Physical activity (PA) and the disablement process: a 14-year follow-up study of older non-disabled women and men.

Few studies have explored the associations of reported PA (RPA) with the processes underlying the development of disability. The present study was performed to explore RPA among older persons and its association with onset of functional dependence and mortality. Among a probability sample of 1782 community-living persons, aged 75-83 years, we evaluated the 1021 who reported no disability in basic activities of daily living. Participants were followed for a median of 8.34 years in public registers to determine onset of disability and mortality. RPA predicted mortality in older women (HR=1.77, 95%CI=1.42-2.19) and men (HR=1.65, 95%CI=1.27-2.14) over long time intervals. The effect of RPA persisted among permanently disabled older women, after adjusting for age, baseline vulnerability and grade of disability. Low RPA was independently associated with risk of incident disability (HR=1.56, 95%CI=1.10-2.23) in men. Among older women, the association between RPA and incidence of disability was attenuated in analyses that controlled for baseline mobility function. Thus, the association between physical activity and mortality reflected processes different from those underlying a simple relation between physical activity, disability and mortality. Physical activity was an ubiquitous predictor of longevity, but only for women.

Number of teeth and fatigue in older adults.

OBJECTIVES: To examine whether tooth loss at age 70 is associated with fatigue in a nondisabled community-dwelling population cross-sectionally at age 70 and with onset of fatigue longitudinally at 5-, 10-, and 15-year follow-ups. SETTING: Community-based population in Copenhagen. PARTICIPANTS: Five hundred seventy-three nondisabled 70-year-old individuals in 1984. MEASUREMENTS: Data from interviews and a medical and oral examination. Oral health was measured according to number of teeth (0, 1-9, 10-19, ≥ 20). Fatigue was measured using the Avlund Mobility-Tiredness Scale on six mobility activities. Covariates, all measured at baseline, were sex, education, income, comorbidity, and smoking. RESULTS: Bivariate logistic regression analyses showed significant cross-sectional and longitudinal associations between number of teeth at age 70 and onset of fatigue at 5- and 10- but not 15-year follow-up. The associations between having no teeth and fatigue were attenuated when adjusted for socioeconomic position and smoking. CONCLUSION: Tooth loss is associated with onset of fatigue in old age, but the estimates are attenuated when adjusting for socioeconomic position and smoking. Tooth loss may be an early indicator of frailty.

Multidimensional intervention and sickness absence in assistant nursing students.

BACKGROUND: When handling patients, nursing assistant (NA) students and nurse students are frequently exposed to risk factors for low back pain (LBP) including sudden loads and twisting and bending of the spine. Furthermore, LBP is a major cause of sickness absence. AIMS: To ascertain if a multidimensional prevention programme combining physical training, patient transfer technique and stress management prevents sickness absence and LBP in NA students. METHODS: The study was a 14-month cluster randomized controlled study. The participants were NA students from 37 randomly selected classes located at two schools of health and social care in Copenhagen, Denmark. The participants completed a comprehensive questionnaire regarding sickness absence, LBP and psychosocial factors on commencement and after completion of the study. RESULTS: Of 766 female NA students, 668 (87%) completed the baseline questionnaire. Sickness absence during the study period increased in both groups but the increase was significantly lower in the intervention group than the control group, mean (standard deviation) number of days 12 (20) versus 18 (34), P < 0.05. The intervention group reported no change in the mean level of general health perception, energy/fatigue or psychological well-being at follow-up, while the control group reported a decline on those scales. There were no significant differences in the prevalence of LBP at follow-up between the intervention and control group. CONCLUSIONS: Compared to the control group, the intervention group had significantly less sickness absence. The intervention had no preventive effect on LBP prevalence.

Barriers to participation in a hospital-based falls assessment clinic programme: an interview study with older people.

