Fasting total homocysteine (tHcy) concentration and mortality in older Mexican Americans

OBJECTIVES

This study examines the association between tHcy on cardiovascular and noncardiovascular mortality.

DESIGN

Longitudinal study of 1,633 Mexican Americans age>60 years recruited in 1998.

SETTING

Sacramento, California.

MEASUREMENTS

Cox proportional models were used to estimate the effects of tHcy on mortality rate in the total sample and in a subgroup of subjects without a history of cardiovascular disease at baseline.

RESULTS

About half of the cohort was born in Mexico. Among Mexican-born participants, high tHcy (>11.0 micromol/L) was associated with a higher rate of cardiovascular mortality compared to those with low tHcy concentration

CONCLUSIONS

The effect of tHcy on cardiovascular mortality is nearly 40% stronger among the immigrant group. tHcy might be an early marker of subclinical vascular pathology amongst the Mexican-born group, despite their apparently healthy profile at baseline.

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Key Words

• homocysteine
• cardiovascular mortality
• mexican americans
• nutritional biomarkers
• elderly

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MESH Headings

• Aged
• Aged, 80 and over
• Biomarkers/blood
• California/epidemiology
• Cardiovascular Diseases/ethnology
• Cardiovascular Diseases/mortality
• Female
• Homocysteine/blood
• Humans
• Longitudinal Studies
• Male
• Mexican Americans
• Mexico/ethnology
• Middle Aged
• Proportional Hazards Models

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Grants

• 1R24HD047861 NICHD NIH HHS
• P60 DK20572 NIDDK NIH HHS
• R01 DK060753 NIDDK NIH HHS
• AG12975 NIA NIH HHS
• R24 HD047861 NICHD NIH HHS
• DK60753 NIDDK NIH HHS
• R01 DK060753-03 NIDDK NIH HHS
• R03 AG033751 NIA NIH HHS
• R01 AG012975 NIA NIH HHS
• P60 DK020572-30 NIDDK NIH HHS
• P30 DK092926 NIDDK NIH HHS
• R01 AG012975-11 NIA NIH HHS
• P60 DK020572 NIDDK NIH HHS
• RWJ04823 PHS HHS

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Use of statins and incidence of dementia and cognitive impairment without dementia in a cohort study

OBJECTIVE

Evidence of a relation between use of lipid lowering drugs and cognitive outcomes is mixed. This study aimed to test the association between use of statins and incidence of dementia and cognitive impairment without dementia (CIND) over 5 years of follow-up.

METHODS

Data were from a population-based cohort study comprising 1,789 older Mexican Americans. All participants had cognitive and clinical evaluations performed every 12 to 15 months. Participants who fell below specified cutpoints on cognitive tests were then evaluated clinically. Dementia diagnoses were finalized by an adjudication team. A total of 1,674 participants free of dementia/CIND at baseline were included in these analyses. Statin use was verified at each participant's home by medicine cabinet inspection. Cox proportional hazards models were used to evaluate the association between statin use and incidence of dementia/CIND.

RESULTS

Overall, 452 of 1,674 participants (27%) took statins at any time during the study. Over the 5-year follow-up period, 130 participants developed dementia/CIND. In Cox proportional hazards models adjusted for education, smoking status, presence of at least one APOE epsilon4 allele, and history of stroke or diabetes at baseline, persons who had used statins were about half as likely as those who did not use statins to develop dementia/CIND (HR = 0.52; 95% CI 0.34, 0.80).

CONCLUSION

Statin users were less likely to have incident dementia/cognitive impairment without dementia during a 5-year follow-up. These results add to the emerging evidence suggesting a protective effect of statin use on cognitive outcomes.

Central obesity and increased risk of dementia more than three decades later

BACKGROUND

Numerous reports show that a centralized distribution of adiposity is a more dangerous risk factor for cardiovascular disease and diabetes than total body obesity. No studies have evaluated whether the same pattern exists with dementia. The objective was to evaluate the association between midlife central obesity and risk of dementia three decades later.

METHODS

A longitudinal analysis was conducted of 6,583 members of Kaiser Permanente of Northern California who had their sagittal abdominal diameter (SAD) measured in 1964 to 1973. Diagnoses of dementia were from medical records an average of 36 years later, January 1, 1994, to June 16, 2006. Cox proportional hazard models adjusted for age, sex, race, education, marital status, diabetes, hypertension, hyperlipidemia, stroke, heart disease, and medical utilization were conducted.

