Prestroke physical function predicts stroke outcomes in the elderly.

OBJECTIVE: To determine whether physical function before stroke is an independent predictor of physical function and institutionalization 6 months after discharge from hospital in elderly stroke patients. DESIGN: Population-based prospective cohort design where incidence of stroke was monitored from 1982 through 1988. Baseline demographic and health information including prestroke function was collected prospectively. Eligible subjects who had a stroke were interviewed 6 months after discharge from hospital to assess outcomes. SETTING: New Haven, Connecticut. PATIENTS: Subjects were recruited from an initial sample of 2,812 older adults. Of 79 subjects who survived a first stroke at 6 months postdischarge, complete follow-up data were obtained on 63 subjects. MAIN OUTCOME MEASURE: Physical function as measured by the Katz scale and institutionalization. RESULTS: Fewer limitations in activities of daily living before stroke were associated with fewer limitation in physical function after stroke controlling for stroke severity and other relevant health and sociodemographic conditions (p < .01). Fewer limitations in gross mobility function before stroke were also independently associated with a lower risk of institutionalization (p < .05). CONCLUSION: This study provides useful information in assessing the prognosis of elderly stroke patients upon admission to hospital. It also supports the concept of general frailty being a risk factor for poorer health and institutionalization overall in aged persons. Studies have shown that factors related to physical frailty, such as decline in muscle function, can be reversed. The effect of interventions aimed at improving the physical function of the elderly on stroke incidence, stroke outcomes, and all-cause mortality, however, needs to be determined.

Depressive symptoms in the elderly: association with total white blood cell count.

1. The white blood cell (WBC) count in those with high depressive symptoms and non-depressed participants in the Established Populations for Epidemiologic Studies of the Elderly (EPESE) were compared. 2. Of 3769 participants 10.8% had high depressive symptoms as assessed by the Centers for Epidemiologic Studies Depression (CES-D) Scale. The mean white blood cell count was higher in the high depressive symptoms group compared to the non-depressed group (6.8 +/- 0.12 x 10(9) WBC/1 and 6.5 +/- 0.03 x 10(9) WBC/1, respectively, p < 0.01). 3. Because older adults frequently have disabling chronic conditions which could both influence their leukocyte count and cause depressive symptoms, models were developed which controlled for the potential confounding. Even after adjusting for potential confounders, high depressive symptoms were still associated with higher white blood cell counts.

Use of antihypertensive drugs and trends in blood pressure in the elderly.

BACKGROUND: During the 1980s data became available from randomized trials concerning the clear benefits of treating hypertension in the elderly. In three large communities, we examined the impact of these findings on rates of treatment, use of specific antihypertensive drugs, and rates of elevated blood pressure as well as distributions of levels. METHODS: In 1981 the National Institute on Aging initiated population-based cohort studies in the residents of three communities who were 65 years and older. East Boston, Mass; Washington and Iowa counties, Iowa; and New Haven, Conn. Participation rates ranged from 80% to 85% across sites with 10,294 community-dwelling participants in the combined cohorts. Baseline evaluation included inhome blood pressure assessment and medication inventory. Repeated in-home evaluations occurred 3 and 6 years after baseline and follow-up rates ranged from 71% to 88%. RESULTS: Use of antihypertensive drugs increased over time in all three communities: the age- and sex-adjusted rates of use were between 14% and 32% higher in 1988 and 1989 relative to 1982 and 1983. Parallel declines in the use of thiazide diuretics occurred in all three populations along with large increases in the use of angiotensin-converting enzyme inhibitors and calcium channel blockers. In East Boston and New Haven mean systolic blood pressure decreased substantially over time and the prevalence of elevated systolic pressure (> or = 160 mmHg) decreased overall as well as by age and sex. In Iowa the mean levels of systolic blood pressure were lowest at baseline and increased slightly. CONCLUSIONS: The reported evidence about the benefits of treatment for hypertension in the elderly was followed by substantial increases in treatment rates. The use of drugs with proven efficacy declined while the use of newer agents with theoretical advantages, not yet tested in clinical trials of mortality, increased. In the United States, the ongoing therapeutic efforts to lower elevated blood pressure in elderly populations may be contributing to the continuing decline in cardiovascular and stroke mortality.

Does weight loss from middle age to old age explain the inverse weight mortality relation in old age?

