Impaired lung compliance and DL,CO but no restrictive ventilatory defect in sarcoidosis

Sarcoidosis is a systemic granulomatous disease with predominant manifestation in the lungs, often presenting as interstitial lung disease. Pulmonary function abnormalities in sarcoidosis include restriction of lung volumes, reduction in diffusing capacity of the lung for carbon monoxide (D(L,CO)), reduced static lung compliance (C(L,s)) and airway obstruction. The aim of the present study was to assess various lung function indices, including C(L,s) and D(L,CO), as markers of functional abnormality in sarcoidosis patients. Results from 830 consecutive patients referred for lung function tests with a diagnosis of sarcoidosis (223 in stage I, 486 in stage II and 121 in stage III) were retreospectively analysed. The mean ± sd age of the patients was 40 ± 11 yrs; 18% were active smokers and 24% were former smokers. Normal total lung capacity was found in 772 (93%) patients. Of these cases, 24.5% had a low C(L,s) and 21.5% had a low D(L,CO). At least one abnormality was observed in 39.3% of these patients, whereas, in restrictive patients, this figure was 88%. Airway obstruction was present in 11.7% of cases. Lung volumes usually remain within the normal range and measurement of either C(L,s) or D(L,CO) often reveal impaired lung function in sarcoidosis patients, even when their lung volumes are still in the normal range; these two measurements provide complementary information.

Comparison of spirometry criteria for the diagnosis of COPD: results from the BOLD study

Published guidelines recommend spirometry to accurately diagnose chronic obstructive pulmonary disease (COPD). However, even spirometry-based COPD prevalence estimates can vary widely. We compared properties of several spirometry-based COPD definitions using data from the international Burden of Obstructive Lung Disease (BOLD)study. 14 sites recruited population-based samples of adults aged > or =40 yrs. Procedures included standardised questionnaires and post-bronchodilator spirometry. 10,001 individuals provided usable data. Use of the lower limit of normal (LLN) forced expiratory volume in 1 s (FEV(1)) to forced vital capacity (FVC) ratio reduced the age-related increases in COPD prevalence that are seen among healthy never-smokers when using the fixed ratio criterion (FEV(1)/FVC <0.7) recommended by the Global Initiative for Chronic Obstructive Lung Disease. The added requirement of an FEV(1) either <80% predicted or below the LLN further reduced age-related increases and also led to the least site-to-site variability in prevalence estimates after adjusting for potential confounders. Use of the FEV(1)/FEV(6) ratio in place of the FEV(1)/FVC yielded similar prevalence estimates. Use of the FEV(1)/FVC<LLN criterion instead of the FEV(1)/FVC <0.7 should minimise known age biases and better reflect clinically significant irreversible airflow limitation. Our study also supports the use of the FEV(1)/FEV(6) as a practical substitute for the FEV(1)/FVC.

Can a normal peak expiratory flow exclude severe chronic obstructive pulmonary disease?

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is underdiagnosed. One barrier to diagnosis is the limited availability of spirometry testing, but in adults at risk for COPD, a normal pre-bronchodilator (pre-BD) peak expiratory flow (PEF) may rule out clinically significant COPD.

OBJECTIVE

To identify post-BD airway obstruction using data from 13 708 individuals aged >or=40 years from the PLATINO and BOLD studies.

METHODS

We evaluated different cut-off points of pre-BD. The PEF was obtained from a diagnostic-quality spirometer (not a mechanical PEF meter). At least one of the following COPD risk factors was present in 77% of the subjects: chronic respiratory symptoms; exposure to tobacco smoke, biomass smoke or dust in the workplace; or a previous diagnosis of asthma, COPD, emphysema or chronic bronchitis.

RESULTS

Although the positive predictive value was low as expected, a pre-BD PEF of >or=70% predicted effectively ruled out Stages III and IV COPD of the Global Initiative for Chronic Obstructive Lung Disease. Among those with at least one risk factor, only 12% would require confirmatory spirometry using this criterion.

CONCLUSIONS

Adding PEF measurement to a screening questionnaire may rule out severe to very severe COPD without the need for pre- and post-BD spirometry testing. Confirmation is needed from a study using inexpensive PEF meters or pocket spirometers with a staged screening protocol.

A new perspective on concepts of asthma severity and control

Concepts of asthma severity and control are important in the evaluation of patients and their response to treatment but the terminology is not standardised and the terms are often used interchangeably. This review, arising from the work of an American Thoracic Society/European Respiratory Society Task Force, identifies the need for separate concepts of control and severity, describes their evolution in asthma guidelines and provides a framework for understanding the relationship between current concepts of asthma phenotype, severity and control. "Asthma control" refers to the extent to which the manifestations of asthma have been reduced or removed by treatment. Its assessment should incorporate the dual components of current clinical control (e.g. symptoms, reliever use and lung function) and future risk (e.g. exacerbations and lung function decline). The most clinically useful concept of asthma severity is based on the intensity of treatment required to achieve good asthma control, i.e. severity is assessed during treatment. Severe asthma is defined as the requirement for (not necessarily just prescription or use of) high-intensity treatment. Asthma severity may be influenced by the underlying disease activity and by the patient's phenotype, both of which may be further described using pathological and physiological markers. These markers can also act as surrogate measures for future risk.

Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction

AIM

The prevalence of airway obstruction varies widely with the definition used.

OBJECTIVES

To study differences in the prevalence of airway obstruction when applying four international guidelines to three population samples using four regression equations.

METHODS

We collected predicted values for forced expiratory volume in 1 s/forced vital capacity (FEV(1)/FVC) and its lower limit of normal (LLN) from the literature. FEV(1)/FVC from 40 646 adults (including 13 136 asymptomatic never smokers) aged 17-90+years were available from American, English and Dutch population based surveys. The prevalence of airway obstruction was determined by the LLN for FEV(1)/FVC, and by using the Global Initiative for Chronic Obstructive Lung Disease (GOLD), American Thoracic Society/European Respiratory Society (ATS/ERS) or British Thoracic Society (BTS) guidelines, initially in the healthy subgroup and then in the entire population.

RESULTS

The LLN for FEV(1)/FVC varied between prediction equations (57 available for men and 55 for women), and demonstrated marked negative age dependency. Median age at which the LLN fell below 0.70 in healthy subjects was 42 and 48 years in men and women, respectively. When applying the reference equations (Health Survey for England 1995-1996, National Health and Nutrition Examination Survey (NHANES) III, European Community for Coal and Steel (ECCS)/ERS and a Dutch population study) to the selected population samples, the prevalence of airway obstruction in healthy never smokers aged over 60 years varied for each guideline: 17-45% of men and 7-26% of women for GOLD; 0-18% of men and 0-16% of women for ATS/ERS; and 0-9% of men and 0-11% of women for BTS. GOLD guidelines caused false positive rates of up to 60% when applied to entire populations.

CONCLUSIONS

Airway obstruction should be defined by FEV(1)/FVC and FEV(1) being below the LLN using appropriate reference equations.

