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Ungar A, Rivasi G, Di Bari M, Virdis A, Casiglia E, Masi S, Mengozzi A, Barbagallo CM, Bombelli M, Bruno B, Cicero AF, Cirillo M, Cirillo P, Desideri G, D’elia L, Ferri C, Galletti F, Gesualdo L, Giannattasio C, Iaccarino G, Ciccarelli M, Lippa L, Mallamaci F, Maloberti A, Mazza A, Muiesan ML, Nazzaro P, Palatini P, Parati G, Pontremoli R, Quarti-Trevano F, Rattazzi M, Salvetti M, Tikhonoff V, Tocci G, Cianci R, Verdecchia P, Viazzi F, Volpe M, Grassi G, Borghi C. The association of uric acid with mortality modifies at old age: data from the uric acid right for heart health (URRAH) study. J Hypertens 2022; 40:704-711. [PMID: 34939996 PMCID: PMC10863659 DOI: 10.1097/hjh.0000000000003068] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/03/2021] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In older individuals, the role of serum uric acid (SUA) as risk factor for mortality is debated. This study investigated the association of SUA with all-cause and cardiovascular (CV) mortality in older adults participating in the large multicentre observational uric acid right for heart health (URRAH) study. METHODS Eight thousand URRAH participants aged 65+ were included in the analysis. The predictive role of SUA was assessed using Cox regression models stratified according to the cut-off age of 75. SUA was tested as continuous and categorical variable (age-specific quartiles). The prognostic threshold of SUA for mortality was analysed using receiver operating characteristic curves. RESULTS Among participants aged 65-74, multivariate Cox regression analysis adjusted for CV risk factors and comorbidities identified an independent association of SUA with both all-cause mortality (hazard ratio [HR] 1.169, 95% confidence interval [CI] 1.107-1.235) and CV mortality (HR 1.146, 95% CI 1.064-1.235). The cut-off value of 4.8 mg/dl discriminated mortality status. In participants aged 75+, we observed a J-shaped relationship of SUA with all-cause and CV mortality, with risk increasing at extreme SUA levels. CONCLUSIONS These results confirmed the predictive role of SUA for all-cause and CV mortality in older adults, while revealing considerable age-related differences. Mortality risk increased at higher SUA levels in participants aged 65-74, with a prognostic threshold of 4.8 mg/dl. The relationship between SUA and mortality was J-shaped in oldest participants. Large interventional studies are needed to clarify the benefits and possible risks of urate-lowering treatments in older adults.
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Affiliation(s)
- Andrea Ungar
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Giulia Rivasi
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Mauro Di Bari
- Department of Geriatric and Intensive Care Medicine, Careggi Hospital and University of Florence, Florence
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | | | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa
| | | | - Carlo M. Barbagallo
- Biomedical Department of Internal Medicine and Specialistics, University of Palermo, Palermo
| | - Michele Bombelli
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Bernardino Bruno
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila
| | - Arrigo F.G. Cicero
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna
| | - Massimo Cirillo
- Department of Public Health, “Federico II” University of Naples, Naples
| | - Pietro Cirillo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari, Bari
| | | | - Lanfranco D’elia
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples Medical School, Naples
| | - Claudio Ferri
- Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila
| | - Ferruccio Galletti
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples Medical School, Naples
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, “Aldo Moro” University of Bari, Bari
| | - Cristina Giannattasio
- Cardiology IV, “A.De Gasperi's” Department, Niguarda Ca’ Granda Hospital, Milan
- School of Medicine and Surgery, Milano-Bicocca University, Milan
| | - Guido Iaccarino
- Department of Advanced Biomedical Sciences, "Federico II" University of Naples, Naples
| | - Michele Ciccarelli
- Department of Medicine Surgery and Odontology, University of Salerno, Fisciano
| | - Luciano Lippa
- Italian Society of General Medicine (SIMG), Avezzano, L’Aquila
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Cal Unit, Reggio Calabria
| | - Alessandro Maloberti
- Cardiology IV, “A.De Gasperi's” Department, Niguarda Ca’ Granda Hospital, Milan
- School of Medicine and Surgery, Milano-Bicocca University, Milan
| | - Alberto Mazza
- Department of Internal Medicine, Santa Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo
| | | | - Pietro Nazzaro
- Department of Medical Basic Sciences, Neurosciences and Sense Organs, University of Bari Medical School, Bari