The authors examined body mass index at middle age, body mass index in old age, and weight change between age 50 years and old age in relation to mortality in old age. The study population from the Established Populations for Epidemiologic Studies of the Elderly consisted of 6,387 whites age 70 years or older who experienced 2,650 deaths during the period 1982-1987. Mortality risk was highest for persons in the heaviest quintile of body mass index at age 50 (men, relative risk (RR) = 1.33, 95% confidence interval (CI) 1.13-1.57; women, RR = 1.31, 95% CI 1.12-1.53) compared with persons in the middle quintile. This pattern was reversed for body mass index in old age, with persons in the lowest quintile having the highest mortality risk (men, RR = 1.40, 95% CI 1.19-1.65; women, RR = 1.38, 95% CI 1.17-1.63) relative to persons in the middle quintile. This reversal was explained, in part, by weight change. Compared with persons with stable weight, those who lost 10 percent or more of body weight between age 50 and old age had the highest risk of mortality (men, RR = 1.69, 95% CI 1.45-1.97; women, RR = 1.62, 95% CI 1.38-1.90). Exclusion of participants who lost 10 percent or more of their weight and adjustment for health status eliminated the higher risk of death associated with low weight. The inverse association of weight and mortality in old age appears to reflect illness-related weight loss from heavier weight in middle-age. Weight history may be critical to understanding weight and mortality relations in old age.

Intermittent claudication and subsequent cardiovascular disease in the elderly.

BACKGROUND: This study reports the prevalence of intermittent claudication (IC) in ambulatory community-resident adults age 65 years or older, compares cardiovascular risk factors and comorbidity of persons with and without IC, and examines the independent association of IC in predicting all cause and cardiovascular mortality, myocardial infarction, stroke, and disability. METHODS: Data are from a pooled sample of 8996 older adults from the East Boston, New Haven, and Iowa sites of the Established Populations for Epidemiologic Studies of the Elderly, conducted between 1982 and 1988. RESULTS: 2.4% and 1.5% of men and women, respectively, reported IC. Persons with IC had significantly higher rates of diabetes and cardiovascular comorbidity than persons without IC, and they were more likely to smoke. Claudication predicted higher rates of mortality, myocardial infarction, stroke, and disability independent of associated cardiovascular conditions and risk factors. Among persons with a history of angina, myocardial infarction, and/or stroke, those who reported IC had a twofold greater risk of cardiovascular mortality. CONCLUSION: The study demonstrated that IC is an important predictor of mortality and cardiovascular morbidity in ambulatory older adults independent of associated coronary ischemia and cardiovascular disease risk factors. Results suggest that inclusion of a measure of IC improves the prediction of cardiovascular morbidity and mortality in older adults.

Malnutrition and subsequent ischemic heart disease in former prisoners of war of World War II and the Korean conflict.

The harsh treatment of former prisoners of war (POWs) of World War II and the Korean conflict resulted in severe malnutrition. Although rarely linked to specific long-term medical problems, a specific marker of malnutrition, self-reported lower limb edema (presumably due to a vitamin B deficiency) was associated with a three-fold increase in subsequent death attributed to ischemic heart disease (IHD) during the follow-up period from 1967 through 1975. Although there is at present no medical basis for linking edema, which is perhaps a marker for some unmeasured risk factor, to subsequent IHD, this finding may nonetheless have medical implications for the group of former POWs and other populations with severe dietary deficiency. It also suggests there may be a need to reexamine currently held theories on malnutrition and subsequent chronic disease.

The health burden of diabetes for the elderly in four communities.

Although diabetes is a common health problem of the elderly, the impact of diabetes on health and functioning in older persons is not well established. The purpose of this analysis was to identify health conditions accompanying diabetes in four samples of community dwelling elderly people. The study samples consisted of 13,601 persons ages 65 or older who participated in the Established Populations for Epidemiologic Studies in the Elderly (EPESE). Extensive interviews were conducted in respondents' homes to obtain information on diabetes and other health conditions, health behaviors, use of health services, and demographic characteristics. A lifetime history of diabetes was reported by 14 percent of respondents. The prevalence of the disease was higher in blacks than whites, especially among women. Persons with diabetes were more likely to report myocardial infarction, stroke, vision problems, physical disability, incontinence, and nursing home stays than persons without diabetes, but the diabetics were less likely to consume alcohol or tobacco. Those with diabetes were only slightly heavier than those without diabetes at the time of the interview. However, body mass at age 50 was substantially greater among persons with diabetes. Associations between diabetes and other health conditions and behaviors were similar for whites and blacks. These results show that aged persons with diabetes experience substantial comorbidity, which has important ramifications for functioning and survival.

