Showing papers in "Age and Ageing in 2006"
TL;DR: Considerable evidence now documents that the most effective (and cost-effective) fall reduction programmes have involved systematic fall risk assessment and targeted interventions, exercise programmes and environmental-inspection and hazard-reduction programmes.
Abstract: Falls are a common and often devastating problem among older people, causing a tremendous amount of morbidity, mortality and use of health care services including premature nursing home admissions. Most of these falls are associated with one or more identifiable risk factors (e.g. weakness, unsteady gait, confusion and certain medications), and research has shown that attention to these risk factors can significantly reduce rates of falling. Considerable evidence now documents that the most effective (and cost-effective) fall reduction programmes have involved systematic fall risk assessment and targeted interventions, exercise programmes and environmental-inspection and hazard-reduction programmes. These findings have been substantiated by careful meta-analysis of large numbers of controlled clinical trials and by consensus panels of experts who have developed evidence-based practice guidelines for fall prevention and management. Medical assessment of fall risks and provision of appropriate interventions are challenging because of the complex nature of falls. Optimal approaches involve interdisciplinary collaboration in assessment and interventions, particularly exercise, attention to co-existing medical conditions and environmental inspection and hazard abatement.
2,775 citations
TL;DR: The effective rehabilitation of balance to improve mobility and to prevent falls requires a better understanding of the multiple mechanisms underlying postural control.
Abstract: Postural control is no longer considered simply a summation of static reflexes but, rather, a complex skill based on the interaction of dynamic sensorimotor processes. The two main functional goals of postural behaviour are postural orientation and postural equilibrium. Postural orientation involves the active alignment of the trunk and head with respect to gravity, support surfaces, the visual surround and internal references. Sensory information from somatosensory, vestibular and visual systems is integrated, and the relative weights placed on each of these inputs are dependent on the goals of the movement task and the environmental context. Postural equilibrium involves the coordination of movement strategies to stabilise the centre of body mass during both self-initiated and externally triggered disturbances of stability. The specific response strategy selected depends not only on the characteristics of the external postural displacement but also on the individual’s expectations, goals and prior experience. Anticipatory postural adjustments, prior to voluntary limb movement, serve to maintain postural stability by compensating for destabilising forces associated with moving a limb. The amount of cognitive processing required for postural control depends both on the complexity of the postural task and on the capability of the subject’s postural control system. The control of posture involves many different underlying physiological systems that can be affected by pathology or sub-clinical constraints. Damage to any of the underlying systems will result in different, context-specific instabilities. The effective rehabilitation of balance to improve mobility and to prevent falls requires a better understanding of the multiple mechanisms underlying postural control.
1,993 citations
TL;DR: 1. Office of Population Census and Surveys (OPCS)—Surveys of Psychiatric Morbidity in Great Britain Report 1: The prevalence of psychiatric morbidity amongst adults living in private households.
Abstract: 1. Meltzer H, Gill H, Petticrew M, Hinds K. Office of Population Census and Surveys (OPCS)—Surveys of Psychiatric Morbidity in Great Britain Report 1: The prevalence of psychiatric morbidity amongst adults living in private households. London: HMSO, 1995. 2. Beekman AT, Copeland JR, Prince MJ. Review of community prevalence of depression in later life. Br J Psychiatry 1999; 174: 307–11. 3. Prescription Pricing Authority (PPA) PACT Centre Pages. Drugs used in Mental Health. http://www.ppa.org.uk/news/ pact-112003/pact-112003.htm (4 November 2004, date last accessed). 4. Middleton N, Gunnell D, Whitley E, Dorling D, Frankel S. Secular trends in antidepressant prescribing in the UK, 1975–1998 J Public Health Med 2001; 23: 262–6. 5. National Institute for Clinical Excellence. Management of depression in primary and secondary care. Clinical Guideline 23. National Institute for Clinical Excellence 2004. 6. Percudani M, Barbui C, Fortino I, Petrovich L. Antidepressant drug prescribing among elderly subjects: a population-based study. Int J Geriatr Psychiatry 2005; 20: 113–8. 7. Lawreson RA, Tyrere F, Newson RB, Farmer RDT. The treatment of depression in UK general practice: selective serotonin reuptake inhibitors and tricyclic antidepressants compared. J Affect Disord 2000; 59: 149–57. 8. Wilson KC, Copeland JR, Taylor S, Donoghue J, McCracken CF. Natural history of pharmacotherapy of older depressed community resident. The MRC-ALPHA Study. Br J Psychiatry 1999; 175: 439–43. 9. Living in Britain. A summary of changes over time – Use of health services. Office of National Statistics (ONS). http://www.statistics.gov.uk (16 February 2005, date last accessed). 10. Rosenbaum JF, Zajecka J. Clinical management of antidepressant discontinuation. J Clin Psychiatry 1998; 59: 535–7. 11. Zermansky AG. Who controls repeats? Br J Gen Prac 1996; 46: 643–7.
1,075 citations
TL;DR: Delirium is common in medical in-patients and has serious adverse effects on mortality, functional outcomes, LOS and institutionalisation.
Abstract: Background: Despite the acknowledged clinical importance of delirium, research evidence for measures to improve its management is sparse. A necessary first step to devising appropriate strategies is to understand how common it is and what its outcomes are in any particular setting. Objective: To determine the occurrence of delirium and its outcomes in medical in-patients, through a systematic review of the literature. Method: We searched electronic medical databases, the Consultation-Liaison Literature Database and reference lists and bibliographies for potentially relevant studies. Studies were selected, quality assessed and data extracted according to preset protocols. Results: Results for the occurrence of delirium in medical in-patients were available for 42 cohorts. Prevalence of delirium at admission ranged from 10 to 31%, incidence of new delirium per admission ranged from 3 to 29% and occurrence rate per admission varied between 11 and 42%. Results for outcomes were available for 19 study cohorts. Delirium was associated with increased mortality at discharge and at 12 months, increased length of hospital stay (LOS) and institutionalisation. A significant proportion of patients had persistent symptoms of delirium at discharge and at 6 and 12 months. Conclusion: Delirium is common in medical in-patients and has serious adverse effects on mortality, functional outcomes, LOS and institutionalisation. The development of appropriate strategies to improve its management should be a clinical and research priority. As delirium prevalent at hospital admission is a significant problem, research is also needed into preventative measures that could be applied in community settings.
