Withdrawal of psychotropic drugs decreases the risk of falls requiring treatment.

This non-randomized, controlled trial assessed the effects of ceasing fall-risk-increasing drugs (FRIDs) (psychotropics or opiates or potent anticholinergics) on the risk of falls requiring medical treatment as a sub-analysis of a randomized, controlled multifactorial fall prevention. The population in this 12-month study consisted of 528 community-dwelling subjects aged 65 years or older with a history of at least one fall. The subjects were divided retrospectively into three groups according to the use of any FRID, any psychotropic drug, and benzodiazepine or related drug (BZD/BZDRD). The subjects in the intervention group (IG) ceasing the drug use were compared with the subjects in IG and the control group (CG) not ceasing the use of the corresponding type of drugs during the intervention period. Falls were recorded from medical records. For the year after the 12-month intervention the relative risk ratio (with 95% confidence intervals=CI) for controls in CG compared with the withdrawal group in IG was 8.26 (1.07-63.73) among the users of psychotropics and 8.11 (1.03-63.60) among the users of BZDs/BZDRDs. Withdrawal of psychotropics, especially BZDs/BZDRDs may have played an important role by lowering the risk of falls requiring medical treatment during the year after the 12-month multifactorial intervention.

The metabolic syndrome defined by modified International Diabetes Federation criteria and mortality: a 9-year follow-up of the aged in Finland.

AIM: The aim of this study was to investigate the relationship between the metabolic syndrome (MetS) and mortality in the aged population. METHODS: In this prospective population-based study with a 9-year follow-up, the participants were all residents of the municipality of Lieto, Finland, aged 64 and over in 1998-99 (n=1529). Altogether, 1260 (82%) were included in the study. Cox proportional-hazard models were used to estimate hazard ratios (HRs) for all-cause, cardiovascular (CVD), coronary heart disease (CHD) and cerebrovascular (CV) mortality as predicted by MetS (defined by modified International Diabetes Federation criteria). RESULTS: At baseline, 17% of the men and 21% of the women had MetS. During the 9-year follow-up, 422 deaths occurred. After multivariable adjustment, no significant differences were found between subjects with and without MetS for all-cause, CVD, CHD or CV mortality in all study participants or by gender. On evaluating MetS components separately, elevated blood pressure was found to predict lower all-cause mortality in all participants [HR: 0.65; 95% confidence interval (CI): 0.47-0.89], and lower CHD mortality in men (HR: 0.42; 95% CI: 0.18-0.97). In women, high triglyceride levels predicted lower all-cause mortality (HR: 0.67; 95% CI: 0.47-0.95), whereas low HDL cholesterol predicted higher all-cause (HR: 1.61; 95% CI: 1.15-2.24) and CV (HR: 2.44; 95% CI: 1.05-5.67) mortality. CONCLUSION: These findings suggest that MetS does not predict mortality later in life and, of the separate components of MetS, only low HDL cholesterol is predictive of mortality in women. Also, even markedly higher blood pressure values than those included in the criteria for MetS fail to predict mortality in this age group.

The long-term effect of a multifactorial fall prevention programme on the incidence of falls requiring medical treatment.

OBJECTIVES: To evaluate the long-term effects of a multifactorial fall prevention programme on the incidence of falls requiring medical treatment. STUDY DESIGN: A randomized controlled trial. METHODS: Five hundred and ninety-one community-dwelling elderly people (> or = 65 years) living in the town of Pori, Finland with at least one fall during the previous 12 months were randomized into an intervention group (n=293) and a control group (n=298). Subjects in the intervention group participated in a multifactorial 12-month fall prevention programme. This study evaluated the incidence of falls requiring medical treatment during the 3-year follow-up period. RESULTS: The intervention did not significantly reduce the incidence of falls requiring medical treatment during the 3-year follow-up period [incidence rate ratio (IRR) for the intervention group compared with the control group 0.87, 95% confidence interval (CI) 0.63-1.21]. The number of falls requiring medical treatment was lower in the intervention group (n=32) compared with the control group (n=50) (IRR 0.65, 95%CI 0.40-1.07) during the second year of follow-up, but this was not found during the first year (48 and 48 falls, respectively; IRR 1.04, 95%CI 0.64-1.69) or the third year (44 and 48 falls, respectively; IRR 0.94, 95%CI 0.58-1.53) of follow-up. CONCLUSIONS: The multifactorial fall prevention programme did not decrease the incidence of falls requiring medical treatment of fall-prone elderly people during the 3-year follow-up period. However, some positive effect was found during the second year of follow-up (immediately after the 12-month intervention).

