcelona). Of 696 referred people who were born in 1924, 328 were randomized to an intervention group or a control group. The intervention model used an algorithm and was multifaceted for both patients and their primary care providers. Primary outcomes were risk of falling and time until falls. Data analyses were by intention-to-treat.

Results

Sixty-five (39.6%) subjects in the intervention group and 48 (29.3%) in the control group fell during follow-up. The difference in the risk of falls was not significant (relative risk 1.28, 95% confidence interval [CI] 0.94–1.75). Cox regression models with time from randomization to the first fall were not significant. Cox models for recurrent falls showed that intervention had a negative effect (hazard ratio [HR] 1.46, 95% CI 1.03–2.09) and that functional impairment (HR 1.42, 95% CI 0.97–2.12), previous falls (HR 1.09, 95% CI 0.74–1.60), and cognitive impairment (HR 1.08, 95% CI 0.72–1.60) had no effect on the assessment.

Conclusion

This multifactorial intervention among octogenarians, including individuals with cognitive impairment or comorbidities, did not result in a reduction in falls. A history of previous falls, disability, and cognitive impairment had no effect on the program among the community-dwelling subjects in this study.

Thyroid status and functional and cognitive status at baseline and survival after 3 years of follow-up: the OCTABAIX study

OBJECTIVE

Subclinical thyroid disorders are common in older individuals. Health risks associated with subclinical hypothyroidism in older adults are unclear. The aim of the study is to evaluate whether thyroid status in elderly subjects correlates with physical and cognitive function at baseline and with 3-year mortality.

DESIGN

A population-based, prospective cohort of the OCTABAIX study (307 inhabitants aged 85 years at baseline).

METHODS

Chronic drug prescription, functional status (Barthel and Lawton indices) and cognitive status according to the Spanish version of the Mini-Mental State Examination were recorded. Quality of life was assessed using the visual analogue scale of the quality of life test. Concentrations of TSH and thyroxine were measured. Participants were classified in accordance with clinical categories of thyroid function.

RESULTS

Twenty (6.5%) individuals had subclinical hypothyroidism and five (1.6%) had subclinical hyperthyroidism. Compared with euthyroid subjects (n=280; 91.8%), subclinical hypo- and hyperthyroidism subjects were not significantly associated with poor physical or cognitive function at baseline. Fifty-one (15.1%) subjects died during the 36 months of follow-up. TSH values and subclinical hypo- and hyperthyroidism were not associated with an increased overall mortality risk (hazard ratio (HR) 1.086, 95% CI 0.987-1.196 and HR 0.905, 95% CI 0.902-1.053 respectively).

CONCLUSIONS

This study does not support the association of TSH or thyroid disorders with physical or cognitive function at baseline or with 3-year mortality in the oldest old subjects.

Risk of being undernourished in a cohort of community-dwelling 85-year-olds: the Octabaix study

OBJECTIVES

To describe the prevalence of the risk of being undernourished in a community-dwelling population of 85-year-olds, and to study associated factors.

METHODS

A cross-sectional community-based survey of 328 inhabitants assigned to seven primary healthcare teams was carried out. Geriatric assessment was based on sociodemographic variables, the Barthel Index (BI), the Lawton Index (LI), the Spanish version of the Mini-Mental State Examination, the Charlson Comorbidity Index, chronic diseases, social risk measured by Gijon's Social-Familial Evaluation Scale, prescriptions and blood tests. Nutritional status was assessed using the Mini Nutritional Assessment (MNA). Participants were defined as being at risk of undernourishment when they had a MNA score above or equal to 23.5. A comparative analysis was carried out between patients with and without risk of being undernourished, and a multiple logistic regression analysis was carried out.

RESULTS

The prevalence risk of being undernourished was 34.5%. A statistically significant association was found with being female (OR 2.44, 95% CI 1.28-4.54), LI (OR 1.47, 95% CI 1.29-1.66), social risk (OR 1.15, 95% CI 1.02-1.29) and prescription drugs taken (OR 5.58, 95% CI 2.09-14.92). Cardiovascular prescription showed a protective association (OR 4.34, 95% CI 1.78-10.0). No statistical differences between the risks of being undernourished were found in the laboratory analysis.