| | | | - Gianfranco Parati
- Istituto Auxologico Italiano, IRCCS, Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, Milan
- Department of Medicine and Surgery, University of Milan-Bicocca, Milan
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genoa
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Marcello Rattazzi
- Department of Medicine, University of Padua, Padua
- Medicina Interna I, Ca’ Foncello University Hospital, Treviso
| | - Massimo Salvetti
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia
| | | | - Giuliano Tocci
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant’Andrea Hospital, Rome
- IRCCS Neuromed, Pozzilli
| | | | | | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and Policlinico San Martino, Genoa
| | - Massimo Volpe
- Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant’Andrea Hospital, Rome
- IRCCS Neuromed, Pozzilli
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza
| | - Claudio Borghi
- Department of Medical and Surgical Science, Alma Mater Studiorum University of Bologna, Bologna
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Salva A, Coll-Planas L, Bruce S, De Groot L, Andrieu S, Abellan G, Vellas B, Andrieu S, Bartorelli L, Berner YN, Bruce S, Corman B, Domingo A, Egger TP, de Groot L, Guigoz Y, Imedio A, Planas M, Porras C, Rovira JC, Salvà A, Serra JA, Vellas B. Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA. J Nutr Health Aging 2009; 13:475-83. [PMID: 19536415 DOI: 10.1007/s12603-009-0097-7] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Unintentional weight loss and Undernutrition are major problems among older people living in Long-Term Care Facilities (LTCF). Undernutrition manifests in LTCF particularly as weight loss and low Body Mass Index (BMI) and is associated with increased morbidity and mortality as well as with functional decline. There are many factors associated with poor nutritional status and affecting protein-energy intake and/or energy expenditure. These include age of 85 years or older, low nutrient intake, loss of ability to eat independently, swallowing and chewing difficulties, becoming bed-ridden, pressure ulcers, history of hip fracture, dementia, depressive symptoms and suffering from two or more chronic illnesses. Nutritional evaluation is an essential part of the Comprehensive Geriatric Assessment (CGA). This evaluation ranges from methods such as BMI to several validated tools such as Mini-Nutritional Assessment (MNA). After diagnosis, the management of undernutrition in LTCF requires a multidisciplinary approach which may involve dietary and environmental improvements and managing multiple co-morbidities, while avoiding polypharmacy as far as possible. Finally, the need for supplementation or artificial (tube) feeding may be considered taking into account the CGA and individual needs. This document presents a succinct review and recommendations of evaluation and treatment of undernutrition.
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Affiliation(s)
- A Salva
- Institut Catala de l'Envelliment. Universitat Autonoma de Barcelona. Spain
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Kikuchi M, Inagaki T, Miyagawa K, Ueda R, Shinagawa N, Hanaki H. Risk factors of disseminated intravascular coagulation in septic systemic inflammatory response syndrome in nursing home residents. Geriatr Gerontol Int 2006. [DOI: 10.1111/j.1447-0594.2006.00333.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Hasegawa T, Watase H. Multiple risk factors of periodontal disease: a study of 9260 Japanese non-smokers. Geriatr Gerontol Int 2004. [DOI: 10.1111/j.1447-0594.2003.00116.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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5
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Kikuchi M, Inagaki T, Shinagawa N, Ueda R. Clinical significance of the soluble interleukin-2 receptor as a putative systemic nutritional index in the elderly*. Geriatr Gerontol Int 2004. [DOI: 10.1111/j.1447-0594.2003.00107.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Rozzini R, Sabatini T, Franzoni S, Trabucchi M. Cholesterol and Mortality in Elderly Patients. J Am Geriatr Soc 2004; 52:469-70; author reply 471. [PMID: 14962171 DOI: 10.1111/j.1532-5415.2004.52125_4.