A population-based study on dementia and stroke in 97 year olds

Life-Weariness, Wish to Die, Active Suicidal Ideation, and All-Cause Mortality in Population-Based Samples of Older Adults

OBJECTIVES

To investigate potential differences in the strength of associations between different levels of passive and active suicidal ideation and all-cause mortality in older adults.

DESIGN

Prospective cohort study.

SETTING

Population-based samples of older adults in Gothenburg, Sweden.

PARTICIPANTS

Older adults aged 79 and above who participated in any wave of the Gothenburg H70 Birth Cohort Studies or the Prospective Population Study of Women between 1986 and 2015 (n = 2,438; 1,737 women, 701 men; mean age 86.6).

MEASUREMENTS

Most intense level of passive or active suicidal ideation during the past month: life-weariness, wish to die, or active suicidal ideation. The outcome was all-cause mortality over 3 years.

RESULTS

During follow-up, 672 participants (27.6%) died. After adjustments for sex, age, and year of examination, participants who reported a wish to die (HR 2.01; 95% CI 1.55-2.60) as the most intense level of ideation, but not participants who reported life-weariness (HR 1.40; 95% CI 0.88-2.21) or active suicidal ideation (HR 1.10; 95% CI 0.69-1.76) were at increased risk of all-cause mortality. Reporting a wish to die remained associated with mortality in a fully adjusted model, including somatic conditions, dementia, depression, and loneliness (HR 1.70; 95% CI 1.27-2.26).

CONCLUSION

In older adults, reporting a wish to die appears to be more strongly associated with all-cause mortality than either life-weariness or active suicidal ideation.

Overcoming protein-energy malnutrition in older adults in the residential care setting: A narrative review of causes and interventions

Malnutrition, in particular protein-energy malnutrition, is a highly prevalent condition in older adults, and is associated with low muscle mass and function, and increased prevalence of physical frailty. Malnutrition is often exacerbated in the residential care setting due to factors including lack of dentition and appetite, and increased prevalence of dementia and dysphagia. This review aims to provide an overview of the available literature in older adults in the residential care setting regarding the following: links between sarcopenia, frailty, and malnutrition (in particular, protein-energy malnutrition (PEM)), recognition and diagnosis of malnutrition, factors contributing to PEM, and the effectiveness of different forms of protein supplementation (in particular, oral nutritional supplementation (ONS) and protein-fortified foods (PFF)) to target PEM. This review found a lack of consensus on effective malnutrition diagnostic tools and lack of universal requirement for malnutrition screening in the residential care setting, making identifying and treating malnutrition in this population a challenge. When assessing the use of protein supplementation in the residential care setting, the two primary forms of supplementation were ONS and PFF. There is evidence that ONS and PFF increase protein and energy intakes in residential care setting, yet compliance with supplementation and their impact on functional status is unclear and conflicting. Further research comparing the use of ONS and PFF is needed to fully determine feasibility and efficacy of protein supplementation in the residential care setting.

Revealing the Influences of Sex Hormones and Sex Differences in Atrial Fibrillation and Vascular Cognitive Impairment

The impacts of sex differences on the biology of various organ systems and the influences of sex hormones on modulating health and disease have become increasingly relevant in clinical and biomedical research. A growing body of evidence has recently suggested fundamental sex differences in cardiovascular and cognitive function, including anatomy, pathophysiology, incidence and age of disease onset, symptoms affecting disease diagnosis, disease severity, progression, and treatment responses and outcomes. Atrial fibrillation (AF) is currently recognized as the most prevalent sustained arrhythmia and might contribute to the pathogenesis and progression of vascular cognitive impairment (VCI), including a range of cognitive deficits, from mild cognitive impairment to dementia. In this review, we describe sex-based differences and sex hormone functions in the physiology of the brain and vasculature and the pathophysiology of disorders therein, with special emphasis on AF and VCI. Deciphering how sex hormones and their receptor signaling (estrogen and androgen receptors) potentially impact on sex differences could help to reveal disease links between AF and VCI and identify therapeutic targets that may lead to potentially novel therapeutic interventions early in the disease course of AF and VCI.

Time trends in the relation between blood pressure and dementia in 85-year-olds

OBJECTIVES

Blood pressure has decreased in the general population. We aimed to examine whether this is true also among the very old, and among persons with and without dementia. Further, we aimed to investigate how common undetected and untreated hypertension is in the very old, both among people with and without dementia.

METHOD

Blood pressure was measured in representative population samples of 85-year-olds living in Gothenburg, Sweden, examined 1986-1987 (n = 484) and 2008-2010 (n = 571). Dementia was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, edition 3 revised, by the same medical doctor at both examinations.

RESULTS

Both systolic and diastolic blood pressure were lower in 85-year-olds examined 2008-2010 than in those examined 1986-1987, both among those with and without dementia. Participants with dementia had lower systolic blood pressure than those without dementia in both cohorts, and blood pressure levels related to dementia severity. Despite this, hypertension (≥140/90 mmHg) was found in almost half (46.5%) of those with dementia in 2008-2010.