FEV6 as a surrogate for FVC in detecting airways obstruction and restriction in the workplace

Compared with measurements of forced vital capacity (FVC), using the forced expiratory volume in six seconds (FEV(6)) reduces test time and frustration. It was hypothesised that using FEV(6) in the workplace setting would result in an acceptably low misclassification rate for detecting airways obstruction and spirometry-defined restriction when compared with using the traditional FVC. Experienced technicians from the National Institute for Occupational Safety and Health performed spirometry using dry rolling-seal spirometers as per American Thoracic Society guidelines in four workplace investigations. Airways obstruction was defined as an FEV(1)/FVC % below the lower limit of normal (LLN) using National Health and Nutrition Examination Survey III reference equations. Restriction was defined as an FVC below the LLN with a normal FEV(1)/FVC %. These "gold standard" definitions were compared with definitions based on FEV(6) (obstruction: FEV(1)/FEV(6) below the LLN; restriction: FEV(6) below the LLN with a normal FEV(1)/FEV(6)). The median (range) age of the 1,139 workers was 37 yrs (18-71 yrs) and 51.4% were male. A significantly high overall agreement was obtained between the two definitions. In conclusion, the current results confirm that forced expiratory volume in six seconds can be used as a surrogate for forced vital capacity in detecting airways obstruction and restriction in workers, although with some misclassification when compared to obtaining American Thoracic Society-acceptable manoeuvres of longer duration.

Respiratory muscle strength and the risk of incident cardiovascular events

BACKGROUND

Maximal inspiratory pressure (MIP) is a measure of inspiratory muscle strength. The prognostic importance of MIP for cardiovascular events among elderly community dwelling individuals is unknown. Diminished forced vital capacity (FVC) is a risk factor for cardiovascular events which remains largely unexplained.

METHODS

MIP was measured at the baseline examination of the Cardiovascular Health Study. Participants had to be free of prevalent congestive heart failure (CHF), myocardial infarction (MI), and stroke.

RESULTS

Subjects in the lowest quintile of MIP had a 1.5-fold increased risk of MI (HR 1.48, 95% CI 1.07 to 2.06) and cardiovascular disease (CVD) death (HR 1.54, 95% CI 1.09 to 2.15) after adjustment for non-pulmonary function covariates. There was a potential inverse relationship with stroke (HR 1.36, 95% CI 0.97 to 1.90), but there was little evidence of an association between MIP and CHF (HR 1.22, 95% CI 0.93 to 1.60). The addition of FVC to models attenuated the HR associated with MIP only modestly; similarly, addition of MIP attenuated the HR associated with FVC only modestly.

CONCLUSIONS

A reduced MIP is an independent risk factor for MI and CVD death, and a suggestion of an increased risk for stroke. This association with MIP appeared to be mediated through mechanisms other than inflammation.

Lung function and mortality in the United States: data from the First National Health and Nutrition Examination Survey follow up study

BACKGROUND

A study was undertaken to define the risk of death among a national cohort of US adults both with and without lung disease.

METHODS

Participants in the first National Health and Nutrition Examination Survey (NHANES I) followed for up to 22 years were studied. Subjects were classified using a modification of the Global Initiative for Chronic Obstructive Lung Disease criteria for chronic obstructive pulmonary disease (COPD) into the following mutually exclusive categories using the forced expiratory volume in 1 second (FEV(1)), forced vital capacity (FVC), FEV(1)/FVC ratio, and the presence of respiratory symptoms: severe COPD, moderate COPD, mild COPD, respiratory symptoms only, restrictive lung disease, and no lung disease. Proportional hazard models were developed that controlled for age, race, sex, education, smoking status, pack years of smoking, years since quitting smoking, and body mass index.

RESULTS

A total of 1301 deaths occurred in the 5542 adults in the cohort. In the adjusted proportional hazards model the presence of severe or moderate COPD was associated with a higher risk of death (hazard ratios (HR) 2.7 and 1.6, 95% confidence intervals (CI) 2.1 to 3.5 and 1.4 to 2.0), as was restrictive lung disease (HR 1.7, 95% CI 1.4 to 2.0).

CONCLUSIONS

The presence of both obstructive and restrictive lung disease is a significant predictor of earlier death in long term follow up.

Feasibility of using unattended polysomnography in children for research--report of the Tucson Children's Assessment of Sleep Apnea study (TuCASA)

STUDY OBJECTIVES

The Tucson Children's Assessment of Sleep Apnea study (TuCASA) is designed to investigate the prevalence and correlates of objectively measured sleep-disordered breathing in pre-adolescent children. This paper documents the methods and feasibility of attaining quality unattended polysomnograms in the first 162 TuCASA children recruited.

DESIGN

A prospective cohort study projected to enroll 500 children between 5 and 12 years of age who will undergo unattended polysomnography, neurocognitive evaluation, and physiological and anatomical measurements thought to be associated with sleep-disordered breathing.

SETTING

Children are recruited through the Tucson Unified School District. Polysomnograms and anthropometric measurements are completed in the child's home.

PARTICIPANTS

Of the 157 children enrolled in TuCASA, there were 100 children (64%) between 5-8 years old and 57 children (36%) between the ages of 9 to 12. There were 74 (47%) Hispanic children, and 68 (43%) female participants.

INTERVENTIONS

N/A.

MEASUREMENTS & RESULTS

Technically acceptable studies were obtained in 157 children (97%). The initial pass rate was 91%, which improved to 97% when 9 children who failed on the first night of recording completed a second study which was acceptable. In 152 studies (97%), greater than 5 hours of interpretable respiratory, electroencephalographic, and oximetry signals were obtained. The poorest signal quality was obtained from the chin electromyogram and from the combination thermister/nasal cannula. Parents reported that 54% of children slept as well as, or better than usual, while 40% reported that their child slept somewhat worse than usual. Only 6% were observed to sleep much worse than usual. Night-to-night variability in key polysomnographic parameters (n=10) showed a high degree of reproducibility on 2 different nights of study using identical protocols in the same child. In 5 children, polysomnograms done in the home were comparable to those recorded in a sleep laboratory.

CONCLUSIONS

The high quality of data collected in TuCASA demonstrates that multi-channel polysomnography data can be successfully obtained in children aged 5-12 years in an unattended setting under a research protocol.

Correlates of peak expiratory flow lability in elderly persons

OBJECTIVE

To determine the correlates of the lability of peak expiratory flow (PEF) in the elderly.

METHODS

A community sample of 4,581 persons > or = 65 years old from the Cardiovascular Health Study completed an asthma questionnaire and underwent spirometry. During a follow-up examination of the cohort, 1,836 persons agreed to measure PEF at home twice daily for 2 weeks, and 90% successfully obtained at least 4 days of valid measurements. PEF lability was calculated as the highest daily (PEF maximum - PEF minimum)/mean PEF.

RESULTS

Mean PEF measured at home was accurate when compared to PEF determined by spirometry in the clinic. Mean PEF lability was 18% in those with current asthma (n = 165) vs 12% in healthy nonsmokers (upper limit of normal, 29%). Approximately 26% of those with asthma and 14% of the other participants had abnormally high PEF lability (> 29%). After excluding participants with asthma, other independent predictors of high PEF lability included black race, current and former smoking, airway obstruction on spirometry, daytime sleepiness, recent wheezing, chronic cough, emphysema, and wheezing from lying in a supine position. Despite having a lower mean PEF, those reporting congestive heart failure (n = 82) did not have significantly higher PEF lability.

CONCLUSIONS

Measurement of PEF lability at home is highly successful in elderly persons. PEF lability > or = 30% is abnormal in the elderly and is associated with asthma.

Weight change in old age and its association with mortality

OBJECTIVES

Previous studies of weight change and mortality in older adults have relied on self-reported weight loss, have not evaluated weight gain, or have had limited information on health status. Our objective was to determine whether 5% weight gain or loss in 3 years was predictive of mortality in a large sample of older adults.

DESIGN

Longitudinal observational cohort study.

SETTING

Four U.S. communities.

