The Relationship Between Mentally Unhealthy Days and Depressive Symptoms Among Older Adults Over Time.

This article sought to determine the extent to which the number of self-reported mentally unhealthy days (MUDs) in the past 30 days estimates depressive symptoms in older adults. The sample of 4,321 community-dwelling residents aged 65 and above originated from an ongoing population-based study of older Blacks and Whites. Participants' data from 1993 through 2005 included the single MUD question and questions from the Center for Epidemiologic Studies Short Depression Scale (CES-D). Fourteen percent of participants had four or more depressive symptoms at baseline; of these, only 52% reported one or more MUD. Thirty-eight percent of those with one or more MUDs had four or more depressive symptoms. The results illustrate an interesting association regarding the measurements of two distinct, but related, mental health constructs. Although the number of MUDs was associated with having more depressive symptoms over time, the single-question MUD measure does not fully capture depressive symptomatology.

Relation of cardiac ventricular repolarization and global cognitive performance in a community population.

Atherosclerosis is a risk factor for dementia. However, little is known about the association between cognitive performance and a widely used indicator of coronary heart disease, at rest electrocardiography. We identified 839 older residents (mean age 81 years, 58% black) from a geographically defined biracial community in Chicago, Illinois, who had undergone extensive cognitive performance testing and met the electrocardiographic eligibility criteria, including a QRS duration of < 120 ms. We then examined multivariate regression coefficients that described the associations between global cognitive performance and 4 novel descriptors of ventricular repolarization waveforms. All analyses were adjusted for age, gender, education, and race. The T wave nondipolar voltage had a significant association with global cognitive performance (p = 0.01), and this association largely remained after adjustment for cardiovascular disease risk factors (p = 0.03). In contrast, global cognitive performance was not significantly associated with the rate-adjusted QT interval, the voltage change from the beginning to end of the ST segment in lead V(5), or the spatial angle between the mean QRS and T wave vectors. In conclusion, the strengths of the associations varied between the novel electrocardiographic descriptors of ventricular repolarization and global cognitive performance. Nevertheless, the significant association observed with T wave nondipolar voltage suggests that the cardiac effects of heart disease are associated with cognitive declines.

Upper and lower extremity motor performance and functional impairment in Alzheimer's disease.

This report examines the relation of upper and lower extremity motor performance to functional impairment among 371 persons with probable Alzheimer's disease (AD). Cognitive and motor performance tests were administered at 6-month intervals for up to 4 years. Motor performance was assessed using 3 lower extremity tests and 2 upper extremity tests. Functional impairment was measured at 3-month intervals using caregiver ratings of impairments in activities of daily living, mobility, and range of motion. Both lower and upper extremity performance were inversely related to functional impairments on all 3 scales (all Ps < .001), after controlling for age, sex, and level of cognitive impairment. This suggests that motor performance contributes to functional impairments in AD, independent of cognitive impairment. It is important to preserve motor performance in individuals with AD because it influences physical function throughout the course of the disease.

The association of magnetic resonance imaging measures with cognitive function in a biracial population sample.

BACKGROUND: White matter hyperintensity volume (WMHV), cerebral infarcts, and total brain volume (TBV) are associated with cognitive function, but few studies have examined these associations in the general population or whether they differ by race. OBJECTIVE: To examine the association of WMHV, cerebral infarcts, and TBV with global cognition and cognition in 5 separate domains in a biracial population sample. SETTING: A biracial community population of Chicago, Illinois. DESIGN: Cross-sectional population study. PARTICIPANTS: The study population comprised 575 participants from the Chicago Health and Aging Project (CHAP). MAIN OUTCOME MEASURES: Volumetric magnetic resonance imaging (MRI) measures of WMHV, TBV, and cerebral infarcts and detailed neuropsychological testing assessments of global cognition and 5 cognitive domains. RESULTS: Overall and among those without dementia, cognition was inversely associated with WMHV and number of infarcts but was positively associated with TBV. When all 3 measures were simultaneously added to the model, the association of global cognition with WMHV and TBV remained significant and unchanged but was no longer significant with infarcts. Among subjects without dementia, all 3 MRI measures were associated with performance in multiple cognitive domains, specifically perceptual speed. However, among subjects with dementia, only TBV was associated with cognition and performance in multiple cognitive systems. Race did not significantly modify any of these associations. CONCLUSIONS: In this biracial general population sample, the associations of MRI measures with cognition differed according to clinical status of subjects (stronger among subjects without dementia) and were not modified by race. These associations did not affect all cognitive domains equally but were more consistent with impairments in perceptual speed.

Race differences in emotional adaptation of family caregivers.

