Physical activity, function, and longevity among the very old.

BACKGROUND: Recommendations encouraging physical activity (PA) set no upper age limit, yet evidence supporting the benefits of PA among the very old is sparse. We examined the effects of continuing, increasing, or decreasing PA levels on survival, function, and health status among the very old. METHODS: Mortality data from ages 70 to 88 years and health, comorbidity, and functional status at ages 70, 78, and 85 years were assessed through the Jerusalem Longitudinal Cohort Study (1990-2008). A representative sample of 1861 people born in 1920 and 1921 enrolled in this prospective study, resulting in 17 109 person-years of follow-up for all-cause mortality. RESULTS: Among physically active vs sedentary participants, respectively, at age 70, the 8-year mortality was 15.2% vs 27.2% (P < .001); at age 78, the 8-year mortality was 26.1% vs 40.8% (P <.001); and at age 85 years, the 3-year mortality was 6.8% vs 24.4% (P < .001). In Cox proportional-hazards models adjusting for mortality risk factors, lower mortality was associated with PA level at ages 70 (hazard ratio, 0.61; 95% confidence interval, 0.38-0.96), 78 (0.69; 0.48-0.98), and 85 (0.42; 0.25-0.68). A significant survival benefit was associated with initiating PA between ages 70 and 78 years (P = .04) and ages 78 and 85 years (P < .001). Participation in higher levels of PA, compared with being sedentary, did not show a dose-dependent association with mortality. The PA level at age 78 was associated with remaining independent while performing activities of daily living at age 85 (odds ratio, 1.92; 95% confidence interval, 1.11-3.33). CONCLUSIONS: Among the very old, not only continuing but also initiating PA was associated with better survival and function. This finding supports the encouragement of PA into advanced old age.

Reading daily predicts reduced mortality among men from a cohort of community-dwelling 70-year-olds.

OBJECTIVES: Although social and physical components of leisure activity have proven beneficial to successful aging, the influence of solitary and nonstrenuous activity on subsequent aging is unclear. This study examined reading activity to investigate the relationship of a solitary, nonstrenuous activity on aging and mortality. METHODS: A cohort of visually and cognitively intact community-dwelling participants born in 1920-1921, taken from the Jerusalem Longitudinal Study, underwent comprehensive assessment at ages 70 and 78. We collected mortality data spanning 8 years. We dichotomized reading frequency to daily or less and performed data analyses separately by gender. RESULTS: Reading daily was common at both ages 70 (62% of the sample) and 78 (68%) and was associated at baseline with female gender, Western origin, higher socioeconomic and educational statuses, employment, and reduced medications. The hazard ratio for mortality over the 8-year follow-up among men was significantly reduced (hazard ratio = 0.44, 95% confidence interval = 0.23-0.84) after we adjusted for numerous social, medical, and health parameters. DISCUSSION: The findings suggest that leisure activities devoid of social or physical benefits may nonetheless contribute to improved aging, predicting reduced mortality among men. A broader definition of leisure activities may be useful when considering the impact of these activities among older people.

Going outdoors daily predicts long-term functional and health benefits among ambulatory older people.

OBJECTIVE: This article examines the association between frequency of going out of the house and health and functional status among older people. METHOD: A randomly chosen cohort of ambulatory participants born in 1920 or 1921 from the Jerusalem Longitudinal Study underwent assessments for health, functional, and psychosocial variables at ages 70 and 77. Twelve-year mortality data were collected. RESULTS: Women went out daily less than did men. Participants going out daily at age 70 reported significantly fewer new complaints at age 77 of musculoskeletal pain, sleep problems, urinary incontinence, and decline in activities of daily living (ADLs). Logistic regression analysis indicated that not going out daily at age 70 was predictive of subsequent dependence in ADL, poor self-rated health, and urinary incontinence at age 77. DISCUSSION: Going out daily is beneficial among independent older people, correlating with reduced functional decline and improved health measures.

Holocaust survivors in old age: the Jerusalem Longitudinal Study.

