Primitive reflexes and dementia in older adults: a meta-analysis of observational and cohort studies.

Primitive reflexes (PRs) are clinical signs that indicate diffuse cerebral dysfunction and frontal lesions. We aimed to present a comprehensive analysis of the prevalence and risk of PRs in patients with dementia. English-language articles published from January 1990 to April 2021 were searched in PubMed, ScienceDirect, Cochrane, and Web of Science with keywords. The titles and abstracts of the identified articles were screened to identify potentially relevant papers. Odds ratios and risk ratios were extracted with 95% confidence intervals and combined using the random-effects model after logarithmic transformation. The prevalence in dementia patients was also combined using the random-effects model. This meta-analysis involved 29 studies. The snout reflex (48% of cases) was the most prevalent. It was found that the risk of PRs in individuals with dementia was significantly elevated, ranging from 13.94 to 16.38 times higher than in healthy controls. The grasp reflex exhibited the highest risk for dementia. This meta-analysis showed that the prevalence and the risk of PRs is high in older patients with dementia. Therefore, PRs, especially the grasp reflex, should be carefully assessed as a part of routine physical examination in the diagnostic process for dementia.

Orthostatic hypotension in dementia with Lewy bodies: a meta-analysis of prospective studies.

PURPOSE: Orthostatic hypotension (OH), one of the supportive clinical features in the diagnosis of dementia with Lewy bodies (DLB), is a significant problem in advanced age because of its severe negative consequences. The aim of this meta-analysis was to investigate the prevalence and risk of OH in patients with DLB. METHODS: The indexes and databases cited to identify relevant studies were PubMed, ScienceDirect, Cochrane, and Web of Science. The keywords for the search were "Lewy body dementia" and "autonomic dysfunction" or "dysautonomia" or "postural hypotension" or "orthostatic hypotension." English-language articles published from January 1990 to April 2022 were searched. The Newcastle-Ottawa scale was applied to evaluate the quality of the studies. Odds ratios (OR) and risk ratios (RR) were extracted with 95% confidence intervals (CI) and combined using the random effects model after logarithmic transformation. The prevalence in the patients with DLB was also combined using the random effects model. RESULTS: Eighteen studies (10 case controls and 8 case series) were included to evaluate the prevalence of OH in patients with DLB. Higher rates of OH were found to be associated with DLB (OR 7.71, 95% CI 4.42, 13.44; p < 0.001), and 50.8% of 662 patients had OH. CONCLUSION: DLB increased the risk of OH by 3.62- to 7.71-fold compared to healthy controls. Therefore, it will be useful to evaluate postural blood pressure changes in the follow-up and treatment of patients with DLB.

Transanal endorectal or transabdominal pull-through for Hirschsprung's disease; which is better? A systematic review and meta-analysis.

AIM: Hesitations concerning the long-term results of transanal endorectal pull-through (TEPT) due to prolonged anal stretching and resultant stricture and continence problems has been started to be questioned. This meta-analysis intended to compare long-term results between TEPT and transabdominal (TAB) pull-through techniques in the surgical management of Hirschsprung's disease. METHODS: All publications between the years 1998-2021 in the PubMed, Medline, Google Scholar, Cochrane databases were reviewed. Retrospective and prospective comparative studies for TEPT, TAB as well as Laparoscopic-assisted TEPT (LTEPT) were included. Data included age at operation, postoperative constipation, enterocolitis, incontinence, stricture, and soiling rates. RESULTS: Eighteen publications met the inclusion criteria for TAB and TEPT, and six for TEPT and LTEPT. Patients who underwent TEPT had significantly younger operation age than patients with TAB (SMD - 1.02, 95%Cl - 1.85 to - 0.18, p: 0.0168). Postoperative constipation (OR 0.39, 95% Cl 0.25-0.61 p < 0.0001) and enterocolitis (OR 0.65, 95% Cl 0.46-0.90, p: 0.0108) rates were significantly lower in TEPT groups. Postoperative incontinence (OR 1.06, 95% Cl 0.56-2.01, p: 0.8468), stricture (OR 1.97, 95% Cl 0.81-4.80, p: 0.1352) and soiling rates were similar between the two groups. Furthermore, when TEPT and LTEPT results were compared, incidence of incontinence (OR 7.01, 95% Cl 0.75-65.33, p: 0.0871), constipation (OR 1.95, 95% Cl 0.70-5.37, p: 0.199), enterocolitis (OR 3.16, 95% Cl 0.34-29.55 p: 0.3137), stricture (OR 1.33, 95% Cl 0.29-6.15, p: 0.7188) and soiling (OR 1.57, 95% Cl 0.57-4.31, p: 0.3778) were similar for both techniques. DISCUSSION: TEPT is superior to TAB in terms of constipation and enterocolitis. Contrary to concerns, postoperative incontinence rates are not statistically different. However, further publications about long-term LTEPT results are necessary for more reliable conclusions.