AIMS: To gain new knowledge about barriers to participation in hospital-based falls assessment. METHODS: Semi-structured interviews with 20 older people referred to falls assessment at a hospital-based clinic were conducted. A convenience sample of 10 refusers and 10 accepters was collected. Those who refused referral were recruited in relation to a systematic falls screening programme performed by preventive home visitors. Accepters were selected among 72 participants successively completing the falls assessment clinic programme. The time between the interviews was 12 months; different levels of knowledge were expected, owing to accepters' participation in the programme. Interview transcriptions were thematically analysed. The analysis was directed towards identification of barriers to falls assessment. RESULTS: Barriers to participation were categorized as being either within or outside the falls clinic, and included administration, time, communication, attitudes to fall prevention, and expected future costs. Accepters completing the programme expressed a feeling of being ''met'' in the system and maintaining authority over their own life, while the refusers expressed concern about the healthcare system taking over their life. CONCLUSIONS: This study indicates that older at-risk patients acknowledge their falls problem, but refuse to participate in hospital-based assessment programmes because they expect to lose their authority and to be caught up in the healthcare system. In order to transform the findings of this study to a public health message, we have to consider moving the focus of falls prevention strategies from disease control to the domain of health promotion in order to engage older adults in preventive healthcare.

Effect of inflammation in the periodontium in early old age on mortality at 21-year follow-up.

OBJECTIVES: To analyze whether inflammatory processes in the periodontium in early old age are related to subsequent mortality during 21 years of follow-up in a nondisabled 70-year-old population. SETTING: Community-based population in Copenhagen. DESIGN: The study was based on the Glostrup Aging Study of the 1914 population, with baseline in 1984 when the participants were 70 years old and follow-up 21 years later. PARTICIPANTS: Three hundred thirty-five dentate men and women participated in the clinical oral health examination. MEASUREMENTS: Severe periodontal inflammation was measured for all teeth present as the number of teeth with inflammation and periodontal pockets 6 mm deep or more. Mortality data were obtained from the Danish Death Register at 21-year follow-up. The Cox proportional hazards regression model was used. Covariates were measured at baseline and included number of teeth, caries, sex, education, income, hypertension, diabetes mellitus, osteoarthritis, arteriostenosis, myocardial infarction, comorbidity, fatigue, and ability to brush teeth. RESULTS: The analyses showed that severe periodontal inflammation in at least three teeth at age 70 was marginally related to mortality during 21-year follow-up (crude hazard ratio (HR)=1.17, 95% confidence interval (CI)=0.91-1.78). The estimate increased slightly when adjusted for sex, income, fatigue, and smoking (adjusted HR=1.37, 95% CI=0.97-1.92). The estimates were attenuated when adjusted for the specific diseases, especially arteriostenosis and osteoarthritis. CONCLUSION: Inflammation in the periodontium in early old age tends to be associated with mortality in older age.

Establishing a new falls clinic--conflicting attitudes and inter-sectoral competition affecting the outcome.

Falls clinics are a newer model for falls management among the elderly. Few studies have addressed the impact of the strategy on falls prevention in the healthcare system. The aim of the present study was to describe the social processes that affect the implementation of new strategies in falls management. A newly established falls clinic was chosen as an instrumental case to describe the systematic and comprehensive approach to falls prevention among the elderly. The investigation had a qualitative case study research design with triangulation of sources and methods, including interviews, participant observation and analysis of documents. The study was conducted from January 2006 to June 2007 at a newly established falls clinic at a Danish hospital. Data were analysed qualitatively according to four main themes: The concept of falls, success/failure, competition and expertise. The study showed that the falls clinic was embedded in a context where interests varied at different levels of the organizational hierarchy. In contrast to the political agenda for falls prevention, patients and professionals did not associate falls with chronological age. The biomedical structure of the falls clinic and the hegemonic mode of handling falls prevention may have facilitated falls prevention services and patient trajectories across sectors, but if falls are associated with chronic disease secondary to an unhealthy lifestyle, the individual patient becomes responsible for the falls problem. This may subsequently prevent the patients from seeking timely help from the healthcare system, or patients may drop out of the existing programmes. Future research needs to look at sustainability and dropping out in relation to falls prevention programmes.

Cognitive impairment as assessed by a short form of MMSE was predictive of mortality.