RESULTS

A total of 1,049 participants (15.9%) were diagnosed with dementia. Compared with those in the lowest quintile of SAD, those in the highest had nearly a threefold increased risk of dementia (hazard ratio, 2.72; 95% CI, 2.33-3.33), and this was only mildly attenuated after adding body mass index (BMI) to the model (hazard ratio, 1.92; 95% CI, 1.58-2.35). Those with high SAD (>25 cm) and normal BMI had an increased risk (hazard ratio, 1.89; 95% CI, 0.98-3.81) vs those with low SAD (<25 cm) and normal BMI (18.5-24.9 kg/m(2)), whereas those both obese (BMI >30 kg/m(2)) and with high SAD had the highest risk of dementia (HR, 3.60; 95% CI, 2.85-4.55).

CONCLUSIONS

Central obesity in midlife increases risk of dementia independent of diabetes and cardiovascular comorbidities. Fifty percent of adults have central obesity; therefore, mechanisms linking central obesity to dementia need to be unveiled.

Cross-sectional correlates of fasting hyperinsulinaemia in post-menopausal women of different ethnic origin

AIMS

In a large ethnically diverse nationwide sample of post-menopausal women we explored the relationship between fasting insulin levels, ethnicity, and a wide range of anthropometric, socio-economic, and lifestyle factors.

METHODS

Subjects were post-menopausal women aged 50-79 years without diagnosed diabetes mellitus comprising a subsample (n = 3500) of the Women's Health Initiative (WHI) Clinical Trial and Observational Study. In a cross-sectional survey at baseline, we analysed the association between ethnicity and fasting insulin using analysis of covariance procedures and identified independent correlates of hyperinsulinaemia, defined by the 75th percentile cut point for each ethnic group.

RESULTS

Fasting insulin levels were higher among African-American and Hispanic women than among non-Hispanic White or Asian women. These differences persisted after adjustment for age, educational attainment, total and central body obesity, adult weight change, family history of diabetes, smoking status, alcohol consumption, use of menopausal hormone therapy and physical activity. Higher levels of body mass index, waist-hip ratio, adult weight gain, and lower levels of total and moderate or strenuous recreational activity were independent correlates of fasting hyperinsulinaemia. Habitual walking was also inversely associated with fasting insulin.

CONCLUSIONS

In this cross-sectional analysis, fasting insulin levels were higher among African-American and Hispanic post-menopausal women as compared with non-Hispanic White and Asian women. In addition, obesity, adult weight gain, and low levels of moderate or strenuous physical activity were independently associated with hyperinsulinaemia.

Low erythrocyte folate, but not plasma vitamin B-12 or homocysteine,is associated with dementia in elderly Latinos

The relationship between B vitamin status and cognitive function has been of interest for many years. There is evidence of relationships between intake and status of folate and vitamin B-12 with neurological, cognitive, and memory impairment, but results have been inconsistent. Plasma B-12, erythrocyte folate, methylmalonic acid,and homocysteine were evaluated as predictors of cognitive function in a large population based sample of Latino elderly living in the Sacramento, California region. The hypothesis tested was that low folate and/or B-12 status predicts cognitive function impairment and dementia. Logistic regression was used to examine the differences in B-vitamin status by cognitive function category. Erythrocyte folate was related to dementia after controlling for age, gender, education, income, diabetes diagnosis, serum creatinine, and depressive symptoms. The highest prevalence of low erythrocyte folate occurred in the Dementia group and was significantly higher than in the Normal group. Plasma B-12, MMA, Hcy, and prevalence of a normal values for these variables, were not significantly different among the cognitive function classes. We conclude that folate status is associated with dementia but that more research is needed on the relationship between vitaminB-12 status, Hcy and cognitive function to explore possible associations with these parameters.

Body composition in the elderly: the influence of nutritional factors and physical activity

BACKGROUND

Controversy exists regarding the relative contribution of diet and exercise to body composition. Few studies have examined these associations in the elderly, where changes occur in the body fat to muscle ratio.

OBJECTIVE

The primary objective of this paper is to determine whether energy intake or physical activity are associated with body composition. Secondly, to investigate whether specific macronutrients are associated with fat or lean tissue.

DESIGN

Data (n= 1404) for this cross-sectional analysis were collected from a population-based sub-sample of elderly enrollees in the Cardiovascular Health Study (CHS). Dietary intake and physical activity were assessed by questionnaires. Body composition was measured by Dual Energy X-ray Absorptiometry (DEXA). Linear regression models were used to assess the associations of diet and activity with body composition.

RESULTS

Total energy intake was not associated with any of the body composition measures. Higher dietary saturated fat was associated with higher percent body mass as fat and trunk fat in both sexes (p<0.01), and in men other dietary fats were associated with body fat. In women, distance walked was inversely associated with fat masses even after adjustment for pace of walking. In both sexes, faster pace of walking was associated with lower body and fat mass (p<0.01). Lean muscle mass was not associated with physical activity or dietary intakes.

