Comparison of mortality and hospitalizations of older adults living in residential care facilities versus nursing homes or the community. A systematic review

Residential care facility may provide a transition between living at home and a nursing home for dependent older people or an alternative to nursing homes. The objective of this review was to compare mortality and hospitalizations of older adults living in residential care facilities with those living in nursing homes or in the community. We searched Medline, Scopus and Web of Science from inception to December 2022. Fifteen cohort studies with 6 months to 10 years of follow-up were included. The unadjusted relative risk (RR) of mortality was superior in nursing homes than in residential care facilities in 6 of 7 studies (from 1.3 to 1.68). Conversely, the unadjusted relative risk of hospitalizations was higher in residential care facilities in 6 studies (from 1.3 to 3.37). Studies conducted on persons with dementia found mixed results, the only study adjusted for co-morbidities observing no difference on these two endpoints. Compared with home, unadjusted relative risks were higher in residential care facilities for mortality in 4 studies (from 1.34 à 10.1) and hospitalizations in 3 studies (from 1.12 to 1.62). Conversely, the only study that followed older adults initially living at home over a 10-year period found a reduced risk of heavy hospital use (RR = 0.68) for those who temporarily resided in a residential care facilities. There is insufficient evidence to determine whether residential care facilities might be an alternative to nursing homes for older people with similar clinical characteristics (co-morbidities and dementia). Nevertheless, given the high rate of hospitalizations observed in residential care facilities, the medical needs of residents should be better explored.

Health trajectories of elderly living in French senior housing: a longitudinal perspective

Senior housing for older adults could be an alternative or a transitional care model between home care and nursing home care. Using two longitudinal cohorts of community dwellers aged 65 years or older, we compared risks of mortality and of nursing homes admission between older adults who did or did not move to senior housing over time. In the 3C study (n = 2104, 17 years of follow-up), 143 (6.8%) participants moved into a senior housing during the follow-up. This move was associated with a lower risk of mortality (hazard ratio (HR): 0.64; 95% confidence interval (CI) 0.46-0.77) and a higher risk of nursing home admissions (HR: 1.54 (1.10-2.15)). The risks of hospitalizations (HR: 0.54 (0.40-0.73)) and falls (HR: 0.63 (0.50-0.79)) were lower. In the PAQUID study (n = 3777, 27 years of follow-up), 161 (4.3%) participants moved into a senior housing. This move was also associated with a lower mortality risk (HR: 0.72 (0.58-0.88)) and a higher risk of nursing home admissions (HR: 1.39 (1.05-1.86)). Our results showing lower risks of mortality suggest that senior housing may be a relevant model for vulnerable older adults.

Heritable defects in telomere and mitotic function selectively predispose to sarcomas

Cancer genetics has to date focused on epithelial malignancies, identifying multiple histotype-specific pathways underlying cancer susceptibility. Sarcomas are rare malignancies predominantly derived from embryonic mesoderm. To identify pathways specific to mesenchymal cancers, we performed whole-genome germline sequencing on 1644 sporadic cases and 3205 matched healthy elderly controls. Using an extreme phenotype design, a combined rare-variant burden and ontologic analysis identified two sarcoma-specific pathways involved in mitotic and telomere functions. Variants in centrosome genes are linked to malignant peripheral nerve sheath and gastrointestinal stromal tumors, whereas heritable defects in the shelterin complex link susceptibility to sarcoma, melanoma, and thyroid cancers. These studies indicate a specific role for heritable defects in mitotic and telomere biology in risk of sarcomas.

Co-Occurrence of Geriatric Syndromes and Diseases in the General Population: Assessment of the Dimensions of Aging

OBJECTIVES

The co-occurrence of multiple medical or psycho-social conditions (geriatric syndromes (GS) and age-related diseases) is a growing concern in older people. Given the diversity of these conditions and their complex interactions, our aim was to determine whether they could be structured into synthetic dimensions in order to facilitate the management of multimorbidity.

DESIGN

The underlying structure of 10 GSs and 8 age-related diseases was identified using a multiple correspondence analysis (MCA), and confronted to subjective and objective health outcomes.

SETTING

community residents from Bordeaux City (France) older than 75 years in 2010.

PARTICIPANTS

630 adults aged 75+ years who lived in Bordeaux and participated in the 10-year follow-up of the Three-City study.

MEASUREMENTS

GSs included physical frailty, cognitive impairment and dementia, dependency, depressive symptoms, polymedication, thinness, falls, sensory deficit, social isolation, incontinence. Age-related diseases were cancer, cardiac diseases, peripheral vascular diseases, diabetes, hypertension, pulmonary diseases, osteoporosis, other chronic diseases. Association of the MCA-derived independent dimensions was assessed with 10-year visit subjective health and well-being, and with incident death and entry into institution during the remaining cohort follow-up.