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Ponzetto M, Maero B, Maina P, Rosato R, Ciccone G, Merletti F, Rubenstein LZ, Fabris F. Risk Factors for Early and Late Mortality in Hospitalized Older Patients: The Continuing Importance of Functional Status. J Gerontol A Biol Sci Med Sci 2003; 58:1049-54. [PMID: 14630889 DOI: 10.1093/gerona/58.11.m1049] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prognostic information collected at hospital admission may be useful in defining care objectives and in deciding on therapy for older people. The aim of our study was to identify admission risk factors for in-hospital and postdischarge mortality. METHODS The study included 987 patients aged 70 years and older admitted to the geriatric ward of San Giovanni Battista Hospital in Torino during 1995 and 1996. Demographic, clinical, and functional variables were collected on admission to hospital and examined as potential risk factors for mortality during hospitalization and at 5 years of follow-up. RESULTS During their hospital stay, 147 patients (14.9%) died. Risk factors independently associated with in-hospital mortality included functional impairment (Activities of Daily Living [ADL]) (OR [odds ratio] 1.73, CI [confidence interval] 95% 1.02-2.95), dependence related to medical conditions (OR 2.18, CI 95% 1.39-3.42), cerebrovascular disease (OR 3.23, CI 95% 1.64-6.37), cancer (OR 4.52, CI 95% 1.99-10.24), albumin 3.0-3.4 g/dl (OR 4.51, CI 95% 2.76-7.35), albumin <3.0 g/dl (OR 6.83, CI 95% 3.59-13.0), creatinine 1.5-3 mg/dl (OR 2.23, CI 95% 1.36-3.65), creatinine >3 mg/dl (OR 2.55, CI 95% 1.10-5.93), and fibrinogen >/=452 mg/dl (OR 1.91, CI 95% 1.26-2.89). During the 5-year follow-up, 553 patients (67.7%) died. Variables independently associated with mortality in multivariate analysis were age 75-84 years (HR [hazard ratio] 1.40, CI 95% 1.10-1.78), >/=85 years (HR 2.08, CI 95% 1.59-2.72), male sex (HR 1.50, CI 95% 1.24-1.81), ADL dependency (HR 1.24, CI 95% 1.01-1.52), >/=5 errors on Short Portable Mental Status Questionnaire (HR 1.34, CI 95% 1.10-1.63), dependence on Dependence Medical Index (HR 1.36, CI 95% 1.10-1.67), presence of cancer (HR 2.58, CI 95% 1.80-3.71), hemoglobin </=11 g/dl (HR 1.46, CI 95% 1.17-1.81), and Charlson's Index >/=2 (HR 1.49, CI 95% 1.14-1.95). CONCLUSIONS A complete functional and clinical evaluation at hospital admission permits identification of patients at higher risk of early and long-term mortality.
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Affiliation(s)
- Maria Ponzetto
- Medical and Surgical Department, Geriatric Section, University of Torino, Italy
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8
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Abstract
OBJECTIVES To identify factors associated with 1-year mortality in newly admitted and long-stay (in nursing home longer than 1 year) nursing home residents by linking Minimum Data Set (MDS) information with data from the National Death Index and use these factors to create a useful tool for estimating risk levels for 1-year mortality. DESIGN Retrospective cohort study with development and validation cohorts. SETTING All 643 Medicare and Medicaid certified nursing homes in New York State during the study period. PARTICIPANTS The study included data on residents collected during full MDS assessments from June 1994 through December 1997. A total of 100,669 nursing home residents met the inclusion criteria for the newly admitted resident analysis. The newly admitted development cohort included 60,341 residents, and the newly admitted validation cohort included 40,328 residents. A total of 36,125 nursing home residents met inclusion criteria for the long-stay (residing in nursing home>1 year) cohort. The long-stay development cohort included 22,749 residents, and the long-stay validation cohort included 15,068 residents. MEASUREMENTS The analytical approach was similar for the newly admitted and long-stay resident cohorts. Resident characteristics that were considered potential risk factors for mortality were examined individually in bivariate proportional hazards models, and factors with P <.05 were entered into a proportional hazards regression stepwise model. The strongest factors based on their chi-square values were selected for entry into a multivariate proportional hazards analysis. Hazard ratios (HRs), 95% confidence intervals, and P-values were derived from this model. A mortality risk index score was created for each resident by summing the value of each HR in the multivariate model for those who had the risk factor. A sensitivity analysis was performed to determine the effect of residents with an unknown death status. A similar analysis was performed on the validation cohort to validate the original results. RESULTS Major factors associated with 1-year mortality were identified in both the newly admitted and long-stay cohorts. In both newly admitted and long-stay residents, a higher mortality risk index score was associated with increased 1-year mortality in both the development and validation cohorts. CONCLUSIONS MDS data can identify major factors associated with 1-year mortality in newly admitted and long-stay nursing home residents. These factors can be used to stratify residents into risk categories for 1-year mortality. This information could be important to residents, their families, and their physicians when developing care plans, as well as to agencies interested in healthcare resource planning.