CONCLUSION

Physical activity and dietary fat intake in this the elderly population were more closely associated with body fat mass than was total energy intake.

Preliminary evidence that estrogen protects against age-related hippocampal atrophy

Few studies have examined gender differences in hippocampal volumes, and the potential effect of estrogen on these measures has not been well studied. We used MRI to measure hippocampal volumes in elderly Mexican American men and women subjects in order to determine if there were gender differences and if estrogen replacement therapy (ERT) had an effect on hippocampal volume in postmenopausal women. MRI measures of hippocampal volumes (normalized to intracranial volume) were compared in 59 women and 38 men. Further comparisons were made between men subjects, women subjects taking ERT, and women subjects not taking ERT. There were no significant effects of gender on normalized hippocampal volumes. However, women subjects taking ERT had larger right hippocampal volumes than women subjects not taking ERT and larger anterior hippocampal volumes than men subjects and women subjects not taking ERT. These findings suggest a neuroprotective effect of estrogen.

Brain function and cognition in a community sample of elderly Latinos

BACKGROUND

Previous studies using PET to measure cerebral glucose metabolism in AD have found metabolic reductions in the temporoparietal and posterior cingulate cortices in individuals with dementia and those at risk of developing it. This study was designed to extend this finding to individuals selected from a population-based cohort of Mexican Americans with a wide spectrum of cognitive ability.

METHODS

A group of 93 individuals was selected from the Sacramento Area Latino Study on Aging, and subjects were categorized into four groups of increasing levels of cognitive impairment: normal, memory impaired, cognitively impaired but not demented (CIND), and demented. PET was performed with the tracer [(18)F]-fluorodeoxyglucose, and data were analyzed with both statistical parametric mapping and an atrophy-corrected volume of interest approach.

RESULTS

Individuals with dementia had metabolic reductions that were most robust in the posterior cingulate cortex, whereas CIND subjects had less statistically robust reductions in the posterior cingulate cortex. Cingulate hypometabolism increased the risk of dementia and was a significant risk factor for dementia in logistic regression models that also incorporated MR measures of hippocampal volume and white matter hyperintensities.

CONCLUSION

Posterior cingulate cortical hypometabolism is clearly detected in individuals with dementia who are selected from a population with lower education and a high prevalence of cerebrovascular risk factors, supporting the generalizability of this finding. These metabolic reductions occur prior to the onset of dementia but only in those persons with relatively advanced symptoms.

Brain structure and cognition in a community sample of elderly Latinos

BACKGROUND

Previous studies have found that hippocampal atrophy and white matter hyperintensities (WMH) on MRI are linked to cognitive impairment and dementia. The authors measured these variables in a population-based cohort of older Mexican Americans with a wide spectrum of cognitive ability, ranging from normal cognition to dementia.

OBJECTIVE

To investigate whether these structural brain changes were seen in individuals prior to the development of dementia and how these changes were related to the presence of dementia.

METHODS

A sample of 122 subjects was selected from the Sacramento Area Latino Study on Aging, and subjects were categorized into four groups of increasing levels of cognitive impairment: normal, memory impaired (MI), cognitively impaired but not demented (CIND), and demented. Hippocampal volume was quantified using a region of interest approach. WMH was rated on a semiquantitative scale as the percent of total volume of white matter.

RESULTS

Hippocampal volume was significantly reduced in CIND and demented individuals, and WMH were significantly increased in demented subjects. MI subjects did not have any significant changes in hippocampal volume or WMH. The risk for developing dementia was significantly and comparably increased in subjects with either hippocampal atrophy or high WMH. However, the risk for dementia increased dramatically in subjects with both hippocampal atrophy and a high degree of WMH.

CONCLUSION

Reductions in hippocampal volume may be present before dementia but not until cognitive impairment is relatively severe. Because there is a synergistic effect between high WMH and hippocampal atrophy, interactions between vascular and degenerative processes may be important determinants of dementia.

A new verbal learning and memory test for English- and Spanish-speaking older people

Word-list verbal learning and memory tests with appropriate normative data can be highly sensitive to cognitive decline, but there are significant limitations of such tests available for use with older Hispanic and non-Hispanic people living in the US. The purpose of this study was to (1) create a new word-list learning and memory test in both English and Spanish and, (2) validate it with respect to sensitivity to cognitive impairment, and (3) develop statistical corrections for the effects of significant demographic variables, including ethnicity, language of administration, age, education, and gender. A community dwelling sample of 801 English- and Spanish-speaking older people was employed. Recall on learning trials and the delayed recall trial of the word-list learning test were strongly related to the Mini-Mental State Examination (MMSE). moderately related to age, and weakly related to gender and education. The relationship of word-list variables and the MMSE did not significantly differ across ethnicity/language groups. Regression coefficients for demographic variables were used in a statistical correction formula to adjust raw word-list scores, and then to develop specific percentile cut-off values.