OBJECTIVES: This study compares black and white caregivers of persons with Alzheimer's disease (AD) on two general measures of negative and positive emotion (depressive symptoms, positive mood) and two caregiving specific measures of negative and positive emotion (caregiver burden, caregiver satisfaction). We hypothesized that black caregivers would exhibit lower levels of negative emotion and higher levels of positive emotion over time than whites. METHOD: Three hundred ninety-six caregivers were recruited from the Rush Alzheimer's Disease Center in Chicago, Illinois, as part of a longitudinal study of persons with AD. The analyses for this report are based on data from 307 caregivers who were interviewed quarterly over approximately 4 years from 1999 to 2002, an average of nine observations per person. RESULTS: The results showed that black caregivers reported fewer depressive symptoms over time than whites ( beta = -0.14, p < 0.01) but this finding was only for those caregivers living with the care recipient with AD. No race differences were found for measures of positive emotion. CONCLUSION: Our data add to the growing body of evidence that blacks have better emotional outcomes when exposed to the stress of providing informal care to a disabled family member.

A hospitalist-run short-stay unit: features that predict length-of-stay and eventual admission to traditional inpatient services.

BACKGROUND: Short-stay units (SSUs) provide an alternative to traditional inpatient services for patients with short anticipated hospital stays. Yet little is known about which patient types predict SSU success. OBJECTIVE: To describe patients admitted to our hospitalist-run SSU and explore predictors of length-of-stay (LOS) and eventual admission to traditional inpatient services. DESIGN: Prospective observational cohort study. SETTING: Large public teaching hospital. PATIENTS: Consecutive admissions (n = 755) to the SSU over 4 months. INTERVENTION: Hospitalist attending physicians prospectively collected data from patients' histories, physical exams, and medical records upon admission and discharge. MEASUREMENTS: Risk assessments were made for patients with our most common provisional diagnoses: possible acute coronary syndrome (ACS) and heart failure. Patient stays were considered successful when LOS was less than 72 hours and eventual admission to traditional inpatient services was not required. RESULTS: Of 738 eligible patients, 79% (n = 582) had successful SSU stays. In a multivariable model, the provisional diagnosis of heart failure predicted stays longer than 72 hours (P = 0.007) but risk assessments were unimportant. Patients who received specialty consultations were most likely to need eventual admission (odds ratio [OR], 13.1; 95% confidence interval [CI], 6.9-24.9), and the likelihood of long stays was inversely proportional to the accessibility of diagnostic tests. CONCLUSIONS: In our hospitalist-run SSU, the inaccessibility of diagnostic tests and the need for specialty consultations were the most important predictors of unsuccessful stays. Designs for other SSUs that care for mostly low-risk patients should focus on matching patients' diagnostic and consultative needs with readily accessible services.

Biracial population study of mortality in mild cognitive impairment and Alzheimer disease.

OBJECTIVE: To assess mortality associated with mild cognitive impairment (MCI) and Alzheimer disease (AD) among older African Americans and whites from an urban community. DESIGN: Longitudinal population-based observational study. SETTING: Four adjacent neighborhoods in Chicago, Illinois. PARTICIPANTS: Persons deemed free of dementia in a previous wave of data collection (n = 1715) underwent detailed clinical evaluation: 802 had no cognitive impairment (46.8%), 597 had MCI (34.8%), 296 had AD (17.3%), and 20 had other forms of dementia (1.2%). MAIN OUTCOME MEASURE: All-cause mortality. RESULTS: During as many as 10 years of observation (mean [SD], 4.7 [3.0] years), 634 individuals died (37.0%). Compared with people without cognitive impairment, risk of death was increased by about 50% among those with MCI (hazard ratio [95% confidence interval], 1.48 [1.22-1.80]) and was nearly 3-fold greater among those with AD (2.84 [2.29-3.52]). These effects were seen among African Americans and whites and did not differ by race. Among participants with MCI, risk of death increased with more severe cognitive impairment, and this effect did not vary by race. A similar effect was seen among participants with AD, but it was slightly stronger for African Americans vs whites. In the MCI and AD groups, the association of cognitive impairment with survival was stronger for perceptual speed than for other cognitive functions. CONCLUSION: The presence and severity of MCI and AD are associated with reduced survival among African Americans, and these effects are comparable to those seen among whites.

Hostility and change in cognitive function over time in older blacks and whites.