PARTICIPANTS

Four thousand seven hundred fourteen community-dwelling older adults, age 65 and older.

MEASUREMENTS

Weight gain or loss of 5% in a 3-year period was examined in relationship to baseline health status and interim health events. Risk for subsequent mortality was estimated in those with weight loss or weight gain compared with the group whose weight was stable.

RESULTS

Weight changes occurred in 34.6% of women and 27.3% of men, with weight loss being more frequent than gain. Weight loss was associated with older age, black race, higher weight, lower waist circumference, current smoking, stroke, any hospitalization, death of a spouse, activities of daily living disability, lower grip strength, and slower gait speed. Weight loss but not weight gain of 5% or more was associated with an increased risk of mortality that persisted after multivariate adjustment (Hazard ratio (HR) = 1.67, 95% CI = 1.29-2.15) and was similar in those with no serious illness in the period of weight change. Those with weight loss and low baseline weight had the highest crude mortality rate, although the HR for weight loss was similar for all tertiles of baseline weight and for those with or without a special diet, compared with those whose weight was stable.

CONCLUSIONS

This study confirms that even modest decline in body weight is an important and independent marker of risk of mortality in older adults.

Spirometry reference values for American Indian adults: results from the Strong Heart Study

STUDY OBJECTIVE

To derive spirometry normative values from a large population of American Indian adults and compare them to reference values for white adults.

DESIGN

Pulmonary function was assessed using spirometry in participants of the Strong Heart Study, a multicenter, community-based, prospective study of cardiovascular risk factors and disease in American Indians, utilizing American Thoracic Society guidelines and a vigorous quality assurance program.

SETTING

Central Arizona, southwestern Oklahoma, central South Dakota, and northeastern North Dakota.

PARTICIPANTS

Acceptable spirometry results were obtained from 1,619 women and 1,005 men aged 45 to 74 years.

RESULTS

Internal reference values and normal ranges for FEV(1), FVC, and the FEV(1)/FVC ratio were derived from a healthy subgroup of 253 women and 190 men, identified by excluding participants with factors associated with a lower FEV(1). Ten percent of the entire cohort (269 of 2,624 subjects) had airways obstruction, as defined by an FEV(1)/FVC below the lower limit of the normal (LLN) using the internal reference equations. After allowing for measurement "noise," 31 participants were below the LLN using reference equations for white adults from the large National Health and Nutrition Examination Study (NHANES) III study but were normal using the internal reference equations (1.3% false-positive), while 27 participants were classified as normal using NHANES III equations but had airways obstruction using the internal reference equations (1.2% false-negative). Similarly low misclassification rates were seen for a low FVC (prevalence, 17.6%).

CONCLUSION

For clinical purposes, NHANES III spirometry reference equations for white adults may be used when testing American Indian women and men aged 45 to 74 years.

Predictors of oxygen desaturation during submaximal exercise in 8,000 patients

STUDY OBJECTIVES

To determine predictors of oxygen desaturation during submaximal exercise in patients with various lung diseases.

DESIGN AND SETTING

This retrospective case series used pulmonary function laboratory results from all patients referred to a major tertiary-care center.

PATIENTS AND MEASUREMENTS

All patients > or = 35 years old who underwent spirometry, diffusing capacity of the lung for carbon monoxide (DLCO), lung volumes, and pulse oximetry during 3-min submaximal step-test exercise during 1996 were included (4,545 men and 3,472 women). Logistic regression models, correcting for gender, age, and weight, determined the odds ratios (ORs) for oxygen desaturation of > or = 4% during exercise for each category of lung function abnormality (compared to those with entirely normal lung function).

RESULTS

Approximately 74% of the patients had airways obstruction, while only 5.6% had restriction of lung volumes. One third of those with obstruction had a low DLCO, compared to 56% with restriction, while 2.7% had a low DLCO without obstruction or restriction. The risk of oxygen desaturation during submaximal exercise was very high (OR, 34) in patients with restriction and low DLCO (as in interstitial lung disease) and in patients with obstruction and low DLCO (as in COPD; OR, 18), intermediate (OR, 9) in patients with only a low DLCO, and lowest in those with a normal DLCO (OR, 4 if restricted; OR, 2 if obstructed). A cut point of DLCO < 62% predicted resulted in 75% sensitivity and specificity for exercise desaturation. No untoward cardiac events occurred in any patients during or following the submaximal exercise tests.

CONCLUSIONS

The risk of oxygen desaturation during submaximal exercise is very high in patients with a low DLCO. Submaximal exercise tests are safe, even in elderly patients with heart and lung diseases.

Importance of heart failure with preserved systolic function in patients > or = 65 years of age. CHS Research Group. Cardiovascular Health Study

Although congestive heart failure (CHF) is a common syndrome among the elderly, there is a relative paucity of population-based data, particularly regarding CHF with normal systolic left ventricular function. A total of 4,842 independent living, community-dwelling subjects aged 66 to 103 years received questionnaires on medical history, family history, personal habits, physical activity, and socioeconomic status, confirmation of pre-existing cardiovascular and cerebrovascular disease, anthropometric measurements, casual seated random-zero blood pressure, forced vital capacity and expiratory volume in 1 second, 12-lead supine electrocardiogram, fasting glucose, creatinine, plasma lipids, carotid artery wall thickness by ultrasonography, and echocardiography-Doppler examinations. Participants with at least 1 confirmed episode of CHF by Cardiovascular Health Study criteria were considered prevalent for CHF. The prevalence of CHF was 8.8% and was associated with increased age, particularly for women, in whom it increased more than twofold from age 65 to 69 years (6.6%) to age > or = 85 years (14%). In multivariate analysis, subjects with CHF were more likely to be older (odds ratio [OR] 1.2 for 5-year difference, men OR 1.1), and more often had a history of myocardial infarction (OR 7.3), atrial fibrillation (OR 3.0), diabetes mellitus (OR 2.1), renal dysfunction (OR 2.0 for creatinine < or = 1.5 mg/ dl), and chronic pulmonary disease (OR 1.8; women only). The echocardiographic correlates of CHF were increased left atrial and ventricular dimensions. Importantly, 55% of subjects with CHF had normal left ventricular systolic function and 80% had either normal or only mildly reduced systolic function. Among subjects with CHF, women had normal systolic function more frequently than men (67% vs 42%; p < 0.001). Thus, CHF is common among community-dwelling elderly. It increases with age and is usually associated with normal systolic LV function, particularly among women. The finding that a large proportion of elderly with CHF have preserved LV systolic function is important because there is a paucity of data to guide management in this dominant subset.

Hormone replacement therapy is associated with higher FEV1 in elderly women

Estrogen and progesterone use have been associated with improved pulmonary function in premenopausal women. However, little research has examined the relationship between hormone replacement therapy (HRT) and pulmonary function in postmenopausal women. We examined the relationship of HRT with spirometry in 2,353 women aged 65 yr and older participating in the Cardiovascular Health Study in 1993/1994. Current use of HRT was hypothesized to be associated with higher FEV1, higher FVC, and less pulmonary obstruction (FEV1/FVC < 65%). FEV1 was higher among current HRT users compared to noncurrent users in the following groups: overall (1.82 L versus 1.66 L, p < 0.0001), among women without asthma (1.85 L versus 1.69 L, p < 0.0001), among former smokers (1.76 L versus 1.60 L, p = 0.013), and among never smokers (1.90 L versus 1.72 L, p < 0.0001). Overall, HRT use was associated with a lower prevalence of pulmonary obstruction (OR 0.75 [95% CI 0.55, 0.99]). After controlling for potential confounders, HRT use was significantly associated with higher FEV(1) (p = 0.031) and with a lower prevalence of obstruction (OR 0.67 [95% CI 0.48, 0.95]). We conclude that postmenopausal women who use HRT have higher levels of FEV1 and less obstruction, which could not be explained by their lower rates of smoking and other health factors associated with HRT use.

