Fall-related brain injuries and the risk of dementia in elderly people: a population-based study.

Severe head injury in early adulthood may increase the risk of dementia in older age, but it is not known whether head injury in later life also increases the risk of dementia. A representative sample (82%) of persons aged 70 years or older with a Mini-Mental State Examination (MMSE) test score of > or =26 (n = 325) were followed-up for 9 years to record all their fall-related head injuries resulting in traumatic brain injury (TBI). At the end of the follow-up period, 152 persons (81% of the surviving population) were examined for clinical dementia, according to DSM-IV criteria. Eight persons sustained a TBI and 34 developed dementia. Brain injury was associated with younger age at detection of dementia even when adjusted for sex and educational status (low educational status significantly associated with dementia); age-specific hazard ratio (95% confidence interval) 2.80 (1.35-5.81). In a population scoring > or =28 points in the baseline MMSE an apolipoprotein E (ApoE) epsilon4 phenotype was also associated with younger age at the time of detecting dementia; 3.56 (1.35-9.34), and the effect of brain injury and ApoE epsilon4 phenotype was synergistic; 7.68 (2.32-25.3). We conclude that fall-related TBI predicts earlier onset of dementia and the effect is especially high amongst subjects who carry the ApoE epsilon4 allele.

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.

Fracture risk associated with a fall according to type of fall among the elderly.

The kinetic energy and direction of a fall contribute to the occurrence of fracture. However, the fracture risk associated with different types of fall, different amounts of energy and different landing directions is poorly understood. We recorded all falls and fall-related fractures over 7 years in an aged semi-rural home-dwelling population (n = 980), using intensive fall recording. The falls were classified according to type and place of occurrence into slip falls (SLFs), trip falls (TRFs), other extrinsic falls on the level (OEFs), intrinsic falls on the level (IFs), stair falls (STFs), falls from an upper level (ULFs) and nondefined falls (NDFs) occurring indoors or outdoors. Incidences of falls and fractures were calculated for the whole follow-up period. The population was clinically examined to assess general risk factors of fracture, after which the risk of fracture was determined in the first fall according to the different fall types. Comparison was made with intrinsic falling on the level. The overall incidences of indoor and outdoor falls were 328 (95% CI 314-345) and 198 (186 210) per 1000 person-years (PY), respectively, and those of fractures 23 (19-27) and 11 (8-4) per 1000 PY, respectively. Indoor SLFs, TRFs, OEFs, IFs, STFs, ULFs and NDFs occurred relatively evenly throughout the study period. The crude and adjusted relative fracture risks were greater in SLFs, OEFs and STFs compared with IFs. Indoor falls and fractures are more common than those occurring outdoors in aged home-dwelling persons. The kinetic energies produced in SLFs, OEFs and STFs may be higher than those generated in IFs, leading to increased risk of fracture.

High-intensity physical training in adults with asthma. A 10-week rehabilitation program.

Twenty-six adults (23 to 58 years) with mild to moderate asthma underwent a 10-week supervised rehabilitation program, with emphasis on physical training. In the first 2 weeks, they exercised daily in an indoor swimming pool (33 degrees C) and received education about asthma, medication, and principles of physical training. In the following 8 weeks, they exercised in the pool twice a week. Every training session lasted 45 min. The training sessions were made as suitable as possible for the individual subjects, in order to minimize "drop outs" from the program. The aim of the study was to evaluate the efficacy of the rehabilitation program and to determine if inactive asthmatic adults can exercise at high intensity. The rehabilitation program was preceded by a 6-min submaximal cycle ergometry test, a 12-min walking test, spirometry, and a methacholine provocation test. The subjects also responded to a five-item questionnaire related to anxiety about exercise, breathlessness, and asthma symptoms using a visual analogue scale. All subjects were able to perform physical training at a very high intensity, to 80 to 90% of their predicted maximal heart rate. No asthmatic attacks occurred in connection with the training sessions. Twenty-two of the 26 subjects completed the rehabilitation program, felt confident with physical training, and planned to continue regular physical training after the 10-week program. Improvements in cardiovascular conditioning, measured as a decreased heart rate at the same load on the cycle ergometer (average of 12 beats/min), and as a longer distance at the 12-min walking test (average of 111 m), were observed during the program. FEV1 increased significantly from 2.2 to 2.5 L. Forced expiratory flow at 25% of vital capacity also increased slightly but significantly. Methacholine provocation dose causing a fall in FEV1 by 20% was unchanged. Seventeen subjects had a peak expiratory flow reduction of more than 15% after the preprogram ergometry test and were classified as having exercise-induced asthma (EIA). Only three of these subjects had EIA after 10 weeks. The asthmatic subjects were less afraid of experiencing breathlessness during exercise and less anxious about exercising at a high intensity after 10 weeks (p < 0.05). The asthma symptoms abated significantly during the rehabilitation program and the subjects needed less acute asthma care after the rehabilitation program. The results indicate that asthmatic persons benefit from a rehabilitation period, including physical training. Rehabilitation programs are therefore of value as a supplement to conventional pharmacologic treatment of asthma. This rehabilitation program can be adapted for use in clinical practice.