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Affiliation(s)
- Jonathan M Flacker
- Division of Geriatric Medicine and Gerontology, Emory University School of Medicine, Atlanta, Georgia 30303, USA.
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9
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Hu P, Seeman TE, Harris TB, Reuben DB. Does inflammation or undernutrition explain the low cholesterol-mortality association in high-functioning older persons? MacArthur studies of successful aging. J Am Geriatr Soc 2003; 51:80-4. [PMID: 12534850 DOI: 10.1034/j.1601-5215.2002.51014.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To explore the effect of inflammation and undernutrition on the association between hypocholesterolemia and higher overall mortality in high-functioning older persons. DESIGN Prospective cohort study. SETTING Three U.S. communities. PARTICIPANTS A cohort of 870 participants from the MacArthur Studies of Successful Aging. MEASUREMENTS Baseline information was obtained for serum levels of cholesterol, C-reactive protein, interleukin-6, and albumin; body mass index; prevalent medical conditions; health behaviors; and medications. Crude and multivariate logistic regression analyses were used to examine the association between serum total cholesterol levels and 7-year all-cause mortality, while adjusting for potential confounders. RESULTS In univariate analysis, the risk ratio of low serum total cholesterol level (<169 mg/dL) for 7-year total mortality was 1.90 (95% confidence interval (CI) = 1.18-3.07). The multiple adjusted risk ratios were 1.82 (95% CI = 1.10-3.00) after controlling for markers of inflammation and nutrition and 1.39 (95% CI = 0.80-2.40) after adjustment for additional cardiovascular risk factors. Sex was an important confounding variable that contributed to the observed inverse association between low serum cholesterol and overall mortality in univariate analysis. CONCLUSIONS Hypocholesterolemia is not an independent risk factor for increased overall mortality in high-functioning community-dwelling older men and women. The association between low total cholesterol and high mortality observed in crude analysis is mainly confounded by common cardiovascular risk factors, rather than underlying inflammation or undernutrition.
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Affiliation(s)
- Peifeng Hu
- Multicampus Program in Geriatric Medicine and Gerontology, UCLA School of Medicine, Los Angeles, California 90095, USA.
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10
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Bonnefoy M, Abidi H, Jauffret M, Garcia I, Surrace JP, Drai J. [Hypocholesterolemia in hospitalized elderly: relations with inflammatory and nutritional status]. Rev Med Interne 2002; 23:991-8. [PMID: 12504235 DOI: 10.1016/s0248-8663(02)00718-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE Hypocholesterolemia is a common finding in hospitalized elderly people and is associated with increased mortality. Changes in plasma lipid levels are well known in the acute phase response. It has also been suggested that malnutrition is a cause of hypocholesterolemia. However, malnutrition is the reflect of general condition, and the respective roles of malnutrition and inflammation have not yet been clearly established. This research project was undertaken to examine the impact of nutritional and inflammatory status on the hypocholesterolemia. METHODS In a prospective study, 597 elderly patients (83 +/- 7 years) consecutively admitted in a geriatric acute care unit were included. Clinical and anthropometric data: Body Mass Index (BMI), Tricipital Skinfold Thickness (TSF), Sub-Scapular Skinfold Thickness (SSF), Mid Arm Circumference (MAC) have been collected. The blood samples were obtained within the 72 hours following the admission. Nutritional proteins (albumin, prealbumin, transferrin, retinol binding protein); inflammatory proteins (CRP, alpha-1 acid glycoprotein), and blood lipids (cholesterol, LDL, HDL cholesterol, triglycerides, apoproteins A1 and B) were dosed. RESULTS The anthropometric and biologic parameters have been compared on the two sexes, significant differences were observed only for blood lipids. The analyses are thus realized and presented by sex separately. Four groups of patients are generated according to the quartile of total cholesterol. Means and standard deviation for all factors are calculated within each group. Both, the trend of means and analyses of correlation show associations with cholesterol in the two sexes. The analysis of variance showed that the cholesterolemia is associated with 1/ decrease in the values of the anthropometrics, and nutritional proteins and 2/ upward trends of the inflammatory parameters. Significant correlations were observed for all transport proteins and CRP with total cholesterol in men and women. The multiple linear regression of the total cholesterol retained albumin, APO A1, APO B and RBP as predictor factors of cholesterolemia for women and APO A1, APO B and tryglicerid for men. When patients with infectious diseases were compared to the others, significant differences have been observed for total cholesterol and all blood lipids, as well as for nutritional and inflammatory proteins. CONCLUSION The results confirm an association between nutritional status and hypocholesterolemia, and suggest also the responsability of inflammation as a cause of hypocholesterolemia.