Predictors of loss of lung function in the elderly: the Cardiovascular Health Study

Pulmonary function, as measured by spirometry (FEV1 or FVC), is an important independent predictor of morbidity and mortality in elderly persons. In this study we examined the predictors of longitudinal decline in lung function for participants of the Cardiovascular Health Study (CHS). The CHS was started in 1990 as a population-based observational study of cardiovascular disease in elderly persons. Spirometry testing was conducted at baseline, 4 and 7 yr later. The data were analyzed using a random effects model (REM) including an AR(1) error structure. There were 5,242 subjects (57.6% female, mean age 73 yr, 87.5% white and 12.5% African-American) with eligible FEV1 measures representing 89% of the baseline cohort. The REM results showed that African-Americans had significantly lower spirometry levels than whites but that their rate of decline with age was significantly less. Subjects reporting congestive heart failure (CHF), high systolic blood pressure (> 160 mm Hg), or taking beta-blockers had significantly lower spirometry levels; however, the effects of high blood pressure and taking beta-blockers diminished with increasing age. Chronic bronchitis, pneumonia, emphysema, and asthma were associated with reduced spirometry levels. The most notable finding of these analyses was that current smoking (especially for men) was associated with more rapid rates of decline in FVC and FEV1. African-Americans (especially women) had slower rates of decline in FEV1 than did whites. Although participants with current asthma had a mean 0.5 L lower FEV1 at their baseline examination, they did not subsequently experience more rapid declines in FEV1.

Controversies in the use of spirometry for early recognition and diagnosis of chronic obstructive pulmonary disease in cigarette smokers

Office spirometry used to detect COPD in smokers ages 44 and above with respiratory symptoms probably meets the criteria for a population-based screening test and for clinical case finding: If not detected early, COPD causes substantial morbidity or mortality, and smoking cessation is more effective when COPD is recognized before exertional dyspnea develops. Office spirometry is a feasible testing strategy and may be used to encourage smoking cessation efforts that change behavior in at least some patients. Office spirometry is relatively simple and affordable, is safe, and includes an action plan with minimal adverse effects. On the other hand, the false-positive and false-negative rates of office spirometry in the primary care setting may be higher than diagnostic spirometry performed during epidemiologic studies or in diagnostic pulmonary function laboratories, and the incremental benefit of office spirometry on smoking cessation rates is poorly established (when added to referral to an AHCPR-based smoking cessation program).

Quality of spirometry test performance in children and adolescents : experience in a large field study

STUDY OBJECTIVE

To determine the ability of children and adolescents to meet the American Thoracic Society (ATS) goals for spirometry quality that were based on results from adults.

DESIGN

Observational.

PARTICIPANTS

More than 4,000 public school students, ages 9 to 18 years.

MEASUREMENTS

Spirometry was performed annually for 3 years, with the recording of maneuver quality measures of forced expiratory time, end-of-test volume, back-extrapolated volume, and time to peak expiratory flow (PEFT), and the recording of differences between best and second-best FVC, FEV(1), and peak expiratory flow (PEF) values.

RESULTS

Regression analyses showed significant influences of participant age, gender, ethnicity, size, clinical status, and previous testing experience, as well as differences among individual test technicians. In general, these influences were small and explained little of the variance in performance. On average, children with a history of asthma or wheeze performed better quality spirometry than did others. Only PEFT improved significantly from year to year. Overall, only 15% of girls' tests and 32% of boys' tests met the PEFT criterion derived from adults in the Lung Health Study.

CONCLUSION

Most of the children met adult-based ATS goals for spirometry test performance. Age group-specific criteria are needed to ensure adequately fast PEFT and reproducible PEF values.

Sleep disturbances and their correlates in elderly Japanese American men residing in Hawaii

BACKGROUND

Elderly people frequently report the presence of chronically disturbed sleep. However, most data are derived from predominantly Caucasian populations. The current study is an investigation of the prevalence and correlates of sleep disturbances in a cohort of elderly Japanese American men residing in Hawaii. The importance of this population lies in its representation of an ethnic group living in a culture different from their ancestry.

METHODS

This study is a cross-sectional cohort analysis of data pertaining to sleep disturbances and their potential correlates from 3,845 elderly Japanese American men residing in Hawaii (mean age. 78 years; range, 71-93 years) who participated in the fourth survey of the Honolulu Heart Program (1991-1994), which is the baseline exam for the Honolulu-Asia Aging Study. Information collected included an extensive survey of medication use, medical history, and assessments of physical and mental function, quality of life, and sleep.

RESULTS

The prevalence of insomnia (DIMS) was 32.6%, a rate similar to that reported in predominantly Caucasian populations. Depression, benzodiazepine use, and several chronic health problems were the most important factors associated with DIMS. In contrast, excessive daytime sleepiness (EDS) had a prevalence of 8.9%, a rate lower than that found in elderly Caucasian populations but close to that reported among native Japanese. Important factors related to EDS were symptoms of nocturnal respiratory disturbance, depression, perception of adverse quality of life, Parkinson's disease, and digitalis use.

CONCLUSIONS

Elderly Japanese men are less likely than elderly Caucasian men to report excessive daytime sleepiness. However, their insomnia rates are similar.

Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program

Chronic obstructive pulmonary disease (COPD) is easily detected in its preclinical phase using spirometry, and successful smoking cessation (a cost-effective intervention) prevents further disease progression. This consensus statement recommends the widespread use of office spirometry by primary-care providers for patients > or = 45 years old who smoke cigarettes. Discussion of the spirometry results with current smokers should be accompanied by strong advice to quit smoking and referral to local smoking cessation resources. Spirometry also is recommended for patients with respiratory symptoms such as chronic cough, episodic wheezing, and exertional dyspnea in order to detect airways obstruction due to asthma or COPD. Although diagnostic-quality spirometry may be used to detect COPD, we recommend the development, validation, and implementation of a new type of spirometry-office spirometry--for this purpose in the primary-care setting. In order to encourage the widespread use of office spirometers, their specifications differ somewhat from those for diagnostic spirometers, allowing lower instrument cost, smaller size, less effort to perform the test, improved ease of calibration checks, and an improved quality-assurance program.

Office spirometry for lung health assessment in adults: A consensus statement from the National Lung Health Education Program

COPD is easily detected in its preclinical phase using spirometry, and successful smoking cessation (a cost-effective intervention) prevents further disease progression. This consensus statement recommends the widespread use of office spirometry by primary-care providers for patients >/= 45 years old who smoke cigarettes. Discussion of the spirometry results with current smokers should be accompanied by strong advice to quit smoking and referral to local smoking cessation resources. Spirometry also is recommended for patients with respiratory symptoms such as chronic cough, episodic wheezing, and exertional dyspnea in order to detect airways obstruction due to asthma or COPD. Although diagnostic-quality spirometry may be used to detect COPD, we recommend the development, validation, and implementation of a new type of spirometry-office spirometry-for this purpose in the primary-care setting. In order to encourage the widespread use of office spirometers, their specifications differ somewhat from those for diagnostic spirometers, allowing lower instrument cost, smaller size, less effort to perform the test, improved ease of calibration checks, and an improved quality-assurance program.