OBJECTIVE: To test whether the level of hostility predicted the rate of cognitive decline in a community of older blacks and whites and whether the association varied as a function of race. METHODS: Over 4800 persons from a defined community in Chicago completed up to three structured interviews at approximately 3 year intervals over a period of up to 8.8 years (mean = 4.4 years). At the baseline interview, hostility was assessed with 8-items from the Cook-Medley Hostility Scale. Cognitive function was assessed at each interview with four cognitive function tests from which a composite measure of cognition was formed. Mixed effects models were used to assess change in cognition and its relation to hostility, controlling for age, sex, education, and race. RESULTS: The average score on the hostility scale at baseline was 3.0 (SD = 2.1). Higher levels of hostility were associated with lower cognitive scores (estimate = -0.028, SE = 0.004, p < .001). Cognition declined at a rate of 0.051 U per year on average, but hostility was not related to the rate of decline. Results were unchanged after controlling for depressive symptoms, chronic health, neuroticism, and social and cognitive activity patterns, or when persons with cognitive impairment at baseline were excluded. The association was similar in blacks and whites. CONCLUSION: The results suggest that hostility is associated with level of cognitive function in older persons but not related to cognitive decline.

Isthmus dependent atrial flutter cycle length correlates with right atrial cross-sectional area.

BACKGROUND: Right atrial flutter cycle length can prolong in the presence of antiarrhythmic drug therapy. We hypothesized that the cycle length of right atrial isthmus dependent flutter would correlate with right atrial cross-sectional area measurements. METHODS: 60 patients who underwent ablation for electrophysiologically proven isthmus dependent right atrial flutter, who were not on Class I or Class III antiarrhythmic drugs and had recent 2-dimensional echocardiographic data comprised the study group. Right atrial length and width were measured in the apical four chamber view. Cross-sectional area was estimated by multiplying the length and width. 35 patients had an atrial flutter rate >/= 250 bpm (Normal Flutter Group) and 25 patients had an atrial flutter rate < 250 bpm (Slow Flutter Group). RESULTS: Mean atrial flutter rate was 283 bpm in the normal flutter group and 227 bpm in the slow flutter group. Mean atrial flutter cycle length was 213 ms in the Normal Flutter Group and 265 ms in the Slow Flutter Group (p< 0.0001). Mean right atrial cross sectional area was 1845 mm(2) in the Normal Flutter group and 2378 mm(2) in the Slow Flutter Group, (p< 0.0001). Using linear regression, CSA was a significant predictor of cycle length (beta =0.014 p = 0.0045). For every 1 mm(2) increase in cross-sectional area, cycle length is 0.014 ms longer. CONCLUSIONS: In the absence of antiarrhythmic medications, right atrial cross sectional area enlargement correlates with atrial flutter cycle length. These findings provide further evidence that historical rate-related definitions of typical isthmus dependent right atrial are not mechanistically valid.

Perceived discrimination and blood pressure in older African American and white adults.

BACKGROUND: The current study was designed to examine the cross-sectional association between perceived discrimination and blood pressure (BP) in a sample of older African American and white adults. We hypothesized that perceived discrimination would be associated with higher levels of BP and that this association would be stronger for older African Americans compared with whites. METHODS: Participants were 4,694 (60% African American, 60% women) community-dwelling older adults. Perceived discrimination and other relevant risk factors were assessed via interview, and BP was measured using standard sphygmomanometers. Multivariate linear regression models were conducted to test associations among race, perceived discrimination, and BP. RESULTS: In models adjusted for age, sex, race, and education, perceived discrimination was not associated with higher levels of systolic blood pressure (p=.10) but was associated with higher levels of diastolic blood pressure (DBP) (p=.01). Further analyses revealed that the association between perceived discrimination and DBP was present in older African Americans (p=.0003) but not whites (p=.46). Results persisted after adjusting for relevant risk factors. CONCLUSIONS: Findings suggest that discrimination may be a unique risk factor for elevated DBP in older African Americans. Because these findings are cross-sectional, additional research is needed to determine whether the observed associations persist over time.

Repetition priming and change in functional ability in older persons without dementia.

Adverse consequences such as institutionalization and death are associated with compromised activities of daily living in aging, yet there is little known about risk factors for the development and progression of functional disability. Using generalized linear models, the authors examined the association between the ability to benefit from repetition and rate of change in functional ability in 160 nondemented elders participating in the Religious Orders Study. Three single-word repetition priming tasks were administered that varied in the degree to which visual-perceptual or conceptual processing was invoked. Decline in functional ability was less rapid, during follow-up of up to 10 years, in persons with better baseline priming performance on a task known to draw on both visual-perceptual and conceptual processing (word-stem completion). By contrast, change in functional ability was not associated with priming on tasks that are known to draw primarily on either visual-perceptual (threshold word-identification) or conceptual (category exemplar production) processing. The results are discussed in terms of a common biological substrate in the inferotemporal neocortex, supporting efficient processing of meaningful visual-perceptual experience and proficient performance of activities of daily living.