E-mail-based health care in patients with dementia during the pandemic.

Introduction/aim: Frail and cognitively impaired older patients are particularly vulnerable groups during the pandemic. Lockdowns, social isolation, and physical inactivity considerably affect physical and mental wellbeing. During the pandemic process, routine medical checks and acute medical care services may be disrupted. The study aimed to demonstrate the feasibility and effectiveness of telemedicine in the delivery of healthcare services to elderly patients during the pandemic. Materials and methods: E-mails sent to the e-mail address of the department of geriatrics, which has been actively used for 4 years, between April 2020 and June 2021, were retrospectively evaluated. The time and reason for each application, referral to the patients, demographic data of the patients, and chronic diseases were recorded. E-mail frequencies were considered monthly time series, and time series charts for e-mail frequencies from patients were produced. Results: A total of 374 e-mails that 213 patients sent were assessed. A vast majority, 97.6% of the e-mails, were sent by proxies. The mean age of patients was 78.7 ± 8.1 years, and 59.2% were women. Hypertension and dementia were the most common comorbidities. The applications mostly occurred in April-May and October-November 2020. The most common complaint in dementia was behavioral disturbances (13.6%). Geriatric outpatient appointments were arranged for 29.9% of the applicants, 14.2% were referred to the emergency department, and 23.0% were offered medical treatment. Outpatient examination and treatment were completed in 15% of the patients and 10.4% of them were hospitalized. The time series charts showed that e-mails were sent more frequently by patients with dementia than the others (p = 0.03). Conclusions: Telemedicine, which enables many problems of patients to be solved in geriatric practice without face-to-face appointments, can also prevent infections and unnecessary hospitalizations, especially during these unusual pandemic days.

A Comparison of Cerebrospinal Fluid Beta-Amyloid and Tau in Idiopathic Normal Pressure Hydrocephalus and Neurodegenerative Dementias.

Purpose: Idiopathic normal pressure hydrocephalus (iNPH) is the leading reversible cause of cognitive impairment and gait disturbance that has similar clinical manifestations and accompanies to major neurodegenerative disorders in older adults. We aimed to investigate whether cerebrospinal fluid (CSF) biomarker for Alzheimer's disease (AD) may be useful in the differential diagnosis of iNPH. Patients and Methods: Amyloid-beta (Aß) 42 and 40, total tau (t-tau), phosphorylated tau (p-tau) were measured via ELISA in 192 consecutive CSF samples of patients with iNPH (n=80), AD (n=48), frontotemporal dementia (FTD) (n=34), Lewy body diseases (LBDs) (n=30) consisting of Parkinson's disease dementia and dementia with Lewy bodies. Results: The mean age of the study population was 75.6±7.7 years, and 54.2% were female. CSF Aß42 levels were significantly higher, and p-tau and t-tau levels were lower in iNPH patients than in those with AD and LBDs patients. Additionally, iNPH patients had significantly higher levels of t-tau than those with FTD. Age and sex-adjusted multi-nominal regression analysis revealed that the odds of having AD relative to iNPH decreased by 37% when the Aß42 level increased by one standard deviation (SD), and the odds of having LBDs relative to iNPH decreased by 47%. The odds of having LBDs relative to iNPH increased 76% when the p-tau level increased 1SD. It is 2.5 times more likely for a patient to have LBD relative to NPH and 2.1 times more likely to have AD relative to iNPH when the t-tau value increased 1SD. Conclusion: Our results suggest that levels of CSF Aß42, p-tau, and t-tau, in particularly decreased t-tau, are of potential value in differentiating iNPH from LBDs and also confirm previous studies reporting t-tau level is lower and Aß42 level is higher in iNPH than in AD.

The relationship between morning blood pressure surge and asymptomatic episodes of paroxysmal atrial fibrillation in patients with systemic arterial hypertension.