Cervical hip fracture in a Finnish population: incidence and mortality.

BACKGROUND AND AIMS: Our aim was to describe the incidence of cervical hip fractures and to describe the relationships between selected background variables and mortality at 30 days, 6 months, and 3 years postoperatively. MATERIAL AND METHODS: The basic material consisted of population-based data set of patients aged 65 years or older who had sustained a hip fracture and were treated operatively between 1999 and 2000. Out of these, we identified 266 consecutive patients with cervical hip fracture. RESULTS: The age-adjusted incidence of cervical hip fractures in women was 1.3-fold compared to men. In age-adjusted analysis, occurrence of chronic lung disease, cardiovascular disease or 2-5 comorbidities, male gender, the need for 2-person mobility assistance, and poor ambulation postoperatively were associated with excess mortality at least at one evaluation point. CONCLUSIONS: Only chronic lung disease and male gender were independent predictors of increased mortality at each follow-up assessment in multivariate analysis.

The impact of proximal femur geometry on fracture type--a comparison between cervical and trochanteric fractures with two parameters.

INTRODUCTION: Only a few studies have tested the ability of proximal femur geometry parameters to discriminate between cervical hip fractures and those of the trochanter. The main objective of this study was to evaluate the geometrical differences between these two fracture types by measuring the neck shaft angle (NSA) and the femoral neck axis length (FNAL). We also compared the distributions of these parameters and the distributions of fracture type by gender. MATERIAL AND METHODS: A retrospective analysis was made in a population-based material of 428 hip fractures collected during a two-year period from 1999 to 2000 (323 women and 105 men aged 65 years or older). NSA and FNAL were manually measured from pelvic radiographs. RESULTS: No significant differences in NSA or FNAL were found between cervical and trochanteric hip fractures in women or in men. Men had significantly higher NSA and FNAL than women. Age was not related to these geometrical parameters. The distributions by fracture type were similar in both genders. CONCLUSIONS: The different pathogenesis of cervical and trochanteric hip fractures cannot be explained by NSA or FNAL. A standardized measurement setup is needed when evaluating the role of hip geometry in fracture patients.

Association between markers of renal function and C-reactive protein level in the elderly: confounding by functional status.

OBJECTIVE: To analyse the cross-sectional association between measures of renal function and inflammation in an elderly population and to evaluate the confounding effect of impaired physical functioning on these relationships. MATERIAL AND METHODS: Cystatin C and creatinine were measured in serum samples from 1110 elderly subjects in a community-based cross-sectional survey (Lieto Study) in southwestern Finland. Glomerular filtration rate (GFR) was estimated by means of the Modification of Diet in Renal Disease (MDRD) equation. Associations between renal measures and sensitive C-reactive protein (CRP) and the impact of functional status were determined by multivariate linear models. RESULTS: Based on standardized coefficients, cystatin C (beta 0.19; p<0.001) showed the strongest association with CRP compared to creatinine (beta 0.14; p<0.001) and estimated GFR (beta -0.13; p<0.001). Levels of CRP linearly increased across quintiles of cystatin C, whereas for creatinine and estimated GFR the increase was less graded. Impaired physical functioning was strongly associated with elevated levels of cystatin C (p<0.001) and CRP (p<0.001), but not with creatinine (p = 0.45) or estimated GFR (p = 0.38). For persons with impaired physical functioning, the odds ratio for belonging to the highest compared to the lowest cystatin C quintile was 7.04 (95% confidence interval 3.49-14.9; p<0.001), whereas for creatinine and estimated GFR this difference was not significant. CONCLUSION: The weaker association observed between CRP and creatinine-based measures, as compared to cystatin C, reflects the misclassification of elderly frail subjects as having normal kidney function rather than suggests cystatin C itself to be a marker of inflammation.