RESULTS

Most of the participants (82%) had at least two age-related syndromes or diseases. The MCA structured the 18 conditions into three major dimensions: Degradation (D) driven by GS, Vascular (V), and Psychosocial (P) representing 68.7%, 7.4%, and 5.7% of the total variance, respectively. Dimension D was a strong predictor of future death and institutionalization. Dimensions D and P were strongly associated with current well-being.

CONCLUSIONS

This work confirmed that multimorbidity is very common among older adults, and demonstrated the essential role of GS as manifestations of aging, even more than age-related diseases.

Older People Facing the Crisis of COVID-19: Between Fragility and Resilience

The health crisis we are facing is challenging seniors’ resources and capacities for adaptation and resilience. The PACOVID survey, set up a few days after containment, investigates their psychological and social experiences with regard to the COVID-19 crisis and to what extent these characteristics, representations and attitudes have an impact on health and mortality. A telephone survey is being carried out on 935 people already followed up in the framework of ongoing epidemiological studies. As we are writing this article, the interviews conducted during the containment have just ended. Even though we will have to wait for the analysis of the results to draw conclusions, words collected by the psychologists during the interviews already illustrate a great heterogeneity in the way older adults lived this experience: social isolation, anxiety, the importance of family and the difficulty of being deprived of it, but also remarkable coping skills and resilience capacities.

Older Adults and the COVID-19 Pandemic, What About the Oldest Old? The PACOVID Population-Based Survey

Introduction: The literature draws a mitigated picture of the psychosocial effects of the lockdown in older adults. However, the studies conducted so far are mainly based on web surveys which may involve selection bias. The PACOVID survey relies on a population-based design and addresses the attitudes, psychological and social experiences of the oldest old regarding the pandemic and lockdown and their impact. Material and Methods: Cross-sectional phone survey involving 677 persons. Baseline report on attitudes, psychological, and social experiences of the oldest old, regarding the pandemic and lockdown measures. Results: The mean age was 87.53 (SD 5.19). About 46% were living alone during the lockdown. Concerning difficulties, "none" was the most frequent answer (35.6%). For questions addressing how often they had felt sad, depressed, or lonely (CESD-scale), the most frequent answers were "never/very rarely" (58.7, 76.6, 60.8%) and 27.1% had anxious symptomatology (STAI scale). Most (92.9%) felt socially supported. Engaging in leisure activities was the most frequent coping strategy, and for numerous participants the lockdown did not represent much of a change in terms of daily routine. A very good knowledge and awareness of COVID-19 and the safety measures was observed. Comparisons with measures collected before the pandemic showed low changes in subjective health and the CES-D questions. Discussion: With a methodological design limiting selection bias, our results claim for a weakened psychosocial impact even though the participants are concerned and aware of the pandemic issues. These results highlight the resources and resilience abilities of older persons including in advancing age.

Interaction between APOE4 and herpes simplex virus type 1 in Alzheimer's disease

INTRODUCTION

Numerous results suggest the implication of infectious agents in the onset of Alzheimer's disease (AD).

METHODS

In the Bordeaux-3C prospective cohort, we assessed the impact of herpes simplex virus type 1 (HSV-1) infection on the incidence of AD according to apolipoprotein E (APOE) status, a genetic susceptibility factor. Cox models were performed to estimate the 10-year risk of AD associated with anti-HSV antibodies in 1037 participants according to APOE4 status.

RESULTS

Among APOE4 carriers, subjects for whom the frequency of HSV-1 reactivation is supposed to be high, that is, immunoglobulin M (IgM) positive or elevated levels of IgG, had an increased risk of AD with adjusted hazard ratios (HRs) of 3.68 (1.08-12.55) and 3.28 (1.19-9.03), respectively. No significant association was found in APOE4-negative subjects.

DISCUSSION

These results, in accordance with a solid pathophysiological rationale, suggest a role for HSV-1 in AD development among subjects with a genetic susceptibility factor, the APOE4 allele.

The disability process: is there a place for frailty?

BACKGROUND

frailty and disability are very common in older adults; they share some risk factors and pathophysiological mechanisms. Yet, they are different clinical entities.

OBJECTIVES

this study aimed to explore a potential hierarchical relationship between frailty and disability along the continuum of the disablement process.

DESIGN

prospective cohort study.

SETTING

the French Three-City (3C) study.

SUBJECTS

the sample included 943 participants aged 75 and older.

METHODS

the Fried frailty phenotype, Instrumental Activities of Daily Living (IADL) and basic Activities of Daily Living (ADL) were used. We distinguished between four mutually excluding groups: (i) robust (no frailty and no disability); (ii) pure frailty (no disability); (iii) frailty with IADL disability (no ADL disability) and (iv) frailty with IADL and ADL disabilities. We used Cox's regression models to study the 4-year mortality risk associated with each status.

RESULTS

Eight-two per cent of participants were classified according to the assumed hierarchy: 61.3% was robust, 5.4% frail, 10.5% frail and IADL-disabled and 4.8% frail, IADL and ADL-disabled. An extra group of 17% was identified with IADL-disabled individuals without frailty. This extra group was similar to pure frailty in terms of characteristics and risk of death, placing them along the continuum at an intermediate stage between robustness and the two most disabled sub-groups.

