Associations Between Anemia, Cognitive Impairment, and All-Cause Mortality in Oldest-Old Adults: A Prospective Population-Based Cohort Study

Mediating effects of physical activities and cognitive function on the relationship between dietary diversity and all-cause mortality in community-dwelling older adults

Background

Although dietary diversity (DD) has been confirmed to be associated with multiple health outcomes and longevity in older people, the related mechanisms have not been elucidated. In this study, we explored the mediating roles of physical activities and cognitive function in the relationship between DD and all-cause mortality.

Methods

We recruited 34 068 community-dwelling older adults aged ≥60 years from the Chinese Longitudinal Healthy Longevity Study and followed them up until 2018. Dietary diversity score (DDS) was assessed by the intake frequency of nine food sources. We evaluated physical activities and cognitive function using the Katz index and Mini-Mental State Examination. We explored the mediating roles of physical activities and cognitive function between DDS and all-cause mortality using mediated analyses in Cox proportional risk regression models.

Results

A total of 25 362 deaths were recorded during 148 188.03 person-years of follow-up. Participants with physical disability and cognitive impairment had lower DDS than the normal group (P < 0.001). After controlling for all covariates, DDS, physical activities, and cognitive functioning were negatively associated with all-cause mortality. Physical activities and cognitive function mediated 18.29% (95% confidence interval (CI) = 12.90-23.10) and 27.84% (95% CI = 17.52-37.56) of the total effect of DDS on mortality, respectively.

Conclusions

Physical activities and cognitive function mediated the association between DDS and all-cause mortality. Maintaining DD may benefit early death prevention by reducing physical disability and cognitive impairment in community-dwelling older people.

Prevalence and classification of anemia among children in Sudan: a systematic review and meta-analysis

Anemia remains a significant public health concern, particularly in developing countries like Sudan, where children are particularly vulnerable to its associated health implications. This study aimed to systematically assess the prevalence of anemia among Sudanese children. We conducted a comprehensive literature search in August 2021 and updated it in December 2022 to identify studies on anemia among Sudanese children. We searched databases including PubMed, Scopus, Science Direct, and Google Scholar. Studies eligible for inclusion in this systematic review and meta-analysis (SRMA) reported data to calculate anemia prevalence in children using WHO criteria. We performed meta-analysis using R software with metaprop and metafor packages. Using a random effects model, we estimated the pooled prevalence of anemia among 8006 Sudanese children to be 53.5% (95% CI, 36.6-70.4%). Subgroup analysis revealed that 62.7% of the children had unclassified anemia, 39.1% had iron deficiency anemia, and 8.7% had sickle cell anemia. Over a 21-year period, childhood anemia in Sudan showed an increasing trend, rising from 40.7% (1999-2009) to 55.1% (2010-2015) and 58.1% (2016-2020). The findings indicate a significantly higher prevalence of anemia among Sudanese children compared to many other countries, highlighting the need for proactive measures to prevent and control anemia in this population.

Anemia, Iron Deficiency, and Cause-Specific Mortality: The Atherosclerosis Risk in Communities Study

INTRODUCTION

Anemia is a risk factor for all-cause mortality in older adults. Iron deficiency may also be associated with adverse outcomes, independent of its role in causing anemia. This study tested the hypotheses that anemia, and low ferritin among non-anemic participants, were associated with all-cause and cause-specific mortality in a community-based cohort of older adults.

METHODS

Fasting blood was obtained from 5,070 ARIC participants (median age: 75 years) in 2011-2013. Anemia was defined by hemoglobin concentrations <12 g/dL in women and <13 g/dL in men. We classified 4,020 non-anemic participants by quartiles of plasma ferritin, measured by the SomaScan proteomics platform. Cox proportional hazards regression was used. Mortality was ascertained via phone calls with proxies as part of twice-yearly cohort follow-up, surveillance of local hospital discharge indexes, state death records, and linkage to the National Death Index.