Lack of association between cholesterol and coronary heart disease mortality and morbidity and all-cause mortality in persons older than 70 years.

OBJECTIVES: To determine whether elevated serum cholesterol level is associated with all-cause mortality, mortality from coronary heart disease, or hospitalization for acute myocardial infarction and unstable angina in persons older than 70 years. Also, to evaluate the association between low levels of high-density lipoprotein cholesterol (HDL-C) and elevated ratio of serum cholesterol to HDL-C with these outcomes. DESIGN: Prospective, community-based cohort study with yearly interviews. PARTICIPANTS: A total of 997 subjects who were interviewed in 1988 as part of the New Haven, Conn, cohort of the Established Population for the Epidemiologic Study of the Elderly (EPESE) and consented to have blood drawn. MAIN OUTCOME MEASURES: The risk factor-adjusted odds ratios of the 4-year incidence of all-cause mortality, mortality from coronary heart disease, and hospitalization for myocardial infarction or unstable angina were calculated for the following: subjects with total serum cholesterol levels greater than or equal to 6.20 mmol/L (> or = 240 mg/dL) compared with subjects with cholesterol levels less than 5.20 mmol/L (< 200 mg/dL); subjects in the lowest tertile of HDL-C level compared with those in the highest tertile; and subjects in the highest tertile of the ratio of total serum cholesterol to HDL-C level compared with those in the lowest tertile. RESULTS: Elevated total serum cholesterol level, low HDL-C, and high total serum cholesterol to HDL-C ratio were not associated with a significantly higher rate of all-cause mortality, coronary heart disease mortality, or hospitalization for myocardial infarction or unstable angina after adjustment for cardiovascular risk factors. The risk factor-adjusted odds ratio for all-cause mortality was 0.99 (95% confidence interval [CI], 0.56 to 2.69) for the group who had cholesterol levels greater than or equal to 6.20 mmol/L (> or = 240 mg/dL) compared with the group that had levels less than 5.20 mmol/L (< 200 mg/dL); 1.00 (95% CI, 0.59 to 1.70) for the group in the lowest tertile of HDL-C compared with those in the highest tertile; and 1.03 (95% CK, 0.62 to 1.71) for subjects in the highest tertile of the ratio of total serum cholesterol to HDL-C compared with those in the lowest tertile. CONCLUSIONS: Our findings do not support the hypothesis that hypercholesterolemia or low HDL-C are important risk factors for all-cause mortality, coronary heart disease mortality, or hospitalization for myocardial infarction or unstable angina in this cohort of persons older than 70 years.

Family networks: predictors of nursing home entry.

Despite the importance of kin in caring for older relatives, few studies have examined the relationship between the family network and the risk of nursing home placement. Data from a cohort of noninstitutionalized elderly persons living in New Haven in 1982 were used to predict nursing home admission through 1985. Logistic regression analyses show that older persons who have regular contact with kin have a lower risk of institutionalization. For men, the spouse is most important in reducing the risk of entry; for women, having regular contact with at least one family member--of any relation--reduces the risk of entry.

Association of visual impairment with mobility and physical function.

OBJECTIVE: To examine the association of distant vision and physical function in the population of older adults. DESIGN: Cross-sectional and cohort study. PARTICIPANTS: 5143 older residents of three communities (Established Populations for the Epidemiologic Studies of the Elderly) who were interviewed in 1988-89, including residents of two communities who were re-interviewed 15 months later (n = 3133, 97% of those eligible). MEASURES: Visual acuity screening, self-reported activities of daily living and mobility, and objective physical performance measures of balance, walking, and rising from a chair. RESULTS: Limitations in mobility, activities of daily living, and physical performance were associated with worse visual function. In prospective analyses controlling for potential confounders, participants with severe visual impairment had 3-fold higher odds of incident mobility and activity of daily living limitations than those with acuity of 20/40 or better (P < 0.001). In prospective analyses investigating the relationship of vision with improvement in function, those with poor vision were about half as likely to improve as those with better acuity, but this relationship was only statistically significant for improvement in mobility limitations. CONCLUSIONS: Distant visual function appears to play an important role in physical function, particularly for mobility. An intervention to improve vision in at-risk elders might preserve function and prevent disability; this warrants further investigation.