CONCLUSION

Our findings show that time-trends of lower blood pressure in western populations also applies to the very old, and that individuals with dementia continue to have lower blood pressure compared to the rest of the population. The latter finding suggests that the pathophysiological processes in dementia affect blood pressure regulating regions in the brain independent of time trends. Still, hypertension is common in dementia and needs to be detected and treated.

Contributions of sex to cerebrovascular function and pathology

Sex differences exist in how cerebral blood vessels function under both physiological and pathological conditions, contributing to observed sex differences in risk and outcomes of cerebrovascular diseases (CBVDs), such as vascular contributions to cognitive impairment and dementia (VCID) and stroke. Throughout most of the lifespan, women are protected from CBVDs; however, risk increases following menopause, suggesting sex hormones may play a significant role in this protection. The cerebrovasculature is a target for sex hormones, including estrogens, progestins, and androgens, where they can influence numerous vascular functions and pathologies. While there is a plethora of information on estrogen, the effects of progestins and androgens on the cerebrovasculature are less well-defined. Estrogen decreases cerebral tone and increases cerebral blood flow, while androgens increase tone. Both estrogens and androgens enhance angiogenesis/cerebrovascular remodeling. While both estrogens and androgens attenuate cerebrovascular inflammation, pro-inflammatory effects of androgens under physiological conditions have also been demonstrated. Sex hormones exert additional neuroprotective effects by attenuating oxidative stress and maintaining integrity and function of the blood brain barrier. Most animal studies utilize young, healthy, gonadectomized animals, which do not mimic the clinical conditions of aging individuals likely to get CBVDs. This is also concerning, as sex hormones appear to mediate cerebrovascular function differently based on age and disease state (e.g. metabolic syndrome). Through this review, we hope to inspire others to consider sex as a key biological variable in cerebrovascular research, as greater understanding of sex differences in cerebrovascular function will assist in developing personalized approaches to prevent and treat CBVDs.

Sex differences in risk factors for vascular contributions to cognitive impairment & dementia

Vascular contributions to cognitive impairment and dementia (VCID) is the second most common cause of dementia. While males overall appear to be at a slightly higher risk for VCID throughout most of the lifespan (up to age 85), some risk factors for VCID more adversely affect women. These include female-specific risk factors associated with pregnancy related disorders (e.g. preeclampsia), menopause, and poorly timed hormone replacement. Further, presence of certain co-morbid risk factors, such as diabetes, obesity and hypertension, also may more adversely affect women than men. In contrast, some risk factors more greatly affect men, such as hyperlipidemia, myocardial infarction, and heart disease. Further, stroke, one of the leading risk factors for VCID, has a higher incidence in men than in women throughout much of the lifespan, though this trend is reversed at advanced ages. This review will highlight the need to take biological sex and common co-morbidities for VCID into account in both preclinical and clinical research. Given that there are currently no treatments available for VCID, it is critical that we understand how to mitigate risk factors for this devastating disease in both sexes.

Vascular cognitive impairment

The term vascular cognitive impairment (VCI) was introduced around the start of the new millennium and refers to the contribution of vascular pathology to any severity of cognitive impairment, ranging from subjective cognitive decline and mild cognitive impairment to dementia. Although vascular pathology is common in elderly individuals with cognitive decline, pure vascular dementia (that is, dementia caused solely by vascular pathology) is uncommon. Indeed, most patients with vascular dementia also have other types of pathology, the most common of which is Alzheimer disease (specifically, the diffuse accumulation of amyloid-β plaques and neurofibrillary tangles composed of tau). At present, the main treatment for VCI is prevention by treating vascular diseases and other risk factors for VCI, such as hypertension and diabetes mellitus. Despite the current paucity of disease-modifying pharmacological treatments, we foresee that eventually, we might be able to target specific brain diseases to prevent cognitive decline and dementia.

A Longitudinal Study of the Mini-Mental State Examination in Late Nonagenarians and Its Relationship with Dementia, Mortality, and Education

OBJECTIVES

To examine level of and change in cognitive status using the Mini-Mental State Examination (MMSE) in relation to dementia, mortality, education, and sex in late nonagenarians.

DESIGN

Three-year longitudinal study with examinations at ages 97, 99, and 100.

SETTING

Trained psychiatric research nurses examined participants at their place of living.

PARTICIPANTS

A representative population-based sample of 97-year-old Swedes (N = 591; 107 men, 484 women) living in Gothenburg, Sweden.

MEASUREMENTS

A Swedish version of the MMSE was used to measure cognitive status. Geriatric psychiatrists diagnosed dementia according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised. Mixed models were fitted to the data to model the longitudinal relationship between MMSE score and explanatory variables.

RESULTS

Individuals with dementia between age 97 and 100 had lower mean MMSE scores than those without dementia. Those who died during the 3-year follow-up had lower MMSE scores than those who survived. MMSE scores at baseline did not differ between those without dementia and those who developed dementia during the 3-year follow-up. Participants with more education had higher MMSE scores, but there was no association between education and linear change.

CONCLUSION

MMSE score is associated with dementia and subsequent mortality even in very old individuals, although the preclinical phase of dementia may be short in older age. Level of education is positively associated with MMSE score but not rate of decline in individuals approaching age 100.