CONCLUSIONS

our findings suggest that including frailty along the continuum could be relevant to describe the whole disablement process. Frailty would occur upstream of the process and might be relevant to identify an opportune time window, where specific monitoring and clinical interventions could be implemented in order to interrupt the process at a potentially more reversible stage.

Impact of self-perception of aging on mortality of older patients in oncology

OBJECTIVE

Several studies show that self-perception of aging (SPA) is a significant predictor of mental and physical health. In this study, we analyze the effect of SPA on mortality in the specific context of geriatric oncology.

METHODS

The sample constituted of 140 individuals aged 65 years and older suffering from a recent nonmetastatic cancer (breast, lung, gynecological, or hematological), followed up to 6 years. We used Cox proportional hazards model to assess the effect of SPA at baseline on mortality. It was adjusted for age, gender, educational and cognitive level, oncological information (the site and kind of cancer), number of comorbidities, and physical and mental health at baseline.

RESULTS

Patients were aged 73 years at diagnosis and were more often women (85.7%). Individuals with more negative SPA were 3.62 times more likely to die than those with a more positive SPA, with control of gender, age, education and cognitive level, mental and physical health, the category (breast, lung, gynecological, or hematological), and kind (initial or recurrence) of cancer.

CONCLUSIONS

These findings suggest that SPA influence the mortality of older people in the particular context of oncology. Therefore, the need to change our attitudes toward aging and older people implied indirectly by these results is discussed.

Ginkgo Biloba Extract Consumption and Long-Term Occurrence of Death and Dementia

OBJECTIVES

To study the benefit of Ginkgo Biloba Extract (GBe) consumption on the long term risk of dementia and death in elderly people.

DESIGN

The Paquid study is a population-based cohort with regular follow-up screenings up to twenty-two years and systematic detection of incident cases of dementia. Statistical analysis was conducted with an illness-death model dealing with interval censoring of dementia and competing risk of death.

SETTING

The sample was randomly selected from electoral rolls in two administrative areas of southwestern France in 1988-1989.

PARTICIPANTS

3,777 subjects aged 65 years or older at baseline who were living at home.

MEASUREMENT

Participants were visited at home by a trained psychologist at baseline in 1988/1989, and then again approximately every two years. Drug consumption for the treatment of cognitive or neurosensory impairment was collected at baseline. Participants were classified as GBe consumers, other drug (OD) consumers and untreated controls (UC) for this motive.

RESULTS

After adjustment for sociodemographic factors and cognitive measures at baseline the risk for dementia was not significantly different in GBe consumers and UC (Hazard Ratio (HR)=1.21, 95% Confidence Interval (95% CI)=0.95-1.55, p=0.42) and it was of the same magnitude but significantly increased in the OD group versus UC (HR=1.25, 95% CI=1.06-1.46, p=0.004). With the same adjustment, the risk of dying in non-demented subjects was reduced in GBe consumers versus UC (HR=0.67, 95% CI=0.49-0.93, p=0.02) while it was the same as the reference group in OD consumers. The mean lifetimes without dementia was of 11.2 years in the UC group (95% CI=10.9-11.5), 11.1 years in the GBe group (10.2-11.9) and 9.1 years for the OD group (8.7-9.6).

CONCLUSION

GBe consumers have a lower risk of dying before dementia and a longer lifetime without dementia than participants taking other drugs for the same indication.

Analysis of shared heritability in common disorders of the brain

Disorders of the brain can exhibit considerable epidemiological comorbidity and often share symptoms, provoking debate about their etiologic overlap. We quantified the genetic sharing of 25 brain disorders from genome-wide association studies of 265,218 patients and 784,643 control participants and assessed their relationship to 17 phenotypes from 1,191,588 individuals. Psychiatric disorders share common variant risk, whereas neurological disorders appear more distinct from one another and from the psychiatric disorders. We also identified significant sharing between disorders and a number of brain phenotypes, including cognitive measures. Further, we conducted simulations to explore how statistical power, diagnostic misclassification, and phenotypic heterogeneity affect genetic correlations. These results highlight the importance of common genetic variation as a risk factor for brain disorders and the value of heritability-based methods in understanding their etiology.

Pattern of polyphenol intake and the long-term risk of dementia in older persons

OBJECTIVE

To investigate the optimal combination of dietary polyphenols associated with the long-term risk of dementia in a large prospective French cohort of older persons, the Three-City (3C) Study.

METHODS

We included 1,329 older adults without dementia from the 3C study with assessment of intake of 26 polyphenol subclasses who were followed up for 12 years for dementia. Using partial least squares for Cox models, we identified a pattern of polyphenol intake associated with dementia risk.