BACKGROUND: Hypertension is a known risk factor for developing atrial fibrillation. However, there is limited data to investigate the association between morning blood pressure surge (MBPS) and paroxysmal atrial fibrillation (PAF). We conducted the present study to determine whether there is a relationship between asymptomatic PAF and MBPS and whether MBPS may be a predictor of asymptomatic PAF episodes. METHODS: This prospective study comprised 264 adult patients who were newly diagnosed with essential hypertension or were previously diagnosed but not receiving regular antihypertensive therapy. We evaluated the patients in 2 groups according to their 24-h electrocardiography monitoring results: group 1 included patients who exhibited PAF (n = 32, 23 females/9 males; mean age 60.2 ± 7.4 years) and group 2 included patients with no signs of PAF as a control group (n = 232, 134 females/98 males; mean age 56.9 ± 9.4 years). We calculated the MBPS as the difference between mean systolic blood pressure (SBP) in the 2 h after getting up and the minimum nocturnal SBP. RESULTS: : MBPS values were significantly higher in group 1 than in group 2 (35.3 ± 7.0 vs. 22.0 ± 6.7, p < 0.001). MBPS was positively associated with left atrial diameter (LAD) (r = 0.441, p < 0.001), left ventricle mass index (LVMI) (r = 0.235, p < 0.001), the ratio of early (E) peak of mitral inflow velocity to early (Em) diastolic mitral annular velocity (E / Em) (r = 0.239, p < 0.001), 24-h mean (r = 0.270, p < 0.001) and daytime SBP (r = 0.291, p < 0.001). We determined a cut-off value for MBPS as 28.6 for predicting PAF episodes development and identified LAD and MBPS as independent risk factors for PAF. DISCUSSION: Patients who had larger MBPS were observed to have higher PAF incidence. MBPS values may be sensitive in predicting asymptomatic episodes of paroxysmal atrial fibrillation.

Orthostatic hypotension in patients with Alzheimer's disease: a meta-analysis of prospective studies.

BACKGROUND: Orthostatic hypotension (OH) is a clinical sign associated with severe adverse health outcomes in older adults. It has been reported to be common in patients with Alzheimer's disease (AD). The present meta-analysis aimed to investigate the prevalence and risk of OH in AD patients. METHODS: English-language articles published from January 1990 to August 2020 were searched in PubMed, ScienceDirect, Cochrane, and Web of Science with the keywords "Alzheimer" and "autonomic dysfunction" or "dysautonomia" or "postural hypotension" or "orthostatic hypotension." All prospective clinical studies (case-control, cohort, and cross-sectional studies, and randomized controlled trials) that were regarded as pertinent were included in this study. For quality assessment, the Newcastle-Ottawa Scale was used. Odds ratios (OR) and risk ratios (RR) were extracted with 95% confidence intervals (CI) and combined using the random effects model after logarithmic transformation. The prevalence in the AD patients was also combined using the random effects model. RESULTS: The meta-analysis involved 11 studies (7 case-control and 4 case series) to assess the risk of OH in AD. It was found that AD increased the risk of OH with an RR of 1.98 (95% CI: 0.97-4.04) and an OR of 2.53 (95% CI:1.10-5.86) compared to healthy controls, and OH was present in 28% (95% CI: 0.17-0.40) of 500 AD patients. CONCLUSION: There is an elevated risk of OH in AD by nearly 2.5-fold. Therefore, the evaluation of postural blood pressure changes should definitely be among the follow-up and treatment goals of AD.

Comparison of forecast accuracy of Ata and exponential smoothing.

Forecasting is a crucial step in almost all scientific research and is essential in many areas of industrial, commercial, clinical and economic activity. There are many forecasting methods in the literature; but exponential smoothing stands out due to its simplicity and accuracy. Despite the facts that exponential smoothing is widely used and has been in the literature for a long time, it suffers from some problems that potentially affect the model's forecast accuracy. An alternative forecasting framework, called Ata, was recently proposed to overcome these problems and to provide improved forecasts. In this study, the forecast accuracy of Ata and exponential smoothing will be compared among data sets with no or linear trend. The results of this study are obtained using simulated data sets with different sample sizes, variances. Forecast errors are compared within both short and long term forecasting horizons. The results show that the proposed approach outperforms exponential smoothing for both types of time series data when forecasting the near and distant future. The methods are implemented on the U.S. annualized monthly interest rates for services data and their forecasting performance are also compared for this data set.

Long-term effects of vitamin D deficiency on gait and balance in the older adults.