Much more medicine for the oldest old: trends in UK electronic clinical records

BACKGROUND

the oldest old (85+) pose complex medical challenges. Both underdiagnosis and overdiagnosis are claimed in this group.

OBJECTIVE

to estimate diagnosis, prescribing and hospital admission prevalence from 2003/4 to 2011/12, to monitor trends in medicalisation.

DESIGN AND SETTING

observational study of Clinical Practice Research Datalink (CPRD) electronic medical records from general practice populations (eligible; n = 27,109) with oversampling of the oldest old.

METHODS

we identified 18 common diseases and five geriatric syndromes (dizziness, incontinence, skin ulcers, falls and fractures) from Read codes. We counted medications prescribed ≥1 time in all quarters of studied years.

RESULTS

there were major increases in recorded prevalence of most conditions in the 85+ group, especially chronic kidney disease (stages 3-5: prevalence <1% rising to 36.4%). The proportions of the 85+ group with ≥3 conditions rose from 32.2 to 55.1% (27.1 to 35.1% in the 65-84 year group). Geriatric syndrome trends were less marked. In the 85+ age group the proportion receiving no chronically prescribed medications fell from 29.6 to 13.6%, while the proportion on ≥3 rose from 44.6 to 66.2%. The proportion of 85+ year olds with ≥1 hospital admissions per year rose from 27.6 to 35.4%.

CONCLUSIONS

there has been a dramatic increase in the medicalisation of the oldest old, evident in increased diagnosis (likely partly due to better record keeping) but also increased prescribing and hospitalisation. Diagnostic trends especially for chronic kidney disease may raise concerns about overdiagnosis. These findings provide new urgency to questions about the appropriateness of multiple diagnostic labelling.

[Hospitalization and dementia: what was new in 2012?: literature review]

The present work provides a review of literature published in 2012 that were found in a PubMed search with the terms "hospitalization and dementia. Further information was obtained from personal contacts. The rate of publications was ten times higher in 2012 as in previous years. Frequency of dementia, hospital admission, acute coronary syndrome, femoral neck fracture, stroke, complications during hospital stay, outcomes after hospitalization, prediction, rehabilitation, and training are the common topics.

Predictors of institutionalization of dementia patients in mild and moderate stages: a 4-year prospective analysis

Background

Institutionalization is the most important milestone in the care of dementia patients. This study was aimed at identifying relevant predictors of institutionalization in a broad empirical context and interpreting them on the basis of the predictor model proposed by Luppa et al. [Dement Geriatr Cogn Disord 2008;26:65-78].

Methods

At the start of this study, 357 patients with mild to moderate dementia were examined by their general practitioners, and a telephone interview was conducted with their caregivers. Four years later, the outcomes ‘institutionalization’ and ‘death’ were determined from health insurance data. Forty-one variables were examined for their predictive influence by univariate and multivariate Cox regression.

Results

The risk of institutionalization increased significantly (p ≤ 0.05) with older ages of patients [hazard ratio (HR) = 1.05] and caregivers (HR = 1.03), a higher educational level of the caregiver (HR = 1.83), greater use of community health services (HR = 1.59), greater caregiver burden (HR = 1.02), and when the caregiver and patient lived apart (HR = 1.97).

Conclusion

The results show that there is a multifactorial influence on institutionalization of dementia patients by sociodemographic, health-related, and psychological aspects as well as the care situation, thus validating the predictor model by Luppa et al. [Dement Geriatr Cogn Disord 2008;26:65-78]. Caregiver burden was found to be the strongest predictor accessible to interventions.

Suicidal feelings in the twilight of life: a cross-sectional population-based study of 97-year-olds

OBJECTIVE

To examine the occurrence of past month suicidal feelings in extreme old age. Further, to identify factors associated with such feelings.

DESIGN

Cross-sectional population-based study.

SETTING

Gothenburg, Sweden.

PARTICIPANTS

269 adults (197 women, 72 men) without dementia born in 1901-1909 who participated in a psychiatric examination.

MAIN OUTCOME MEASURES

Death thoughts and suicidal feelings. The latter were rated in accordance with the Paykel questions (life not worth living, death wishes, thoughts of taking own life, seriously considered taking own life, attempted suicide) during the past month.

RESULTS

One quarter of the sample (26.7%) reported that they thought about their own death at least once a month. Past month thoughts that life was not worth living were acknowledged by 7.9% of the total sample, death wishes by 10.5% and thoughts of taking life by 3.8%. Few had serious thoughts of taking own life (0.8%) and none had attempted suicide. In all, 11.5% acknowledged some level of suicidal feelings. Most (77.4%) of those who reported such feelings fulfilled criteria for neither major nor minor depression. Neither poor perceived health nor disability (hearing, vision and motor function) was associated with suicidal feelings. Problematic sleep and deficient social contacts were also related to suicidal feelings after adjustment for depression.

CONCLUSIONS

Suicidal feelings may occur outside the context of depression and disability in this age group. Results can inform clinicians who care for persons who reach extreme old age.