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Affiliation(s)
- M Bonnefoy
- Service de médecine gériatrique, centre hospitalier Lyon-Sud, 69495 Pierre-Bénite cedex, France.
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11
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Lecerf JM. [Hypocholesterolemia: a risk factor for mortality?]. Rev Med Interne 2002; 23:969-72. [PMID: 12504232 DOI: 10.1016/s0248-8663(02)00701-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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12
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Greenberg JA. Hypothesis - the J-shaped follow-up relation between mortality risk and disease risk-factor is due to statistical confounding. Med Hypotheses 2002; 59:568-76. [PMID: 12376081 DOI: 10.1016/s0306-9877(02)00155-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
There is currently conflicting evidence from longitudinal follow-up studies concerning the relation between mortality risk and disease risk factor at low levels or the risk factor. This applies to risk factors such as blood pressure, cholesterol, and body-mass index. In some studies, this relation was found to be positive. In others it was negative. This is an issue of importance to clinical and public-health policy, because a negative relation between mortality risk and blood pressure, for instance, implies that anithypertensive medication which lowers blood pressure below a critical threshold could be dangerous. It seemed likely that the conflict could be due to statistical confounding that artifactually elevates mortality risk at low risk-factor levels in survival analyses of longitudinal data. The present paper describes a crude analysis using data from the Framingham Offspring Study to test the idea that such statistical confounding could be caused by the decrease in risk factor with age among subjects near the end of the lifespan (referred to as late-life subjects). The analysis yielded evidence supporting this idea. on the basis of the findings it is hypothesized that: (1). the decrease in risk factor with age during late life causes the late-life bias. This bias distorts a positive relation between mortality risk and risk factor to appear U- or J-shaped in mixed-age adult follow-up cohorts; and (2). removal of the late-life and reverse-causation biases will show that this relation is monotonically positive.
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Affiliation(s)
- James A Greenberg
- Department of Health and Nutrition Sciences, Brooklyn College, New York, Brooklyn 11210, USA.
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Thomas DR, Ashmen W, Morley JE, Evans WJ. Nutritional management in long-term care: development of a clinical guideline. Council for Nutritional Strategies in Long-Term Care. J Gerontol A Biol Sci Med Sci 2000; 55:M725-34. [PMID: 11129394 DOI: 10.1093/gerona/55.12.m725] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Involuntary weight loss resulting from malnutrition is a major problem among residents in long-term care facilities. Although body weight is easily measured, the evaluation of unintended weight loss in long-term care facilities is difficult. METHODS The Council for Nutritional Clinical Strategies in Long-Term Care, an expert panel of interdisciplinary thought leaders representing academia and the medical community, derived a structured approach aimed at improving management of malnutrition in long-term care settings, using literature review and consensus development. The Clinical Guide to Prevent and Manage Malnutrition in Long-Term Care is based on a best-evidence approach to the management of nutritional problems in long-term care. RESULTS The Clinical Guide is divided into two parts, one designed for nursing staff, dietary staff, and dietitians, and a second directed to physicians, pharmacists, and dietitians. CONCLUSIONS A structured approach to the management of unintended weight loss or malnutrition in long-term care is intended to ensure a comprehensive resident evaluation. While the Clinical Guide is presented in a linear fashion, many of the considerations can be done simultaneously and the order varied dependent on the individual resident's needs. Further research to validate the effectiveness of using the algorithm in long-term care settings will be required.
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Affiliation(s)
- D R Thomas
- Division of Geriatric Medicine, Saint Louis University School of Medicine, Missouri 63104, USA.