996 citations
TL;DR: It is important for clinicians to assess compensatory stepping and reaching, in order to identify individuals who are at risk of falling and to pinpoint specific control problems to target for balance or strength training or other intervention.
Abstract: Background: balancing reactions that involve rapid stepping or reaching movements are critical for preventing falls. These compensatory reactions are much more rapid than volitional limb movements and can be very effective in decelerating the centre-of-mass motion induced by sudden unpredictable balance perturbation; however, age-related deterioration in the neural, sensory and/or musculoskeletal systems may impede the ability to execute these reactions effectively. Objective: this paper summarises recent research regarding age-related changes in compensatory stepping and reaching reactions and the practical implications of these findings for fall prevention programmes. Results: even healthy older adults experience pronounced difficulties. For stepping reactions, the main problems pertain to control of lateral stability—arresting the lateral body motion that occurs during forward and backward steps, and controlling lateral foot movement so as to avoid collision with the stance limb during lateral steps. Older adults appear to be more reliant on arm reactions than young adults but are less able to execute reach-to-grasp reactions rapidly. Conclusions: it is important for clinicians to assess compensatory stepping and reaching, in order to identify individuals who are at risk of falling and to pinpoint specific control problems to target for balance or strength training or other intervention. More effective use of stepping and reaching reactions can be promoted through improved design and appropriate use of sensory aids, mobility aids, footwear, handrails and grab-bars. It is particularly important to address the problems associated with the control of lateral stability because it is the lateral falls that are most likely to result in hip fracture.
455 citations
TL;DR: The standard of reporting falls in published trials is poor and significantly impedes comparison between studies, which has been used to inform an international consensus exercise to make recommendations for a core set of outcome measures for fall prevention trials.
Abstract: OBJECTIVE: to review systematically the range of case definitions and methods used to measure falls in randomised controlled trials. Design/methods: a Cochrane review of fall prevention interventions was used to identify fall definitions in published trials. Secondary searches of various databases were used to identify additional methodological or theoretical papers. Two independent reviewers undertook data extraction, with adjudication by a third reviewer in cases of disagreement. Settings: community-dwelling and institutionalised older persons. RESULTS: 90 publications met the predefined inclusion criteria. Of these, 44 provided no definition of the term fall. In the remainder, there were substantial variations in the definition and methods of measuring falls. Reporting periods ranged from 1 week to 4 years with only 41% using prospective data collection methods. CONCLUSION: the standard of reporting falls in published trials is poor and significantly impedes comparison between studies. The review has been used to inform an international consensus exercise to make recommendations for a core set of outcome measures for fall prevention trials.
438 citations
TL;DR: The impact of pharmacist-conducted clinical medication review with elderly care home residents leads to substantial change in patients' medication regimens without change in drug costs and there is a reduction in the number of falls.
Abstract: Objective: to measure the impact of pharmacist-conducted clinical medication review with elderly care home residents. Design: randomised controlled trial of clinical medication review by a pharmacist against usual care. Setting: sixty-five care homes for the elderly in Leeds, UK. Participants: a total of 661 residents aged 65+ years on one or more medicines. Intervention: clinical medication review by a pharmacist with patient and clinical records. Recommendations to general practitioner for approval and implementation. Control patients received usual general practitioner care. Main outcome measures: primary: number of changes in medication per participant. Secondary: number and cost of repeat medicines per participant; medication review rate; mortality, falls, hospital admissions, general practitioner consultations, Barthel index, Standardised Mini-Mental State Examination (SMMSE). Results: the pharmacist reviewed 315/331 (95.2%) patients in 6 months. A total of 62/330 (18.8%) control patients were reviewed by their general practitioner. The mean number of drug changes per patient were 3.1 for intervention and 2.4 for control group (P < 0.0001). There were respectively 0.8 and 1.3 falls per patient (P < 0.0001). There was no significant difference for GP consultations per patient (means 2.9 and 2.8 in 6 months, P = 0.5), hospitalisations (means 0.2 and 0.3, P = 0.11), deaths (51/331 and 48/330, P = 0.81), Barthel score (9.8 and 9.3, P = 0.06), SMMSE score (13.9 and 13.8, P = 0.62), number and cost of drugs per patient (6.7 and 6.9, P = 0.5) (£42.24 and £42.94 per 28 days). A total of 75.6% (565/747) of pharmacist recommendations were accepted by the general practitioner; and 76.6% (433/565) of accepted recommendations were implemented. Conclusions: general practitioners do not review most care home patients’ medication. A clinical pharmacist can review them and make recommendations that are usually accepted. This leads to substantial change in patients’ medication regimens without change in drug costs. There is a reduction in the number of falls. There is no significant change in consultations, hospitalisation, mortality, SMMSE or Barthel scores.
332 citations
TL;DR: The evidence concerning the association of back pain prevalence with age is more sparse than currently believed and this association seems to be modified by the severity of the problem.