OBJECTIVES: To examine the hypothesis that Holocaust exposure during young adulthood negatively affects physical aging, causing greater morbidity, faster deterioration in health parameters, and shorter survival. DESIGN: A longitudinal cohort study of the natural history of an age-homogenous representative sample born in 1920/21 and living in Jerusalem. SETTING: Community-based home assessments. PARTICIPANTS: Four hundred fifty-eight subjects of European origin aged 70 at baseline and 77 at follow-up. MEASUREMENTS: Comprehensive assessment of physical, functional, and psychosocial domains; biographical history of concentration camp internment (Camp), exposure to Nazi occupation during World War II (Exposure), or lack thereof (Controls); and 7-year mortality data from the National Death Registry. RESULTS: Holocaust survivors of the Camp (n=93) and Exposure (n=129) groups were more likely than Controls (n=236) to be male and less educated and have less social support (P=.01), less physical activity (P=.03), greater difficulty in basic activities of daily living (P=.009), poorer self-rated health (P=.04), and greater usage of psychiatric medication (P=.008). No other differences in health parameters or physical illnesses were found. Holocaust survivors had similar rates of deterioration in health and illness parameters over the follow-up period, and 7-year mortality rates were identical. Proportional hazard models showed that being an elderly Holocaust survivor was not predictive of greater 7-year mortality. CONCLUSION: Fifty years after their Holocaust trauma, survivors still displayed significant psychosocial and functional impairment, although no evidence was found to support the hypothesis that the delayed effects of the trauma of the Holocaust negatively influence physical health, health trajectories, or mortality.

Evolution of medication use in Jerusalem elders: Results from the Jerusalem Longitudinal Study.

BACKGROUND: While overall rates of medication use have been increasing over time, less is known about how medication use changes within individuals as they age. OBJECTIVE: The aim of this study was to evaluate changes in medication use and predictors of medication accrual among community-dwelling elders followed for a 7-year period, from age 70 +/- 1 years to age 77 +/- 1 years. METHODS: The study was a community-based, longitudinal, cohort study. The study group consisted of 280 patients from the Jerusalem Longitudinal Study, a population-based sample of Jerusalem residents born in 1920-1 who underwent extensive evaluation in 1990-1 and again in 1997-8. The main outcome measure of the study was the change in the total number of medications taken between baseline and follow-up. Medication use was assessed by home interviews. RESULTS: Half of the sample were men. Medication use more than doubled over the 7-year study period, from a mean of 2.0 to 5.3 medications per patient (p < 0.001), and 57 patients (20%) increased their total drug use by six or more medications. Vitamins, minerals and cardiovascular medications were the most commonly prescribed medications at follow-up, and accounted for approximately half of the total increase in medication use. On multivariable logistic regression analyses, decline in self-rated health was the strongest predictor of above-median increases in medication use (odds ratio [OR] 3.2; 95% CI 1.8, 6.2). The only nonclinical predictor of above-median increases in medication use was good social engagement at baseline (OR 1.8; 95% CI 1.1, 3.1). CONCLUSION: Medication use in Jerusalem elders grew rapidly over the 1990s, more than doubling in volume over a 7-year period. While health status was the factor most strongly predictive of the degree of change, the magnitude of increase for elders as a whole suggests major changes in prescribing practices over this interval.

Closure of a home hospital program: impact on hospitalization rates.

Home hospitalization (HH), as a substitute to in-patient care, is an area of growing interest, particularly amongst the elderly. Debate nonetheless exists concerning its economic justification. This study describes a natural experiment that arose following spending cuts and closure of the 400 patient Jerusalem HH program. It examines the hypothesis that HH closure would cause increasing geriatric and general medical hospital utilization amongst the 45,000 beneficiaries of the Jerusalem Clalit Health Fund (HMO) aged 65 years and over. Hospitalization rates were measured prior to and following HH closure, and analysis of variance confirmed the significance of the differences in both geriatric (p<0.0001) and general medical hospitalization rates (p=0.02) over the study period. Linear regression analyses of the hospitalization rates prior to HH closure were performed to determine the expected trajectory of hospitalization rates following HH closure. The observed hospital utilization in the year following HH closure cost 6.2 million US dollars in excess of predicted expenditure; closure of the HH resulted in the saving of 1.3 million USdollars. The ratio of direct increased costs to savings was 5:1 thus confirming the hypothesis that HH closure would result in increased hospital utilization rates among the local elderly population.

Aspirin prophylaxis and the prevalence of anaemia.