Race and gender differences in the effects of smoking on lung function

STUDY OBJECTIVE

To assess the extent to which the relationship between smoking and lung function in adults varies by gender and race/ethnicity.

DESIGN

A random-effects metaregression analysis to synthesize results from common cross-sectional regression models fit to participants in each of 10 gender-race strata in each of eight large population-based observational studies or clinical trials.

SETTING

Source data collected as part of the most recently completed examination cycle for each of the participating studies.

PARTICIPANTS

Participants ranged in age from 30 to 85 years, although the age, race, gender, and general health characteristics of each of the populations varied greatly.

INTERVENTIONS

Most of the studies were observational in nature, although some did involve lifestyle interventions. All treatment assignments were ignored in the analysis.

MEASUREMENTS AND RESULTS

All studies measured lung function using standardized methods with centrally trained and certified technicians. Study findings confirm statistically significant, dose-related smoking effects in all race-gender groups studied. Significant gender differences in the effects of cigarette smoking were seen only for blacks; black men who smoked had greater smoking-related declines in FEV(1) than did black women. This effect was present in only one of two smoking models, however. Significant racial differences in the effects of smoking were seen only for men, with Asian/Pacific Islanders having smaller smoking-related declines than white men in both models.

CONCLUSIONS

In summary, this analysis generally failed to support the hypothesis of widespread differences in the effects of cigarette smoking on lung function between gender or racial subgroups.

Clinical correlates of ventricular and sulcal size on cranial magnetic resonance imaging of 3,301 elderly people. The Cardiovascular Health Study. Collaborative Research Group

To identify potential risk factors for and clinical manifestations of ventricular and sulcal enlargement on cranial magnetic resonance imaging (MRI), 3,301 community-dwelling people 65 years or older without a history of stroke or transient ischemic attack underwent extensive standardized evaluations and MRI. In the multivariate model, increased age and white matter grade on MRI were the dominant risk factors for ventricular and sulcal grade. For ventricular grade, other than race, for which non-Blacks had higher grades, models for men and women shared no other factors. For sulcal grades, models for men and women shared variables reflecting cigarette smoking and diabetes. Clinical features were correlated more strongly with ventricular than sulcal grade and more strongly for women than men. Significant age-adjusted correlations between ventricular grade and the Digit-Symbol Substitution Test were found for men and women. Prospective studies will be needed to extend findings of this cross-sectional analysis.

Predictors of longitudinal change in diffusing capacity over 8 years

Low single-breath diffusing capacity (DL(CO)) values are associated with anatomic emphysema, but the predictors of longitudinal change in DL(CO) over many years are unknown. Study subjects were adult participants in the longitudinal Tucson Epidemiology Study of Obstructive Lung Disease who had at least one DL(CO) measurement during either of two surveys 8 yr apart (n = 543). Smoking status was determined at each examination (current, former, or never smoker). Quitters were defined as those currently smoking at the baseline DL(CO) examination (1982-1983) and self-reported as no longer smoking at the follow-up exam (1990-1991). The longitudinal DL(CO) data were analyzed using repeated measures analysis; because of missing observations this was done using a saturated random effects model. The results showed that males had higher levels of DL(CO) than females, current smokers had significantly lower levels of DL(CO) than never smokers, but there was no difference in their mean slopes over time. Smoking history, assessed using pack-years of smoking, was associated with reduced DL(CO) levels, independent of whether current or ex-smokers. Males and females demonstrated equivalent rates of decline in DL(CO) that accelerated with increasing age, and mean DL(CO) declines were associated with declines in FEV(1) between surveys.

Underdiagnosis and undertreatment of asthma in the elderly. Cardiovascular Health Study Research Group

OBJECTIVE

To describe the clinical correlates of asthma in a community-based sample of elderly persons.

PARTICIPANTS

A community sample of 4,581 persons > or = 65 years old from the Cardiovascular Health Study.

MEASUREMENTS

Standardized respiratory, sleep, and quality-of-life (QOL) questions, a medication inventory, spirometry, and ambulatory peak flow.

RESULTS

Four percent of the participants reported a current diagnosis of asthma (definite asthma), while another 4% reported at least one attack of wheezing accompanied by chest tightness or dyspnea during the previous 12 months (probable asthma). Smokers and those with congestive heart failure were excluded from the subsequent analyses, leaving 2,527 participants. Of those who had definite asthma, 40% were taking a sympathomimetic bronchodilator, 30% inhaled corticosteroids, 21% theophylline, and 18% oral corticosteroids; 39% were taking no asthma medications. The participants with definite or probable asthma were much more likely than the others to have a family history of asthma, childhood respiratory problems, a history of workplace exposures, dyspnea on exertion, hay fever, chronic bronchitis, nocturnal symptoms, and daytime sleepiness. They were also more likely to report poor general health, symptoms of depression, and limitation of activities of daily living. There was little difference in the morbidity and QOL of participants with recent asthma-like symptoms who had received the diagnosis of asthma versus those who had not.

CONCLUSIONS

Asthma in elderly persons is associated with a lower QOL and considerable morbidity when compared with those who do not have asthma symptoms. Asthma is underdiagnosed in this group and is often associated with allergic triggers; inhaled corticosteroids are underutilized.

Associations of symptoms of sleep apnea with cardiovascular disease, cognitive impairment, and mortality among older Japanese-American men

OBJECTIVES

To examine the association between symptoms of sleep apnea and prevalent cardiovascular disease, cognitive impairment, and subsequent 3-year mortality.

DESIGN

A longitudinal study.

SETTING

Participants lived in the community on Oahu, Hawaii.

PARTICIPANTS

A total of 2905 older Japanese-American men participating in the fourth examination of the Honolulu Heart Program cohort study from 1991-1993, which is the baseline for the Honolulu-Asia Aging Study of dementia.

MEASUREMENTS

Self-reported snoring, daytime sleepiness, and breathing pauses; diagnosed cardiovascular disease and dementia; cognitive functioning and vital status approximately 3 years later.

RESULTS

More than 12% of the participants reported that they often or always snored loudly, and 8% reported being sleepy most of the day. Fewer than 2% reported that they stop breathing when sleeping, and this was found more frequently among habitual snorers (7%, P < .001) and those sleepy during the day (5%, P < .001). The prevalence of habitual snoring declined in the older age groups, was higher among those with greater Body Mass Index scores, and was not associated with the reporting of daytime sleepiness, diagnosis of heart disease, stroke, dementia, or cognitive impairment. Daytime sleepiness was more prevalent at older ages and was associated with a higher prevalence of heart disease and with cognitive impairment and dementia, chronic obstructive pulmonary disease, and diabetes. Self-reported apnea was associated only with a history of pneumonia. Three-year mortality was not associated with these symptoms after adjusting for prevalent heart disease and cognitive impairment.

CONCLUSION

Symptoms of sleep apnea are reported less frequently in older Japanese-American men. Excessive daytime sleepiness is associated with poor cognition and dementia, but whether it also is an indicator for sleep apnea in this age group remains unclear. Epidemiologic studies of sleep apnea in older adults will require polysomnography to determine accurately the correlates and consequences of this condition.

Lung volumes in 4,774 patients with obstructive lung disease

STUDY OBJECTIVES

To determine the correlates of static lung volumes in patients with airways obstruction, and to determine if static lung volumes differ between asthma and COPD.

PATIENTS AND METHODS

We examined the data from all of the adult patients (mean age of 69) who were referred to a pulmonary function laboratory from January 1990 through July 1994 with an FEV1/FVC ratio of < 0.70 and tested using a body plethysmograph. Correlates were determined using regression analysis.