Abstract: Background: it is believed that the prevalence of back pain decreases around the middle of the sixth decade. However, back pain is still among the most commonly reported symptoms in the elderly and osteoarthritis, disc degeneration, osteoporosis and spinal stenosis all increase with age. In light of this, it is difficult to understand why the prevalence of back pain would decrease with increasing age. Objective: this study aimed at summarising the scientific evidence on the trends of back pain prevalence with age. Methods: population-based studies reporting the prevalence of back pain, including people aged 65 years and over, were systematically retrieved from several bibliographic databases. These were read and assessed by two reviewers, and papers retained (‘good quality studies’) were aggregated according to specific criteria. Results: good quality studies showed a large heterogeneity as to their methods and prevalence figures. No specific patterns were detected by country nor outcome measure. However, most studies that considered severe forms of back pain found an increase of prevalence with increasing age. The curvilinear association between age and back pain prevalence that is widely mentioned in the literature was found only for benign and mixed problems. Conclusions: the evidence concerning the association of back pain prevalence with age is more sparse than currently believed and this association seems to be modified by the severity of the problem. This knowledge could have important public health implications, as the proportion of older people will increase considerably in the coming years in most industrialised societies.
321 citations
TL;DR: It is suggested that lower grip strength is associated with reduced HRQoL in older men and women and may reflect the link between sarcopaenia and generalised frailty.
Abstract: Objective: to investigate the relationship between grip strength and health-related quality of life (HRQoL). Design: cross-sectional survey within a cohort study design. Setting: the county of Hertfordshire in the UK. Participants: a total of 2,987 community-dwelling men and women aged 59–73 years of age. Measurements: grip strength was used as a marker of sarcopaenia and measured using a Jamar dynamometer. HRQoL was assessed using the eight domain scores of the Short Form-36 (SF-36) questionnaire, and subjects in the lowest sex-specific fifth of the distribution were classified as having ‘poor’ status for each domain. Results: men and women with lower grip strength were significantly more likely to report a poor as opposed to excellent to fair overall opinion of their general health (GH) [odds ratio (OR) per kilogram decrease in grip strength = 1.13, 95% CI = 1.06–1.19, P<0.001 in men, 1.13, 95% CI = 1.07–1.20, P<0.001 in women]. Among men, after adjustment for age, size, physical activity and known co-morbidity, decreased grip strength was associated with increased prevalence of poor SF-36 scores for the physical functioning (PF) (OR per kilogram decrease in grip strength = 1.03, 95% CI = 1.01–1.06, P = 0.007) and GH domains (OR = 1.03, 95% CI = 1.01–1.05, P = 0.01). Similar associations were seen in women. Conclusions: our findings suggest that lower grip strength is associated with reduced HRQoL in older men and women. This does not appear to be explained by age, size, physical activity or co-morbidity and may reflect the link between sarcopaenia and generalised frailty. Individuals with sarcopaenia may benefit from interventions to improve muscle mass and strength before the onset of chronic disorders usually associated with impaired HRQoL.
320 citations
TL;DR: A review of a variety of features of cortical bone known to provide mechanical competence and how these features may be applied for fracture risk prediction is provided.
Abstract: Bone's mechanical competence and its fragility in particular depend to a certain extent on the structure and microstructure of the cortical bone compartment. Beyond bone mineral density (BMD) and bone mineral content, a variety of other features of cortical bone contribute to whole bone's resistance to fracture. Structural properties of cortical bone most commonly employed as surrogate for its mechanical competence include thickness of the cortex, cortical cross-sectional area and area moment of inertia. But microstructural properties such as cortical porosity, crystallinity or the presence of microcracks also contribute to bone's mechanical competence. Microcracks in particular not only weaken the cortical bone tissue but also provide an effective mechanism for energy dissipation. Bone is a damageable, viscoelastic composite and most of all a living material capable of self-repair and thus exhibits a complex repertoire of mechanical properties. This review provides an overview of a variety of features of cortical bone known to provide mechanical competence and how these features may be applied for fracture risk prediction.
315 citations
TL;DR: Reducing hazards in the home appears not to be an effective falls-prevention strategy in the general older population and those at low risk of falls, but home hazard reduction is effective if targeted at older people with a history of falls and mobility limitations.
Abstract: Most homes contain potential hazards, and many older people attribute their falls to trips or slips inside the home or immediate home surroundings. However, the existence of home hazards alone is insufficient to cause falls, and the interaction between an older person's physical abilities and their exposure to environmental stressors appears to be more important. Taking risks or impulsivity may further elevate falls risk. Some studies have found that environmental hazards contribute to falls to a greater extent in older vigorous people than in older frail people. This appears to be due to increased exposure to falls hazards with an increase in the proportion of such falls occurring outside the home. There may also be a non-linear pattern between mobility and falls associated with hazards. Household environmental hazards may pose the greatest risk for older people with fair balance, whereas those with poor balance are less exposed to hazards and those with good mobility are more able to withstand them. Reducing hazards in the home appears not to be an effective falls-prevention strategy in the general older population and those at low risk of falls. Home hazard reduction is effective if targeted at older people with a history of falls and mobility limitations. The effectiveness may depend on the provision of concomitant training for improving transfer abilities and other strategies for effecting behaviour change.
TL;DR: The study findings indicate that impaired vision is an important and independent risk factor for falls, andequate depth perception and distant-edge-contrast sensitivity, in particular, appear to be important for maintaining balance and detecting and avoiding hazards in the environment.
Abstract: Poor vision reduces postural stability and significantly increases the risk of falls and fractures in older people. Most studies have found that poor visual acuity increases the risk of falls. However, studies that have included multiple visual measures have found that reduced contrast sensitivity and depth perception are the most important visual risk factors for falls. Multifocal glasses may add to this risk because their near-vision lenses impair distance contrast sensitivity and depth perception in the lower visual field. This reduces the ability of an older person to detect environmental hazards. There is now evidence that maximising vision through cataract surgery is an effective strategy for preventing falls. Further randomised controlled trials are required to determine whether individual strategies (such as restriction of use of multifocal glasses) or multi-strategy visual improvement interventions can significantly reduce falls in older people. Public health initiatives are required to raise awareness in older people and their carers of the importance of regular eye examinations and use of appropriate prescription glasses.
TL;DR: Speech and language changes in PD impact upon individual and family life long before frank impairment of intelligibility is apparent, and the role of early referral to speech and language therapy is therefore worthy of detailed investigation.