RESULTS

Of the total participants, 21% had anemia at baseline. Over a median of 7.5 years, there were 1,147 deaths, including 357 due to cardiovascular disease (CVD), 302 to cancer, and 132 to respiratory disease. Compared to those with normal hemoglobin, participants with anemia had a higher risk of all-cause mortality (hazard ratio 1.81 [95% CI: 1.60-2.06]), and mortality due to CVD (1.77 [1.41-2.22]), cancer (1.81 [1.41-2.33]), and respiratory disease (1.72 [1.18-2.52]) in demographics-adjusted models. In fully adjusted models, associations with all-cause mortality (1.37 [1.19-1.58]) and cause-specific mortality were attenuated. In non-anemic participants, lower ferritin levels were not associated with all-cause or cause-specific mortality, though associations were observed among participants with lesser evidence of inflammation (CRP below the median level of 1.9 mg/L) and for cancer mortality in men only.

CONCLUSION

Anemia is common among older adults and is associated with all-cause mortality, as well as mortality due to CVD, cancer, and respiratory disease. Our results do not provide evidence that iron deficiency, independent of anemia, is associated with mortality in this population.

Synergistic impact of plasma albumin and cognitive function on all-cause mortality in Chinese older adults: a prospective cohort study

Background

Hypoalbuminemia and cognitive impairment (CI) each independently increase the mortality risk in older adults. However, these two geriatric syndromes can occur simultaneously. In community-dwelling older adults, is the combination of hypoalbuminemia and CI linked to a higher mortality risk than either condition alone?

Objective

We aimed to investigate the association between plasma albumin, cognitive function, and their synergistic effect on mortality in Chinese community-dwelling older adults.

Methods

Data from the Chinese Longitudinal Healthy Longevity Survey (2012) included 1,858 participants aged ≥65. Baseline assessments comprised albumin levels and cognitive status. All-cause mortality was confirmed through 2014-2018 surveys. Cox proportional hazards models assessed associations, and restricted cubic splines explored albumin-mortality relationship.

Results

During a median follow-up of 48.85 months, 921 deaths. Albumin≥35 g/L vs < 35g/L [HR: 1.33 (95%CI, 1.10, 1.62)] and CI vs normal cognition [HR: 1.69 (95%CI, 1.43, 1.99)] independently predicted mortality. A dose-response relationship with mortality was observed for albumin quartiles (p < 0.001). Each SD increase in MMSE or albumin correlated with 22% and 15% lower mortality risk, respectively. Combined hypoproteinemia and CI increased the mortality risk by 155%, with a notably higher risk in males, those aged <85 years, and individuals living in rural areas. Interaction effects of albumin and CI on mortality were observed (p < 0.001). In the single CI group, older adults had a 61% increased risk of mortality in the hypoproteinaemia group compared with the albumin-normal group. Restricted cubic spline revealed a reverse J-shaped association, particularly for participants without CI. For individuals with CI, albumin levels were inversely associated with mortality risk.

Conclusion

Hypoproteinemia and CI, individually and combined, increased all-cause mortality risk in Chinese older adults, with stronger effects observed in males, younger older adults, and those living in rural areas. These findings emphasize the importance of targeted adjustments and early nutrition programs in health prevention and clinical care for older adults.

Effects of lifestyle and its interaction with anemia on cognitive function in older adults: A longitudinal study

A better understanding of the impact of lifestyle factors on cognitive function in older adults is critical for developing intervention strategies to achieve successful aging. Moreover, older adults who fulfill the World Health Organization criteria for anemia have a significantly higher risk of developing dementia. In the current study, we aimed to assess the buffering effects of lifestyle on cognitive function in older Chinese adults through a nationally representative survey. The sample consisted of 1201 participants (mean age: 82.39 ± 12.08 years, 52.1% female) from the 2011/2012 and 2014 waves of the Chinese Longitudinal Healthy Longevity Survey. Multiple linear regression analyses were used to explore the relationship between changes in lifestyle factors and the rate of cognitive function changes, as well as the effects of the interaction between lifestyle factors and anemia on cognitive function changes. Increased levels of participation in leisure activities, social activities, and dietary diversity delayed cognitive decline. Persistent anemia accelerated cognitive decline, while frequent participation in leisure activities delayed cognitive decline due to anemia. The increased levels of participation in leisure activities, social activities, and dietary diversity can alleviate the cognitive decline caused by aging itself, and more frequently participation in leisure activities can also alleviate the adverse effects of anemia on cognitive function in older adults.