BACKGROUND: Anaemia and vascular disease are both common amongst the elderly and frequently co-exist. Whilst a consensus exists concerning the benefits of low-dose aspirin in reducing risk from atheromatous disease, nonetheless concerns arise in view of its harmful effect on gastric mucosa and its influence upon haemostasis, with the possibility of subsequent gastrointestinal bleeding. This study examined the relationship between chronic low-dose aspirin therapy and the presence of anaemia. SETTING: A cross-sectional study of a representative cohort of 464 community-dwelling subjects aged 77 years. METHODS: Subjects underwent comprehensive assessment of psychosocial, functional, medical and laboratory variables. In accordance with the World Health Organization criteria, anaemia was defined as less than 13 g/dl for men and 12 g/dl for women. RESULTS: Chronic low-dose aspirin use was found amongst 29% of the 227 women and 38% of the 237 males (P = 0.026). Aspirin use was significantly associated with hypertension, ischaemic heart disease and diabetes mellitus. Anaemia was 42% less common among aspirin users, a statistically robust finding (OR 2.44, 95%CI 1.28-4.66) according to logistic regression analysis which included the confounding variables of gender, education, diabetes, hypertension, heart disease, peptic diseases, antipeptic therapy and smoking. Similarly, no association was observed between aspirin use and reduced serum iron or iron saturation, reduced mean corpuscular haemoglobin or mean corpuscular volume. CONCLUSIONS: Chronic low-dose aspirin use amongst an elderly cohort was associated with increased likelihood of normal haemoglobin.

Chronic back pain among the elderly: prevalence, associations, and predictors.

STUDY DESIGN: A longitudinal age homogeneous cohort study. OBJECTIVE: To describe the prevalence, nature, and predictors of chronic back pain (CBP) in older people. SUMMARY OF BACKGROUND DATA: CBP is a growing source of morbidity among the elderly. Few longitudinal studies exist, and its time course and predictors are largely undefined. METHODS: The Jerusalem Longitudinal Study assessed 277 subjects aged 70 years at baseline and 77 years at follow-up. Data collection included back pain symptoms, psychosocial, functional, and physical domains. RESULTS: The prevalence of CBP increased from 44% to 58% at ages 70 and 77 years, respectively, while frequency and severity decreased. CBP was associated with female gender, economic difficulties, loneliness, fatigue, poor self-rated health, dependence in activities of daily living, joint pain, and obesity. Depression was associated at age 70 years, and unemployment, not leaving the house for leisure, poor sleep satisfaction, hypertension, and osteoporosis were at age 77 years. Predictors of CBP at age 77 years were female gender, loneliness, joint pain, hypertension, and preexisting CBP. Unemployment and not leaving the house for leisure showed a trend toward significance. CONCLUSION: CBP is increasingly common in the elderly. Psychosocial factors, female gender, hypertension, and existing joint pain identify individuals most at risk.

Global sleep satisfaction of older people: the Jerusalem Cohort Study.

OBJECTIVES: To describe the nature of global sleep satisfaction (GSS) of older people and the factors associated with it. DESIGN: A 7-year follow-up of an age-homogenous cohort. SETTING: Community based. PARTICIPANTS: Two hundred ninety subjects aged 70 at baseline and 77 at follow-up. MEASUREMENTS: Self-reported sleep domains and a comprehensive assessment of health variables, including psychosocial, physical, and functional factors, at ages 70 and 77. RESULTS: GSS was found to be poor in 25% of subjects at ages 70 and 77, with an estimated average annual remission rate of 7% and an annual incidence of 2.4%. Poor GSS at ages 70 and 77 was significantly associated with difficulty falling asleep, awakening feeling tired, two or more nocturnal awakenings, and taking sleeping tablets. Significant cross-sectional associations were found at age 70 and 77 between poor GSS and poor self-rated health, general fatigue, depression, dependence in one or more activities of daily living, and low level of physical activity. In a regression analysis, risk factors at age 70 for subsequent poor GSS were loneliness, depression, poor self-rated health, economic difficulties, back pain, obesity, and prior poor GSS. The only significant long-term association was between poor GSS and poor self-rated health. GSS did not influence mortality data. CONCLUSION: Poor GSS in older people is common and chronic. Its chief determinants are loneliness, depression, poor self-rated health, economic difficulties, back pain, and obesity. It predicts poor self-rated health but not increased mortality.

The impact of visual impairment on health, function and mortality.

BACKGROUND AND AIMS: Our aim was to determine the impact of visual impairment on self-rated health, function and mortality amongst a community-dwelling elderly cohort. METHODS: The study design was prospective and longitudinal, subjects being taken from an age-homogeneous, community-dwelling cohort comprising 452 subjects aged 70 in 1990 and 839 subjects aged 77 in 1998. Comprehensive data were collected by structured interviews and medical examinations carried out during home visits. Data included each subject's demographic and socio-economic profile, medical history, physical findings, functional status and self-rated health status. Visual acuity was measured using a Snellen chart and visual impairment was defined as best-eye corrected visual acuity of 20/40 or worse on Snellen chart testing. RESULTS: Measured and self-reported visual impairment correlated closely, and were significantly more prevalent amongst subjects with low education and poor financial status. Visually impaired subjects showed significantly greater dependence in ADL and IADL, poor self-rated health, less ability to rely on friends, increased loneliness and, in men aged 77, increased visits to the emergency room and hospital admissions. Visual impairment at age 70 significantly predicted poor self-rated health (p=0.029, OR 2.36, 95% CI 1.09-5.10), dependence in ADL (p=0.007, OR 2.91, 95% CI 1.34-6.33), general tiredness (p=0.037, OR 2.40, 95% CI 1.06-5.44), and mortality, with a two-and-a-half-fold increase in risk of death at seven years (p=0.0017,OR 2.84, 95% CI 1.48-5.46). CONCLUSIONS: Visual impairment in the elderly increases the risk of social, functional and medical decline.