OBJECTIVE: This study explores the association between cognitive impairment and mortality in late senescence. A specific purpose was to validate the ability of a short form of the Mini-Mental State Examination (MMSE) in predicting mortality. STUDY DESIGN AND SETTING: The cognition-mortality link, as assessed by the original MMSE and D-MMSE (a subscale associated to dementia) was estimated on a community sample of 1,111 older people using Cox proportional hazards models. RESULTS: Impaired cognitive function as assessed by both the original MMSE and D-MMSE predicted mortality in older men and women over long intervals. The association persisted after controlling for sociodemographic variables, Body Mass Index, mobility, and comorbidity and was unaffected by self-reported specific chronic diseases in both men and women. In addition, disease related risk of mortality was substantially reduced by sociodemographic and health variables including cognitive functioning. Only in women, stroke and diabetes remained statistically significant associated with mortality. CONCLUSION: The association between cognitive impairment and mortality reflects processes different from those underlying a simple relation between chronic diseases and mortality. A short, valid MMSE subscale, which was a powerful predictor of mortality especially among men, is attractive for research and clinical practice.

Tooth loss and subsequent disability and mortality in old age.

OBJECTIVES: To examine whether tooth loss at age 70 is associated with onset of disability at 5-, 10-, 15-, and 20-year follow-up and to mortality at 21-year follow-up. SETTING: Community-based population in Copenhagen. DESIGN: A baseline study of a random sample of 70-year-old people born in 1914 and follow-up 5, 10, 15, and 20 years later. PARTICIPANTS: A total of 573 nondisabled individuals participated in the study of 70-year-olds in 1984, 460 participated in the 5-year follow-up, 292 in the 10-year follow-up, 150 in the 15-year follow-up, and 78 in the 20-year follow-up. MEASUREMENTS: Data from interviews and a medical and oral examination. Oral health was measured according to number of teeth (0, 1-9, 10-19, > or = 20). Disability was measured using the Avlund Mob-H scale at age 75, 80, 85, and 90. Mortality data were obtained from the National Death Register. RESULTS: Being edentulous or having one to nine teeth was associated with onset of disability at age 75 and 80. Health-related variables and education attenuated the associations between edentulism and onset of disability, although they remained marginally significant, whereas the association between having one to nine teeth and onset of disability remained unchanged and statistically significant at 10-year follow-up (odds ratio=3.02, 95% confidence interval (CI)=1.26-7.24). Persons who were edentulous at age 70 were at significantly higher risk of mortality 21 years later, also in the adjusted analysis (hazard ratio=1.26, 95% CI=1.03-1.55). CONCLUSION: Tooth loss is independently associated with onset of disability and mortality in old age. The findings indicate that tooth loss may be an early indicator of accelerated aging.

Mini-Mental Status Examination: a short form of MMSE was as accurate as the original MMSE in predicting dementia.

OBJECTIVES: This study assesses the properties of the Mini-Mental State Examination (MMSE) with the purpose of improving the efficiencies of the methods of screening for cognitive impairment and dementia. A specific purpose was to determine whether an abbreviated version would be as accurate as the original MMSE in predicting dementia. STUDY DESIGN AND SETTING: A population-based post hoc examination of the performance characteristics of the MMSE for detecting dementia in an existing data set of 243 elderly persons. RESULTS: Sensitivity, specificity, and predictive values were computed for the original MMSE as well as new MMSE scale models derived from a Rasch model item analysis. The optimal threshold for the original MMSE screen yielded sensitivity and specificity estimates of 72.5% and 91.3%, respectively. The use of a subscale resulted in a slightly lower sensitivity (71.0%), specificity (88.4%), and positive predictive value (71.0%) but equal area under the receiver operating characteristic curve. Cross-validation on follow-up data confirmed the results. CONCLUSION: A short, valid MMSE, which is as sensitive and specific as the original MMSE for the screening of cognitive impairments and dementia is attractive for research and clinical practice, particularly if predictive power can be enhanced by combining the short MMSE with neuropsychological tests or informant reports.

Mini-Mental Status Examination: mixed Rasch model item analysis derived two different cognitive dimensions of the MMSE.