Validity of point-of-care device for diagnosing anemia in workers exposed to lead

Detecting anemia in occupational health settings is critical in a high-risk population for anemia like the lead-exposed. Whether the point-of-care devices are sensitive to detect anemia in individuals with high levels of lead exposure is unknown. We compared hemoglobin (Hb) levels from HemoCue® Hb 301 System and standard analyzer, Mindrey-BC 5300, in individuals (n=58) exposed to lead (mean levels = 44.9 ?g/dL) for a chronic period (mean duration of exposure = 105 months). We observed high sensitivity (0.95), specificity(0.95) in detecting anemia by hemocue, and high agreement between the methods. The significant difference in Hb values between the methods (0.171g/dL, p=0.018) was clinically minimal. We conclude that hemocue is a good method for rapidly detecting anemia and estimating Hb levels among the lead-exposed in resource-limited settings.

Cognitive impairment assessed by Mini-Mental State Examination predicts all-cause and CVD mortality in Chinese older adults: A 10-year follow-up study

Objective

Cognitive impairment (CI) has been demonstrated as a useful proxy measure of mortality in Western populations. However, the predictive value of CI in Chinese populations is unknown. We aimed to explore whether CI is independently associated with increased long-term all-cause and cardiovascular disease (CVD) mortality in Chinese older adults and the association of performance in specific MMSE sub-domains to subsequent mortality.

Methods and results

A total of 4,499 older adults [mean (SD) age, 70.3(6.7) years] who received a sample investigation from 2011 to 2014 were followed up till 2021 for mortality. The Mini-Mental State Examination was used to assess cognitive function, and Cox's proportional hazard models were used to evaluate the effects of cognitive function on the risk of all-cause and CVD mortality. Demographic characteristics, lifestyle, and health status were included as covariates. During a 10-year follow-up, a total of 667 (14.8%) died. In the fully adjusted model, compared with cognitively normal participants with CI had a 1.33-fold [HR, 1.33; (95% CI, 1.10-1.61)] greater risk of all-cause mortality and a 1.45-fold [HR, 1.45; (95% CIs, 1.11-1.92)] greater risk of CVD mortality. After a similar multivariable adjustment, a per-SD increase in MMSE scores was associated with a reduced risk of all-cause mortality [HR, 0.85; (95% CI, 0.78-0.93)] and CVD mortality [HR, 0.74; (95% CI, 0.65-0.84)]. In the unadjusted model, MMSE sub-domains (apart from immediate recall) were associated with mortality. But only orientation and calculation and attention were still independently associated with all-cause and CVD mortality in a multivariable model.

Conclusion

These findings confirmed that CI is a marker of all-cause and CVD mortality risk in Chinese older adults, independently of other commonly assessed risk factors, and some sub-domains of the MMSE may have stronger associations with mortality. Further research is needed to identify the mechanisms underlying the observed associations.

Factors associated with access to healthcare services for older adults with limited activities of daily living

Background

Limited studies focused on the situation and related factors of access to healthcare services for older adults with limited activities of daily living (ADL) in China. This study explores factors associated with access to healthcare services of them based on Andersen's healthcare utilization model (namely, need, predisposing, and enabling dimensions).

Methods

A total of 3,980 participants aged 65 years and older adults with limited ADL from the latest wave (2018) of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) were included. Binary logistic regression was used to explore the influencing factors.

Results

Factors in enabling dimension were associated with access to healthcare services for older adults with limited ADL. Those who lived with better economic status (fair vs poor, OR = 2.98, P < 0.01; rich vs poor, OR = 7.23, P = 0.01), could afford daily life (yes vs no, OR = 2.33, P = 0.03), and lived in the eastern or central region of China (eastern vs western, OR = 2.91, P < 0.01; central vs western, OR = 2.40, P = 0.02) could access to healthcare services more easily. However, factors in predisposing dimension and need dimension showed no statistical significance. Meanwhile, inconvenience in the movement was the major barrier reported by some participants for not going to the hospital when they got sick.