Abstract: Background: acoustic and perceptual changes to speech in Parkinson’s disease (PD) have been widely studied. Little empirical evidence exists concerning the individual’s own perception of changes, the impact these have on their life and coping strategies to deal with them.
Objective: to establish if, and how, changes in communication impact on the lives of people with PD.
Design: in-depth interviews with qualitative analysis of content.
Setting: community.
Subjects: twenty-three men and 14 women with PD.
Methods: participants were purposively sampled to give a mix of men, women, family circumstances, stage and duration of PD and severity of speech symptoms. Individuals were interviewed at home. Interviews were transcribed. Emergent themes were identified and fed back to participants for confirmation and clarification.
Results: participants identified changes to voice and articulation. Language changes featured prominently. Four impact themes: (i) interaction with others, (ii) problems with conversations, (iii) feelings about intelligibility and (iv) voice; and four corresponding coping themes (a) helping others understand, (b) managing conversations, (c) monitoring and adjusting and (d) physical strategies emerged. Of main concern was not the nature of speech-voice-language changes, but how these affected self-concept, participation inside and outside the family and family dynamics. Individuals employed a range of fluid coping strategies moving from background withdrawal to foreground striving strategies.
Conclusions: speech and language changes in PD impact upon individual and family life long before frank impairment of intelligibility is apparent. The role of early referral to speech and language therapy is therefore worthy of detailed investigation.
TL;DR: Overall, the results showed that the cost associated with the addition of a challenge to the basic walking task differs by executive function and the nature of the task.
Abstract: BACKGROUND: previous studies have reported an association between cognitive function and physical performance, particularly among older adults. OBJECTIVE: to examine the association between executive function and performance difference on complex versus usual walking tasks in a sample of non-demented older adults. DESIGN: population-based epidemiological study of older people residing in the Chianti area (Tuscany, Italy). PARTICIPANTS: 737 community-dwelling individuals aged 65 years and older. METHODS: gait speed (m/s) was measured during the performance of complex walking tasks (walking/talking, walking/picking-up an object, walking/carrying a large package, walking over obstacles, walking with a weighted vest) and reference walking tasks (7 m usual pace, 7 m fast pace and 60 m fast pace). Executive function was assessed using the Trail Making Test (TMT). Other measures included Mini-Mental State Examination (MMSE), sociodemographic characteristics and selected physiological impairments. RESULTS: gait speed for the selected reference and complex walk tasks was consistently lower among participants with poor executive function. Per cent decline in gait speed compared with the reference task differed by executive function for certain tasks (e.g. walking/obstacles: 30 versus 24% decline in low versus high executive function respectively, P = 0.0006) but not for others. CONCLUSIONS: poor executive function is associated with measures of gait, including specific challenges. Overall, the results showed that the cost associated with the addition of a challenge to the basic walking task differs by executive function and the nature of the task. Further research is needed to determine whether improvement in executive function abilities translates to better performance on selected complex walking tasks. Language: en
TL;DR: Based on the accumulating research data, it is no longer appropriate to consider that the sole action of AChEIs in AD is through direct acetylcholine-medicated enhancement of neuronal transmission, and evidence points to a possible anti-inflammatory role for these agents as well.
Abstract: The pathogenesis of Alzheimer’s disease (AD) has been linked to a deficiency in the brain neurotransmitter acetylcholine. Subsequently, acetylcholinesterase inhibitors (AChEIs) were introduced for the symptomatic treatment of AD. The prevailing view has been that the efficacy of AChEIs is attained through their augmentation of acetylcholine-medicated neuron to neuron transmission. However, AChEIs also protect cells from free radical toxicity and β-amyloid-induced injury, and increased production of antioxidants. In addition, it has been reported that AChEIs directly inhibit the release of cytokines from microglia and monocytes. These observations are supported by evidence showing a role for acetylcholine in suppression of cytokine release through a ‘cholinergic anti-inflammatory pathway’. Based on the accumulating research data so far, it is no longer appropriate to consider that the sole action of AChEIs in AD is through direct acetylcholine-medicated enhancement of neuronal transmission. Evidence points to a possible anti-inflammatory role for these agents as well.
TL;DR: Impairment of ADL is already present in MCI, and intact ADL cannot be used as a criterion to define the syndrome of MCI and to distinguish it from mild dementia.
Abstract: Background: the impact of cognitive impairment on activities of daily living (ADL) is being used as a major criterion for differentiating between mild cognitive impairment (MCI) and dementia. The concept of an ADL threshold that separates MCI from dementia, however, appears to be improbable for several reasons. Objectives: to determine whether complex ADL are impaired in patients with MCI; to examine the usefulness of the assessment of ADL impairment for the diagnosis of MCI; to explore whether both cognitive testing and assessment of impaired ADL are significant predictors of the diagnosis according to the diagnostic gold standard of MCI. Design: cross-sectional study. Setting: university-based outpatient clinic. Subjects: a total of 45 elderly MCI patients diagnosed according to research diagnostic criteria and 30 age-matched cognitively unimpaired controls. Methods: clinical assessment – Alzheimer’s disease Assessment scale, cognitive subscale (ADAS-cog) for the assessment of cognitive functions, Alzheimer’s disease Cooperative Study scale for ADL in MCI (ADCS-MCI-ADL) for the assessment of impairments of complex ADL. Statistical evaluation – Mann–Whitney U tests for significant differences on measures of cognition and everyday functioning. Non-parametric correlations for associations between ADL and cognitive ability. Receiver operator curve (ROC) analyses to identify optimal cut-off scores on the ADCS-MCI-ADL and ADAS-cog scales to differentiate between MCI patients and controls. Binary logistic regression analyses to predict the diagnosis of MCI on the basis of the above-mentioned instruments. Results: patients scored significantly higher than controls on the ADAS-cog scale and significantly lower on the ADCSMCI-ADL scale. There was a significant negative correlation of the above-mentioned scales in MCI patients (r = −0.46, P<0.01). Both instruments discriminated well between patients and controls (ADCS-MCI-ADL: optimal cut-off 52 points, sensitivity 0.89, specificity 0.97; ADAS-cog: optimal cut-off 10 points, sensitivity 0.78, specificity 1.0). With regard to the linear predictor in the logistic regression built, both instruments were strong predictors of the diagnosis according to the diagnostic gold standard (ADCS-MCI-ADL: P = 0.002; ADAS-cog: P = 0.041). Conclusion: impairment of ADL is already present in MCI. Therefore, intact ADL cannot be used as a criterion to define the syndrome of MCI and to distinguish it from mild dementia. The assessment of complex ADL is probably useful for the diagnosis of MCI.