Effects of positive expiratory pressure (PEP), continuous positive airway pressure (CPAP) and hyperventilation in COPD patients with chronic hypercapnea.

We have studied the effects of positive expiratory pressure (PEP), continuous positive airway pressure (CPAP) and hyperventilation on 9 hypoxemic and hypercapnic chronic obstructive pulmonary disease (COPD) patients. All the patients were in a stable condition and received continuous oxygen. PEP and nasal CPAP were each given for 3 days in random order once every hour during the day and 3 times overnight. The effects of treatment were compared with a 3-day period in which the patients had no treatment for CO2 elimination. The effects were based on transcutaneous measurements of PO2 (PtcO2), PCO2 (PtcCO2) and SO2 (SpO2) and arterial blood gas measurements. The transcutaneous measurements showed that the PEP treatment reduced the PtcCO2 in COPD patients by 0.5 kPa and the CPAP treatment reduced it by 0.1 kPa (p < 0.05). The hyperventilation maneuver caused a decrease in the PtcCO2 of 0.7 kPa. The nocturnal treatments and measurements were all similar to the daytime measurements; the PtcCO2 decreased by 0.6 kPa using PEP and by 0.3 kPa using CPAP (p < 0.01). This indicated that all 3 methods reduced the PtcCO2, but only in the short term as the effects lasted for less than 4 min. COPD patients had no "late response" after any form of treatment. Arterial blood gases in COPD patients showed an elevation in PaCO2 (1.2 kPa) and a decrease in PaO2 and SaO2 during the night (11 pm to 7 am) without treatment. After 3 days of treatment with PEP and CPAP, the same pattern was noticed. The PaCO2 increased with both therapies, 1.3 kPa with PEP and 0.6 kPa with CPAP. Our data indicate that the effects were not of clinical significance and there is no justification for treating stable hypercapnic COPD patients with these methods.

Dyspnea in acute asthma: relationship with other clinical and physiologic variables.

This investigation comprised 58 patients (35 men, mean age 61 years) with acute asthma: mean FEV1 35% of the predicted. The dyspnea score (Borg's scale), breathing rate, pulse rate, blood pressure, FEV1, and PEF were measured on arrival and 30, 60, and 150 minutes after bronchodilator treatment. The level of clinical severity was evaluated using Hedstrand's asthma severity scale. The variables that correlated most closely with dyspnea score at arrival were asthma severity score (r = .51 P < .001) and breathing rate (r = .38, P < .01). The measurement of airflow obstruction with the closest correlation to improvement in dyspnea was FEV1 expressed as a percentage of the pretreatment value (r = -.30* after 30 min, r = -.42** after 60 and r = -.34* after 150 minutes, *P < .05, **P < .01). When examining the intraindividual correlation between the change in dyspnea score and FEV1, a correlation coefficient of more than 0.80 was found in 74% of the patients. Of 18 patients with an increase in FEV1 of less than 20% of baseline, 11 had a decrease in dyspnea score in 3 or more categories. We conclude that there is a discrepancy in the treatment of acute asthma between the effect on dyspnea and airflow obstruction, the clinical implication of which remains to be investigated.