Acculturation and the prevalence of depression in older Mexican Americans: baseline results of the Sacramento Area Latino Study on Aging

OBJECTIVE

To determine the association between acculturation, immigration, and prevalence of depression in older Mexican Americans.

DESIGN

Cross-sectional analysis from a cohort study.

SETTING

Urban and rural counties of the Central Valley of Northern California.

PARTICIPANTS

One thousand seven hundred and eighty-nine Latinos recruited from a population-based sample (85% Mexican Americans) with a mean age of 70.6 (range 60-100; standard deviation (SD) = 7.13); 58.2% were women.

MEASUREMENTS

Depressive symptoms were assessed with the Center for Epidemiologic Studies--Depression scale (CES-D). Acculturation was measured with the Acculturation Rating Scale for Mexican Americans--II. Psychosocial, behavioral, and medical histories were also obtained.

RESULTS

The prevalence of depression (CES-D > or = 16) was 25.4%. Women were at greater risk (32.0%) than men (16.3%; male/female odds ratio (OR) = 2.43, 95% confidence interval (CI) = 1.90-3.09). The prevalence of depression was higher among immigrants (30.4%, OR = 1.70, 95% CI = 1.36-2.13), bicultural participants (24.2%, OR = 1.66, 95% CI = 1.24-2.24), and less-acculturated participants (36.1%, OR = 2.95, 95% CI = 2.22-3.93) compared with U.S.-born (20.5%) and more-acculturated groups (16.1%). When adjustments for education, income, psychosocial, behavioral, and health-problem factors were made, the least-acculturated participants were at significantly higher risk of depression than highly acculturated Mexican Americans (OR = 1.56, 95% CI = 1.06-2.31).

CONCLUSIONS

These findings are consistent with previously reported estimates of a higher prevalence of depression for older Mexican Americans than non-Hispanic Caucasians and African Americans and are the first to report the prevalence and risk of depression for older U.S.-born and immigrant Mexican Americans. The high prevalence of depression of the least acculturated group may be related to cultural barriers encountered by immigrants and less-acculturated older Mexican Americans and to poorer health status.

Trends in dementia-free life expectancy among elderly members of a large health maintenance organization

BACKGROUND

This study examined the secular trends of life expectancy without dementia among elderly American members of a health maintenance organization, and observed if an increased life expectancy is accompanied by an increase in the duration of life with dementia.

METHODS

The data derived from two chronological 9-year prospective cohort studies of members of the Kaiser Permanente Medical Care Program of Northern California. The first and second cohorts included 2,702 and 2,926 people aged > or =65 years free from dementia at baseline. Life expectancy without dementia or dementia-free life expectancy (DemFLE) is defined as the average number of years a person is expected to live without dementia. Total life expectancy is equal to the sum of DemFLE and life expectancy with dementia. Estimations of DemFLE were based on mortality data and incidence of dementia, using double-decrement life tables.

RESULTS

Between the first and second cohorts, all-cause mortality rates declined, while the incidence of dementia remained constant in both men and women. Among the males, total life expectancy increased at a higher rate than DemFLE. Consequently, the duration of life with dementia was extended in the second cohort. Conversely, among the females DemFLE increased at a higher rate than total life expectancy, thus the duration of life with dementia decreased in the second cohort. The median age of dementia onset was postponed by 2-3 years in the second cohort for females, and did not show any specific difference between the two cohorts in males.

CONCLUSION

The trends of health expectancies suggest an extension of the duration of life with dementia for males and a compression of dementia for females. A decreased incidence of risk factors for dementia among females in the second cohort such as stroke may explain these trends.

Factors associated with weight gain in women after diagnosis of breast cancer. Women's Healthy Eating and Living Study Group

OBJECTIVE

To identify the factors associated with weight gain after diagnosis of breast cancer in a heterogeneous population of women.

DESIGN

Descriptive cross-sectional study.

SUBJECTS

1,116 patients who had been diagnosed with stage I, stage II, or stage IIIA primary, operable breast cancer within the previous 4 years. Patients were recruited during enrollment into a diet intervention trial to reduce risk for breast cancer recurrence. Analysis Demographic data, weight history, and physical activity information obtained by questionnaire and medical information obtained by chart review; dietary assessment based on four 24-hour dietary recalls collected by telephone. Associations between weight change after the diagnosis of breast cancer and prediction variables were examined using univariate and multiple linear regression analyses.