MEASUREMENTS AND RESULTS

Of the 4,774 patients observed with evidence of airways obstruction, 61% were men. Self-reported diagnoses included asthma, 19%; emphysema or COPD, 23%; chronic bronchitis, 1.5%; and alpha1-antiprotease deficiency, 0.6%. Fifty-six percent of the patients did not report a respiratory disease. The degree of hyperinflation, as determined by the residual volume (RV)/total lung capacity (TLC) ratio, or the RV % predicted (but not the TLC % predicted), was strongly associated with the degree of airways obstruction (the FEV1 % predicted). Patients with moderate to severe airways obstruction and high RV and TLC levels were more likely to have COPD than asthma. Of the 1,872 patients with a reduced vital capacity determined by spirometry testing, 87% had hyperinflation as defined by the RV/TLC, and 9.5% had a low TLC (with less severe airways obstruction).

CONCLUSION

In patients found to have airways obstruction by spirometry, the additional measurement of static lung volumes added little to the clinical interpretation.

Reference equations for the six-minute walk in healthy adults

In order to establish reference equations for prediction of the total distance walked during six minutes (6MWD) for healthy adults, we administered the standardized 6-min walk test to 117 healthy men and 173 healthy women, aged 40 to 80 yr. Oxygen saturation (SaO2), pulse rate, and the degree of dyspnea (Borg scale) were determined before and at the end of the walk. The median distance walked was 576 m for men and 494 m for women. The 6MWD was significantly less for men and women who were older and heavier, and for shorter men. The resulting gender-specific regression equations explained about 40% of the variance in the distance walked for healthy adults: for men, 6MWD = (7.57 x heightcm) - (5.02 x age) - (1.76 x weightkg) - 309 m, and for women, 6MWD = (2.11 x heightcm) - (2.29 x weightkg) - (5.78 x age) + 667 m. These reference equations may be used to compute the percent predicted 6MWD for individual adult patients performing the test for the first time, when using the standardized protocol.

Long-term particulate and other air pollutants and lung function in nonsmokers

The associations between lung function measures (spirometry and peak expiratory flow lability) and estimated 20-yr ambient concentrations of respirable particles, suspended sulfates, sulfur dioxide, ozone, and indoor particles were studied in a sample of 1,391 nonsmokers followed since 1977. Differences in air pollutants across the population were associated with decrements of lung function. An increase of 54 d/yr when particles < 10 micro(m) in diameter (PM10) exceeded 100 microg/m3 was associated with a 7.2% decrement in FEV1, as percent of predicted, in males whose parents had asthma, bronchitis, emphysema, or hay fever and with increased peak expiratory flow lability of 0.8% for all females and 0.6% for all males. An increase in mean SO4 concentration of 1.6 microg/m3 was associated with a 1.5% decrement in FEV1, as percent of predicted, in all males. An increase of 23 ppb of ozone as an 8-h average was associated with a 6.3% decrement in FEV1, as percent of predicted, in males whose parents had asthma, bronchitis, emphysema, or hay fever.

Spirometric reference equations for older adults

The objective of this study was to develop spirometric reference equations for healthy, never-smoking, older adults. It was designed as a cross-sectional observational study consisting of 1510 Seventh Day Adventists, ages 43-79 years enrolled in a study of health effects of air pollutants. Individuals were excluded from the reference group (n = 565) for a history of current respiratory illness, smoking, or chronic respiratory disease, and for a number of 'non-respiratory' conditions which were observed in these data to be related to lower values of FEV1. Gender-specific reference equations were developed for the entire reference group and for a subset above 65 years of age (n = 312). Controlling for height and age, lung function was found to be positively related to the difference between armspan and height, and in males was found to be quadratically related to age. The predicted values for this population generally fell within the range of those of other population groups containing large numbers of adults over the age of 65 years. Individuals with lung function below the 5th percentile in this sample, however, could not be reliably identified by using the lower limits of normal predictions commonly used in North America and Europe.

Correlates of daytime sleepiness in 4578 elderly persons: the Cardiovascular Health Study

OBJECTIVES

To describe the prevalence of self-reported daytime sleepiness in older men and women and to describe their relationships with demographic factors, nocturnal complaints, health status, and cardiovascular diseases (CVD).

DESIGN

Cross-sectional survey and clinical exam.

SETTING

Participants in the Cardiovascular Health Study, 4578 adults aged 65 and older, recruited from a random sample of non-institutionalized Medicare enrollees in four U.S. communities.

MEASURES

Daytime sleepiness measured by the Epworth Sleepiness Scale (ESS), magnetic resonance imaging of the brain (MRI), cognitive function tests, and standardized questionnaires for cardiopulmonary symptoms and diseases, depressive symptoms, social support, activities of daily living, physical activity, and current medications.

RESULTS

Approximately 20% of the participants reported that they were "usually sleepy in the daytime". Although elderly black men were less likely to report frequent awakenings than those in the other three race and gender groups, they had significantly higher mean ESS scores. The following were independently associated with higher ESS scores in gender-specific models: non-white race, depression, loud snoring, awakening with dyspnea or snorting, frequent nocturnal awakenings, medications used to treat congestive heart failure, non-use of sleeping pills, a sedentary lifestyle, and limitation of activities of daily living in both men and women; additional correlates included hip circumference and current smoking in men, and hayfever in women. The following were not independently associated with ESS in the models: age, education, use of wine or beer to aid sleep, use of tricyclic antidepressants, long- or short-acting benzodiazepines, asthma, angina, myocardial infarction, congestive heart failure itself, forced vital capacity, social support, cognitive function, or MRI evidence of global brain atrophy or white matter abnormality.

CONCLUSIONS

Daytime sleepiness is common in the elderly, probably due to nocturnal disturbances such as frequent awakenings and snoring. The occasional use of sleeping pills for insomnia is associated with reduced daytime sleepiness in the elderly, while the use of medications for congestive heart failure is associated with daytime sleepiness. Surprisingly, anatomic abnormalities such as evidence of previous strokes and brain atrophy (as seen on brain MRI scans) were not associated with daytime sleepiness in these non-institutionalized elderly persons.

Effect of weight gain on pulmonary function after smoking cessation in the Lung Health Study

The objective of this study was to determine if the weight gain that accompanies smoking cessation is independently associated with reductions in FEV1 and FVC, using a multicenter randomized intervention trial of smoking cessation in 10 communities in the United States and Canada. Enrollees were currently smoking women and men 35 to 60 yr of age with mild-to-moderate airway obstruction. Participants were randomized to one of three study groups: an intensive smoking cessation program with an inhaled bronchodilator (or a placebo), and usual care. Changes in absolute and percent predicted FEV1 and FVC between baseline and fifth annual follow-up visit were monitored in relation to changes in body weight during the interval. At the baseline examination, percent predicted FEV1 was maximal at 90 to 100% ideal body weight (IBW) and was lower as body weight deviated from this range. The FVC decreased linearly when IBW exceeded 100%. Weight gain was greatest during the first 12 mo after smoking cessation. Weight gain was associated with lower fifth-year FEV1 and FVC in all smoking categories: continuous smokers, intermittent smokers, and sustained quitters. The FVC was affected by weight gain more than was the FEV1, and the FEV1 was affected by smoking cessation more than FVC. Men showed more impairment of FVC with weight gain than did women, possibly because of differential patterns of fat deposition. In sustained quitters, after adjustment for baseline factors, the estimated reduction of FVC was 17.4 ml/kg weight gain for men and 10.6 ml/kg for women. The estimated loss of FEV1 was 11.1 ml/kg weight gain for men and 5.6 ml/kg for women. Lung function after smoking cessation is significantly influenced by weight gain and affects men more than women. The deleterious effects of weight gain are small, however, in comparison with the beneficial effects of smoking cessation.

