Outcomes after spinal stenosis surgery by type of surgery in adults aged 60 years and older.

AIMS OF THE STUDY: Mobility disability due to spinal stenosis is common in the senior population and often surgery is warranted for patients with severe symptoms and neurological dysfunction. However, although current clinical guidelines recommend stabilisation surgery in addition to decompression in patients with spinal stenosis and instability due to degenerative spondylolisthesis, the relationship between outcomes and the specific type of surgery have not been well studied. We therefore assessed the postoperative recovery timeline for 12 months and compared patient-reported outcomes dependent on the extent of decompression and additional stabilisation among seniors undergoing spinal stenosis surgery. METHODS: We investigated 457 patients (mean age 76.0 ± 10.7 years, 58% women) from a consecutive cohort prior to spinal stenosis surgery. Follow-up was at 3 or 6months and at 12 months postoperatively. At each visit, pain, neurological dysfunction and disability were assessed using the North American Spine Society questionnaire. Repeated-measures analysis compared outcomes by type of surgery adjusting for baseline symptoms, gender, age, number of comorbidities, centre and year of surgery. RESULTS: Most improvement occurred within the first 3 to 6 months with little or no further improvement at 12 months. Over 12 months and in adjusted models, patients receiving one-segment versus multi-segment decompression experienced significantly greater reduction of pain (−49.2% vs −41.9%, p = 0.013) and neurological dysfunction (−37.1% vs −25.9%, p <0.0001), but only borderline greater reduction of disability (−32.7% vs −28.2%, p = 0.051). Moreover, reduction in pain and neurological function did not differ with or without additional stabilisation and extend of decompression. However, patients who received one-segment (−28.9%) or multi-segment (−28.3%) stabilisation experienced significantly less reduction in disability after surgery compared with those who were not stabilised (−34.1%, p <0.043). CONCLUSIONS: Among senior patients undergoing spinal stenosis surgery, recovery was largely complete by 3 to 6 months after surgery and differed little by type of surgery independently of symptoms prior to surgery and other covariates. However we could document a trend toward more improvement in particularly neurological dysfunction and disability with less invasive surgery.

Effect of daily 2000 IU versus 800 IU vitamin D on blood pressure among adults age 60 years and older: a randomized clinical trial.

BACKGROUND: Observational studies report higher blood pressure (BP) among individuals with lower 25-hydroxyvitamin D concentration. Whether dosage of vitamin D supplementation has a differential effect on BP control remains unclear. OBJECTIVE: The study aimed to determine if daily vitamin D supplementation with 2000 IU is more effective than 800 IU for BP control among older adults. METHODS: This randomized, double-blind, ancillary trial of the Zurich Multiple Endpoint Vitamin D Trial in Knee Osteoarthritis enrolled adults aged ≥60 y who underwent elective surgery due to severe knee osteoarthritis. Participants were randomly assigned to receive high dose (2000 IU) or standard dose (800 IU) daily vitamin D3 for 24 mo. Outcomes included daytime and 24-h mean systolic BP. BP variability and serum 25-hydroxyvitamin D concentration were examined in a post hoc and observational analysis. RESULTS: Of the 273 participants randomly assigned, 250 participants completed a follow-up 24-h ambulatory BP monitoring (mean age: 70.4 ± 6.4 y; 47.2% men). The difference in daytime mean systolic BP reduction between the 2000 IU (n = 123) and 800 IU (n = 127) groups was not statistically significant (-2.75 mm Hg vs. -3.94 mm Hg; difference: 1.18 mm Hg; 95% CI: -0.68, 3.05; P = 0.21), consistent with 24-h mean systolic BP. However, systolic BP variability was significantly reduced with 2000 IU (average real variability: -0.37 mm Hg) compared to 800 IU vitamin D3 (0.11 mm Hg; difference: -0.48 mm Hg; 95% CI: -0.94, -0.01; P = 0.045). Independent of group allocation, maximal reductions in mean BP were observed at 28.7 ng/mL of achieved serum 25-hydroxyvitamin D concentrations. CONCLUSIONS: While daily 2000 IU and 800 IU vitamin D3 reduced mean systolic BP over 2 y to a small and similar extent, 2000 IU reduced mean systolic BP variability significantly more compared with 800 IU. However, without a placebo control group we cannot ascertain whether vitamin D supplementation effectively reduces BP.This trial was registered at www.clinicaltrials.gov as NCT00599807.