The effects of fall prevention trials on depressive symptoms and fear of falling among the aged: a systematic review.

Firstly, to explore whether depressive symptoms and fear of falling have been used as outcome measures in fall prevention trials. Secondly, to determine the effects of fall prevention trials on these variables among the aged. A literature search covering various medical databases was conducted to identify randomised controlled trials regarding the effects of fall prevention programmes on depressive symptoms and fear of falling among the aged. The studies were classified according to the intervention method (single/multifactorial) and study results (positive/negative) regarding depressive symptoms or fear of falling. Methodological quality was assessed in relation to blinding at outcome assessment, follow-up and whether intention-to-treat analysis was used. Depressive symptoms were used as an outcome measure in eight and fear of falling in 21 studies. A multifactorial approach seems the most effective method in reducing fear of falling, while some single methods such as Tai Chi also seem beneficial. Little evidence was found relating to the effects of fall prevention trials on depressive symptoms. Fear of falling may be reduced by fall prevention programmes. More studies assessing the effects on depressive symptoms, especially among the depressed aged are needed.

Incidence of hip fractures among the elderly in Satakunta, Finland.

BACKGROUND AND AIMS: The aim was to describe the incidence rate of hip fractures in the elderly in a specific region in Finland and circumstances around them. MATERIAL AND METHODS: Retrospective analysis of 461 women and men aged 65 or older undergoing an operation for hip fracture during a two-year period between 1999 and 2000. 80 variables in all were obtained from the hospital discharge register and patient documents. RESULTS: The age-specific incidence of hip fractures was higher in women than in men (women 6.88/1000 person/y vs. 3.50/1000 person/y). Prior to the fracture, patients were primarily doing well; 63.4% lived at home and 65.1% used no mobility equipment or aids. Altogether 41.9% of hip fractures occurred in institutions. Both women and men more often suffered their injury indoors (91.1% and 75.7% respectively), and only a slight seasonal variation was observed. More than every fourth (26.9%) had experienced a previous fracture. CONCLUSIONS: The age-specific incidence of hip fractures was higher in women than in men. The fractures took place mostly indoors and often in institutions. Therefore the measures that impact on indoor safety are particularly important for the elderly.

A multifactorial fall prevention programme in home-dwelling elderly people: a randomized-controlled trial.

OBJECTIVES: To describe the implementation and the effects of a multifactorial fall prevention trial on the specified risk factors of falling, incidence of falls and injurious falls, and on specified secondary outcome measures; to describe the design of the study and to assess the success of randomization. STUDY DESIGN: Randomized-controlled trial. METHODS: Recruitment started in March 2003 and lasted until the end of January 2005, when a total number of 591 participants was reached. Participants were randomized into two age groups (65-74 years and 75 years and over), then into an intensive multifactorial risk-based prevention programme or into a one-time counselling on fall prevention. The intervention included individual geriatric assessment, guidance and treatment, individual guidance on fall prevention, physical exercise in small groups, psychosocial group activities, lectures, home-exercises and home hazards assessment. RESULTS: A total of 293 people were randomized into the 1-year prevention programme and 298 into the control condition. The mean age was 73.5 years in both groups; 84% of the participants were women. The groups were well balanced at baseline in relation to risk factors of falls, and the only statistically significant difference was found in the amount of regularly taken medicines, which was significantly lower in the control group: mean 3.7 (SD 3.0) vs. 4.2 (SD 3.1), P=0.028. CONCLUSIONS: Participants were successfully randomized into a multifactorial fall prevention trial.

Association of bovine respiratory disease with clinical status and acute phase proteins in calves.

Eighty-four calves with respiratory disease from 18 herds in different parts of Finland were chosen for a study evaluating the capacity of different respiratory pathogens to cause changes in different acute phase protein concentrations, white blood cell (WBC) count and clinical signs. The selected acute phase proteins were fibrinogen, haptoglobin, serum amyloid-A, lipopolysaccharide binding protein and alpha1-acid glycoprotein. From each calf, a paired blood sample was obtained for serological studies of bovine parainfluenza virus-3, bovine respiratory syncytial virus, bovine coronavirus, bovine adenovirus-3 and bovine adenovirus-7. Tracheobronchial lavage was performed to detect bacteria and mycoplasma. Isolation of Pasteurella multocida was associated with increased concentrations of all tested acute phase proteins. For other pathogens, no significant relationships were observed. No association was present between viral or bacterial findings and WBC count.