Conclusion

Access to healthcare services for older adults with ADL limitation was mainly related to the factors of economic status, affordability for daily life, and living regions in enabling dimension. Strategies focused on health insurance, healthcare system, barrier-free facilities, and social support were proposed to increase the access to healthcare services for participants, which could benefit their health.

Development, validation, and visualization of a web-based nomogram to predict 5-year mortality risk in older adults with hypertension

Background

Hypertension-related mortality has been increasing in older adults, resulting in serious burden to society and individual. However, how to identify older adults with hypertension at high-risk mortality remains a great challenge. The purpose of this study is to develop and validate the prediction nomogram for 5-year all-cause mortality in older adults with hypertension.

Methods

Data were extracted from National Health and Nutrition Examination Survey (NHANES). We recruited 2691 participants aged 65 years and over with hypertension in the NHANES 1999-2006 cycles (training cohort) and 1737 participants in the NHANES 2007-2010 cycles (validation cohort). The cohorts were selected to provide at least 5 years follow-up for evaluating all-cause mortality by linking National Death Index through December 31, 2015. We developed a web-based dynamic nomogram for predicting 5-year risk of all-cause mortality based on a logistic regression model in training cohort. We conducted internal validation by 1000 bootstrapping resamples and external validation in validation cohort. The discrimination and calibration of nomogram were evaluated using concordance index (C-index) and calibration curves.

Results

The final model included eleven independent predictors: age, sex, diabetes, cardiovascular disease, body mass index, smoking, lipid-lowering drugs, systolic blood pressure, hemoglobin, albumin, and blood urea nitrogen. The C-index of model in training and validation cohort were 0.759 (bootstrap-corrected C-index 0.750) and 0.740, respectively. The calibration curves also indicated that the model had satisfactory consistence in two cohorts. A web-based nomogram was established (https://hrzhang1993.shinyapps.io/dynnomapp).

Conclusions

The novel developed nomogram is a useful tool to accurately predict 5-year all-cause mortality in older adults with hypertension, and can provide valuable information to make individualized intervention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03087-3.

Anemia in nursing homes, proton pump inhibitors and prescribing cascade of antianemic drugs

PURPOSE

Some medications can cause anemia through their effect on gastrointestinal function, such as proton pump inhibitors and H2-antagonists, and on the risk of bleeding, such as anticoagulants and antiplatelet agents. The main aim of this study is to evaluate how anemia is related with the most commonly used drugs in a large sample of NH residents.

METHODS

This retrospective cross-sectional multicenter study was conducted in a sample of Italian long-term care NHs distributed throughout the country.

RESULTS

In all, 2602 NH residents recruited from 27 Italian long-term NHs (mean age ± SD: 88.4 ± 8.5) and 441 (16.9%) had a diagnosis of anemia. The unadjusted model showed a significant relation with PPI (OR 1.71, 95% CI 1.39-2.11, p < 0.0001). This relation was maintained in the model adjusted for age, sex, CKD, atrophic gastritis, peptic ulcer and rheumatic disease (OR 1.61, 95% CI 1.31-1.99, p < 0.0001). PPI users were also at higher risk of being treated with antianemic drugs-iron supplements, folate, vitamin B12 and erythropoietin (OR 2.03, 95% CI 1.67-2.48, p < 0.0001)-even if they did not have anemia (OR 1.94, 95% CI 1.55-2.42, p < 0.0001).

CONCLUSION

Proton pump inhibitors are associated with anemia in NH residents. PPIs are also related with an increased probability of receiving drugs to treat anemia, such as iron supplements, folate or cyanocobalamin and erythropoietin, as the effect of a prescribing cascade. Optimization of PPI prescription is needed to avoid adverse events and promote rational drug prescription.

Synergistic impact of diabetes and cognitive impairment on all-cause and cause-specific mortality in Chinese older adults: A prospective population-based cohort study

BACKGROUND

Diabetes mellitus (DM) or cognitive impairment (CI) is known to be strongly associated with mortality. DM commonly coexists with CI and proportionally increases with age. However, little is known about the combined effect of cognitive function and diabetes on mortality. This study aimed to evaluate the combined effects of DM and CI on all-cause and cause-specific mortality in Chinese older adults.