TL;DR: It is confirmed that the presence of dysphagia during the acute phase of stroke is associated with poor outcome during the subsequent year, particularly at 3 months, and is related with increased institutionalisation rate in the long term.
Abstract: Background swallowing problems (dysphagia) are common following acute stroke and are independent predictors of short-term outcome. It is uncertain as to whether these swallowing problems are associated with outcome in the longer-term. Aim insert to determine whether dysphagia present in the first week of acute stroke associated with long-term outcome. Methods a population-based long-term follow-up of people with first in a life-time stroke. Dysphagia was assessed within 1 week of stroke and patients were followed up at 3 months and yearly for 5 years by face-to-face interview. Outcome was defined by survival and place of residence, using multinomial logistic regression. Barthel Scores were divided into the two groups 15-20 and 0-14, and modelled using multiple logistic regression. Results there were 567 patients with dysphagia (mean age 74.3 years) and 621 with a safe swallow (mean age 69.6 years). Following multinomial logistic regression, residence in a nursing home was more likely to occur in those who failed the swallow test during the first week of their stroke; however, this only reached statistical significance at 3 months (relative risk ratio (RRR)=1.73; 95% confidence interval (CI) 1.02 to 2.95), and years 4 (RRR 3.35, 1.37-8.19) and 5 (RRR 3.06, 1.06-8.83). There was also a significant association with increased mortality only during the first three months (RRR 2.03, 1.12 to 3.67). Conclusion this study confirms that the presence of dysphagia during the acute phase of stroke is associated with poor outcome during the subsequent year, particularly at 3 months, and is associated with increased institutionalisation rate in the long term.
TL;DR: If and how changes in swallowing impact on the lives of people with Parkinson's disease is established and the psychosocial consequences of the physical changes concerned people most.
Abstract: Background: swallowing changes occur from the earliest stages of Parkinson’s disease (PD), even in cases asymptomatic for dysphagia. Little empirical evidence exists concerning the individual’s own perception of changes, the impact these have on their life and coping strategies to deal with them.
Objective: to establish if and how changes in swallowing impact on the lives of people with PD.
Design: in-depth interviews with qualitative analysis of content.
Setting: community.
Subjects: a total of 23 men and 14 women and their carers.
Methods: participants were purposively sampled to give a mix of men, women, family circumstances, stage and duration of PD and severity of swallowing symptoms. Individuals were interviewed at home. Interviews were transcribed. Emergent themes were identified and fed back to participants for confirmation and clarification.
Results: two broad themes emerged: (i) effects on swallowing of underlying physical changes, with subthemes of oral-pharyngeal-laryngeal changes, manual changes, effects of fatigue and (ii) psychosocial impact, with subthemes of alterations to eating habits, feelings of stigma, need for social adjustment and carers’ issues. Coping strategies could aid swallowing problems but often to the detriment of others in the family through altered demands on preparation and organisation. Presence of significant impact was not necessarily associated with abnormal range scores on objective swallowing assessments.
Conclusions: the psychosocial consequences of the physical changes concerned people most. The importance of the early detection of changes for health and quality of life is underlined.
TL;DR: It is suggested that disability, handicap and HRQOL should all be assessed to acquire a broader measure of stroke outcome, due to variable correlations between differentHRQOL domains with disability and handicap.
Abstract: Objectives: to estimate levels of disability, handicap and health-related quality of life (HRQOL) up to 3 years after stroke and examine the relationships between these domains. Design: a longitudinal, observational study Setting: population-based register of first-ever strokes Methods: subjects, registered between 1 January 1995 and 31 December 1997, were assessed at 1 year (n = 490) and 3 years (n = 342) post-stroke for disability [Barthel index (BI)], handicap [Frenchay activity index (FAI)] and HRQOL (SF-36). BI was categorised as severe, moderate, mild and independent (0–9, 10–14, 15–19 and 20); FAI was categorised as inactive, moderately active and very active (0–15, 16–30 and 31–45). SF-36 domains include: Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE) and Mental Health (MH). Physical (PHSS) and Mental Health (MHSS) Summary Scores were computed. Results: at 1 and 3 years, 26.1 and 26.3%, respectively, were disabled (BI 0.70) with PF, moderate (r = 0.31–0.70) with RP, SF and PHSS, but weak (r<0.30) with other domains. Correlations between FAI and SF-36 domains were strong with PF, weak with BP, RE and MHSS, and moderate with other domains. Conclusions: disability and handicap remain highly prevalent up to 3 years after stroke. Patients’ perception of physical health is persistently low, but mental health perception is satisfactory up to 3 years. Due to variable correlations between different HRQOL domains with disability and handicap, it is suggested that disability, handicap and HRQOL should all be assessed to acquire a broader measure of stroke outcome.
TL;DR: The lay-based, more multidimensional, model of successful ageing predicted perceived quality of life (QoL) more powerfully than unidimensional models and should be used to evaluate the outcomes of health promotion in older populations.