Physical health and depressive symptoms in older Europeans. Results from EURODEP.

BACKGROUND: Associations between physical health and depression are consistent across cultures among adults up to 65 years of age. In later life, the impact of physical health on depression is much more substantial and may depend on sociocultural factors. AIMS: To examine cross-national differences in the association between physical health and depressive symptoms in elderly people across western Europe. METHOD: Fourteen community-based studies on depression in later life in nine western European countries contributed to a total study sample of 22 570 respondents aged 65 years and older. Measures were harmonized for depressive symptoms (EURO-D scale), functional limitations and chronic physical conditions. RESULTS: In the majority of the participating samples, the association of depressive symptoms with functional disability was stronger than with chronic physical conditions. Associations were slightly more pronounced in the UK and Ireland. CONCLUSIONS: The association between physical health and depressive symptoms in later life is consistent across western Europe.

Estimation of glomerular filtration rate in the elderly: a comparison of creatinine-based formulae with serum cystatin C.

OBJECTIVES: To estimate the prevalence of decreased kidney function in an elderly population and to evaluate the impact of using alternative markers of glomerular filtration rate (GFR), focusing on serum cystatin C (Cys C) and the Modification of Diet in Renal Disease (MDRD) Study prediction equation. DESIGN AND METHODS: In a cross-sectional community-based survey renal function was assessed by serum creatinine (SCreat), Cys C and GFR predicted by the Cockcroft-Gault (CG) and the MDRD Study formulae. Associations with age, gender and proteinuria were analysed by linear models. SUBJECTS: A total of 1246 elderly residents in Lieto, Finland, 64-100 years of age. RESULTS: The prevalence of moderately or severely decreased renal function, estimated by the MDRD Study equation, was 35.7%; the CG formula yielded 58.6%. The profile of Cys C performance, including variation across age groups and level of health status, showed greater similarity to GFR estimated using the MDRD Study equation than to SCreat alone, or GFR estimated using the CG formula. Discordance between high Cys C levels and only mildly decreased GFR estimates was observed in subjects with functional limitations. Microalbuminuria was associated with Cys C levels only (P =0.047). CONCLUSION: Prevalence estimates of decreased renal function amongst the elderly vary considerably depending on prediction formula used. Variation in creatinine metabolism amongst elderly comorbid patients and the critical dependence on the SCreat assay and exact calibration, make the use of creatinine-based formulae to predict GFR questionable in geriatric clinical practice. In this setting, Cys C is a promising alternative.

Viral and bacterial pathogens in bovine respiratory disease in Finland.

Pathogens causing bovine respiratory tract disease in Finland were investigated. Eighteen cattle herds with bovine respiratory disease were included. Five diseased calves from each farm were chosen for closer examination and tracheobronchial lavage. Blood samples were taken from the calves at the time of the investigation and from 86 calves 3-4 weeks later. In addition, 6-10 blood samples from animals of different ages were collected from each herd, resulting in 169 samples. Serum samples were tested for antibodies to bovine parainfluenza virus-3 (PIV-3), bovine respiratory syncytial virus (BRSV), bovine coronavirus (BCV), bovine adenovirus-3 (BAV-3) and bovine adenovirus-7 (BAV-7). About one third of the samples were also tested for antibodies to bovine virus diarrhoea virus (BVDV) with negative results. Bacteria were cultured from lavage fluid and in vitro susceptibility to selected antimicrobials was tested. According to serological findings, PIV-3, BAV-7, BAV-3, BCV and BRSV are common pathogens in Finnish cattle with respiratory problems. A titre rise especially for BAV-7 and BAV-3, the dual growth of Mycoplasma dispar and Pasteurella multocida, were typical findings in diseased calves. Pasteurella sp. strains showed no resistance to tested antimicrobials. Mycoplasma bovis and Mannheimia haemolytica were not found.

Effectiveness of multidisciplinary lifestyle intervention for hypertension: a randomised controlled trial.