Adiposity and stroke among older adults of low socioeconomic status: the Chicago Stroke Study.

OBJECTIVES: The purpose of this study was to test the hypothesis that overall and truncal adiposity increase the risk of stroke independent of their association with cardiovascular disease risk factors and other preexisting illnesses. METHODS: Analyses were conducted of longitudinal data from a poor, biracial cohort of noninstitutionalized adults 65 to 74 years of age who participated in the Chicago Stroke Study from 1965 to 1970. RESULTS: Ponderal index (cm/kg1/3) and chest skinfold were significantly associated with systolic and diastolic blood pressure, serum cholesterol and triglycerides, plasma glucose, and smoking. Ponderal index was also associated with diabetes and risk of stroke. After potential confounders were controlled, the following variables showed significant independent associations with risk of stroke: Black race, female gender, and age 70+; hypertensive heart disease; and diabetes. Neither adiposity variable was associated with risk of stroke in the presence of these powerful predictors. CONCLUSIONS: Control of hypertension and diabetes continues to be important among older adults. Since excess adiposity seems to influence risk of stroke through its association with these disorders and other cardiovascular disease risk factors, control of weight and fat remains an important concern as well.

Driving cessation and changes in mileage driven among elderly individuals.

The factors associated with driving cessation, number of miles driven, and changes in mileage were assessed in a community-living elderly population. A driving survey was administered in 1989 to surviving members of the New Haven EPESE cohort. Of 1,331 respondents, 456 had driven and 139 had stopped driving between 1983 and 1989. Independent predictors of driving cessation from a multiple logistic regression model included higher age, lower income, not working, neurologic disease, cataracts, lower physical activity level, and functional disability. These risk factors were combined to assess their ability to predict driving cessation. If no factors were present, no subjects stopped driving; if one or two factors were present, 17 percent stopped; if three or more factors were present, 49 percent stopped. Along with the expected medical factors, physical activity level and social and economic factors contributed to driving cessation. High mileage drivers tended to be younger, active males who still worked. Increasing age and disability were associated with mileage reduction compared to five years earlier.

Psychosocial predictors of stroke outcomes in an elderly population.

The influence of premorbid psychosocial factors on physical function and institutionalization 6 weeks after hospital discharge was studied in elderly stroke patients. The predictor variables of interest were social networks, availability of social support, pre-stroke depression (CES-D), and religiousness. The data were obtained from a prospective longitudinal study based on 2,812 noninstitutionalized individuals aged 65 years and older living in New Haven, Connecticut. Incident stroke cases from this study were followed for post-stroke outcomes. Results from 87 survivors indicated that larger social networks were associated with fewer limitations in physical function, controlling for relevant health and sociodemographic conditions. Larger networks were also associated with a lower risk of institutionalization (p < .05). None of the other psychosocial factors assessed appeared to be related to these outcomes.

Risk factors for septicemia-associated mortality in older adults.

Septicemia is the 10th leading cause of death among older adults in the United States; its mortality rate has steadily increased over the past decades. Little is known about factors which predispose to septicemia mortality in the elderly. The authors investigated risk factors for septicemia-associated mortality in 10,269 older adults as part of a longitudinal study of three communities (East Boston, MA; New Haven, CT; and Iowa and Washington Counties, IA). During 6 years of followup, 177 persons (3.2 per 1,000 person-years) had septicemia ICD9 038 (International Classification of Diseases, ninth revision) reported on their death certificate. In a multivariate proportional-hazards model, septicemia mortality was significantly (P < 0.05) and independently associated with age, male sex, history of diabetes, history of cancer requiring hospitalization, smoking one pack of cigarettes per day or more, not drinking alcohol in the year prior to baseline, disability in activities of daily living, cognitive impairment, and missing cognitive testing score. These factors might be useful in developing an at-risk population for testing septicemia treatment or prevention strategies in a community setting. Further investigation is needed to explain underlying mechanisms of increased risk of subsequent septicemia.

A survey for assessing physical activity among older adults.