RESULTS

Overall, 60% of the subjects reported weight gain, 26% reported weight loss, and 14% reported no change in weight after the diagnosis of breast cancer. The overall mean weight change was a gain of 2.7 kg (6 lb). Factors positively and independently associated with weight gain were time since diagnosis of breast cancer, adjuvant chemotherapy, African-American ethnicity, current energy intake, and postmenopausal status at time of study entry. Factors inversely and independently associated with weight gain were prediagnosis body mass index, age at diagnosis, education level, and exercise index score.

APPLICATIONS

Higher energy intake and lower level of physical activity are independently associated with increased risk for weight gain after the diagnosis of breast cancer. Strategies to modify these behaviors are likely to influence the long-term pattern of weight change.

The role of APOE epsilon4 in modulating effects of other risk factors for cognitive decline in elderly persons

CONTEXT

Cognitive decline in elderly persons is often an early predictor of dementia. Subclinical cardiovascular disease (CVD) and diabetes mellitus may contribute to substantial decline in cognitive function in the elderly. These risks may be modified by gene-environment interactions between apolipoprotein E (APOE) genotype and CVD risk factors or subclinical CVD.

OBJECTIVES

To examine the association between subclinical CVD and decline in cognitive functioning in the elderly and to examine effect modification by the APOE genotype of the association between subclinical disease and cognitive decline.

DESIGN

The Cardiovascular Health Study, a population-based, prospective cohort study.

SETTING AND POPULATION

A total of 5888 randomly selected Medicare-eligible participants from Sacramento County, California; Forsyth County, North Carolina; Washington County, Maryland; and Pittsburgh, Pa, aged 65 years or older, who were recruited in 1989-1990 (n = 5201) and in 1992-1993 (n = 687) and who were followed up for 7 and 5 years, respectively.

MAIN OUTCOME MEASURES

Change over time in scores on the Modified Mini-Mental State Examination and the Digit Symbol Substitution Test as a function of APOE genotype, subclinical CVD, and diabetes mellitus.

RESULTS

Seventy percent of participants had no significant decline on the Modified Mini-Mental State Examination. Systolic blood pressure, the ankle-arm brachial index, atherosclerosis of the internal carotid artery, diabetes mellitus, and several diagnoses of prevalent CVD were significantly associated with declines in scores on the Modified Mini-Mental State Examination and the Digit Symbol Substitution Test. The rate of cognitive decline associated with peripheral vascular disease, atherosclerosis of the common and internal carotid arteries, or diabetes mellitus was increased by the presence of any APOE epsilon4 allele.

CONCLUSIONS

Most healthy elderly people did not experience cognitive decline. Measures of subclinical CVD were modest predictors of cognitive decline. Those with any APOE epsilon4 allele in combination with atherosclerosis, peripheral vascular disease, or diabetes mellitus were at substantially higher risk of cognitive decline than those without the APOE epsilon4 allele or subclinical CVD. High levels of atherosclerosis increased cognitive decline independently of APOE genotype.

Understanding changing risk factor associations with increasing age in adults

With an increasingly older population, there is considerable interest in understanding the potential for risk factor interventions in order to prevent, postpone, or slow down the common diseases seen in older persons. However, it is often reported that the strength of association between risk factors and common disease outcomes decreases with increasing age. Actually, many different age-related patterns are observed. Understanding these patterns requires knowledge of issues related to the pathophysiology of aging, including age-related physiologic and metabolic alterations, detection and diagnosis of disease in the elderly, measurement of risk factors, sample selection, comorbidity, competing risks, selective survival, ceiling effects, and methods of analysis in aging populations.

Chart-recorded psychiatric diagnoses in women giving birth in California in 1992

OBJECTIVE

Although major advances have been made in the diagnosis and treatment of mental disorders in primary care, few population-based investigations have focused on the obstetrical sector. This study examines the occurrence of chart-recorded psychiatric discharge diagnoses among all women delivering in California hospitals in 1992.

METHOD

The authors undertook an archival analysis of the California Health Information for Policy Project data set, which consists of linked hospital discharge and birth certificate data for 580,282 deliveries. Frequencies of ICD-9 psychiatric diagnoses were ascertained.

RESULTS

Among all women delivering, 1.5% received psychiatric or substance use diagnoses. Of diagnoses recorded, 75% were substance use disorders, 21% were classified generically as "mental disorder of pregnancy," and other psychiatric disorders accounted for 4%.

CONCLUSIONS

The occurrence of psychiatric diagnoses in these women is markedly lower than expected, suggesting an underreporting of psychiatric disorders at delivery. Further investigations into the detection of mental disorders in the obstetrical sector are needed.

Brain perfusion imaging predicts survival in Alzheimer's disease

BACKGROUND

The variability of disease course in patients diagnosed with AD makes prediction of survival difficult, despite the identification of numerous predictors to date. This study evaluated the predictive utility of measurements of regional cerebral blood flow (rCBF) obtained with SPECT in a group of AD patients.