OBJECTIVES: This study published in two companion papers assesses properties of the Mini-Mental State Examination (MMSE) with the purpose of improving the efficiencies of the methods of screening for cognitive impairment and dementia. STUDY DESIGN AND SETTING: An item analysis by conventional and mixed Rasch models was used to explore empirically derived cognitive dimensions of the MMSE, to assess item bias, and to construct diagnostic cut-points. The scores of 1,189 elderly residents were analyzed. RESULTS: Two dimensions of cognitive function, which are statistically and conceptually different from those obtained in previous studies, were derived. The corresponding sum scales were (1) age-correlated MMSE scale (A-MMSE scale: orientation to time, attention/calculation, naming, repetition, and three-stage command) and (2) non-age-correlated MMSE scale (B-MMSE scale: orientation to place, registration, recall, reading, and copying). The "writing" item was not included due to differential effects of age and sex. The analysis also showed that the study sample consisted of two cognitively different groups of elderly. CONCLUSIONS: The findings indicate that a two-scale solution is a stable and statistically supported framework for interpreting data obtained by means of the MMSE. Supplementary analyses are presented in the companion paper to explore the performance of this item response theory calibration as a screening test for dementia.

Tiredness in daily activities: a subjective measure for the identification of frailty among non-disabled community-living older adults.

The objective of this study was to determine whether the responses to questions about tiredness in daily activities is an early subjective sign of frailty indicating older community-living adults at increased risk for disability and mortality. Tiredness in daily activities as measured by the Mob-T Scale, maximal power in sustained work, and comorbid diseases were assessed together with sociodemographic variables in a sample of 705 non-disabled, 70-year old men and women surveyed in 1984. Vital status of members was determined prospectively over the next 15 years. Onset of disability was measured at 5-, 10-, and 15-year follow-up. Onset of disability among non-disabled 70-year old men and women was strongly related to tiredness in daily activities at 5- and 10-year follow-up. Scores on the Mob-T Scale were significantly associated with mortality during the aggregate 15-year follow-up period. Multiple stepwise regression analyses not only indicated that tiredness in daily activities is a strong independent predictor of both disability and mortality, but also that tiredness mediates the effects of comorbidity and maximal power in sustained work on disability/mortality. Self-reported tiredness in daily activities is suggested as a basis for identifying vulnerable frail subsets of older adults requiring targeted strategies for prevention.

Religion and survival in a secular region. A twenty year follow-up of 734 Danish adults born in 1914.

The aim of the study was to analyse associations of religiosity and mortality in a secular region. The sample consisted of 734 Danish, community dwelling elderly persons, living in a secular culture, and all aged 70 when primary data were collected. Secondary data consisted of a 20 year follow-up on vital status or exact age of death. The study was designed to be highly comparable to studies conducted in more religious environments in order to compare results. Three variables of religion were investigated in relation to survival: importance of affiliation, church attendance and listening to religious media. Relative hazards (RH) of dying were controlled in models including gender, education, medical and mental health, social relations, help given and received, and health behaviour. The results showed significant and positive associations between claiming religious affiliation important and survival (relative hazard of dying=RH .70; 95% CI .58-.85) and church attendance and survival (RH .73; 95% CI .64-.87). Results decreased and only stayed significant regarding church attendance when controlled for covariates. Nearly all significant effects were seen in women, but not in men. The effect size of the full sample is less than in more religious environments in United States samples. Although the positive overall RHs are comparable to those of other studies, the mediating variables and pathways of effects seem dissimilar in this sample from a secular environment. Receiving and especially giving help to others are suggested as variables of explanatory value.

Does educational level influence the effects of smoking, alcohol, physical activity, and obesity on mortality? A prospective population study.

OBJECTIVES: This study aims at examining whether the relation between established risk factors and mortality differs with socioeconomic status as measured by level of education. METHODS: A population-based sample of 14,399 women and 16,236 men aged 20-93 years from Copenhagen was stratified into three educational levels measured as basic schooling, and the effect of smoking habits, alcohol consumption, physical activity, and body mass index, respectively, on mortality was assessed. RESULTS: Those with the lowest level of education were most frequently heavy smokers, heavy drinkers, physically inactive, and obese. During a mean follow up of 16 years 10,952 subjects died. Compared with subjects with the lowest educational level, women with the highest educational level had a relative risk of 0.80 (95% CI; 0.70-0.91), and men of 0.71 (0.65-0.78). Heavy smoking compared with never smoking implied a more than twofold increased risk at all three educational levels among both men and women. The relation between alcohol intake and mortality was J-shaped on all three educational levels. There were decreasing risk functions describing the relations between physical activity and mortality on all three strata. Further, subjects who were either very lean or obese had increased risks of death compared with those of normal weight at all educational levels in both genders. CONCLUSIONS: The difference in distribution of the main known risk factors may be part of the explanation for the differences in mortality risk. However, these risk factors seem to influence mortality equally at different educational levels. Therefore, social inequalities in mortality do not seem to be explained only by differences in effect of lifestyle risk factors, but are also related to the social rank or unexamined factors within.