In 1988, the Yale Physical Activity Survey (YPAS) was designed and then administered to healthy older populations of volunteers (aged 60-86) to establish its 2-wk repeatability and relative validity. Among the 76 volunteers in the repeatability substudy, correlation coefficients between the two administrations of the survey for the eight YPAS summary indices ranged from 0.42 (P = 0.0002) to 0.65 (P = 0.0001). Among the 25 subjects in the validation substudy, weekly energy expenditure (r = -0.47; P = 0.01) and daily hours spent sitting (r = 0.53; P = 0.01) correlated with resting diastolic blood pressure, while the YPAS activity dimensions summary index (composed of questions on vigorous activity, leisurely walking, moving, sitting, and standing) correlated positively with estimated VO2max (r = 0.58; P = 0.004) and inversely with percent body fat (r = -0.43; P = 0.03). The YPAS index of vigorous activity also correlated positively with estimated VO2max (r = 0.60; P = 0.003) and the moving index correlated marginally with body mass index (r = -0.37; P = 0.06). We conclude that the YPAS demonstrates adequate repeatability, and some validity by correlating with several physiologic variables reflecting habitual physical activity. The value of the YPAS, however, in accurately assessing low intensity activity remains to be established.

Disability and cognitive impairment are risk factors for pneumonia-related mortality in older adults.

The role of functional and cognitive limitations in the risk of pneumonia-related mortality in older adults was examined. As part of a cohort study in 3 communities (East Boston, MA; New Haven, CT; and Iowa and Washington Counties, IA), 6,234 women and 4,035 men ages 65 or older completed baseline interviews between 1981 and 1983 and were followed for up to 6 years. Sex-specific Cox proportional-hazards regression models were used to examine the association of baseline physical and cognitive functioning with report of pneumonia (ICD9 480-486) as an underlying, immediate, or contributing cause of death. During followup, a total of 243 men and 160 women died with pneumonia. Adjusting for age, race, education, evidence of five chronic diseases, and smoking status, a significantly increased risk of pneumonia mortality (P < 0.05) was found for limitations in activities of daily living and cognitive impairment among both men and women. Inability to walk a half mile, climb stairs, or perform heavy housework was significantly associated with increased risk of pneumonia mortality for women but not for men in the same multivariate models. Men and women whose body-mass index was above the median had significantly lower risk of pneumonia mortality compared with those in the lowest quartile. Further elucidation of the sequence between physical and cognitive impairment and risk of pneumonia will be important in reducing pneumonia-associated morbidity and mortality.

The mortality of US nuclear submariners, 1969-1982.

A mortality study of 76,160 men who served on US nuclear submarines is reported. Indirect standardization was used to compare mortality rates to those of the US male population. Multiplicative models were developed to explore patterns of mortality within the cohort. Mortality rates for leukemia, acute myocardial infarction, and for motor vehicle accidents were equivalent to those of US males; rates for other causes were lower, generally consistent with the "healthy worker effect." Motor vehicle accident mortality dropped during the study period, perhaps reflecting efforts to control the problem. Suicide rates were depressed during the period of active duty. There was a suggestion that cancer mortality was associated with submarine type; however, the age distribution casts doubt that the excess was occupationally induced.

Preexisting cardiovascular conditions and long-term prognosis after initial myocardial infarction: the Framingham Study.

Preexisting cardiovascular conditions (angina pectoris, intermittent claudication, stroke or transient ischemic attack, and congestive heart failure) were evaluated in relation to long-term prognosis after an initial MI in 828 subjects from the Framingham Heart Study. Preexisting angina pectoris and intermittent claudication in men were associated with increased risk of coronary mortality and recurrent MI, whereas congestive heart failure increased coronary mortality. In women, prior angina pectoris increased the risk of recurrent MI and congestive heart failure increased the coronary mortality. Adjusting for the major cardiovascular risk factors measured before MI, these results held for men but no significant adverse effects persisted in women. Among subjects who survived to return for subsequent examinations, only prior congestive heart failure in men increased the risk after adjusting for post-MI risk factors. In women who returned, angina pectoris and intermittent claudication were associated with poor post-MI prognosis. These results suggest that atherosclerosis is a diffuse disease of the circulatory system, and one in which post-MI prognosis is influenced by the presence of other preexisting cardiovascular conditions. Hence a patient who has an MI after prior expression of cardiovascular disease requires more vigorous preventive management.