Abstract: Background: there is increasing interest in how to age ‘successfully’ and in reaching consensus over its definition. Objective: to assess different models of successful ageing, using a British longitudinal survey of ageing in 2000–1. Setting: community settings in Britain. Methods: five models of successful ageing were tested on a British cross-sectional population survey of 999 people aged 65+. The models were biomedical, broader biomedical, social, psychological and lay based. Results: the lay model emerged as the strongest. Respondents who were classified as successfully aged with this model, compared with those not successfully aged, had over five times the odds of rating their quality of life (QoL) as good rather than not good [odds ratio (OR) = 5.493, 95% confidence interval (95% CI) = 2.655–11.364]. Conclusion: the lay-based, more multidimensional, model of successful ageing predicted perceived QoL more powerfully than unidimensional models and should be used to evaluate the outcomes of health promotion in older populations.
TL;DR: The FOOD Trial Collaboration, a multicentre randomised controlled trial investigating the effect of timing and method of enteral tube feeding for dysphagic stroke patients, concluded that routine oral nutritional supplementation for stroke patients in hospital is safe and effective.
Abstract: 187 1. The FOOD Trial Collaboration. Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. Lancet 2005; 365: 755–63. 2. The FOOD Trial Collaboration. Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. Lancet 2005; 365: 764–72. 3. Spiegelhalter DJ, Abrams KR, Myles JP. Prior Distributions in Bayesian Approaches to Clinical Trials and Health-Care Interventions. Chichester: John Wiley & Sons Ltd, 2004, 139–80.
TL;DR: ACP and hospital in the home can result in decreased hospital admission and mortality of NHRs, a controlled evaluation monitoring emergency admissions to hospital.
Abstract: Background: the number of nursing home residents (NHRs) in hospital is increasing although hospital admission may be deleterious to their health. Objective: to evaluate a system of educating residents, their families, staff and general practitioners about outcomes of dementia, advance care planning (ACP) and hospital in the home. Methods: we employed one clinical nurse consultant, who utilised the ‘Let Me Decide’ Advance Care Directive. The intervention area consisted of two hospitals and the 21 nursing homes (NHs) around them compared with another, geographically separate, hospital and the 13 homes around it. We conducted a controlled evaluation monitoring emergency admissions to hospital. Results: emergency calls to the ambulance service from intervention NHs decreased (intervention versus control; –1 versus +21%; P = 0.0019). The risk of a resident being in an intervention hospital bed for a day compared with in a control hospital bed, per NH bed, fell by a quarter from being initially similar [Relative Risk (RR) = 1.01; 95% confidence interval (CI) 0.98–1.04; P = 0.442] to being lower (RR = 0.74; 95% CI 0.72–0.77; P<0.0001). There was no significant change in mortality in the intervention homes, but in the control homes mortality rose in the third year to be 11.2 per 100 beds higher than in the intervention area (P<0.05). Conclusion: ACP and hospital in the home can result in decreased hospital admission and mortality of NHRs.
TL;DR: It is found that vitamin D prevents fractures or falls in elderly people in care home accommodation, and the pre-treatment serum 25-hydroxy vitamin D concentration was high.
Abstract: OBJECTIVES: To determine whether vitamin D supplementation reduces the risk of fracture or falls in elderly people in care home accommodation. DESIGN: A randomised controlled trial of cluster design. Setting and subjects: 223 residential units (mainly identical 30-bedded units), within 118 homes for elderly people throughout Britain, with 3,717 participating residents (76% women, average age 85 years). The units provided mainly or entirely residential care (35% of residents), nursing care (42%) or care for elderly mentally infirm (EMI) residents (23%). METHODS: Participants were randomly allocated by residential unit (cluster design) to a treated group offered ergocalciferol 2.5 mg every 3 months (equivalent to a daily dose of 1,100 IU), or to a control group. Fractures were reported by staff and confirmed in hospital, and routinely collected data on reported falls were obtained. RESULTS: After median follow-up of 10 months (interquartile range 7-14 months), 64 (3.6%) of 1,762 vitamin D-treated residents and 51 (2.6%) of 1,955 controls had one or more non-vertebral fractures, and 24 (1.3%) and 20 (1.0%), respectively, had a hip fracture. The proportion reporting at least one fall was 44% in vitamin D-treated and 43% in control residents. The differences between the vitamin D and control groups were not statistically significant. The incidence of all non-vertebral fractures in the care homes (3.2% per year) and of hip fractures (1.1% per year) was low, similar to rates in elderly people in sheltered accommodation, and the pre-treatment serum 25-hydroxy vitamin D concentration was high [median 47 nmol/l, measured in a 1% (n = 18) sample]. CONCLUSIONS: We found no evidence that vitamin D prevents fractures or falls in elderly people in care home accommodation. Language: en
TL;DR: This, the largest ever study of nutritional support after hip fracture, shows that their employment significantly reduced patients' risk of dying in the acute trauma unit; an effect that persisted at 4 month follow-up.
Abstract: Objective: to examine how improved attention to nutritional status and dietary intake, achieved through the employment of dietetic assistants (DAs), will affect postoperative clinical outcome among elderly women with hip fracture. Design: open prospective randomised controlled trial, comparing conventional nursing care with the additional nutritional support provided by DA. Setting: thirty-eight bedded acute trauma ward in a teaching hospital. Participants: all but 11 of 344 consecutive admissions with acute nonpathological hip fracture were approached. Three hundred and eighteen (93%) agreed to inclusion. Sixteen were ineligible as they were immediately transferred to another acute ward, were managed conservatively or died preoperatively. Primary outcome measure: postoperative mortality in the acute trauma unit. Secondary outcome measures: postoperative mortality at 4 months after fracture, length of stay, energy intake and nutritional status. Results: DA-supported participants were less likely to die in the acute ward (4.1 versus 10.1%, P = 0.048). This effect was still apparent at 4 month follow-up (13.1 versus 22.9%, P = 0.036). DA-supported subjects had significantly better mean daily energy intake (1,105 kcal versus 756 kcal/24 h, 95%, CI 259-440 kcal/24 h, P<0.001), significantly smaller reduction in mid-arm circumference during their inpatient stay (0.39 cm, P = 0.002) and nonsignificantly favourable results for other anthropometric and laboratory measurements. Conclusion: dietetic or nutrition assistants are being introduced in units across the UK. This, the largest ever study of nutritional support after hip fracture, shows that their employment significantly reduced patients' risk of dying in the acute trauma unit; an effect that persisted at 4 month follow-up.