RESULTS

The pattern combined several flavonoids (dihydroflavonols, anthocyanins, isoflavonoids, flavanones), stilbenes (including resveratrol), lignans, and other subclasses (hydroxybenzaldehydes, naphthoquinones, furanocoumarins). Compared with participants in the lower quintile of pattern score, those in the higher quintile had a 50% lower risk of dementia (95% confidence interval 20%-68%, p for trend <0.01) in multivariate models.

CONCLUSIONS

In this French cohort, a polyphenol pattern provided by a diet containing specific plant products (nuts, citrus, berries, leafy vegetables, soy, cereals, olive oil) accompanied by red wine and tea was associated with lower dementia risk.

Cerebral and Functional Aging: First Results on Prevalence and Incidence of the Paquid Cohort

Paquid is an interdisciplinary study designed to investigate cerebral and functional aging. A cohort of 3,777 community residents living in two administrative areas of South-Western France was selected. A standardized questionnaire was administered at home by trained psychologists. The same procedure was applied one and three years after the baseline data collection. The identification of demented subjects was made with a two-step procedure. The first step is a systematic screening by the psychologists using the DSM-III criteria for dementia. Subjects who fulfilled the DSM-III criteria were examined by a neurologist. Diagnosis of dementia is confirmed according to the NINCDS-ADRDA criteria. The Paquid cohort is complemented by a random sample of 357 institutionalized subjects. First results of prevalence and incidence rates show an exponential increase of dementia with age.

Occupational social and mental stimulation and cognitive decline with advancing age

Objective

this study investigates the role of social and mental occupational characteristics in cognitive decline after retirement.

Methods

the study included 1,048 subjects aged ≥65 years from the Three City cohort. Participants were evaluated at home at the initial visit and at 2-year intervals for a period of 12 years. The study includes detailed assessments of cognition, health and information about the subjects' main occupation. The four cognitive tests have been grouped into one latent factor. Three independent raters specialised in employment were asked to evaluate the level of social and intellectual stimulation for each occupation, which was then rated as low, medium and high.

Results

after controlling for potential confounding factors, no association was found between higher levels of social stimulation at work and baseline cognition (medium score, P = 0.440; high score, P = 0.700) as compared with a low level. While cognitive trajectories were initially similar between high and medium levels of social stimulation compared with that of a low level, with advancing age this association diverged whereby more social stimulation during work years was related to accelerated cognitive decline that further grew in magnitude with older age. For mental stimulation, differences were only observed at baseline, with greater levels of mental stimulation during work years being associated with better cognitive performance (medium score, β = 0.573, P = 0.015; and high score, β = 0.510; P = 0.090) compared with a low level of mental stimulation.

Conclusion

workers retiring from occupations characterised by high levels of social stimulation may be at risk of accelerated cognitive decline with advancing age.

Psychological transition and adjustment processes related to retirement: influence on cognitive functioning

OBJECTIVE

To investigate the relationship between psychological transition and adjustment to retirement and cognitive performances in older adults.

METHODS

The study's sample was taken from the Approche Multidisciplinaire Intégrée cohort, a French prospective study of retirees from agriculture, aged 65 and over, living in rural settings in southwestern France. The cross-sectional analyses were conducted on a sample of 590 elderly people without dementia at baseline and for whom information on perception of the work setting, experience of the retirement transition and adaptation to retirement life (nine variables) as well as neuropsychological measures (global cognitive functioning, episodic memory, verbal fluency, attention and psychomotor speed) were available at first visit.

RESULTS

Multivariable linear regression analyses, including nine variables related to retirement and adjusted for potential confounding factors, indicated that three of them - positive consideration of former work situation, development of new activities during retirement and good adaptation to free time - were associated with better cognitive performances.

CONCLUSIONS

We found that several factors proved to be determinants of good cognitive functioning at retirement and could serve as a basis for the development of more efficient intervention programs aimed at helping retirees to maintain good cognitive functioning after retirement.

Higher Protein but Not Energy Intake Is Associated With a Lower Prevalence of Frailty Among Community-Dwelling Older Adults in the French Three-City Cohort

BACKGROUND

The hypothesis that increasing protein and energy intakes may confer protection against frailty has been suggested, although few studies have examined these associations, especially regarding current protein energy recommendations in the older population.

AIM

To assess the association between frailty and higher protein and energy intakes.

METHODS

The present study is a secondary, cross-sectional analysis of the French Three-City cohort. Participants were community-dwelling older adults aged 65 and over. Frailty was defined as a score of 3/5 among the 5 Fried criteria: weight loss, exhaustion, muscle weakness, slowness, and physical activity. Protein intake was set at a daily intake ≥1 g/kg body weight and optimal energy intake defined as a daily intake ≥30 kcal/kg. Logistic regressions were performed while adjusting for several sociodemographic and clinical variables.