BACKGROUND & AIMS: Vitamin D deficiency is a public health problem. The resulting data showed that vitamin D is associated not only with calcium homeostasis, skeletal muscle health, but also with some chronic diseases. The aim of the study was to investigate long-term effects of vitamin D deficiency on gait-balance parameters in older adults. METHODS: 370 patients who applied to the geriatric outpatient clinic three times at six-months intervals and underwent comprehensive geriatric assessment (CGA), were retrospectively screened. Patients, whose sociodemographic characteristics, systemic diseases and laboratory findings were reviewed, were divided into 3 groups according to basal serum 25-hydroxy D vitamin [25(OH)D] level: Group 1 (<10 ng/mL), Group 2 (10-20 ng/mL), Group 3 (≥20 ng/mL). The balance-gait performance of patients, the 25(OH)D level of whom reached to the sufficient level at the end of 12th month, was compared to other patients by the Performance Oriented Mobility Assessment (POMA) scale. RESULTS: Demographic characteristics and systemic diseases were similar in the groups except for education (p > 0.05). At baseline, Group 1 had lower Basic and Instrumental Activities of Daily Living (ADL), POMA balance and total score (p < 0.05). At the end of 12th month, POMA balance and total scores improved in the Group 1 patients who reached a sufficient 25(OH)D level, however these scores failed to catch Group 3 (p < 0.05). The basal, 6th and 12th month evaluations of three groups showed that mean POMA balance, gait and total scores were better in patients whose 25(OH)D level was ≥20 ng/mL. CONCLUSIONS: Vitamin D replacement, especially to severe deficient patients, may improve balance and gait functions in older adults. Therefore, vitamin D deficiency should be screened routinely and treated effectively.

Validation of population-based cutoffs for low muscle mass and strength in a population of Turkish elderly adults.

BACKGROUND: Despite differences between the studies regarding methods for estimating low muscle mass, the European Working Group on Sarcopenia in Older People (EWGSOP) recommends use of two standard deviations (SDs) below the reference sex-specific means of healthy young adults. AIMS: The aim of this study was to determine the cutoff points of skeletal muscle mass index (SMI) and handgrip strength (HS) in Turkish population and to compare the power of different cutoff points to predict comprehensive geriatric assessment (CGA) parameters. METHODS: Two hundred and eight young healthy volunteers (104 women, 104 men) were included in the study to define SMI, HS cutoff values. 1150 older adults (784 women, 366 men) underwent CGA, including physical performance, activities of daily living (ADL), HS and frailty. Body composition was obtained from every participant by bioimpedance analysis (BIA). CGA parameters of sarcopenic patients according to EWGSOP and new Turkish cutoff points were compared. RESULTS: SMI cutoff points were defined 5.70 kg/m2 for women, 8.33 kg/m2 for men. HS thresholds were calculated as 14 kg for women, 28 kg for men using measurements of healthy young adult reference. Considering the new threshold values, the prevalence of sarcopenia was 10% (7% women, 17% men). When new sarcopenia criteria were applied and covariates were adjusted, sarcopenia was found to be more closely related to ADL impairment, balance, frailty in men, and balance, slow walking speed, ADL impairment, frailty in women (p < 0.05). DISCUSSION: Muscle mass and strength may vary between populations because of ethnicity and other related discrepancies. The evaluation of sarcopenia according to the present guidelines may cause overdiagnosis in some populations. CONCLUSION: Cutoff points specific to populations should be determined.

Factors that Increase Risk of Falling in Older Men according to Four Different Clinical Methods.

Background: Falling is an important health problem for older men. In this study, we aim to identify factors that increase risk of falling in only older men using four different fall risk assessment methods.Method: 334 men, who attended a geriatric outpatient clinic and underwent comprehensive geriatric assessment, were included in the study. History of falling last year, the Timed Up and Go test, Performance-Oriented Mobility Assessment, and 4-meter walking speed test were carried out on all patients.Results: The mean age (SD) of patients were 74.99 (7.26) years. According to all of the four clinical assessments to predict risk of falling the following risk factors for falling were identified (all p < .05): cerebrovascular disease, urinary incontinence, dizziness and imbalance, high Geriatric Depression Scale (GDS) scores, low Mini-Mental State Examination (MMSE), and The Lawton-Brody Instrumental Daily Living Activity Scale (IADL) and Barthel index (BI) for daily living activities scores, Significant correlations were found between all the assessment methods (p < .001).Conclusion: There is a strong relationship between fall risk and cerebrovascular disease, urinary incontinence, dizziness and imbalance, high GDS scores, low MMSE, BADL and IADL scores in older men. Therefore, older men should be screened for these risk factors to prevent falls.

Assessment of factors that increase risk of falling in older women by four different clinical methods.