METHODS

This prospective population-based cohort study was based on the Beijing Elderly Comprehensive Health Cohort Study. A total of 4,499 older adults were included. Cox's proportional hazard models were utilized to calculate the effect of DM and CI on all-cause, cardiovascular disease (CVD) mortality and cancer mortality, and a multiplicative term was introduced to study a potential interaction between DM and CI on outcomes.

RESULTS

During a median follow-up of 6.8 years (ranging from 6.6 to 11.7 years), 667 (14.8%) participants died from all causes, 292 from CVD, and 215 from cancer. In the fully adjusted model, participants with coexisting DM and CI had the highest risk of all-cause mortality [hazard ratios (HRs), 3.08; 95% confidence intervals (CIs), 2.30,4.11] and CVD mortality (HRs, 3.85; 95% CIs, 2.60,5.71) compared with individuals with normal cognition and non-DM. We also found a multiplicative interaction between DM and CI in respect to all-cause (HRs, 2.46; 95% CI, 1.87,3.22) and CVD mortality (HRs, 3.15 95% CI, 2.19,4.55). In the diabetic population, CI was associated with an increased risk of all-cause mortality (HRs, 2.09; 95% CIs, 1.51,2.89) and CVD mortality (HRs, 3.16; 95% CIs, 2.02,5.05) compared with the normal cognition group. Restricted cubic spline revealed a linear inverse association between Mini-Mental State Examination (MMSE) score and all-cause, CVD mortality in the total sample and participants without diabetes. However, a nearly reverse J association was observed between MMSE and mortality from all causes and CVD in the diabetes group.

CONCLUSION

The findings highlighted that cognitive impairment concomitant with diabetes further increases the risk of mortality. In addition to strengthening routine screening of cognitive functioning in older adults with early-stage diabetes, more extensive assessment of prognostic risks has high clinical value for developing comprehensive treatment plans.

Mild anemia and 11- to 15-year mortality risk in young-old and old-old: Results from two population-based cohort studies

BACKGROUND

Mild anemia is a frequent although often overlooked finding in old age. Nevertheless, in recent years anemia has been linked to several adverse outcomes in the elderly population. Objective of the study was to investigate the association of mild anemia (hemoglobin concentrations: 10.0-11.9/12.9 g/dL in women/men) with all-cause mortality over 11-15 years and the effect of change in anemia status on mortality in young-old (65-84 years) and old-old (80+ years).

METHODS

The Health and Anemia and Monzino 80-plus are two door-to-door, prospective population-based studies that included residents aged 65-plus years in Biella municipality and 80-plus years in Varese province, Italy. No exclusion criteria were used.

RESULTS

Among 4,494 young-old and 1,842 old-old, mortality risk over 15/11 years was significantly higher in individuals with mild anemia compared with those without (young-old: fully-adjusted HR: 1.35, 95%CI, 1.15-1.58; old-old: fully-adjusted HR: 1.28, 95%CI, 1.14-1.44). Results were similar in the disease-free subpopulation (age, sex, education, smoking history, and alcohol consumption adjusted HR: 1.54, 95%CI, 1.02-2.34). Both age groups showed a dose-response relationship between anemia severity and mortality (P for trend <0.0001). Mortality risk was significantly associated with chronic disease and chronic kidney disease mild anemia in both age groups, and with vitamin B12/folate deficiency and unexplained mild anemia in young-old. In participants with two hemoglobin determinations, seven-year mortality risk was significantly higher in incident and persistent anemic cases compared to constant non-anemic individuals in both age groups. In participants without anemia at baseline also hemoglobin decline was significantly associated with an increased mortality risk over seven years in both young-old and old-old. Limited to the Monzino 80-plus study, the association remained significant also when the risk was further adjusted also for time-varying covariates and time-varying anemia status over time.

CONCLUSIONS

Findings from these two large prospective population-based studies consistently suggest an independent, long-term impact of mild anemia on survival at older ages.