The cumulative effect of smoking at age 50, 60, and 70 on functional ability at age 75.

AIMS: As elderly people form a steadily growing part of the population in most parts of the world we are in need of knowledge of the influence of modifiable lifestyle factors on functional ability late in life. This study aims to examine the cumulative impact of smoking from age 50 to 70 on functional ability at age 75. METHODS: 387 men and women born in 1914 and living in seven municipalities in the western part of the County of Copenhagen were followed for 25 years with examinations in 1964, 1974, 1984, and 1989. Associations between smoking and functional ability were examined using multiple logistic regression analyses with cumulative smoking as determinant and physical activity, sex, basic school education, and household composition as possible confounders. RESULTS: There is an adverse relation between smoking and functional ability regardless of the time of examination or the ways of accumulating the smoking habits over the examinations. Cumulated former smokers have a larger risk of having reduced functional ability at age 75 (OR: 1.35 (1.13-1.61)) compared with never smokers. The odds ratios of reduced functional ability were 2.46 (1.44-4.17) among cumulated smokers of 1-14 grams of tobacco/day and 3.32 (1.63-6.72) among smokers of more than 14 grams of tobacco/day. CONCLUSIONS: The findings in this study stress the importance of continuing and strengthening efforts to reduce the prevalence of smokers in the population. Furthermore the results indicate that even after the 50th birthday it is possible to gain a healthier old age by abstaining from smoking.

Stroke rehabilitation: assistive technology devices and environmental modifications following primary rehabilitation in hospital--a therapeutic perspective.

The aim of this article is to describe the need for assistive devices and environmental modifications among long-living stroke survivors and to investigate if the need is continued and growing over time. The study sample of 155 consecutive stroke patients with stroke-related impairment, discharged home from three hospitals in Copenhagen from 1996 through 1998, constituted 20% of the total population of stroke survivors in this area. The results showed that 75% of these patients were provided with assistive devices and/or environmental modifications at discharge. Six months after discharge the proportion was 81%. The aids most frequently prescribed were bath seats, aids for mobility, grab bars, and removal of door thresholds. At follow-up 3-5 years later, 74% of the survivors were seen (76 patients). Almost all of the survivors were dependent on assistive devices and/or environmental modifications, most frequently wheelchairs and aids for walking and bathing. In addition there was a significant increase in aids for cooking/eating and reading/hearing/writing adaptations. Of those devices abandoned, most were aids for the household. These findings suggest that home visits by therapists should be required in order to target stroke survivors' changing needs for assistive devices and environmental modifications.

Follow-up services for stroke survivors after hospital discharge--a randomized control study.

OBJECTIVE: To evaluate whether follow-up services for stroke survivors could improve functional outcome and reduce readmission rate. In this paper results of functional outcome are reported. DESIGN: Randomized controlled trial allocating patients to one of three different types of aftercare: (1) follow-up home visits by a physician, (2) physiotherapist instruction in the patient's home, or (3) standard aftercare. SUBJECTS: Stroke patients with persisting impairment and disability who, after completing inpatient rehabilitation, were discharged to their homes. OUTCOME MEASURES: Six months after discharge, functional outcome was assessed with Functional Quality of Movement, Barthel Index, Frenchay Activity Index and Index of Extended Activites of Daily Living. RESULTS: One-hundred and fifty-five stroke patients were included in the study. Fifty-four received follow-up home visits by a physician, 53 were given instructions by a physiotherapist in their home and 48 received standard aftercare only. No statistically significant differences in functional outcome six months after discharge were demonstrated between the three groups. However, all measurements showed a tendency towards higher scores indicating better function in both interventions groups compared with the control group. CONCLUSION: Follow-up services after stroke may be a way of improving functional outcome. The results of the present study should be evaluated in future trials. More research in this field is needed, especially studies of how to support stroke survivors to resume social and leisure activities.