Neighborhood social cohesion and disorder in relation to walking in community-dwelling older adults: a multilevel analysis.

Objectives. To examine the role of neighborhood social conditions and walking in community-dwelling older adults. Methods. A multi-level analysis of data from 4,317 older adults (mean age = 74.5; 73% black) from a geographically-defined urban community. Participants completed structured interviews including 14 questions on neighborhood conditions and self-reported walking. The neighborhood questions were summarized into individual-level measures of perceived neighborhood social cohesion and disorder. These measures were aggregated by neighborhood to construct neighborhood-level measures of social cohesion and disorder. Results. Neighborhood-level disorder, but not social cohesion, was significantly associated with walking, independent individual-level neighborhood perceptions and other correlates of walking. Further adjustment for race weakened this association to a marginally significant level. Discussion. Neighborhood conditions may shape walking behavior in older adults, especially conditions that reflect physical neglect or social threat. Promotion of walking behavior in older adults may require improvement of the safety and upkeep of the neighborhood environment.

Social engagement and cognitive function in old age.

We examined the association of diverse measures of social engagement with level of function in multiple cognitive domains in 838 persons without dementia who had a mean age of 80.2 (SD = 7.5). Social network size, frequency of social activity, and level of perceived social support were assessed in linear regression models adjusted for age, sex, education, and other covariates. Social activity and social support were related to better cognitive function, whereas social network size was not strongly related to global cognition. The results confirm that higher level of social engagement in old age is associated with better cognitive function but the association varies across domains of social engagement.

Visuoperceptual repetition priming and progression of parkinsonian signs in aging.

Parkinsonian signs in older persons are associated with numerous adverse health outcomes, however there is limited information about factors which predict progression of these signs. Using generalized linear models, we examined the association between efficiency in visuoperceptual and conceptual processing, measured by repetition priming, and rate of change in parkinsonian signs in a large sample of older persons without cognitive impairment or Parkinson's disease. Subjects with better visuoperceptual priming, measured by threshold word-identification and word-stem completion, at study baseline, progressed more slowly during follow-up of up to 11 years. Conceptual priming was not associated with change in parkinsonian signs. The findings demonstrate that individual differences in visuoperceptual processing efficiency, measured by repetition priming, occur in older persons without cognitive impairment and predict important changes in motor function. Reduced visuoperceptual priming in aging may be an early signal of vulnerability in a corticostrial circuit that contributes to sensorimotor integration.

Use of home-based formal services by adult day care clients with Alzheimer's disease.

OBJECTIVES: To explore the association between adult day care (ADC) attendance and utilization of home-based formal services among people with Alzheimer's Disease (AD). METHODS: Data for this secondary analysis came from a longitudinal parent study of 457 subjects from 16 ADC programs and an Alzheimer's diagnostic center in metropolitan Chicago. We used the method of Generalized Estimating Equations to model the use of home-based formal services over time. RESULTS: Adjusting for relevant covariates, more days of ADC use at each follow-up was associated with decreased use of home-based formal services (coefficient = .25, p< .0001). Older, unmarried caregivers who are children of the care recipients had lower use of home-based services. DISCUSSION: Results suggest that ADC services may substitute for specific types of home-based formal services. The projected increase in AD prevalence over the next several decades warrants a clearer understanding of how people with AD use formal services.

Change in direct measures of physical performance among persons with Alzheimer's disease.

OBJECTIVES: Measures of physical performance were used in intact and community populations. We examined upper and lower extremity physical performance tests among people with Alzheimer's disease. METHOD: A total of 367 persons with probable Alzheimer's disease, recruited from an Alzheimer's disease diagnostic center, were given three tests of lower extremity function and two tests of upper extremity function at 6 month intervals for up to 4 years. Gender, race, age and Mini-Mental State Examination (MMSE) score at baseline were used to predict subsequent decline in composite scores of lower and upper extremity function. RESULTS: At baseline, older age and lower MMSE scores were associated with lower scores on both lower and upper extremity function. Males performed better at baseline on lower extremity tests only. For each point higher on MMSE, a person declined 0.023 Standard Unit (SU) less per year (p = 0.0001) on lower extremity tests and declined 0.019 SU less per year (p < 0.0001) on upper extremity tests. CONCLUSION: Physical performance was measured across a range of disease severities and declined over time. Lower cognitive score at baseline predicted faster decline in both lower and upper extremity function. Demographic heterogeneity in decline suggests other predictors may identify factors protective against physical decline.

Pulmonary function, muscle strength and mortality in old age.