CONCLUSIONS

There is a high risk of being undernourished in 85-year-old subjects. This nutritional status was positively associated with being female, disability, increased social risk and a high number of prescription drugs, whereas there was a protective relationship with cardiovascular prescription. In evaluations of nutritional status in the community, a multidisciplinary assessment is more valid than analytical findings.

Low serum vitamin D is not associated with an increase in mortality in oldest old subjects: the Octabaix three-year follow-up study

BACKGROUND

Poor vitamin D status, i.e. low serum levels of 25-hydroxyvitamin D [25(OH)D], is common in the general population. Prospective epidemiologic data on the association between vitamin D and mortality in oldest old subjects are limited.

OBJECTIVE

This study aimed to determine whether 25(OH)D concentrations were prospectively and independently associated with cardiovascular disease (CVD) mortality and all-cause mortality in oldest old subjects.

METHODS

A total of 312 subjects aged 85 years old at baseline (Octabaix study) were followed for 3 years. Sociodemographic and overall geriatric assessment data were collected. Serum 25(OH)D concentrations were used to assess vitamin D status. Data on overall and cardiovascular mortality were collected.

RESULTS

The mean serum 25(OH)D levels were 28 ± 30 ng/ml. During the follow-up period, 58 subjects (18.5%) died. Twenty-five of the deaths (8%) were related to CVD. There were no differences in mortality rates according to the different quartiles of vitamin D (p = 0.41 for total mortality and p = 0.86 for CVD mortality).

CONCLUSION

In community-dwelling oldest old subjects, serum 25(OH)D levels were not associated with overall or CVD mortality after a 3-year follow-up.

[Depression in the elderly: prevalence and associated factors]

AIM

To determine the prevalence of depression, and to study the factors associated with it among community-dwelling 85-year-olds.

MATERIAL AND METHODS

A cross-sectional study was conducted within the framework of a randomized clinical trial in elderly people, all born in 1924, from seven urban and rural primary health care centers. Sociodemographic data and geriatric assessment were performed. Functional status was measured with Barthel index and Lawton index, cognitive impairment with Mini-mental Status Examination, social risk with Gijon test, and comorbidity by Charlson index. The presence of exhaustion and physical activity were recorded along with the chronic prescription of psycothropic drugs, and the presence of depression in clinical registers. Depression was evaluated using the Yesavage Geriatric Depression Scale (GDS) of 5 items (depression ≥ 2). The statistical program used was the R project: (version 2.12.2) Foundation for Statistical Computing, Vienna.

RESULTS

The sample was consisted of 220 subjects, 129 women (58.6%), 76 (34.5% were depressed using the GDS, 46 (20.9%) subjects had depression in the clinical records, and 60 (35.5%) patients were taking antidepressant drugs, 66 (36,8%) benzodiazepine, and 10 (4%) antipsychotic drugs. Depression was associated with poorer functional status according to basic and instrumental activities of daily living, cognitive impairment, exhaustion, low physical activity, and psychotropic drugs. Finally, the factors significantly associated with depression were low physical activity and increased exhaustion.

CONCLUSIONS

The present study found a high prevalence of depression in subjects older than 85 years. Physical activity and having a good self-perception of energy are associated to a lower prevalence of depression.

Predictors of cognitive decline in 85-year-old patients without cognitive impairment at baseline: 2-year follow-up of the octabaix study

BACKGROUND/RATIONALE

To determine how many 85-year-old community-dwelling patients with good cognitive performance at baseline maintain this level at 2-year follow-up.

METHODS

We realized a longitudinal community-based study including 169 inhabitants. Patients who maintained scores >23 on the Spanish version of the Mini-Mental State Examination (MEC) were compared with the rest.

RESULTS

A total of 144 individuals (85.2%) were found maintaining a MEC score >23. Under the combined criteria 110 (65%) presented no new cognitive decline. Multiple logistic regression analysis showed that maintaining a MEC score >23 was significantly associated with having a higher MEC score at baseline (P < .001, odds ratio 1.280, 95% confidence interval 1.104-1.484).

CONCLUSION

Most oldest-old patients with good cognitive function at baseline maintain this level at 2-year follow-up.

