Showing papers by "Jeff D. Williamson published in 2004"

Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care

Abstract: Three terms are commonly used interchangeably to identify vulnerable older adults: comorbidity, or multiple chronicconditions,frailty, anddisability. However, in geriatricmedicine,there isagrowingconsensusthatthese are distinct clinical entities that are causally related. Each, individually, occurs frequently and has high import clinically. This article provides a narrative review of current understanding of the definitions and distinguishing characteristics of each of these conditions,including theirclinical relevance and distinct prevention and therapeutic issues, and how they are related. Review of the current state of published knowledge is supplemented by targeted analysesin selectedareas where no current publisheddataexists. Overall,the goalof this articleis to providea basis fordistinguishingbetweenthesethreeimportantclinicalconditionsinolderadultsandshowinghowuseofseparate, distinct definitions of each can improve our understanding of the problems affecting older patients and lead to development of improved strategies for diagnosis, care, research, and medical education in this area.

Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial.

Abstract: Objective The Arthritis, Diet, and Activity Promotion Trial (ADAPT) was a randomized, single-blind clinical trial lasting 18 months that was designed to determine whether long-term exercise and dietary weight loss are more effective, either separately or in combination, than usual care in improving physical function, pain, and mobility in older overweight and obese adults with knee osteoarthritis (OA). Methods Three hundred sixteen community-dwelling overweight and obese adults ages 60 years and older, with a body mass index of ≥28 kg/m2, knee pain, radiographic evidence of knee OA, and self-reported physical disability, were randomized into healthy lifestyle (control), diet only, exercise only, and diet plus exercise groups. The primary outcome was self-reported physical function as measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcomes included weight loss, 6-minute walk distance, stair-climb time, WOMAC pain and stiffness scores, and joint space width. Results Of the 316 randomized participants, 252 (80%) completed the study. Adherence was as follows: for healthy lifestyle, 73%; for diet only, 72%; for exercise only, 60%; and for diet plus exercise, 64%. In the diet plus exercise group, significant improvements in self-reported physical function (P < 0.05), 6-minute walk distance (P < 0.05), stair-climb time (P < 0.05), and knee pain (P < 0.05) relative to the healthy lifestyle group were observed. In the exercise group, a significant improvement in the 6-minute walk distance (P < 0.05) was observed. The diet-only group was not significantly different from the healthy lifestyle group for any of the functional or mobility measures. The weight-loss groups lost significantly (P < 0.05) more body weight (for diet, 4.9%; for diet plus exercise, 5.7%) than did the healthy lifestyle group (1.2%). Finally, changes in joint space width were not different between the groups. Conclusion The combination of modest weight loss plus moderate exercise provides better overall improvements in self-reported measures of function and pain and in performance measures of mobility in older overweight and obese adults with knee OA compared with either intervention alone.

Antihypertensive medications and differences in muscle mass in older persons: The health, aging and body composition study

Abstract: OBJECTIVES: To evaluate whether older persons usingangiotensin-converting enzyme (ACE) inhibitors have alarger lower extremity muscle mass (LEMM) than users ofother antihypertensive drugs.DESIGN: Cross-sectionalanalysisofdatafromtheHealth,Aging and Body Composition (Health ABC) Study.SETTING: University of Tennessee, Memphis, and Uni-versity of Pittsburgh clinics.PARTICIPANTS: A community-based sample of 2,431wellfunctioningparticipantsoftheHealthABC,aged70to79, who were free of heart failure, were selected accordingto use of antihypertensive medications: ACE inhibitors(n5197), b-blockers (n5169), thiazides (n5216), cal-cium-channel blockers (n5340), or none (n51,509).MEASUREMENTS: LEMM, assessed using dual-energyx-ray absorptiometry, compared by index drug in analysisof variance models unadjusted and adjusted for demo-graphics, study site, height, body fat, physical activity,blood pressure, coronary artery disease, diabetes mellitus,and chronic pulmonary disease.RESULTS: LEMM significantly differed across the studygroups,beinglargerinusersofACEinhibitorsthaninusersof other drugs (unadjusted and adjusted models). LEMMwas comparable in users of ACE inhibitors and no drugusers. A trend toward larger LEMM was also observed insex- and ethnicity-stratified analyses and in the subgroup ofnoncoronary hypertensive participants.CONCLUSION: In older persons, use of ACE inhibitors isassociated cross-sectionally with larger LEMM. Thisfinding suggests a possible explanation of the benefits ofACE inhibitors in wasting syndromes. If confirmed inlongitudinal studies, this pharmacological action mighthave important implications for the prevention of physicaldisability in older patients with hypertension. J Am GeriatrSoc 52:961–966, 2004.Key words: muscle mass; ACE-inhibition; antihyperten-sive medications; body composition