Lifestyle factors like weight, alcohol consumption, salt intake and physical activity have shown to be important in treating hypertension. There have been made some randomised trials about the effects of lifestyle interventions, but the numbers of patients have been relatively small and the durations of follow-ups have been short. No controlled trials assessing the effects of lifestyle intervention in a rehabilitation setting have been reported. In this study, the effects of multidisciplinary lifestyle intervention in rehabilitation centres among middle-aged hypertensive employees were described. A total of 731 hypertensives from 45 worksites were randomised to lifestyle intervention in a rehabilitation centre or to usual care in an occupational or primary health-care centre for 12 months. Standard measurements were conducted before the intervention and 1-year later. Blood pressure (BP) levels were clearly reduced in the intervention group, while only minor changes were observed in the control group. The net changes between the two groups both for systolic and diastolic BPs were -2.1 mmHg (95% confidence intervals (CI) -4.0 to -0.1) and -1.5 mmHg (95% CI -2.6 to -0.4), respectively. The net changes were greater among men than women. The multidisciplinary lifestyle intervention in a rehabilitation centre setting produced significant reductions in BP among middle-aged employees with hypertension.

Psychotropics among the home-dwelling elderly--increasing trends.

OBJECTIVE: To assess the level of and changes in the use of psychotropics among the home-dwelling elderly in the 1990s. METHODS: A descriptive analysis based on data from two cross-sectional interview and health examination surveys of elderly persons aged 64 years or over conducted in Lieto, a typical semi-rural Finnish municipality, in 1990-91 and 1998-99. National prescription data were utilized to compare the use of psychotropics in the late 1990s by all Finnish home-dwelling elderly and the elderly in Lieto. In Lieto drug information was obtained from 1131 persons in 1990-91 and from 1197 in 1998-99, and the mean age of the informants was 73 years in both surveys. The brand names of the prescription drugs (both irregular and regular medication) taken by each interviewee during seven days prior to the interview were recorded and categorized by the Anatomical Therapeutic Chemical (ATC) classification system. RESULTS: Every fourth person was taking at least one psychotropic drug in both surveys. Most users were on regular psychotropic medication. The use of hypnotics and antidepressants increased most during the study period. Polypharmacy and the use of psychotropics were most prevalent among those aged 85 years or over, with women predominating. Concomitant use of two or more psychotropics increased statistically significantly from 7% to 10% between the surveys. The young elderly, aged 64-71 years, used cyclic antidepressants equally commonly in both surveys. None of the young elderly used new atypical antipsychotics in 1998-99. CONCLUSIONS: Psychotropics tend to be overprescribed and overused among the elderly, a group at the highest risk of adverse drug reactions. The tendency of prescribing for the elderly is not going in a better direction. New-generation psychotropics were not used. The need for long-standing use of psychotropics should be assessed regularly.

Recent decline in heavy outdoor work activity predicts occurrence of fractures among the home-dwelling elderly.

The contribution of reduced physical activity of a defined duration to the risk of fall-related fractures and serious soft tissue injuries is not known. We conducted a prospective population-based study among the home-dwelling elderly to examine the association between a recent decline in physical activity and the occurrence of fall-related fractures and soft tissue injuries. The study population consisted of representative sample of home-dwelling older adults who conducted heavy outdoor work activity at least once a week at baseline (n = 284; 136 men, 148 women) and among whom in 93 persons (33%) heavy outdoor work activity was found to have declined during the 2 1/2 years follow-up. Fall-related fractures (n = 24) and serious soft tissue injuries (n = 49) were recorded from the time of the follow-up examination until the end of a further follow-up period lasting 3 1/2 years on average. A decline in heavy outdoor work activity did not predict the occurrence of soft tissue injuries (Mantel-Cox 0.795, p = 0.373), but a greater proportion of those with a decline (n = 14, 15%) than of others (n = 10, 5%) suffered fractures (Mantel-Cox 10.231, p = 0.001). Other risk factors for fractures were female sex (p = 0.03), slow choice reaction time (p = 0.02) and dependency as regards at least one basic activity of daily living (p = 0.01). According to the Cox proportional hazard model, the adjusted hazard ratio of fracture as regards a decline in heavy outdoor work activity was 2.7 (95% CI 1.14-6.62). A recent decline in heavy outdoor work activity predicts the occurrence of fractures, but not the occurrence of serious soft tissue injuries. Early recognition of a decline in physical activity may help in prevention of fractures among the elderly.