TL;DR: Compared with the younger cohort, rtPA-treated stroke patients aged >/=80 years do not seem exceedingly prone to sICH, and there is scope for benefit from thrombolysis for the older age group.
Abstract: Objective: elderly stroke patients were excluded or underrepresented in the randomised controlled trials of intravenous thrombolysis with recombinant tissue plasminogen activator (rtPA) applied within 3 h. Cohort studies comparing intravenous rtPA in stroke patients of ≥80 versus <80 years of age were limited by small sample sizes and yielded conflicting results. Thus, we performed a systematic review across all such studies. Methods: a systematic literature search (PubMed; Science Citation Index) was performed to retrieve all eligible studies. Two reviewers independently extracted data on ‘death’, ‘favourable 3-month outcome (modified Rankin Scale ≤1)’ and ‘symptomatic intracranial haemorrhage (sICH)’. Across studies, weighted odds ratios (ORs) with 95% confidence intervals (95% CI) were calculated. Results: six studies were included [n = 2,244 patients; 477 (21%) aged ≥80 years]. Significant differences in baseline characteristics to the disadvantage of older patients were present in all studies. Compared with younger patients, older patients had a 3.09-time (95% CI = 2.37–4.03; P < 0.001) higher 3-month mortality and were less likely to regain a ‘favourable outcome’ (OR = 0.53; 95% CI = 0.42–0.66; P<0.001). The likelihood for ‘sICH’ (OR = 1.22; 95% CI = 0.77–1.94; P = 0.34) was similar in both age groups. Conclusion: intravenous rtPA-treated stroke patients of ≥80 years of age have a less favourable outcome than younger ones. Imbalances in predictive baseline variables to the disadvantage of the older patients may contribute to this finding. Compared with the younger cohort, rtPA-treated stroke patients aged ≥80 years do not seem exceedingly prone to sICH. Thus, there is scope for benefit from thrombolysis for the older age group. Hence, to obtain reliable evidence on the balance of risk and benefit of intravenous rtPA for stroke patients aged ≥80 years, it is safe and reasonable to include such patients in randomised placebo-controlled trials.
TL;DR: This work concludes that tube feeding associated with altered arterial oxygen saturation in stroke patients?
Abstract: 1. Gordon C, Langton-Hewer R, Wade DT. Dysphagia in acute stroke. Br Med J 1987; 295: 411–4. 2. Rowat A, Wardlaw J, Dennis M. Changes in arterial oxygen saturation before and after enteral feeding tube insertion in dysphagic stroke patients. Age Ageing 2004; 33: 42–5. 3. Brandstetter RD, Zakkay Y, Gutherz P, Goldberg RJ. Effect of nasogastric feedings on arterial oxygen tension in patients with symptomatic chronic obstructive pulmonary disease. Heart Lung 1988; 17: 170–2. 4. Zaidi NH, Smith HA, King SC, Park C, O’Neil PA, Connolly MJ. Oxygen desaturation on swallowing as a potential marker of aspiration in acute stroke. Age Ageing 1995; 24: 267–70. 5. Collins MJ, Bakheit AM. Does pulse oximetry reliably detect aspiration in dysphagic stroke patients? Stroke 1997; 28: 1773–5. 6. Rowat AM, Wardlaw JM, Dennis MS, Warlow CP. Does feeding alter arterial oxygen saturation in patients with acute stroke? Stroke 2000; 31: 2134–40. 7. Dutta D, Bannerjee M, Chambers T. Is tube feeding associated with altered arterial oxygen saturation in stroke patients? Age Ageing 2004; 33: 493–6. 8. Roffe C. Hypoxaemia and stroke. Rev Clin Gerontol 2001; 11: 323–5. 9. Bhalla A, Wolfe SDA, Rudd AG. Management of acute physiological parameters after stroke. QJM 2001; 94: 167–72. 10. Davenport RJ, Dennis MS, Wellwood I, Warlow CP. Complications after acute stroke. Stroke 1996; 27: 415–20. 11. Houston JG, Morris AD, Grosset DG, Lees KR, McMillan N, Bone I. Ultrasonic evaluation of movement of the diaphragm after acute cerebral infarction. J Neurol Neurosurg Psychiatry 1995; 58: 738–41. 12. Nachtmann A, Siebler Rose M, Sitzer G, Steinmetz M, Cheyne-Stokes H. Respiration in ischemic stroke. Neurology 1995; 45: 820–1. 13. Harbison JA, Gibson GJ. Snoring, sleep apnea, and stroke: chicken or scrambled egg? QJM 2000; 93: 647–54. 14. Langhorne P, Stott DJ, Robertson L et al. Medical complications after stroke. Stroke 2000; 31: 1223–9. 15. Roffe C, Sills S, Halim M, Wilde K, Allen M, Jones P. Unexpected nocturnal hypoxia in patients with acute stroke. Stroke 2003; 34: 2641–5. 16. Elisabeth J, Singarayar J, Ellul J, Barer D, Lye M. Arterial oxygen saturation and posture in acute stroke. Age Ageing 1993; 22: 269–72. 17. Roffe C, Sills S, Wilde K, Crome P. Effect of hemiparetic stroke on pulse oximetry readings on the affected side. Stroke 2001; 32: 1808–10. 18. Bamford J, Sandercock P, Dennis M, Burn J, Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991; 337: 1521–6. 19. Rankin J. Cerebral vascular accidents in people over the age of 60. Scott Med J 1957; 2: 200–15. 20. Warlow CP, Dennis MS, van Gijn J et al. Stroke – A Practical Guide to Management, 2nd edition. Oxford: Blackwell, 2001.