Malnutrition and falls risk in community-dwelling older adults

BACKGROUND AND AIMS

Falls and fall-related injuries result in reduced functioning, loss of independence, premature nursing home admissions and mortality. Malnutrition is associated with falls in the acute setting, but little is known about malnutrition and falls risk in the community. The aim of this study was to assess the association between malnutrition risk, falls risk and falls over a one-year period in community-dwelling older adults.

METHODS

Two hundred and fifty four subjects >65 years of age were recruited to participate in a study in order to identify risk factors for falls. Malnutrition risk was determined using the Mini Nutritional Assessment-Short Form.

RESULTS

28.6% had experienced a fall and according to the Mini Nutritional Assessment-Short Form 3.9% (n=10) of subjects were at risk of malnutrition. There were no associations between malnutrition risk, the risk of falls, nor actual falls in healthy older adults in the community setting.

CONCLUSIONS

There was a low prevalence of malnutrition risk in this sample of community-dwelling older adults and no association between nutritional risk and falls. Screening as part of a falls prevention program should focus on the risk of developing malnutrition as this is associated with falls.

Patterns of comorbidity and multimorbidity in the oldest old: the Octabaix study

BACKGROUND

Multimorbidity is associated with higher mortality, increased disability, a decline in functional status and a lower quality of life. The objective of the study is to explore patterns of multimorbidity in an elderly population.

METHODS

328 community inhabitants aged 85 years were included. Socio-demographic variables and data from the global geriatric assessment were evaluated. Information on the presence of sixteen common chronic conditions was collected: hypertension, diabetes mellitus, dyslipidemia, ischemic cardiomyopathy, heart failure, stroke, chronic obstructive pulmonary disease, (COPD), atrial fibrillation, peripheral arterial disease, Parkinson's disease, cancer, dementia, anemia, chronic kidney disease (CKD), visual impairment and deafness. Hierarchical cluster analysis was performed.

RESULTS

The rate of multimorbidity (>1 disease) was 95.1%. Men had a higher percentage of COPD and malignancy. Four main clusters were identified. The highest value of the bivariate correlation matrix was that between heart failure and visual impairment. These two diseases were included in a cluster with atrial fibrillation, CKD, heart failure, stroke, high blood pressure and diabetes mellitus.

CONCLUSIONS

The large majority of oldest old subjects had multimorbidity. The results confirm the non-random co-occurrence of certain diseases in this age group.

Interventions for preventing falls in older people living in the community

BACKGROUND

Approximately 30% of people over 65 years of age living in the community fall each year. This is an update of a Cochrane review first published in 2009.

OBJECTIVES

To assess the effects of interventions designed to reduce the incidence of falls in older people living in the community.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2012), CENTRAL (The Cochrane Library 2012, Issue 3), MEDLINE (1946 to March 2012), EMBASE (1947 to March 2012), CINAHL (1982 to February 2012), and online trial registers.

SELECTION CRITERIA

Randomised trials of interventions to reduce falls in community-dwelling older people.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. We used a rate ratio (RaR) and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person year) between intervention and control groups. For risk of falling, we used a risk ratio (RR) and 95% CI based on the number of people falling (fallers) in each group. We pooled data where appropriate.