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Obialo CI, Okonofua EC, Nzerue MC, Tayade AS, Riley LJ. Role of hypoalbuminemia and hypocholesterolemia as copredictors of mortality in acute renal failure. Kidney Int 1999; 56:1058-63. [PMID: 10469374 DOI: 10.1046/j.1523-1755.1999.00622.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED Role of hypoalbuminemia and hypocholesterolemia as co-predictors of mortality in acute renal failure. BACKGROUND Hypoalbuminemia (LA) and hypocholesterolemia (LC) have been reported to portend high mortality in both older patients and in patients with end-stage renal disease. Even though low levels have been reported in critically ill patients, they have not been clearly defined as predictors of mortality in acute renal failure (ARF). The impact of LA and LC on mortality in ARF is evaluated in this study. METHODS We conducted a computer-assisted three-year retrospective review of all cases of de novo ARF seen at an inner city tertiary-care facility. One hundred cases met the criteria for inclusion in the study. We employed both univariate and multivariate logistic regression models to estimate the relative risks (RR) and 95% confidence intervals (CI) of mortality associated with several variables. RESULTS Predictors associated with a high risk of death identified in this study include LC < or = 150 mg/dl (< or = 3.9 mmol/liter; RR, 7.4; CI, 2.7 to 20.3), LA < or =35 g/liter (RR, 5.0; CI, 1.9 to 13.2), sepsis (RR, 9.4; CI, 3.7 to 23.9), mechanical ventilation (RR, 10.8; CI, 2.8 to 41.0), oliguria (RR 17.0; CI, 6.2 to 46.6), and multisystem organ failure (RR 24.7; CI, 10.3 to 59.1). The overall gross mortality was 39%, but mortality among intensive care unit patients was 82%. Survival was 82% among patients with serum albumin >35 g/liter versus 48% among those with serum albumin < or =35 g/liter (chi2 = 11.9, P = 0.0006). Similarly, survival was higher among patients with cholesterol >150 mg/dl (>3.9 mmol/liter) than those whose levels were < or =150 mg/dl (< or =3.9 mmol/liter; 85 vs. 44%, ch 17.3, P<0.0001). Significant association between LA and LC was observed (R = 0.4, P<0.0001). Age, gender, level of plasma creatinine, and underlying chronic medical conditions were not predictive of mortality. CONCLUSION Survival in ARF is significantly altered by the levels of albumin and cholesterol. Because both LC and LA can be cytokine mediated, their presence in ARF should be considered ominous.
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Affiliation(s)
- C I Obialo
- Department of Medicine, Morehouse School of Medicine, Atlanta, Georgia 30310, USA
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Abstract
The management of hyperlipidemia in the elderly patient is a major problem, given the frequency of dyslipidemias and cardiovascular disorders in this age group. Therapy must take current uncertainties into account and, in the absence of therapeutic studies carried out in the elderly, is typically based upon a case-by-case approach. Raised cholesterol levels remain a significant risk factor for coronary heart disease (CHD) in the elderly. Although the relative risk of CHD tends to diminish with increasing age, this reduction is accompanied by an increase in absolute risk (ie, the number of events) as the frequency of the illness increases markedly with age. The results of major outcome studies with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins), when analyzed according to patient age, indicate that the benefits of these agents are not merely confined to younger individuals. However, the elderly form a unique patient population--the proportion of women is greater and the profile of cardiovascular illnesses is characterized, among others, by a greater incidence of cerebrovascular accidents. Problems relating to poor tolerability and comorbidity (which may give rise to drug-drug interactions) also occur more frequently in this age group. Moreover, the potential widespread treatment of hyperlipidemia in the elderly has profound economic implications. Under these circumstances, the clinical practice recommendations depend upon a reasonable extrapolation of epidemiologic and therapeutic data obtained from middle-aged men. At present, treatment is therefore aimed at patients with the most severe forms of hyperlipidemia, generally in the secondary prevention setting, taking into account the patient's life expectancy. The results of ongoing studies will determine the benefits of lipid-lowering therapy for primary prevention of CHD in the elderly.
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Affiliation(s)
- E Bruckert
- Department of Endocrinology, Cardiovascular Disease Prevention, Hôpital Pitié-Salpêtrière, Paris, France
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16
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Abstract
A prospective cohort study was conducted to examine predictors of mortality in the nursing home. Participants were 399 long-term nursing home residents, who were followed up for 11 years at the end of which 380 had died, 16 were still alive, 2 were discharged with unknown status, and 1 was alive when discharged. The median duration from baseline to death was 2.75 years. For cognitively intact residents, male gender, larger number of medical diagnoses, and manifestations of physically nonaggressive agitated behaviors (e.g., restlessness, pacing) were significant predictors. For cognitively impaired residents, the significant predictors were older age, impaired activities of daily living, and screaming behavior at a high frequency. Cognitive impairment is important both in predicting death in this population and in understanding the impact of other predictors. The impact of agitated behaviors, quality of social relations, and appetite on mortality highlights issues of quality of life at the end of life.