Working late: the impact of work after 70 on longevity, health and function.

BACKGROUND AND AIMS: Although many older persons choose to postpone retirement, the health consequences of this decision are still debated. This study aimed at determining the impact of continued employment on life-style, well-being, health and survival in a cohort of community-dwelling 70-year-olds. METHODS: A longitudinal study of a homogeneously aged cohort was conducted in two stages. Data from extensive interviews, physical examinations and clinical laboratory information were obtained from west Jerusalem residents born in 1920-1 through home-based examinations. In 1990-1, 162 women and 218 men were examined, at age 70, and in 1997-8, 390 women and 398 men at age 77. Two hundred and thirty one subjects participated in both study stages and were available for longitudinal analysis. For each subject at each study stage, a comprehensive profile detailed social characteristics, including life-style and personal functions, and medical status including illnesses and use of medical services. At each stage, employed subjects were compared with those who neither worked for compensation nor as volunteers. Logistic regression compared health outcomes at age 77 for subjects who worked at age 70 with those of subjects who had not. RESULTS: At age 70, 37 women and 98 men were gainfully employed, whereas 125 women and 120 men did not work. At age 77, wage-earners numbered 26 women and 95 men, and non-workers 364 women and 303 men. In the cross-sectional analyses at ages 70 and 77, work correlated with better perceived health and greater independence for both women and men. Independent of pre-existing economic difficulties, education, illnesses, functional dependence and self-assessed health, workers at age 70 after seven years were in better health (OR 2.12, 95% CI 1.04, 4.30), had more ADL independence, (OR 2.60, 95% CI 1.08, 6.29) and increased survival rates (OR 2.13, 95% CI 1.06, 4.28). CONCLUSIONS: Independent of baseline status, working at age 70 correlates with health, self-sufficiency and longevity.

Strategies to enhance longevity and independent function: the Jerusalem Longitudinal Study.

PURPOSE: To analyze the impact of medical and social factors on survival and function from age 70 to 82 and point to possible genetic basis for differences. MATERIALS AND METHODS: Longitudinal, cohort study of a representative sample of Jerusalem residents, born 1920-1921. At age 70, 463 subjects underwent a thorough interview eliciting social determinants as well as a medical history and examination and laboratory investigation. At age 77,265 of the survivors, 71%, were re-examined. In 2002, all death certificates in Israel were reviewed. End points were performance of basic and advanced tasks with ease at age 77 and survival to age 82 or life span in subjects who had succumbed. The independent influence of each factor was tested using logistic regression. RESULTS: 89.6% of women were alive after 6 years and 77.4% after 12. Survival for men was 79.9% and 59.8%, respectively. Social factors predominated in the correlation with longer life: financial security, p=.0004; volunteer activity, p=.0002; regular exercise, p=.0002; positive self-assessed health, p<.0001; and activities of daily living (ADL) independence, p<.0001. Less striking but significant correlation for longevity was noted for avoiding naps, p=.04 and instrumental activities of daily living (IADL) independence, p=.048. Medical conditions associated with increased mortality included diabetes, p<.0001; coronary artery disease, p=.0002; impaired vision, p=.0007; and renal insufficiency, p=.008. Anemia and disturbed sleep did not independently correlate with mortality while the association with hypertension did not reach statistical significance, p=.056. In a regression to determine the independent impact of medical and social factors on mortality, unimpaired renal function, good vision, avoiding afternoon naps, volunteer or compensated work, physical activity and IADL independence all correlated with improved survival. Moreover, good vision, volunteer work or work for pay and physical activity were independently associated with continued ADL independence after 7 years. CONCLUSIONS: These findings highlight the ability of social, economic and functional factors to modify genetic influence on survival and function. Increased physical and social activity is an important tool to lengthen the span of robust function. The role of heredity in determining function and mortality may be expressed through diverse pathways.