MAIN RESULTS

We included 159 trials with 79,193 participants. Most trials compared a fall prevention intervention with no intervention or an intervention not expected to reduce falls. The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials). Sixty-two per cent (99/159) of trials were at low risk of bias for sequence generation, 60% for attrition bias for falls (66/110), 73% for attrition bias for fallers (96/131), and only 38% (60/159) for allocation concealment.Multiple-component group exercise significantly reduced rate of falls (RaR 0.71, 95% CI 0.63 to 0.82; 16 trials; 3622 participants) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96; 22 trials; 5333 participants), as did multiple-component home-based exercise (RaR 0.68, 95% CI 0.58 to 0.80; seven trials; 951 participants and RR 0.78, 95% CI 0.64 to 0.94; six trials; 714 participants). For Tai Chi, the reduction in rate of falls bordered on statistical significance (RaR 0.72, 95% CI 0.52 to 1.00; five trials; 1563 participants) but Tai Chi did significantly reduce risk of falling (RR 0.71, 95% CI 0.57 to 0.87; six trials; 1625 participants).Multifactorial interventions, which include individual risk assessment, reduced rate of falls (RaR 0.76, 95% CI 0.67 to 0.86; 19 trials; 9503 participants), but not risk of falling (RR 0.93, 95% CI 0.86 to 1.02; 34 trials; 13,617 participants).Overall, vitamin D did not reduce rate of falls (RaR 1.00, 95% CI 0.90 to 1.11; seven trials; 9324 participants) or risk of falling (RR 0.96, 95% CI 0.89 to 1.03; 13 trials; 26,747 participants), but may do so in people with lower vitamin D levels before treatment.Home safety assessment and modification interventions were effective in reducing rate of falls (RR 0.81, 95% CI 0.68 to 0.97; six trials; 4208 participants) and risk of falling (RR 0.88, 95% CI 0.80 to 0.96; seven trials; 4051 participants). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment. Home safety interventions appear to be more effective when delivered by an occupational therapist.An intervention to treat vision problems (616 participants) resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses (597 participants) were given single lens glasses, all falls and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Conversely, there was a significant increase in outside falls in intervention group participants who took part in little outside activity.Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93; three trials; 349 participants) but not risk of falling. First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95; one trial; 306 participants), but second eye cataract surgery did not.Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73; one trial; 93 participants), but not risk of falling. A prescribing modification programme for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91; one trial; 659 participants).An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78; one trial; 109 participants). One trial (305 participants) comparing multifaceted podiatry including foot and ankle exercises with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR 0.64, 95% CI 0.45 to 0.91) but not the risk of falling.There is no evidence of effect for cognitive behavioural interventions on rate of falls (RaR 1.00, 95% CI 0.37 to 2.72; one trial; 120 participants) or risk of falling (RR 1.11, 95% CI 0.80 to 1.54; two trials; 350 participants).Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls (RaR 0.33, 95% CI 0.09 to 1.20; one trial; 45 participants) or risk of falling (RR 0.88, 95% CI 0.75 to 1.03; four trials; 2555 participants).No conclusions can be drawn from the 47 trials reporting fall-related fractures.Thirteen trials provided a comprehensive economic evaluation. Three of these indicated cost savings for their interventions during the trial period: home-based exercise in over 80-year-olds, home safety assessment and modification in those with a previous fall, and one multifactorial programme targeting eight specific risk factors.

AUTHORS' CONCLUSIONS

Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling.Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling.Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment.

Geriatric assessment and chronic kidney disease in the oldest old: the Octabaix study

BACKGROUND

The prevalence of chronic kidney disease (CKD) in older people is increasing. We determine the proportion of CKD in a sample of 321, 85-year-old community-dwelling subjects, and assess the association of socio-demographic data, global geriatric assessment data and comorbidity with CKD according to the estimated glomerular filtration rate (eGFR) of subjects.

METHODS

Serum creatinine, eGFR (derived in ml/min/1.73 m(2) using the Modification of Diet in Renal Disease formula), socio-demographic variables, the Barthel Index (BI), the Spanish version of the Mini-Mental State Examination (MEC), the Mini Nutritional Assessment (MNA), the Charlson Index, the Gait Rating Scale, social risk, quality of life and prevalent chronic diseases were collected.

RESULTS

CKD prevalence was 56.7% for eGFR < 60 ml/min/1.73 m(2), 19.9% for eGFR < 45 ml/min/1.73 m(2) and 6.6% for GFR < 30 ml/min/1.73 m(2). Multiple logistic regression analysis showed that a prior diagnosis of hypertension was associated with an eGFR < 60 ml/min/1.73 m(2) (p<0.008, OR 2.134, 95% CI 1.216-3.744). A diagnosis of heart failure (p<0.001, OR 3.610, 95% CI 1.677-7.771) and a poor score on the quality of life measure (p<0.008, OR 0.9660, 95% CI 0.966-0.995) were associated with an eGFR < 45 ml/min/1.73 m(2).

CONCLUSIONS

More than half of the oldest old in this study had an eGFR < 60 ml/min/1.73 m(2). A history of hypertension was associated with CKD. The group of patients with an eGFR < 45 ml/min/1.73 m(2) was associated with a diagnosis of heart failure and a worse quality of life.

Serum high-density lipoprotein cholesterol levels correlate well with functional but not with cognitive status in 85-year-old subjects

OBJECTIVES

We evaluate the association between high-density lipoprotein cholesterol (HDL-C) levels and physical and cognitive performance indicators in 85-year-old subjects.