Ambulatory blood pressure characteristics in normotensive and treated hypertensive older people.

The objective of this study was to determine the normal values and characteristics of 24-h ambulatory blood pressure (ABP) and to describe the ABP level of treated hypertensive subjects in an older Finnish population. ABP was measured in 502 randomly selected subjects aged 64 years or over living in a Finnish municipality (mean age 70 years, range 64-87 years). A total of 211 subjects did not have blood pressure (BP) affecting medication. ABP measurements were taken every 30 min for 24 h, and the day- and night-time periods were diary-based. The results were that in untreated subjects, the average office BP was 134/82 +/- 16/9 (s.d.) mm Hg for men and 140/81 +/- 18/8 mm Hg for women. The 24-h average BP was 120/75 +/- 14/8 mm Hg (95th percentile upper limit 145/93 mm Hg) for men and 125/75 +/- 15/7 (95th = 154/89 mm Hg) for women. The daytime averages were 127/78 +/- 12/7 mm Hg (95th = 154/99 mm Hg) and 131/78 +/- 15/7 mm Hg (95th = 158/91 mm Hg) for men and women, respectively. The ABP daytime value of 130/83 mm Hg corresponded best to the office BP value of 140/90 mm Hg. All BP values were significantly higher in the treated hypertensive group compared to the normotensive group. Night-time BP was markedly lower than daytime BP, and no difference in circadian variability was found between the normotensive and hypertensive subjects. Both office and ambulatory BPs were significantly higher in women than in men. This study provides sex-specific normal values for ABP in a 64 to 87-year-old age group. The normal values of ABP were markedly lower than the office BP values. Hypertensives, even when treated, tended to have elevated values.

Ambulatory blood pressure and left ventricular mass in older age.

BACKGROUND: The purpose of this study was to analyse the association of ambulatory blood pressure (ABP) to left ventricular mass (LVM) in a population aged over 64 years and to describe the level of ABP in subjects with and without left ventricular hypertrophy (LVH) in older age. METHODS: ABP measurement and echocardiography for calculation of LVM were assessed in 490 inhabitants (mean age 70.7 years, range 64-87 years) of a small town in southwestern Finland who were able to visit an outpatient clinic. Explanatory factors associated with LVM were assessed with linear regression analysis. LVH was defined as calculated LVM-index values exceeding 150 g/m2 in men and 120 g/m2 in women adopted from the Framingham Study. RESULTS: Systolic ABP was significantly associated with LVM. No correlation between diastolic ABP and LVM was found. Other factors independently related to LVM were gender, body mass index and age. The prevalence of echocardiographic LVH was 22%. Subjects with LVH had markedly higher systolic ABP levels than those without LVH (mean (SD) 24-h ABP: 132(16)/75(8) mmHg vs. 123(13)/75(8) mmHg). CONCLUSION: Systolic ABP is associated with LVM in older people. In addition, systolic ABP is superior to diastolic ABP in relation to LVM in the aged.

Prevalence of disability in three birth cohorts at old age over time spans of 10 and 20 years.

The prevalence of disability at the age of 75+ measured by the Katz Index of Activities of Daily Living (ADL) was compared among three birth cohorts: those born < or = 1903 (n = 348), those born < or = 1913 (n = 586), and those born < or = 1923 (n = 758). Significant risk factors for disability were female sex and age; the cohort effect was not significant. The prevalence rates of disability were 29.0% (95% CI 24.2-33.8), 34.8% (30.9-38.7), and 28.8% (25.5-32.0) for the first, second, and third cohorts. In the age group 75-79 years the rates were 20.1% (95% CI 13.8-26.4), 25.5% (20.2-30.7), and 14.4% (10.6-18.1). The change was due to the declining disability of women. The distributions in the three cohorts based on the numbers of ADL limitations did not differ. As far as the whole aged populations were concerned, longer life was not accompanied by improving health.