RESULTS

The study sample consisted of 1345 participants [mean age (SD) 74.0 (4.9) years], of whom 55 (4.1%) were identified as frail. After adjusting for sociodemographic and clinical variables, higher protein intake was significantly associated with a lower frailty prevalence [odds ratio (OR) = 0.41, 95% confidence interval (CI) = 0.19-0.89; P = .024] whereas no significant association was observed between an optimal energy intake and the presence of frailty (OR = 0.70, 95% CI = 0.32-1.55, P = .38).

CONCLUSIONS

A 1 g/kg protein intake was associated with a lower prevalence of frailty in French community-dwelling older subjects. This observation adds to the literature, suggesting increasing the daily protein intake to at least 1 g/kg for older adults aged 65 and more.

17q21.31 duplication causes prominent tau-related dementia with increased MAPT expression

To assess the role of rare copy number variations in Alzheimer's disease (AD), we conducted a case-control study using whole-exome sequencing data from 522 early-onset cases and 584 controls. The most recurrent rearrangement was a 17q21.31 microduplication, overlapping the CRHR1, MAPT, STH and KANSL1 genes that was found in four cases, including one de novo rearrangement, and was absent in controls. The increased MAPT gene dosage led to a 1.6-1.9-fold expression of the MAPT messenger RNA. Clinical signs, neuroimaging and cerebrospinal fluid biomarker profiles were consistent with an AD diagnosis in MAPT duplication carriers. However, amyloid positon emission tomography (PET) imaging, performed in three patients, was negative. Analysis of an additional case with neuropathological examination confirmed that the MAPT duplication causes a complex tauopathy, including prominent neurofibrillary tangle pathology in the medial temporal lobe without amyloid-β deposits. 17q21.31 duplication is the genetic basis of a novel entity marked by prominent tauopathy, leading to early-onset dementia with an AD clinical phenotype. This entity could account for a proportion of probable AD cases with negative amyloid PET imaging recently identified in large clinical series.

Dietary B Vitamins and a 10-Year Risk of Dementia in Older Persons

B vitamins may lower the risk of dementia, yet epidemiological findings, mostly from countries with folic acid fortification, have remained inconsistent. We evaluated in a large French cohort of older persons the associations between dietary B vitamins and long-term incident dementia. We included 1321 participants from the Three-City Study who completed a 24 h dietary recall, were free of dementia at the time of diet assessment, and were followed for an average of 7.4 years. In Cox proportional hazards models adjusted for multiple potential confounders, including overall diet quality, higher intake of folate was inversely associated with the risk of dementia (p for trend = 0.02), with an approximately 50% lower risk for individuals in the highest compared to the lowest quintile of folate (HR = 0.47; 95% CI 0.28; 0.81). No association was found for vitamins B6 and B12. In conclusion, in a large French cohort with a relatively low baseline folate status (average intake = 278 µg/day), higher folate intakes were associated with a decreased risk of dementia.

Dietary and Alcohol Intake and Central Nervous System Tumors in Adults: Results of the CERENAT Multicenter Case-Control Study

BACKGROUND

Little is known about the relationship between diet and central nervous system (CNS) tumors, especially in terms of their histological subtypes. This study investigated the overall associations between food groups, alcohol intake and CNS tumors, and in particular about the associations between neuroepithelial tumors and meningiomas.

METHODS

Data were collected through the CERENAT (CEREbral tumors: a NATional study) case-control study conducted in France during the period 2004-2010. Data were available for 1,479 subjects (494 cases, including 201 neuroepithelial tumors, 193 meningiomas, 100 other CNS tumors, and their 985 matched controls). Conditional logistic regressions for matched sets were adjusted based on the participants' educational level, occupation, smoking status and frequency of food group consumption.

RESULTS

A heavy consumption of grilled meat and poultry was associated with neuroepithelial tumors in a dose-related relationship (ORQ4vsQ1 = 3.72, 95% CI 1.62-8.52, p = 0.005). Higher fruit and vegetable intake was inversely associated with meningiomas (for fruits: ORQ4vsQ1 = 0.38, 95% CI 0.17-0.87, p = 0.06, for vegetables ORQ4vsQ1 = 0.26, 95% CI 0.11-0.62, p = 0.007). Consumption of alcohol on a daily basis was inversely associated with CNS tumors especially for meningiomas (ORQ4vsQ1 = 0.33, 95% CI 0.18-0.61, p = 0.001).

CONCLUSIONS

Results obtained in terms of grilled meat, fruits and vegetables consumption were in line with those published in epidemiological literature. Contradictions in results between neuroepithelial tumors and meningiomas confirmed the need to analyze the effects of dietary factors on the basis of the histological subtypes of CNS tumors.