DESIGN

Prospective cohort study.

SETTING

A community-based study.

PARTICIPANTS

321 subjects enrolled in the Octabaix Study.

METHODS

Functional status was determined using the Lawton-Brody Index (LI) and the Barthel Index (BI). Cognition was assessed using the modified Spanish version of the Mini-Mental State Examination (MEC). We also measured risks related to nutrition and falls, as well as comorbidity and chronic drug prescription. HDL-C serum concentrations <40 mg/dl for men and <46 mg/dl for women were used as cut-off values to discriminate between normal and low HDL-C concentrations.

RESULTS

The sample consisted of 197 women (61%) and 124 men. Mean HDL-C levels were 56.5 ± 15 mg/dl, with gender differences being found (59.3 ± 15 mg/dl in women vs. 52.1 ± 13 mg/dl in men; p<0.0001). Sixty-one subjects (19%) had low HDL-C values. HDL-C levels correlated with BI (r=0.11, p=0.04) and LI (r=0.17, p=0.002) scores, but not with MEC scores (r=0.08, p=0.13). Poor BI and LI scores, lower MEC scores, a risk of falls and malnutrition, and polypharmacy were all associated with lower HDL-C values in the bivariate analysis. Multiple logistic regression analysis showed only a significant association between normal HDL-C serum values and better BI scores (p<0.001, OR 1.02, 95% CI 1.01-1.04).

CONCLUSIONS

Individuals with higher levels of HDL-C had better functional and cognitive status, but after multivariate analysis this relationship only remained significant for functional status.

Differences according to gender and health status in CD4:CD8 ratio in a sample of community-dwelling oldest old. The OCTABAIX immune study

BACKGROUND AND AIMS

The presence of an immune-risk phenotype (IRP) has been correlated with survival rates in elderly people. The aim of this study is to characterize the inverted CD4:CD8 ratio as a possible marker of IRP in a sample of oldest old (85 years) by assessing differences in gender and health status.

METHODS

Comorbidity, functional status (Barthel Index), and cognitive status with the Spanish version of the Mini-Mental State Examination were evaluated. Non-disabled subjects were defined as those with better health status, with scores of >90 on the Barthel Index and >23 points on the Spanish version of the Mini-Mental State Examination. CD4:CD8 ratios were recorded, and a ratio of 1.00 or less was used to define IRF.

RESULTS

Three hundred and twelve subjects aged 85 years old were studied, 190 women (60.9%) and 122 men. The CD4:CD8 ratio was 1.00 or less in 47 subjects (15.6%) and higher than 2.2 in 115 (36.8%). There were no differences in CD4:CD8 ratio according to health status. The inverted CD4:CD8 ratio was more frequent in men (55.3%).

CONCLUSION

In this community-dwelling, single year birth cohort study, the subgroup with poor health status did not have a lower CD4:CD8 ratio. The inverted CD4:CD8 ratio was more frequent in men.

[Inappropriate prescription in the community elderly, are we aware of?]

OBJECTIVES

To analyse the prescription according to the STOPP (Screening Tool of Older Person's Prescriptions) and Beer's suitability criteria, and associated factors in patients over 85 years-old.

PATIENTS AND METHODS

Cross-sectional study of inappropriate prescribing to over 85 year-olds. The data recorded were: sociodemographic variables, cardiovascular risk factors, chronic illnesses, multiple medication (or polypharmacy) (4 or more) and geriatric assessment. The inappropriate prescription (IP) was evaluated according to total and cardiovascular prescription.

RESULTS

The mean number of drugs in the total of 78 subjects was 6.1 (3.3). Of the total number, 34.6% patients had 1 IP drug; 19.2% had 2; 15.4% had 3 or more, and in total 69.2% of patients had at least one IP drug, and 37.2% had 1 or more IP cardiovascular drugs. The therapeutic groups involved in the overall IP were benzodiazepines (BZP) 23.1%, loop diuretics 17.9%, selective serotonin reuptake inhibitors (SSRIs) 16.7%, and non-steroidal anti-inflammatory drugs (NSAIDs) made up 10.3% of the total criteria. The bivariate analyse found a relationship between the number of drugs and multiple medication (P=.030 in both) and total IP, with no significance found in cardiovascular IP. The multivariate analysis showed an association between multiple medication (OR: 1.22; 95% CI: 1.02-1.47; P=.031) and total IP, and dyslipaemia (OR: 0.30; 95% CI: 0.10-0.87; P=.026) and AHT (OR: 0.15; 95% CI: 0.03-0.78; P=.024) for cardiovascular IP.