TL;DR: Low vitamin B 12 concentrations are associated with cognitive impairment and missing ankle tendon jerks in older people in the absence of anaemia and large-scale trials of vitamin B12 supplementation are required to assess the clinical significance of these associations.
Abstract: Background: low vitamin B12 concentrations are common in older people, but the clinical relevance of biochemical evidence of vitamin B12 deficiency in the absence of anaemia is uncertain. Objective: to examine associations of cognitive impairment, depression and neuropathy with blood measurements of vitamin B12 and folate status in older people. Design: cross-sectional study in general practice in Banbury, England. Participants: a total of 1,000 individuals aged 75 years or older living in the community. Results: low vitamin B12 concentrations were identified in 13% of older people and were associated with memory impairment and depression. After adjustment for age, sex and smoking, individuals with vitamin B12 or holotranscobalamin (holoTC) in the bottom compared with top quartiles had a 2-fold risk (OR = 2.17; 95% CI 1.11–4.27) and a 3-fold risk (OR = 3.02; 95% CI 1.31–6.98) of cognitive impairment, respectively. Low vitamin B12 status was also associated with missing ankle tendon jerks but not with depression. Treatment with vitamin B12 for 3 months corrected the biochemical abnormalities but had no effect on any of the clinical measurements. Conclusions: low vitamin B12 concentrations are associated with cognitive impairment and missing ankle tendon jerks in older people in the absence of anaemia. Large-scale trials of vitamin B12 supplementation are required to assess the clinical significance of these associations.
TL;DR: A systematic review supports the hypothesis that increased BMI is independently associated with increased risk of dementia and recommends long-term studies to examine the mechanisms underlying the relationship between obesity and dementia.
Abstract: Background identification of modifiable risk factors is crucial in the prevention of dementia, given its limited treatment options. Studies on increased body mass index (BMI) as a risk factor for dementia show conflicting results. Methods we systematically retrieved and reviewed longitudinal population-based studies on increased BMI and dementia using a standard protocol. We searched Medline (1966-2006), Ageline (1978-2006), PsychInfo (1966-2006), CINAHL (1982-2006), and other relevant databases, including the reference lists of the eligible articles for review. Included studies were subjected to a quality assessment protocol. Results we identified eight studies that met our selection criteria. These studies covered 1,688 cases of dementia from 28,697 participants. After adjustment for age, smoking, comorbidities, and other confounders, four studies presented significantly increased risk of dementia with elevated BMI. Conclusion this systematic review supports the hypothesis that increased BMI is independently associated with increased risk of dementia. Long-term studies to examine the mechanisms underlying the relationship between obesity and dementia are needed.
TL;DR: This study confirms previous findings of a negative influence of sun exposure, smoking and a low BMI on facial ageing and indicates that high social status, low depression score and being married are associated with a younger look, but the strength of the associations varies between genders.
Abstract: Background: a recent twin study has shown that ‘looking old for one’s age’ is associated with increased mortality. Approximately 40% of the variation in perceived age is due to non-genetic factors. Objective: to examine environmental factors influencing perceived age controlling for diseases. Design: a twin study. Setting: in the 2001 wave of the population-based survey—the Longitudinal Study of Aging Danish Twins—participants provided information on a wide range of exposures and health indicators. Additionally, they were asked to have a face photograph taken. Subjects: a total of 1826 elderly (70+) twins who had a high-quality face photograph taken. Methods: ten nurses assessed the visual age of each twin from the face photograph. The mean of the nurses’ age estimates for each twin was used as the twin’s perceived age. Multivariate linear regression and intrapair comparison (for intact twin pairs) were used for analyses. Results: statistically significant determinants of facial ageing associated with high perceived age for men were smoking (P = 0.01), sun exposure (P = 0.02) and low body mass index (BMI) (P<0.005), while for women they were low BMI (P = 0.05) and low social class (P<0.005). The number of children (men) and marital status (P = 0.08) and depression symptomatology score (women) were borderline significantly associated with facial ageing. Conclusion: our study confirms previous findings of a negative influence of sun exposure, smoking and a low BMI on facial ageing. Furthermore, our study indicates that high social status, low depression score and being married are associated with a younger look, but the strength of the associations varies between genders.
TL;DR: AI increased with age up to the median age of 55 years but plateaued thereafter, whereas the AG continued to increase steadily with age, which is proposed as a more suitable measure of arterial stiffness than AI.
Abstract: Objectives we investigated the exact relationship between age and gender on augmentation pressure (AG) and augmentation index (AI) measured over the radial (muscular) and carotid (elastic) arteries. Design and methods AG is the contribution that wave reflection makes to systolic arterial pressure. AI is an indirect measure of arterial stiffness and is calculated as AG divided by pulse pressure (PP) x100. AG and AI both increase with age. AG and AI were measured in 458 subjects using SphygmoCor. A total of 755 readings were obtained (302 carotid, 453 radial). The mean age was 57.5 +/- 13.7 years. Diabetic subjects were excluded. Among the subjects, 13.5% were hypertensive. Results statistically, women had mean values of AI significantly higher than men in both radial and carotid arteries. These differences were less marked with AG. Quadratic equations better described the relationship between AI and age but not AG and age. Thus, AI increased with age up to our median age of 55 years but plateaued thereafter, whereas the AG continued to increase steadily with age. A multiple regression analysis demonstrated that both AI and AG were negatively related to height and positively related to diastolic blood pressure (DBP). Conclusions AG continues to increase in the elderly over the age of 55, but not AI. AI is higher in women and higher when measured over the carotid than the radial. AI is positively related to DBP and negatively to height. AG is proposed as a more suitable measure of arterial stiffness than AI.