METHODS

Fifty AD patients were studied with SPECT and followed longitudinally. SPECT measures of relative rCBF were calculated by measuring radioactivity densities in dorsolateral frontal, orbitofrontal, temporal, and parietal cortex normalized to occipital cortical radioactivity density. Subjects were classified into three tertiles of rCBF ratios for each region. These rCBF ratios were used as predictors of survival in life-table and proportional hazard models to predict survival.

RESULTS

Right parietal rCBF was a significant predictor of survival in the life-table analysis, with subjects in the lowest tertile having shortest survivals. No other brain region was a significant predictor of survival. In a proportional hazards model when a variety of other potential predictors were accounted for, right parietal rCBF ratio remained a significant predictor.

CONCLUSIONS

These results demonstrate that brain perfusion in the right parietal lobe is a significant predictor of survival in patients with AD even when other predictors are taken into consideration. This suggests that SPECT perfusion imaging may provide additional useful information on disease prognosis in AD.

Medically recognized urinary incontinence and risks of hospitalization, nursing home admission and mortality

OBJECTIVES

this study examined the association between medically recognized urinary incontinence and risk of several disease conditions, hospitalization, nursing home admission and mortality.

DESIGN

review and abstraction of medical records and computerized data bases from 5986 members, aged 65 years and older, of a large health maintenance organization in northern California.

RESULTS

there was an increased risk of newly recognized urinary incontinence following a diagnosis of Parkinson's disease, dementia, stroke, depression and congestive heart failure in both men and women, after adjustment for age and cohort. The risk of hospitalization was 30% higher in women following the diagnosis of incontinence [relative risk (RR) = 1.3, 95% confidence interval (CI) = 1.2-1.5] and 50% higher in men (RR = 1.5, 95% CI = 1.3-1.6) after adjustment for age, cohort and co-morbid conditions. The adjusted risk of admission to a nursing facility was 2.0 times greater for incontinent women (95% CI = 1.7-2.4) and 3.2 times greater for incontinent men (95% CI = 2.7-3.8). In contrast, the adjusted risk of mortality was only slightly greater for women (RR = 1.1; 95% CI = 0.99-1.3) and men (RR= 1.2; 95% CI= 1.1-1.4).

CONCLUSIONS

urinary incontinence increases the risk of hospitalization and substantially increases the risk of admission to a nursing home, independently of age, gender and the presence of other disease conditions, but has little effect on total mortality.

The impact of aging and chronic disease on use of hospital and outpatient services in a large HMO: 1971-1991

OBJECTIVES

To examine overall and diagnosis-specific trends in the use of inpatient and outpatient medical services (1970-1988) among older members of a large HMO.

DESIGN

Two cohorts of approximately 3000 persons aged 65 or older in 1971 and 1980 were compared for hospital and outpatient utilization during 9-year follow-up periods (1971-79 and 1980-88). All subjects were evaluated for vital status throughout the follow-up period as well.

PARTICIPANTS

All 6057 subjects were members of the Northern California Kaiser Permanente Medical Care Program in 1971 or 1980. The study sample was sex-age stratified (65-69,70-79,80+) at baseline.

MEASUREMENTS

Data on demographics, outpatient health services utilization, categories of outpatient utilization and disease diagnoses were obtained from membership lists or medical chart review; inpatient utilization, including admitting and discharge diagnosis, length of stay, and number of hospital days was assessed from computerized hospitalization records.

RESULTS

Hospital discharge rates (sex-age adjusted) increased by 12% between cohorts, with the largest increases at the oldest ages. There was a 25% increase among women and a 9% increase among men. Length of stay decreased by 20%. Hospitalization for ischemic heart disease decreased by 17%. Congestive heart failure (CHF) discharge rates (sex-age adjusted) were 92% higher in the 1980-88 cohort. For diagnoses related to nursing home institutionalization and frailty, discharge rates were significantly higher in the 1980-88 cohort: pneumonia (+34%), urinary tract infections (+104%), dehydration (+110%), osteoarthritis (+64%), syncope (+246%), leg cellulitis (+70%). In-hospital survival improved, but overall percent of readmissions also increased by 4%; readmissions for CHF increased by 13% and those for conditions of frailty by 120%. Overall outpatient visits increased by 17%. Use of laboratory tests (+57%) and outpatient surgeries (+99%) increased for all age strata in 1980-88 compared with 1971-79.

CONCLUSIONS

While overall outpatient and inpatient utilization has largely decreased over the past 30 years, as a result of economic factors and improved treatments for some major diseases, there has been an increase in utilization among older people. Hospitalization for diagnoses associated with end-stage cardiovascular disease (CHF), musculoskeletal disease, frailty and iatrogenic aspects of institutionalization are clearly increasing substantially. The largest impact of aging on health care may be the result of institutionalization and its sequelae. Improved treatment for cardiovascular disease may also be leading to increased utilization at later stages in the disease process.