CONCLUSIONS

More than half the over 85 year-old patients received an inappropriate prescription. Dyslipaemia and AHT are associated with an inappropriate cardiovascular prescription, and the most frequent drug groups were, BZP, diuretics, SSRIs, and NSAIDs.

[Gender differences in health status in a population of over 85 year-olds: the Octabaix study]

OBJECTIVE

To examine gender differences according to health status in the oldest old people of the community.

DESIGN

Cross-sectional multicentre study, within the framework of a clinical trial on falls and malnutrition.

SETTING

7 primary health centres.

PARTICIPANTS

Non-institutionalised patients of 85 years or over.

METHODS

The data collected included, socioeconomic data, cardiovascular risk factors, Barthel Index (BI), cognitive status with the Mini-Mental State Examination (MMSE), Charlson Index to measure comorbidity, nutritional risk evaluated by Nutritional Assessment questionnaire (MNA), mean visual analogue self-rating scale in Euroqol- 5D (EQ-VAS) to assess health related quality life and, Gijón social risk test, and prescribed drugs.

RESULTS

A total of 312 subjects were included, of which 61.6% were women, 53% widows and a third of them lived alone. High blood pressure was observed in 76%, dyslipidemia in 51.2%, diabetes in 17.4%, median BI 95 (rank 0-100), MMSE 28 (0-35), Charlson index 1 (0-7), MNA 25 (10-30), Gijón test 10 (5-21), EQ-VAS 60 (0-100) and the mean prescription drugs 6.1±3.3. Women most frequently lived alone (P<.001), fell more (P<.006), had a greater nutritional (P<.016) and social risk (P<.001). Men were more likely to be married (P<.001), had better cognition (P<.003), better functional status (P<.018), and higher comorbidity (P<.001).

CONCLUSION

Being a 85 years old man is associated with being married, having better functionality and cognition, and a higher comorbidity. While being a woman is associated with living alone, a higher rate of falls, and nutritional and social risk. These results are important to help this group of elderly to maintain their position in the community.

Utility of geriatric assessment tools to identify 85-years old subjects with vitamin D deficiency

OBJECTIVES

To calculate the prevalence of hypovitaminosis D in subjects aged 85 years old and to study the relationship between some common geriatric evaluation scales and vitamin D status.

DESIGN

Prospective cohort study.

SETTING

A community-based study.

PARTICIPANTS

312 subjects aged 85 years old.

MEASUREMENTS

Geriatric assessment was based on comorbidity, functional status according to the Barthel Index (BI) and Lawton Index (LI), cognitive status measured by the Spanish version of the Mini-Mental State Examination (MEC), nutritional risk according to the Mini Nutritional Assessment (MNA), and gait using the Tinetti Gait Scale. Serum 25(OH)D concentrations were used to assess vitamin D status. Hypovitaminosis D was considered as < 25 ng/ml and deficiency < 11 ng/ml.

RESULTS

Mean serum 25(OH)D level was 28 ± 30 ng/ml. The prevalence of hypovitaminosis D was 52.5% (38.1% insufficiency and 14.4% deficiency). Men had higher levels than women (32.2 ± 44 vs. 25.2 ± 25 ng/ml; p=0.04). The bivariate analyses identified an association between MNA scores and hypovitaminosis D, and showed that females ande participants with poor BI, Tinetti and MNA scores were associated with deficiency. Logistic regression analysis confirmed a significant association between poor MNA scores and both hypovitaminosis D (p < 0.04, OR 1.066, 95% CI 1.002-1.135) and vitamin D deficiency (p < 0.0001, OR 1.192, 95% CI 1.099-1.293).

CONCLUSIONS

More than half the population aged 85 years has a vitamin D deficit and 14.4% show a deficiency. A lower score on the MNA scale is associated with a greater likelihood of having lower vitamin D serum values.