Candidate genes associated with ageing and life expectancy in the Jerusalem longitudinal study.

In an exploratory study, 11 common polymorphisms were examined for contributing to longevity including: apolipoprotein E (apoE), methylenetetrahydrofolate reductase (MTHFR), cathepsin D (CAD), superoxide dismutase 2 (SOD2), angiotensinogen (AGT) and insulin-like growth factor 2 (IGF2), Leiden factor 7, p53 oncogene, dopamine D4 receptor (DRD4) and the serotonin transporter (SERT). Genotype and allele frequencies of these genes were compared in 224 older (75 years) Jewish Jerusalem residents of Ashkenazi ethnicity to a group of 441 younger subjects (22 years). Nominally significant results provide suggestive evidence in the Ashkenazi group that apoE, MHTFR, SOD2, IGF2 ApaI, and factor VII are risk factors for a single outcome, survival to 75. Overall, the more genetically homogenous Ashkenazi ethnic group showed evidence for association in five genes examined suggesting that future studies in this population would gainfully focus on this ethnic group.

Effect of exercise on ease in performing activities of daily living and instrumental activities of daily living from age 70 to 77: the Jerusalem longitudinal study.

OBJECTIVES: To determine the prevalence of independence and ease of performance in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) at ages 70 and 77 in a well-characterized cohort and to measure the effect of regular exercise at age 70 on independence and ease of performance 7 years later. DESIGN: Two stages of a longitudinal study of an age-homogeneous cohort employing extensive interview data, physical examination, and clinical laboratory investigation. SETTING: Home-based interviews and examinations in Jerusalem. PARTICIPANTS: Two hundred eighty-seven west Jerusalem residents, born between June 1920 and May 1921, who participated fully in two phases of an ongoing longitudinal cohort study. Subjects were culled from a larger study population of 605 in the first phase and 1,021 in the second phase. MEASUREMENTS: Two-stage comprehensive demographic, social, and economic profile; medical history and examination; cognitive and affective assessment; and clinical laboratory studies performed in 1990-91 and 1997-98. The investigation questionnaire included details of ADL and IADLs and voluntary exercise. RESULTS: Most aspects of personal and social life did not change from age 70 to 77. Independence in ADLs remained high, as did self-reliance in IADLs for women. A more-sensitive marker of diminished function was reported ease in performance, which declined for use of the toilet, dressing, and all spheres of IADLs. For nearly every task, subjects who reported exercising 4 days a week at age 70 were more likely to report ease in performance at age 77. In a logistic regression accounting for the presence of diabetes mellitus, hypertension, obesity, chronic back pain, loneliness, and performance with ease at age 70 and deterioration in self-assessed health from age 70 to 77, ease of performance in at least three of four ADL tasks was independently related to exercise at age 70 for women (odds ratio (OR) = 8.5, 95% confidence interval (CI) = 2.0-36.2) and for men (OR = 4.3, 95% CI = 1.1-17.1). Ease of independent function in at least four of five IADL tasks also correlated to exercise for men in this regression (OR = 3.7, 95% CI = 1.1-12.2) but not for women (OR = 2.0, 95% CI = 0.6-6.3). Ease in shopping, alternatively, correlated with physical activity for men (OR = 4.3, 95% CI = 1.5-12.0) and women (OR = 2.6, 95% CI = 1.1-6.1). CONCLUSIONS: Subjects remained active and independent at age 77. Reported ease of performance declined and revealed changes in function. Exercise at least four times a week at age 70 preserved ease of performance at age 77 independent of the influence of specific disease or general self-assessed health.

Home hospitalization.

CONTEXT: Home Hospital is a worldwide phenomenon that provides acute and subacute medical care in the home in an attempt to reduce the need for hospitalization. OBJECTIVE: To evaluate the clinical parameters of a home hospitalization program operating in Jerusalem for 8 years. DESIGN: The Jerusalem Home Hospitalization (HH) program admits inpatients for early discharge from the hospital or accepts patients from the community when hospitalization is imminent. A clinical profile of HH was obtained from a chart review. OUTCOME MEASURES: Demographic data, diagnoses, duration of HH and the nature of the care required by patients at the end of HH were surveyed in 1995. RESULTS: From November 1991 until the end of 1999, 6297 patients over age 65 were admitted to HH. As reflected in 1995 data, the most common disease categories in HH were heart disease, malignancy and infection; 51% of HH lasted less than one month, 69% less than two. CONCLUSION: For 8 years, HH in Jerusalem has provided intensive home care with high levels of patient and family satisfaction.