The synergy of low lung function and low body mass index predicting all-cause mortality among older Japanese-American men

OBJECTIVE

To assess the joint characteristics of low standardized weight and compromised pulmonary function in predicting all-cause mortality.

DESIGN

A population-based, prospective cohort study.

SETTING

Oahu Island, Hawaii.

PARTICIPANTS

Surviving Japanese-American men of the Honolulu Heart Program cohort, 71 to 93 years of age (N = 3059).

MEASUREMENTS

Body mass index (BMI-weight in kilograms/square of height in meters) and 1-second forced expiratory volume (FEV1) as a percentage of age- and height-predicted FEV1 from the 1991 to 1993 examination of the cohort. Mortality data derived from the ongoing tracking of deaths of the cohort. Relations of selected risk factors among joint levels of BMI (< or = 21, > 21 to < 25, > or = 25 kg/m2) and percent predicted FEV1 (< or = 70%, > 70%) were determined. The impact of these covariates on relations between joint BMI/percent predicted FEV1 levels and subsequent all-cause mortality was assessed.

RESULTS

The highest age-adjusted mortality rate (91.9 deaths per 1000 person-years) was noted among men characterized by the joint conditions of percent predicted FEV1 < or = 70% and BMI < or = 21 kg/m2. This rate was 4.0 times the mortality rate of a "healthy" reference group characterized by percent predicted FEV1 > 70% and 21 < BMI < 25 kg/m2. This rate ratio is attenuated to 3.2 upon statistical control for measures of current and past smoking behavior. Among the three strata of BMI, statistical interaction is reflected in a heterogeneity of mortality rate differences (49.7, 21.8, -9.6 deaths/person-year, respectively) and rate ratios (2.18, 1.98, .66, respectively) comparing men with percent predicted FEV1 < or = 70% to > 70%.

CONCLUSION

Joint loss of pulmonary function and relative weight is predictive of subsequent all-cause mortality in excess of additive or multiplicative effects of each condition separately. Smoking behavior may contribute to this observation.

Peak flow lability: association with asthma and spirometry in an older cohort

OBJECTIVE

To determine the success rate and correlates of ambulatory peak expiratory flow (PEF) monitoring in an epidemiologic study.

DESIGN

An observational survey.

SETTING

Several communities in California.

PARTICIPANTS

We studied 1,223 nonsmoking men and women (mean age, 66 years) from an established cohort.

OUTCOME MEASURES

A standard respiratory symptoms and diagnoses questionnaire, spirometry before and after bronchodilator, and a diary of PEF recorded four times per day for 7 days at home.

RESULTS

A physician diagnosis of asthma was reported in 8.6% of the women and 9.4% of the men. Of those who agreed to complete PEF diaries at home, 87% successfully provided a valid measure of PEF lability. The mean PEF lability from those with asthma was significantly higher than the others (12.0% vs 8.9% in women and 10.2% vs 8.1% in men). Independent correlates of higher PEF lability included asthma, wheezing symptoms, airways obstruction by spirometry, older age, and male gender.

CONCLUSIONS

Middle-aged and elderly persons are largely successful at providing a measure of PEF lability at home. In nonsmoking adults living in California, increased PEF lability is correlated with asthma, wheezing, airways obstruction, and older age, validating its use in epidemiology studies as an index of airways hyperreactivity.

Factors associated with variations in pulmonary function among elderly Japanese-American men

OBJECTIVE

To identify lifestyle, anthropometric, biochemical, and clinical characteristics associated with pulmonary function in elderly men.

DESIGN

Cross-sectional population-based study.

PARTICIPANTS

Japanese-American men (n=3,111) aged 71 to 93 years, who completed spirometry at the fourth examination of the Honolulu Heart Program (1991 to 1993).

METHODS

Pulmonary function measurements (FEV1 and FVC) were obtained using American Thoracic Society guidelines. Potential factors associated with pulmonary function were examined using Pearson correlation coefficients and general linear models. Age- and height-adjusted mean levels of FEV1 and FVC were compared across quintiles of continuous variables and by status of prevalent disease and medication or vitamin use. Stepwise multiple linear regression was used to identify factors independently associated with pulmonary function overall and among never smokers.

RESULTS

A number of correlates of pulmonary function were initially identified. In multivariate analyses, age, current smoking, pack-years of smoking, emphysema, asthma, wheezing without colds, subscapular skinfold thickness, ECG abnormality, heart rate, WBC count, and eosinophil count were all negatively and independently associated with FEV1, while height, grip strength, physical activity, and mean corpuscular hemoglobin concentration were positively associated. With a few exceptions, similar relations were observed with FVC and among never-smokers.

CONCLUSION

Cigarette smoking, respiratory symptoms and disease, and several cardiovascular risk factors were independently associated with pulmonary function in elderly Japanese-American men. In most cases, inadequate control for smoking does not appear to account for these associations. Results suggest that a number of factors that are correlates of FEV1 and FVC in younger age groups are also associated with pulmonary function beyond the age of 70 years.

Sleep disturbance, psychosocial correlates, and cardiovascular disease in 5201 older adults: the Cardiovascular Health Study

OBJECTIVES

To describe the prevalence of self reported sleep disturbances in older men and women and to describe their relationships with health status and cardiovascular disease (CVD).

DESIGN

Cross-sectional study of sleep disturbance, CVD, general health, psychosocial factors, physical function, and use of psychotropic medications.

SETTING

Participants of the Cardiovascular Health Study, 5201 adults aged 65 and older recruited from a random sample of noninstitutionalized Medicare enrollees in four US communities.

MEASURES

Self-reported sleep disturbances and standardized questionnaires for cardiopulmonary symptoms and diseases, depression, social support, activities of daily living, physical activity, cognitive function, and current medications, spirometry, ECG, echocardiography, and carotid ultrasound.

RESULTS

Women were twice as likely as men to report difficulty falling asleep (30% vs 14%). Daytime sleepiness, difficulty falling asleep, and frequent awakenings increased in prevalence with age. All symptoms were related strongly to depression. Symptoms of daytime sleepiness were also related strongly to poor health and limitations in activities of daily living in men and women. In multivariate analysis, men taking benzodiazepines were likely to report difficulty falling asleep and daytime sleepiness, whereas women taking benzodiazepines reported difficulty falling asleep and waking up too early. After accounting for these factors, the only cardiovascular disease independently associated with sleep disturbances was angina. Men and women with confirmed angina were 1.6 times more likely to report trouble falling asleep. Independent relationships between sleep disturbances and cardiovascular risk factors such as obesity, hypertension, smoking, and diabetes were relatively weak and inconsistent, though smokers were less likely to report frequent awakenings.

CONCLUSIONS

Sleep disturbances are relatively common in older men and women and are associated with poor health, depression, angina, limitations in activities of daily living, and the use of benzodiazepines.