Blood eosinophil count as risk factor for relapse in acute asthma.

In this retrospective investigation comprising 54 adult patients included in two studies of the treatment of acute asthma, the risk of relapse was studied. The set of variables that best predicted the length of time before a new asthmatic attack comprised blood eosinophil count (P less than 0.001), FEV1 on arrival (P less than 0.001) and increased medication on discharge (P less than 0.01). The set of variables that best predicted the number of new attacks during a period of 1 yr consisted of eosinophil count (P less than 0.001), FEV1 (P less than 0.001), increased medication on discharge, age and breathing rate on arrival (P less than 0.05). Patients with an eosinophil count of more than 500 x 10(6) l-1 and a FEV1 of less tha 1.0 l ran a six-fold greater risk of returning with a new attack within 1 month than patients with lower eosinophil count and higher FEV1. No significant correlation was found between post-treatment PEF variation and relapse in acute asthma.

Plasma terbutaline levels in nebulisation treatment of acute asthma.

A study was made of the effects of inhaling 5 mg of terbutaline and 0.5 mg of ipratropium bromide in 11 patients arriving at our emergency room with acute asthma (FEV1 less than or equal to 50% of the predicted). Measurable plasma levels of terbutaline before treatment were found in all patients who reported having taken oral terbutaline (mean value 30 nmol/l, range 11-89). A significant correlation was found between the reported terbutaline medication and the measured terbutaline plasma concentration (p less than 0.01). Plasma terbutaline had increased by 6-20 (mean 15) nmol/l 60 min after the start of treatment and by 6-45 (mean 14) nmol/l at 120 min, compared with the pre-treatment value. A highly significant decrease in dyspnoea and an increase in PEF and FEV1 was measured (p less than 0.01) after treatment, while no significant changes in respiratory rate, pulse rate, blood pressure or tremor were recorded. A significant positive correlation was found between delta plasma terbutaline and delta systolic blood pressure 120 min after treatment (p less than 0.05), but apart from this no statistically significant correlations were found between plasma terbutaline on arrival or delta plasma terbutaline and the other measurements of the effect of treatment. One of the advantages of adding ipratropium to nebulised beta-agonist treatment might be that it permits the use of lower doses of beta 2-agonist and thereby reduces the systemic side-effects of the treatment.

Nebulization versus injection in ambulatory treatment of acute asthma: a comparative study.

Nebulization treatment of acute asthma with terbutaline and ipratropium bromide, given either separately with a 30-minute interval or combined as single inhalation, was compared with injection treatment with a combination of terbutaline given subcutaneously and theophylline given intravenously. Seventy-seven episodes of acute asthma were studied. Nebulization treatment gave the same degree of bronchodilation as the injections, both immediately after treatment [measured as increase in forced expiratory volume in 1 second (FEV1) in peak expiratory flow rate (PEFR) and improvement of dyspnoea] and during the following 6 days (measured by PEFR recordings at home). The injection treatment caused a moderate increase in heart rate, whereas no circulatory side-effects were noted during nebulization treatment. Administration of ipratropium bromide 30 minutes after terbutaline was not more effective than the combination of both substances as a single nebulization.

Chest physiotherapy. Evaluation by transcutaneous blood gas monitoring.

Two respiratory physiotherapy methods were evaluated by analyzing changes in the transcutaneous partial pressure of CO2 (tcPCO2) in 15 patients with respiratory insufficiency. All were receiving continuous oxygen therapy and had CO2 retention. The physiotherapy methods compared were thoracic compression (TC) and positive expiratory pressure (PEP). The mean decrease (+/- SD) in tcPCO2 was the same with both methods, 0.6 +/- 0.4 kPa, but there were interindividual differences. This study indicates that both TC and PEP effectively decrease tcPCO2, although only temporarily in many cases. Continuous tcPCO2 monitoring is a useful clinical method for determining and teaching optimal respiratory therapy.