The influence of diabetes, hypertension, and stroke on ethnic differences in physical and cognitive functioning in an ethnically diverse older population

Prevention of decline in cognitive and physical functioning in the elderly has become an important focus in geriatric medicine. Hispanics are among the fastest-growing group of elderly in the United States, yet few data are available on functional impairments in this group. We examined the association between ethnicity (non-Hispanic whites [NHW], English-speaking Hispanics [EH], and Spanish-speaking Hispanics [SH]) and cognitive status, self-assessed functional status, and physical performance in a community-dwelling sample of 589 people aged > or = 60 years. The purpose of this study was to examine the association between ethnicity and these measures of functional status and to evaluate the influence of comorbid stroke, diabetes, and hypertension on this association. We found that EH and SH had significantly lower scores on the MiniMental State Exam than NHW, but that this difference was almost entirely due to educational level. When SH whose educational attainment was grade 8 or higher were compared to NHWs, there were no differences in cognitive functioning. Those with diabetes and stroke had poorer cognitive functioning. Among those with stroke, EH and SH women had more self-assessed functional limitations (IADLs and ADLs) than NHW. Male SH and EH with diabetes also had more self-assessed functional limitations than NHW. SH with two or three of these conditions had more IADL limitations. Our results suggest that elderly community-dwelling Hispanics experience greater levels of disability and that this is due, in part, to lower socioeconomic status and higher prevalence of disabling conditions.

Functional imaging predicts cognitive decline in Alzheimer's disease

Eighteen patients with Alzheimer's disease were studied with positron emission tomographic measurements of regional cerebral metabolism of glucose. All patients were initially diagnosed and evaluated, underwent positron emission tomography, and then were followed with annual reevaluations, at which time the Mini-Mental State Examination (MMSE) was performed. Patients were followed for an average of 2.5 years, and the rate of cognitive decline was calculated by determining the rate of change in the MMSE score defined as the MMSE score at the initial evaluation minus the MMSE score at the last examination, divided by the number of months between testing. The regional cerebral metabolic rates for glucose determined at the time of the first MMSE were then regressed on these changes in scores. Results showed that glucose metabolic rates in posterior temporal and primary visual cortex regions were significantly correlated with the subsequent rate of cognitive deterioration. These associations were not confounded by age, length of follow-up, baseline MMSE score, or education. Stratification on gender suggested that these associations were much stronger in women than in men. These results replicate previous findings showing that functional brain imaging is predictive of the rate of cognitive decline in Alzheimer's disease.

Trends in cardiovascular disease incidence and survival in the elderly

This study compared the age-specific incidence, postdiagnostic survival, and mortality for cardiovascular disease (CVD) in two cohorts of people aged 65 years and older. All subjects were members of a large prepaid health maintenance organization. The influence of changes in CVD risk factors on these rates also was evaluated. Trends in prevalence, incidence, postdiagnostic survival, and mortality for CVD were examined in both cohorts in 1971 and 1980. Myocardial infarction (MI), angina pectoris, stroke, and congestive heart failure (CHF) were included as CVD outcomes in this analysis. Nine-year prospective data on these diagnoses were abstracted from medical records and computerized hospitalization records for both cohorts. Age-sex-adjusted cardiovascular mortality was lower for both sexes by approximately 20% in the 1980 cohort. Overall survival did not change, whereas cancer mortality increased by 76% in women and 36% in men. With the exception of stroke, there was no increase in age-adjusted or age-specific prevalence. In men, the age-adjusted prevalence of stroke in men was 24% higher in the 1980 cohort. Age-adjusted 9-year incidence of MI, angina pectoris, stroke, and CHF did not change between cohorts in either sex Postdiagnostic, age-adjusted mortality for men with incident stroke was 24% lower in the 1980 cohort, and Postdiagnostic, age-adjusted mortality for men with incident angina was 35% lower in the 1980 cohort. Adjustment for risk factors measured at or before baseline had little influence on cohort differences in CVD incidence or duration of survival after CVD diagnosis. This study confirms other research showing a decline in CVD mortality over the past 20 years. These findings suggest that prevalent angina pectoris is increasing in men, and that survival with stroke and with angina is improving in men. Later diagnosis of incident CHF in men suggests that prevention and early detection may be postponing the development of more serious disease.

Identification of children at risk for lead poisoning: an evaluation of routine pediatric blood lead screening in an HMO-insured population

OBJECTIVES

To estimate the prevalence of elevated blood lead levels in children receiving well-care checkups; and to evaluate the effectiveness of certain key risk factors in detecting children at higher risk for elevated blood lead levels.