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Affiliation(s)
- J Cohen-Mansfield
- Research Institute of the Hebrew Home of Greater Washington, Rockville, Maryland 20852, USA
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17
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Flacker JM, Kiely DK. A practical approach to identifying mortality-related factors in established long-term care residents. J Am Geriatr Soc 1998; 46:1012-5. [PMID: 9706893 DOI: 10.1111/j.1532-5415.1998.tb02759.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Determining prognosis is an important part of medical planning for long-term care residents. Clarifying the resident characteristics associated with increased mortality has received little attention from investigators, and many approaches that have been suggested are unsuitable for widespread use. Using a readily available database, we sought to determine factors associated with 1-year mortality in established long-term care residents. DESIGN A retrospective cohort study. SETTING A 725-bed long-term care facility. MEASUREMENTS We examined Minimum Data Set (MDS) information on 780 residents from April 1994 through August 1997. The association between death and 65 resident factors, covering a broad array of physical, functional, medical, and psychosocial measures, was examined initially in bivariate proportional hazards models. Putative factors with P values < .10 in bivariate analysis were considered in the multivariate analysis. Using these factors, we employed a forward step-wise multivariate proportional hazards regression method to select the set of factors associated independently with mortality at a P value < .05. A mortality score was developed by assigning points to each factor based on the risk ratio in the multivariate proportional hazards model. The performance characteristics of the model were examined using logistic regression. RESULTS Forty-four of the 65 factors examined were associated with 1-year mortality in bivariate proportional hazards analysis. Eight of these 44 factors were associated with 1-year mortality in the multivariate proportional hazards regression. These factors were functional impairment, weight loss, shortness of breath, male gender, low body mass index, swallowing problems, congestive heart failure, and advanced age. A higher mortality score was associated with a higher death rate in the subsequent year. The model demonstrated good performance with an area under the ROC curve of 0.77. CONCLUSIONS Using a widely available database that requires no additional medical testing or staff training, a useful model for identifying factors associated with 1-year mortality in established long-term care residents can be developed. Widespread use of such a practical approach to assess mortality risk could be of benefit to patients, their families, and physicians for informing care plan decisions.
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Affiliation(s)
- J M Flacker
- Hebrew Rehabilitation Center for Aged Research, and Harvard Medical School Division on Aging, Boston, Massachusetts 02131, USA
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18
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Rosenthal AJ, McMurtry CT, Sanders KM, Jacobs M, Thompson D, Adler RA. The soluble interleukin-2 receptor predicts mortality in older hospitalized men. J Am Geriatr Soc 1997; 45:1362-4. [PMID: 9361663 DOI: 10.1111/j.1532-5415.1997.tb02937.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND There is an inverse relationship between the soluble interleukin-2 receptor (sIL-2R) and serum albumin, cholesterol, transferrin, prealbumin, and hemoglobin. Inasmuch as low serum albumin and cholesterol have been associated with excess mortality, we hypothesized that elevated sIL-2R would predict mortality in older adults. OBJECTIVE To determine if elevated sIL-2R predicts mortality in patients on a geriatric rehabilitation unit. DESIGN Prospective cohort. SETTING University-affiliated VA medical center. PARTICIPANTS Seventy-two male patients aged greater than 60 years admitted to a geriatric rehabilitation unit. Patients with severe hepatic or renal disease were excluded. MEASUREMENTS We measured serum albumin, prealbumin, cholesterol, transferrin, hemoglobin, body mass index (BMI), C-reactive protein (CRP), and sIL-2R upon admission. Subjects were followed for 1 year. RESULTS Low serum albumin, prealbumin, and hemoglobin and high sIL-2R and CRP predicted 1-year mortality on univariate analysis. When these predictors were included as covariates in a Cox regression model, only sIL-2R was a significant independent predictor of mortality (P = .043). Multiple linear regression with the above covariates revealed that only sIL-2R predicted time to death at (P = .003). CONCLUSIONS High sIL-2R and CRP and low albumin, prealbumin, and hemoglobin predicted mortality using univariate analysis on a rehabilitation unit. However, with multivariate analysis, sIL-2R was the sole predictor of mortality.
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Affiliation(s)
- A J Rosenthal
- Medical Service, McGuire VA Medical Center (181), Richmond, VA 23249, USA
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