SORL1 rare variants: a major risk factor for familial early-onset Alzheimer's disease

The SORL1 protein plays a protective role against the secretion of the amyloid β peptide, a key event in the pathogeny of Alzheimer's disease. We assessed the impact of SORL1 rare variants in early-onset Alzheimer's disease (EOAD) in a case-control setting. We conducted a whole exome analysis among 484 French EOAD patients and 498 ethnically matched controls. After collapsing rare variants (minor allele frequency ≤1%), we detected an enrichment of disruptive and predicted damaging missense SORL1 variants in cases (odds radio (OR)=5.03, 95% confidence interval (CI)=(2.02-14.99), P=7.49.10(-5)). This enrichment was even stronger when restricting the analysis to the 205 cases with a positive family history (OR=8.86, 95% CI=(3.35-27.31), P=3.82.10(-7)). We conclude that predicted damaging rare SORL1 variants are a strong risk factor for EOAD and that the association signal is mainly driven by cases with positive family history.

ABCA7 rare variants and Alzheimer disease risk

OBJECTIVE

To study the association between ABCA7 rare coding variants and Alzheimer disease (AD) in a case-control setting.

METHODS

We conducted a whole exome analysis among 484 French patients with early-onset AD and 590 ethnically matched controls.

RESULTS

After collapsing rare variants (minor allele frequency ≤1%), we detected an enrichment of ABCA7 loss of function (LOF) and predicted damaging missense variants in cases (odds ratio [OR] 3.40, 95% confidence interval [CI] 1.68-7.35, p = 0.0002). Performing a meta-analysis with previously published data, we found that in a combined sample of 1,256 patients and 1,347 controls from France and Belgium, the OR was 2.81 (95% CI 1.89-4.20, p = 3.60 × 10(-7)).

CONCLUSIONS

These results confirm that ABCA7 LOF variants are enriched in patients with AD and extend this finding to predicted damaging missense variants.

Why Is Later Age at Retirement Beneficial for Cognition? Results from a French Population-based Study

OBJECTIVE

To determine whether and how age at retirement influences the risk of dementia. The association between the age at retirement, the number of working years and the risk of dementia was evaluated over 12 years of follow-up.

DESIGN

A prospective population-based study.

SETTING

Three-City cohort, a French population-based study of community-dwelling individuals aged 65 to 95.

PARTICIPANTS

The sample consisted of 1,658 non-demented participants at baseline.

MEASUREMENTS

All participants were evaluated at home at the initial visit and at two years interval for a period of 12 years. An active research of dementia was conducted at each follow-up; all suspected cases were analysed by an independent committee of neurologists. Information regarding retirement age and number of working years was collected at baseline using a structured questionnaire.

RESULTS

The multivariate Cox model, including both the age at retirement and the number of working years and adjusted for potential confounders, revealed that the risk of dementia was independently associated with the age at retirement (p=0.022) but not with the number of working years (p=0.296).

CONCLUSION

Although our results are in accordance with previous studies (i.e., older age at retirement is associated with decreased risk of dementia), it provides additional information regarding the possible explanation for such results. Given that a longer working life did not reduce the risk of dementia, the age at retirement cannot be considered as a new factor of cognitive reserve but rather seems to be a psycho-social vulnerability factor. Further evidence is necessary to identify work and retirement related factors that influence the association between the age at retirement and the risk of dementia.

Poor nutritional status is associated with a higher risk of falling and fracture in elderly people living at home in France: the Three-City cohort study

Falling and fractures are a public health problem in elderly people. The aim of our study was to investigate whether nutritional status is associated with the risk of falling or fracture in community-dwelling elderly. Poor nutritional status was significantly associated with a higher risk of both falling and fractures.

INTRODUCTION

Nutrition could play a role to prevent falls and fractures. The purpose of this study is to investigate whether a poor nutritional status is associated with the risk of falling and of fracture in community dwelling elderly.

METHODS

Baseline nutritional status of participants was assessed using the Mini Nutritional Assessment (MNA). After a follow-up of 12 years, 6040 individuals with available data for falls and 6839 for fracture were included. People who presented the outcomes at baseline were excluded. Cox models were used to evaluate the associations between nutritional status and the risks of fall or fracture.

RESULTS

The frequency of poor nutritional status (MNA ≤ 23.5), at baseline, was respectively 12.0% in the "fall study sample" and 12.8% in the "fracture study sample." Incident fall and fracture over 12 years were reported in 55.8 and 18.5% of the respective samples, respectively. In multivariate models controlled for sociodemographic data and several baseline health indicators, poor nutritional status was significantly associated with a higher risk of falling (hazard ratio (HR) = 1.66, 95% confidence interval (95% CI) 1.35-2.04 in men and HR = 1.20, 95% CI 1.07-1.34 in women) and with a higher risk of fracture (HR = 1.28, 95% CI 1.09-1.49).

CONCLUSION

Poor nutritional status was associated with a higher risk of both falling and fractures in French elderly community-dwellers. Early screening and management of the nutritional status may be useful to reduce the frequency of these events in older people.

Retirement age and the age of onset of Alzheimer's disease: results from the ICTUS study

Objectives

To test whether deferred retirement is associated with delayed onset of Alzheimer’s disease (AD), and, if so, to determine whether retirement age still predicts the age at onset of AD when two potential biases are considered.