Numerous reports have linked extremity muscle strength with mortality but the mechanism underlying this association is not known. We used data from 960 older persons without dementia participating in the Rush Memory and Aging Project to test two sequential hypotheses: first, that extremity muscle strength is a surrogate for respiratory muscle strength, and second, that the association of respiratory muscle strength with mortality is mediated by pulmonary function. In a series of proportional hazards models, we first demonstrated that the association of extremity muscle strength with mortality was no longer significant after including a term for respiratory muscle strength, controlling for age, sex, education, and body mass index. Next, the association of respiratory muscle strength with mortality was attenuated by more than 50% and no longer significant after including a term for pulmonary function. The findings were unchanged after controlling for cognitive function, parkinsonian signs, physical frailty, balance, physical activity, possible COPD, use of pulmonary medications, vascular risk factors including smoking, chronic vascular diseases, musculoskeletal joint pain, and history of falls. Overall, these findings suggest that pulmonary function may partially account for the association of muscle strength and mortality.

Perceived discrimination and mortality in a population-based study of older adults.

OBJECTIVES: We examined the relation of individual-level perceived discrimination to mortality in a biracial, population-based sample. METHODS: Participants were 4154 older adults from the Chicago Health and Aging Project who underwent up to 2 interviews over 4.5 years. Perceived discrimination was measured at baseline, and vital status was obtained at each follow-up and verified through the National Death Index. RESULTS: During follow-up, 1166 deaths occurred. Participants reporting more perceived discrimination had a higher relative risk of death (hazard ratio [HR]= 1.05; 95% confidence interval [CI]=1.01, 1.09). This association was independent of differences in negative affect or chronic illness and appeared to be stronger among Whites than among Blacks (Whites: HR=1.12; 95% CI=1.04, 1.20; Blacks: HR=1.03; 95% CI=0.99, 1.07). Secondary analyses revealed that the relation to mortality was related to discriminatory experiences of a more demeaning nature and that racial differences were no longer significant when the sample was restricted to respondents interviewed by someone of the same race. CONCLUSIONS: Perceived discrimination was associated with increased mortality risk in a general population of older adults. The results suggest that subjective experience of interpersonal mistreatment is toxic in old age. This study adds to a growing literature documenting discrimination as an important social determinant of health.

Change in depressive symptoms during the prodromal phase of Alzheimer disease.

CONTEXT: Prospective studies have established an association between depressive symptoms and risk of dementia, but how depressive symptoms change during the evolution of dementia is uncertain. OBJECTIVE: To test the hypothesis that depressive symptoms increase during the prodromal phase of Alzheimer disease (AD). DESIGN: Prospective cohort study. PARTICIPANTS AND SETTING: For up to 13 years, 917 older Catholic nuns, priests, and monks without dementia at study onset completed annual clinical evaluations that included administration of the 10-item Center for Epidemiologic Studies Depression Scale and clinical classification of mild cognitive impairment and AD. MAIN OUTCOME MEASURE: Change in depressive symptoms reported on the Center for Epidemiologic Studies Depression Scale. RESULTS: At baseline, participants reported a mean (SD) of 1.0 (1.5) depressive symptoms. Those who developed AD (n = 190) showed no increase in depressive symptoms before the diagnosis was made, and this finding was not modified by age, sex, education, memory complaints, vascular burden, or personality. There was no systematic change in depressive symptoms after the AD diagnosis, although symptoms tended to decrease in women relative to men and in those with a higher premorbid level of openness and a lower premorbid level of agreeableness. Among those without cognitive impairment at baseline, depressive symptoms did not increase in those who subsequently developed mild cognitive impairment. CONCLUSION: We found no evidence of an increase in depressive symptoms during the prodromal phase of AD.

Anti-inflammatory agents and cognitive decline in a bi-racial population.

In a prospective study among 4,409 subjects aged 65+ years, we assessed the relation of nonsteroidal anti-inflammatory agents (NSAIDs) to cognition. The main outcome was decline in global cognitive function, determined by average performance across four cognitive tests, over up to four interviews. We found similar rates of cognitive decline among recent users of aspirin and of other NSAIDs (largely ibuprofen) compared to those who did not use these NSAIDs. For lifetime duration of aspirin use, we failed to find an association with cognitive decline. However, for other NSAIDs, increasing duration of lifetime use was related to slower rates of cognitive decline, relative to no use of other NSAIDs (5+ years vs. no use: mean difference = 0.12; p trend = 0.03). Overall, we found no relation between regular aspirin use and cognitive decline, but long-term use of ibuprofen may be related to decreased rates of cognitive decline in older persons.