Spirometry reference values for healthy elderly blacks. The Cardiovascular Health Study Research Group

Pulmonary function was assessed by spirometry in 497 black and 2,980 white ambulatory elderly male and female participants of the Cardiovascular Health Study. The quality assurance program prompted technicians to exceed American Thoracic Society recommendations for spirometry. A "healthy" subgroup of 235 black and 1,227 white participants age 65 years and older was identified by excluding current and former smoker, and those with self-reported asthma or emphysema, congestive heart failure, and poor-quality results of spirometry tests, since those factors were associated with a lower FEV1. Reference equations and normal ranges for elderly blacks for measurements of FEV1, FVC, and the FEV1/FVC ratio were then determined from the healthy group. These elderly blacks had an FVC about 6% lower than elderly whites, even after correcting for standing height, sitting height (trunk length), and age. The popular use of spirometry reference values from studies of middle-aged white subjects by applying a 12% race correction factor for black patients appears to overestimate predicted values.

Prevalence and correlates of snoring and observed apneas in 5,201 older adults

The objectives of this study were to describe the prevalence of snoring, observed apneas, and daytime sleepiness in older men and women, and to describe the relationships of these sleep disturbances to health status and cardiovascular diseases (CVD). A cross-sectional design was employed to study sleep problems, CVD, general health, psychosocial factors, and medication use. The subjects were participants in the Cardiovascular Health Study, which included 5,201 adults, aged 65 and older, who were recruited from a random sample of Medicare enrollees in four U.S. communities. Study measures employed were sleep questions, echocardiography, carotid ultrasound, resting electrocardiogram, cognitive function, cardiopulmonary symptoms and diseases, depression, independent activities of daily living (IADLs), and benzodiazepine use. Thirty-three percent of the men and 19% of the women reported loud snoring, which was less frequent in those over age 75. Snoring was positively associated with younger age, marital status, and alcohol use in men, and obesity, diabetes, and arthritis in women. Snoring was not associated, however, with cardiovascular risk factors or clinical CVD in men or women. Observed apneas were reported much less frequently (13% of men and 4% women) than snoring, and they were associated with alcohol use, chronic bronchitis, and marital status in men. Observed apneas were associated with depression and diabetes in women. In both men and women, daytime sleepiness was associated with poor health, advanced age, and IADL limitations. The conclusions of the study were that loud snoring, observed apneas, and daytime sleepiness are not associated cross-sectionally with hypertension or prevalent CVD in elderly persons.

Clinical correlates of white matter findings on cranial magnetic resonance imaging of 3301 elderly people. The Cardiovascular Health Study

BACKGROUND AND PURPOSE

Our aim was to identify potential risk factors for and clinical manifestations of white matter findings on cranial MRI in elderly people.

METHODS

Medicare eligibility lists were used to obtain a representative sample of 5888 community-dwelling people aged 65 years or older. Correlates of white matter findings were sought among 3301 participants who underwent MRI scanning and denied a history of stroke or transient ischemic attack. Participants underwent extensive standardized evaluations at baseline and on follow-up, including standard questionnaires, physical examination, multiple blood tests, electrocardiogram, pulmonary function tests, carotid sonography, and M-mode echocardiography. Neuroradiologists graded white matter findings from 0 (none) to 9 (maximal) without clinical information.

RESULTS

Many potential risk factors were related to the white matter grade, but in the multivariate model the factors significantly (all P < .01) and independently associated with increased grade were greater age, clinically silent stroke on MRI, higher systolic blood pressure, lower forced expiratory volume in 1 second (FEV1), and income less than $50,000 per year. If excluded, FEV1 was replaced in the model by female sex, history of smoking, and history of physician-diagnosed hypertension at the baseline examination. Many clinical features were correlated with the white matter grade, especially those indicating impaired cognitive and lower extremity function.

CONCLUSIONS

White matter findings were significantly associated with age, silent stroke, hypertension, FEV1, and income. The white matter findings may not be considered benign because they are associated with impaired cognitive and lower extremity function.

Characteristics associated with rapid decline in forced expiratory volume

Cigarette smoking is known to accelerate decline of pulmonary function; however, the role of other factors is less clear. Characteristics of individuals who experienced rapid decline in forced expiratory volume in 1-sec (FEV1) were examined in 4451 Japanese-American men from the Honolulu Heart Program who were aged 45 to 68 years at baseline (1965-1968) and who produced three acceptable FEV1 measures over a 6-year period. Average annual rates of FEV1 decline were calculated by use of within-person regression and were categorized as rapid (> or = 60 ml/y), moderate (30 to 59 ml/y) or slow (< 30 ml/y). Lifestyle and biologic factors were compared by FEV1 decline categories after adjustment for age. A logistic regression model showed that continued smoking during follow-up, cigarette pack-years, wheezing, coronary heart disease, alcohol intake, and reduced subscapular skinfold were significantly associated with rapid FEV1 decline, after adjustment for age, height, cholesterol, an indicator of Japanese diet, and education. When analyses were restricted to continuous smokers, cigarette pack-years, wheezing, and reduced subscapular skinfold were found to be independent predictors. Among never smokers, lower educational attainment was a predictor of rapid FEV1 decline, and the association involving subscapular skinfold approached significance (P < 0.07). These characteristics may be useful in identifying subgroups of the population who are at increased risk of accelerated decline in pulmonary function and thus would be most likely to benefit from appropriate intervention.

Reference values for pulmonary function tests of Japanese-American men aged 71 to 90 years

Pulmonary function was assessed by spirometry in 3,076 elderly Japanese-American men of the Honolulu Heart Program (HHP) cohort. The assessment was done with a stringent quality assurance program that adhered to American Thoracic Society (ATS) recommendations for spirometry. Less than 6% of the participants were unable to perform three acceptable spirometry maneuvers. A "healthy" subgroup of 528 men between the ages of 71 and 90 yr was identified by excluding almost all smokers and subjects with lung disease and other factors negatively influencing FEV1. Reference equations and normal ranges for FEV1, FVC, and the FEV1/FVC ratio were derived from the healthy group. Use of prediction equations from the Cardiovascular Health Study (CHS) of elderly European-American men consistently overpredicted FVC by 0.3 to 0.4 L and FEV1 by 0.15 L. Men in the HHP were on average 11 cm shorter than those in the CHS. Use of a prediction equation derived from the HHP cohort when the men in the cohort were on average 22.6 yr younger consistently overpredicted FEV1 by 0.2 to 0.3 L. These results underscore the importance of using prediction equations appropriate to the ethnicity, age, and height characteristics of the subjects being studied.

Asthma and its association with cardiovascular disease in the elderly. The Cardiovascular Health Study Research Group

Cardiovascular disease (CVD) is more prevalent in elderly than in middle-aged patients. Symptoms such as intermittent wheezing with dyspnea may then be due to either CVD or asthma. The objective of this study was to determine the prevalence and correlates of asthma in the elderly and their associations with CVD and CVD risk factors. A community sample of 5201 elderly persons from the Cardiovascular Health Study was asked if they had a physician diagnosis of asthma, and multiple cardiovascular risk and disease variables were measured. Six percent of the participants (309) recalled a history of asthma, and half of these were never smokers. Thirty percent of those with asthma were currently taking a bronchodilator, 14% inhaled steroids, and 10% oral prednisone. Men and women with asthma who were cigarette smokers were more likely to report a concurrent diagnosis of congestive heart failure than smokers without asthma (p = .04). However, when we determined the independent CVD correlates of asthma in this cohort, controlling for smoking status, age, gender, and diagnoses of chronic bronchitis and emphysema, only higher levels of high-density lipoprotein cholesterol (HDL-C) and higher plasma fibrinogen levels were significantly associated with asthma. It was concluded that asthma is as prevalent in the elderly as in middle-aged persons and is associated with higher HDL-C and higher fibrinogen levels, but not with prevalent cardiovascular disease.