Patterns of Disability Related to Diabetes Mellitus in Older Women

Abstract: Purpose. To identify pattern(s) of disability related to diabetes in older women and to determine the extent to which disability is mediated by selected diabetes complications. Methods. Cross-sectional analysis of data from a population-based study composed of a representative sample of 3570 noninstitutionalized women aged 65 years and older living in the Baltimore metropolitan area who agreed to be screened for the Women’s Health and Aging Study. Results. 483 (13.5%) of the women reported physician-diagnosed diabetes. Compared to women without diabetes, women with diabetes were significantly more likely to report difficulty in 14 of 15 daily tasks, including walking 2–3 blocks, lifting 10 pounds, using the telephone, and bathing (range of odds ratios [OR] 1.5–2.8; all p , .01). After adjustment for age, race, and marital status, women with diabetes were about twice as likely to report difficulty in any one of four functioning groups (mobility, upper extremity, higher functioning tasks, or self-care) (OR 2.2; 95% confidence interval [CI] 1.8–2.7), and over three times as likely to report difficulty in a group combining higher functioning and self-care tasks (OR 3.2; 95% CI 2.4–4.1). Adjustment for self-reported heart disease, stroke, high blood pressure, and visual problems did not attenuate these associations. Conclusions. Diabetes is strongly associated with a wide range of disabilities in older women. This association does not appear to be mediated by prevalent diabetes complications and risks, heart disease, high blood pressure, stroke, or eye disease. Other complications of diabetes (e.g., neuropathy, peripheral vascular disease) may mediate diabetes-associated disability in older adults.

The combination oral and nutritional treatment of late-onset diabetes mellitus (CONTROL DM) trial results.

Abstract: Objective To examine the effect of short-term improvements in glycaemic control on brachial artery endothelial function as a marker of cardiovascular health. Methods Persons with Type 2 diabetes who were poorly controlled on oral therapy were randomly assigned to monotherapy with repaglinide or combination therapy with repaglinide plus metformin. Brachial artery flow-mediated vasodilation was assessed by ultrasonography at randomization and following 16 weeks of therapy. The primary outcome was change in brachial artery endothelial function from baseline. Comparison of randomized groups was a secondary aim. Results Eighty-six participants were randomized, and 83 were followed to study completion. Post occlusion brachial artery vasodilation was 3.74% at baseline and 3.82% following 16 weeks of therapy (P = 0.77). The treatment effect was 0.08% (95% CI: −0.48%, 0.64%). No difference was seen between treatment groups (P = 0.69). Overall, A1C was reduced from 8.3% to 7.0%, with a greater reduction in the combination therapy group (from 8.4% to 6.7%) than in the monotherapy group (from 8.3% to 7.3%, p for difference between groups = 0.01). Statistically significant reductions were observed in fasting glucose, and plasminogen activator inhibitor-1. Statistically significant increases were observed for fasting insulin, uric acid, weight and BMI. Conclusions Brachial artery endothelial function was not influenced by short-term improvements in glycaemic control. The CONTROL DM group was successful in lowering A1C. Future research should explore more intensive and longer-lasting improvements in glycaemic control on endothelial function. Some data previously published in abstract form (Diabetes 2001; 50 (Suppl. 2): A217).

Progressive cognitive impairment after stroke.

Abstract: Objective: We examined the putative relationship between stroke and cognitive function in the population-based prospective cohort of the Cardiovascular Health Study (CHS). Methods: Of the 5888 participants of the CHS aged 65 years or older, there were 5364 with more than one modified mini-mental (3MS) examination between 1992 and 1998. To determine the effect of baseline stroke before first and subsequent (stroke between two consecutive examinations) 3MS examination on cognitive function, linear regression models were computed with potential confounders entered as additional independent variables. Stroke was divided into right and left hemispheres or posterior circulation on the basis of the clinical and/or imaging information by the hospital that treated the event and subsequent adjudication by CHS committee. Results Participants with baseline stroke had an average 3MS decline of 1.2 (95% confidence interval [CI]: −0.7-−1.7) points per year more than those without one. Those with a history of subsequent stroke had an average first year 3MS decline of 6.2 (CI −8.7-−3.7) for left hemisphere, 3.5 (CI −5.3-−1.8) for right hemisphere, and 1.1 (CI −3.9–1.6) for posterior circulation more than those without stroke. The effect of stroke on the rate of cognitive decline appeared to ameliorate after the first year (test for linear trend among those with stroke, P = .003). Conclusion Results from this prospective population-based data study show that stroke in the left hemisphere results in a more pronounced decline in cognition than that in the right hemisphere and that cognitive loss because of stroke appears to attenuate over time, perhaps as a result of relearning.