Methods

The study sample was gathered from the Impact of Cholinergic Treatment Use/Data Sharing Alzheimer cohort (ICTUS/DSA), a European study of 1,380 AD patients. Information regarding retirement age, onset of symptoms and covariates was collected at baseline whereas age at diagnosis was gathered from the patient’s medical record prior to study entry. Linear mixed models, adjusted for gender, education, occupation, center, country, household income, depression and cardiovascular risk factors were conducted on 815 patients.

Results

(1) The global analyses (n = 815) revealed that later age at retirement was associated with later age at diagnosis (β = 0.31, p < 0.0001); (2) once the selection bias was considered (n = 637), results showed that this association was weaker but remained significant (β = 0.15, p = 0.004); (3) once the bias of the reverse causality (i.e., the possibility that subjects may have left the workforce due to prior cognitive impairment) was considered (n = 447), the effect was no longer significant (β = 0.06, p = 0.18).

Conclusion

The present study supports that there is an association between retirement age and age at onset of AD. However, the strength of this association appears to be overestimated due to the selection bias. Moreover, the causality issue remains unresolved. Further prospective investigations are mandatory in order to correctly address this question.

Natural history of functional decline in Alzheimer's disease: a systematic review

BACKGROUND

Knowledge of functional evolution in dementia is crucial for the patients and their families as well as the clinician.

OBJECTIVE

This review identifies scales and outcomes used to describe the natural history of functional decline and describes the natural history of functional decline in a representative clinical population sample of published studies of patients with Alzheimer's disease (AD).

METHODS

A search of three relevant databases was conducted and limited to articles published in English and French between 1998 to March 2012, using the keywords "Dementia", "Activities of Daily Living", "Instrumental Activities of Daily Living", "Functional Impairment", "Prognosis", and "Disease Progression".

RESULTS

The search strategy displayed 683 articles, 20 of which were found to be related to the functional evolution of AD. In these studies, different scales were used to describe the evolution of the functional decline, except for the decline of instrumental activities, for which the Lawton scale was used in all studies. Thus, it is difficult to represent the evolution of the functional decline from a clinical point of view.

CONCLUSION

Relatively little data are available to estimate the functional evolution of AD. A consensus with broadened thought is required to know if the progression of the incapacities in these scales is additive or hierarchical.

Nutritional status in community-dwelling elderly in France in urban and rural areas

Malnutrition is a frequent condition in elderly people, especially in nursing homes and geriatric wards. Its frequency is less well known among elderly living at home. The objective of this study was to describe the nutritional status evaluated by the Mini Nutritional Assessment (MNA) of elderly community-dwellers living in rural and urban areas in France and to investigate its associated factors.

Methods

Subjects aged 65 years and over from the Approche Multidisciplinaire Intégrée (AMI) cohort (692 subjects living in a rural area) and the Three-City (3C) cohort (8,691 subjects living in three large urban zones) were included. A proxy version of the MNA was reconstructed using available data from the AMI cohort. Sensitivity and specificity were used to evaluate the agreement between the proxy version and the standard version in AMI. The proxy MNA was computed in both cohorts to evaluate the frequency of poor nutritional status. Factors associated with this state were investigated in each cohort separately.

Results

In the rural sample, 38.0% were females and the mean age was 75.5 years. In the urban sample, 60.3% were females and the mean age was 74.1 years. Among subjects in living in the rural sample, 7.4% were in poor nutritional status while the proportion was 18.5% in the urban sample. Female gender, older age, being widowed, a low educational level, low income, low body mass index, being demented, having a depressive symptomatology, a loss of autonomy and an intake of more than 3 drugs appeared to be independently associated with poor nutritional status.

Conclusion

Poor nutritional status was commonly observed among elderly people living at home in both rural and urban areas. The associated factors should be further considered for targeting particularly vulnerable individuals.

Gene-wide analysis detects two new susceptibility genes for Alzheimer's disease

BACKGROUND

Alzheimer's disease is a common debilitating dementia with known heritability, for which 20 late onset susceptibility loci have been identified, but more remain to be discovered. This study sought to identify new susceptibility genes, using an alternative gene-wide analytical approach which tests for patterns of association within genes, in the powerful genome-wide association dataset of the International Genomics of Alzheimer's Project Consortium, comprising over 7 m genotypes from 25,580 Alzheimer's cases and 48,466 controls.

PRINCIPAL FINDINGS

In addition to earlier reported genes, we detected genome-wide significant loci on chromosomes 8 (TP53INP1, p = 1.4×10-6) and 14 (IGHV1-67 p = 7.9×10-8) which indexed novel susceptibility loci.

SIGNIFICANCE

The additional genes identified in this study, have an array of functions previously implicated in Alzheimer's disease, including aspects of energy metabolism, protein degradation and the immune system and add further weight to these pathways as potential therapeutic targets in Alzheimer's disease.