BACKGROUND: Women aged 65 years and over are at increased risk of falling. Falls in this age group increase the risk of morbidity and mortality. AIMS: The aim of the present study was to find the most common factors that increase the risk of falling in older women, by using four different assessment methods. METHODS: 682 women, who attended a geriatric outpatient clinic and underwent comprehensive geriatric assessment, were included in the study. History of falling last year, the Timed Up and Go (TUG) test, Performance-Oriented Mobility Assessment (POMA), and 4-m walking speed test were carried out on all patients. RESULTS: The mean age (SD) of patients were 74.4 (8.5) years. 31.5% of women had a history of falling in the last year. 11%, 36.5%, and 33.3% of patients had a falling risk according to POMA, TUG and 4-m walking speed test, respectively. We identified the following risk factors that increase the risk of falling, according to these four methods: urinary incontinence, dizziness and imbalance, using a walking stick, frailty, dynapenia, higher Charlson Comorbidity Index and Geriatric Depression Scale score, and lower basic and instrumental activities of daily living scores (p < 0.05). We found a significant correlation between all the assessment methods (p < 0.001). CONCLUSION: There is a strong relationship between fall risk and dizziness, using a walking stick, dynapenia, high number of comorbidities, low functionality, and some geriatric syndromes such as depression, frailty, and urinary incontinence in older women. Therefore, older women should routinely be screened for these risk factors.

Cumulative incidence regression for dynamic treatment regimens.

Recently dynamic treatment regimens (DTRs) have drawn considerable attention, as an effective tool for personalizing medicine. Sequential Multiple Assignment Randomized Trials (SMARTs) are often used to gather data for making inference on DTRs. In this article, we focus on regression analysis of DTRs from a two-stage SMART for competing risk outcomes based on cumulative incidence functions (CIFs). Even though there are extensive works on the regression problem for DTRs, no research has been done on modeling the CIF for SMART trials. We extend existing CIF regression models to handle covariate effects for DTRs. Asymptotic properties are established for our proposed estimators. The models can be implemented using existing software by an augmented-data approximation. We show the improvement provided by our proposed methods by simulation and illustrate its practical utility through an analysis of a SMART neuroblastoma study, where disease progression cannot be observed after death.

Effect of Vitamin D on Cognitive Functions in Older Adults: 24-Week Follow-Up Study.

The purpose of this study is to assess the effect of vitamin D replacement on cognitive function in older adults. A total of 560 patients who underwent comprehensive geriatric assessment including Global cognitive assessment, Basic Activities of Daily Living (BADL), and Instrumental Activities of Daily Living (IADL) twice in 6-month period were retrospectively reviewed. Oral cholecalciferol was replaced to patients with vitamin D deficiency routinely. In baseline cognitive scores, BADL-IADL scores were lower in the severe deficiency group than in the deficiency and adequate groups (P < .05). With regard to the relation between changes in cognitive functions, BADL-IADL scores on the 6-month versus baseline, no difference was determined in patients with and without dementia (P > .05). Vitamin D replacement may not improve cognitive performance in older adults, even if vitamin D is raised to adequate level, suggesting that longer term replacement therapy may be needed to improve cognitive function.

Decreased Basal Metabolic Rate Can Be an Objective Marker for Sarcopenia and Frailty in Older Males.

OBJECTIVES: The aim of this study is to demonstrate the ability of the basal metabolic rate (BMR) to detect frailty and sarcopenia in older males. SETTING AND PARTICIPANTS: A total of 305 male patients undergoing comprehensive geriatric assessment were included in the study. MEASURES: The frailty status was assessed with the Fried criteria. Sarcopenia was diagnosed according to the European Working Group on Sarcopenia in Older People criteria. BMR is calculated by bioimpedance analysis. Areas under the curves (AUCs) of receiver operating characteristic analyses were used to test the predictive accuracy of BMR in detecting sarcopenia. RESULTS: The mean age was 74.52 ± 7.51 years. Among the patients in the sample, 95 (31.1%) had sarcopenia and 55 (18%) had frailty. Patients who had a BMR <1612 kcal/d had a higher frequency of frailty than those who had a BMR ≥1612 kcal/d (67.3 vs 32.7, P < .001). Results were similar for sarcopenia (77.9 vs 22.1, P < .001). When BMR was divided by body surface area (BSA), BMR/BSA with a cut-off of 874 kcal/m2 had a sensitivity of 80% and a specificity of 68%, and the AUC was 0.82 for BMR/BSA, in diagnosing sarcopenia (P < .01). The participants without sarcopenia had a higher BMR/BSA for the unadjusted (OR = 8.00, 95% CI 4.52-14.19, P < .001) and adjusted analyses (OR = 6.60, 95% CI 3.52-12.38, P < .001). CONCLUSIONS: Older male patients with sarcopenia and frailty have a higher BMR reduction. Therefore, it should be kept in mind that patients with low BMR should alert us to screen sarcopenia and frailty. BMR/BSA may play a role in objective screening to detect sarcopenia in older males.