DESIGN

Cross-sectional study.

SETTING

Two facilities of the Kaiser Permanente Medical Care Program (KPMCP) health maintenance organization (HMO), northern California region.

PATIENTS

Six hundred thirty-six children, aged 12 to 60 months, who were seen at four KPMCP facilities in two subregions for a well-care checkup from September 1991 through August 1992.

INTERVENTIONS

Blood samples were collected from each child and analyzed for lead content. Participating parents completed a questionnaire that included questions recommended by the Centers for Disease Control and Prevention (CDC) about the child's and the parents' lead exposure via home, workplace, and hobbies.

RESULTS

Ninety-six percent of the children had blood lead levels under 10 micrograms/dL. Blood lead levels declined with increasing age and were higher for black children compared with whites. Age of residential housing, mother's education, and residence in an old house with peeling paint had low sensitivity and positive predictive value for identifying children with blood lead levels over 10 micrograms/dL.

CONCLUSION

Universal routine screening for elevated blood lead levels in children in an employed, HMO-insured population is not warranted on grounds of prevalence. Responses to CDC questions do not effectively identify high-risk children in this population.

Subclinical disease as an independent risk factor for cardiovascular disease

BACKGROUND

The primary aim of the present study was to determine the relation between measures of subclinical cardiovascular disease and the incidence of clinical cardiovascular disease among 5201 adults 65 years of age or older who were participating in the Cardiovascular Health Study.

METHODS AND RESULTS

A new method of classifying subclinical disease at baseline examination in the Cardiovascular Health Study included measures of ankle-brachial blood pressure, carotid artery stenosis and wall thickness, ECG and echocardiographic abnormalities, and positive response to the Rose Angina and Claudication Questionnaire. Participants were followed for an average of 2.39 years (maximum, 3 years). For participants without evidence of clinical cardiovascular disease at baseline, the presence of subclinical disease compared with no subclinical disease was associated with a significant increased risk of incident total coronary heart disease including CHD deaths and nonfatal MI and angina pectoris for both men and women. For individuals with subclinical disease, the increased risk of total coronary heart disease was 2.0 for men and 2.5 for women, and the increased risk of total mortality was 2.9 for men and 1.7 for women. The increased risk changed little after adjustment for other risk factors, including lipoprotein levels, blood pressure, smoking, and diabetes.

CONCLUSIONS

The measurement of subclinical disease provides an approach for identifying high-risk older individuals who may be candidates for more active intervention to prevent clinical disease.

Age-related trends in cardiovascular morbidity and physical functioning in the elderly: the Cardiovascular Health Study

OBJECTIVE

To describe relationships between age and sub-clinical cardiovascular disease, manifest chronic disease, and physical functioning and limitations among persons aged 65 years and older, with emphasis on the "oldest old," those 85 years and older.

DESIGN

Observational population-based study.

SETTING

Four U.S. communities: Forsyth County, North Carolina; Sacramento County, California; Washington County, Maryland; and Pittsburgh, Pennsylvania.

PARTICIPANTS

5,201 men and women aged 65 years and older.

MEASUREMENTS

Demographic data; histories of cardiovascular disease (CVD), chronic lung disease, arthritis, diabetes, and hypertension; measures of subclinical disease including arm and ankle blood pressures, internal carotid wall thickness and stenosis, ejection fraction, left ventricular mass, fractional shortening, and diastolic function, electrocardiographic left ventricular hypertrophy and cardiac injury score, forced expiratory flow and volume; functional status including self-reported physical functioning, hearing and sight limitations and health status, and performance-based measures of function. These variables were examined among men and women in three age groups: 65-74 years, 75-84 years, and 85 + years. Subgroups of participants with and without manifest CVD were also examined.

MAIN RESULTS

In women, the prevalence of CVD and other chronic conditions increased with age, and the highest rates occurred among those 85 years and older. In men, prevalence rates increased between the two younger groups, but the oldest group had lower than expected rates for coronary heart disease, cerebrovascular disease, hypertension, and chronic lung disease. In contrast, there were strong age-related linear trends in most of the subclinical measures of blood pressure, atherosclerosis and pulmonary function and in virtually all measures of functional status in both gender groups across the age range. There was a particularly marked decline in functional status between the two older age groups. While subclinical disease was greater and functional status was poorer among those with manifest CVD, with few exceptions, age-related trends were not significantly different between the two groups.

CONCLUSIONS

Lower than expected prevalence rates of CVD among those aged 85 years and older, particularly among men, in this study of community-dwelling elderly may represent selection bias or a real plateauing in disease prevalence with age. However, subclinical disease appears to increase and functional status to decline across the age range in both men and women regardless of the presence of CVD. The apparent increase in subclinical disease with age indicates potential for CVD prevention after age 65.