A regulatory variant in CCR6 is associated with susceptibility to antitopoisomerase-positive systemic sclerosis

OBJECTIVE

Recognition of the well-known pleiotropism of autoimmune genes supports the concept of a shared pathogenesis across autoimmune diseases such as rheumatoid arthritis (RA) and systemic sclerosis (SSc). Studies have reproducibly demonstrated an association between susceptibility to RA and polymorphisms of the CCR6 gene, a surface marker for Th17 cells, and the causal variant was recently identified. The present study was thus undertaken to investigate whether CCR6 polymorphisms could also be associated with susceptibility to SSc.

METHODS

Twelve tag single-nucleotide polymorphisms (SNPs) of CCR6, including the known RA-associated SNP rs3093023, were genotyped in a total of 2,411 SSc patients and 7,084 healthy individuals from 3 European populations (France, Italy, and Germany). Meta-analyses of the data were performed to assess whether an association exists between CCR6 polymorphisms and susceptibility to SSc or its main subtypes. Direct sequencing of DNA was performed to ascertain whether the functional dinucleotide polymorphism of CCR6 previously identified in RA (CCR6DNP) was also present in SSc.

RESULTS

Combined analyses revealed an association between the rs10946216 SNP and SSc susceptibility (odds ratio [OR] 1.13, 95% confidence interval [95% CI] 1.05-1.21, adjusted P [P(adj)] = 0.026). The rs3093023 A allele and rs10946216 T allele were in high linkage disequilibrium, and both were found to confer disease susceptibility in the antitopoisomerase-positive subset of SSc patients (OR 1.27, 95% CI 1.13-1.42, P(adj) = 1.5 × 10(-3) and OR 1.32, 95% CI 1.17-1.48, P(adj) = 9.0 × 10(-5), respectively, relative to healthy controls). Direct sequencing of the DNA of 78 individuals supported the hypothesis that the regulatory dinucleotide CCR6DNP could be the causal variant in SSc.

CONCLUSION

The results of this study establish CCR6 as a new susceptibility factor for antitopoisomerase-positive SSc, as demonstrated in 3 European Caucasian populations, confirming the notion that SSc and RA could conceivably share autoimmune risk alleles. The results also suggest a potential role of the interleukin-17 pathway in SSc.

Adherence to a Mediterranean diet and risk of fractures in French older persons

Prevention of fractures is a considerable public health challenge. In a population-based cohort of French elderly people, a diet closer to a Mediterranean type had a borderline significant deleterious effect on the risk of fractures, in part linked to a low consumption of dairy products and a high consumption of fruits.

INTRODUCTION

Higher adherence to the Mediterranean diet (MeDi) is linked to a lower risk of several chronic diseases, but its association with the risk of fractures is unclear. Our aim was to investigate the association between MeDi adherence and the risk of fractures in older persons.

METHODS

The sample consisted of 1,482 individuals aged 67 years or older, from Bordeaux, France, included in the Three-City Study in 2001-2002. Occurrences of hip, vertebral and wrist fractures were self-reported every 2 years over 8 years, and 155 incident fractures were recorded. Adherence to the MeDi was evaluated at baseline by a MeDi score, on a 10-point scale based on a food frequency questionnaire and a 24-h recall. Multivariate Cox regression tests were performed to estimate the risk of fractures according to MeDi adherence.

RESULTS

Higher MeDi adherence was associated with a non-significant increased risk of fractures at any site (hazard ratio [HR] per 1-point increase of MeDi score = 1.10, P = 0.08) in fully adjusted model. Among MeDi components, higher fruits consumption (>2 servings/day) was significantly associated with an increased risk of hip fractures (HR = 1.95, P = 0.04), while low intake of dairy products was associated with a doubled risk of wrist fractures (HR = 2.03, P = 0.007). An inverse U-shaped association between alcohol intake and risk of total fracture was observed (HR high vs. moderate = 0.61, P for trend = 0.03).

CONCLUSIONS

Greater MeDi adherence was not associated with a decreased risk of fractures in French older persons. The widely recognized beneficial effects of the MeDi do not seem to apply to bone health in these people.

Meta-analysis of 74,046 individuals identifies 11 new susceptibility loci for Alzheimer's disease

Eleven susceptibility loci for late-onset Alzheimer's disease (LOAD) were identified by previous studies; however, a large portion of the genetic risk for this disease remains unexplained. We conducted a large, two-stage meta-analysis of genome-wide association studies (GWAS) in individuals of European ancestry. In stage 1, we used genotyped and imputed data (7,055,881 SNPs) to perform meta-analysis on 4 previously published GWAS data sets consisting of 17,008 Alzheimer's disease cases and 37,154 controls. In stage 2, 11,632 SNPs were genotyped and tested for association in an independent set of 8,572 Alzheimer's disease cases and 11,312 controls. In addition to the APOE locus (encoding apolipoprotein E), 19 loci reached genome-wide significance (P < 5 × 10(-8)) in the combined stage 1 and stage 2 analysis, of which 11 are newly associated with Alzheimer's disease.