Effect of 2000 IU compared with 800 IU vitamin D on cognitive performance among adults age 60 years and older: a randomized controlled trial.

BACKGROUND: Findings on the effects of vitamin D on cognitive performance have been inconsistent and no clinical trials with detailed cognitive testing in healthy older adults have been reported. OBJECTIVES: We tested whether 2000 IU is superior to 800 IU vitamin D3/d for cognitive performance among relatively healthy older adults. DESIGN: We analyzed data on cognitive performance as the secondary outcome of a 2-y double-blind randomized controlled trial that originally investigated the effect of vitamin D3 on knee function and pain in seniors with osteoarthritis. Participants were randomly assigned to either 2000 or 800 IU vitamin D3/d. Capsules had identical appearances and taste. A total of 273 community-dwelling older adults aged ≥60 y were enrolled 6-8 wk after unilateral joint replacement. Inclusion required a baseline Mini Mental State Examination (MMSE) score of 24. We implemented a detailed 2-h cognitive test battery. The primary cognitive endpoint was the score achieved in the MMSE. Secondary endpoints included a composite score of 7 executive function tests, auditory verbal and visual design learning tests, and reaction times. RESULTS: At baseline, mean age was 70.3 y, 31.4% were vitamin D-deficient [25(OH)D <20 ng/mL], and mean ± SD MMSE score was 28.0 ± 1.5. Although the mean ± SD 25(OH)D concentrations achieved differed significantly between treatment groups at 24-mo follow-up (2000 IU = 45.1 ± 10.2 ng/mL; 800 IU = 37.5 ± 8.8 ng/mL; P < 0.0001), none of the primary or secondary endpoints of cognitive performance differed between treatment group. Results by treatment were similar for predefined subgroups of baseline 25(OH)D status (deficient compared with replete) and age (60-69 y compared with ≥70 y). CONCLUSIONS: Our study does not support a superior cognitive benefit of 2000 IU compared with 800 IU vitamin D/d among relatively healthy older adults over a 24-mo treatment period. This trial was registered at clinicaltrials.gov as NCT00599807.

A pooled analysis of vitamin D dose requirements for fracture prevention.

BACKGROUND: The results of meta-analyses examining the relationship between vitamin D supplementation and fracture reduction have been inconsistent. METHODS: We pooled participant-level data from 11 double-blind, randomized, controlled trials of oral vitamin D supplementation (daily, weekly, or every 4 months), with or without calcium, as compared with placebo or calcium alone in persons 65 years of age or older. Primary end points were the incidence of hip and any nonvertebral fractures according to Cox regression analyses, with adjustment for age group, sex, type of dwelling, and study. Our primary aim was to compare data from quartiles of actual intake of vitamin D (including each individual participant's adherence to the treatment and supplement use outside the study protocol) in the treatment groups of all trials with data from the control groups. RESULTS: We included 31,022 persons (mean age, 76 years; 91% women) with 1111 incident hip fractures and 3770 nonvertebral fractures. Participants who were randomly assigned to receive vitamin D, as compared with those assigned to control groups, had a nonsignificant 10% reduction in the risk of hip fracture (hazard ratio, 0.90; 95% confidence interval [CI], 0.80 to 1.01) and a 7% reduction in the risk of nonvertebral fracture (hazard ratio, 0.93; 95% CI, 0.87 to 0.99). By quartiles of actual intake, reduction in the risk of fracture was shown only at the highest intake level (median, 800 IU daily; range, 792 to 2000), with a 30% reduction in the risk of hip fracture (hazard ratio, 0.70; 95% CI, 0.58 to 0.86) and a 14% reduction in the risk of any nonvertebral fracture (hazard ratio, 0.86; 95% CI, 0.76 to 0.96). Benefits at the highest level of vitamin D intake were fairly consistent across subgroups defined by age group, type of dwelling, baseline 25-hydroxyvitamin D level, and additional calcium intake. CONCLUSIONS: High-dose vitamin D supplementation (≥800 IU daily) was somewhat favorable in the prevention of hip fracture and any nonvertebral fracture in persons 65 years of age or older. (Funded by the Swiss National Foundations and others.).

Oral supplementation with 25(OH)D3 versus vitamin D3: effects on 25(OH)D levels, lower extremity function, blood pressure, and markers of innate immunity.

To test the effect of 25(OH)D(3) (HyD) compared to vitamin D(3) on serum 25-hydroxyvitamin D levels (25(OH)D), lower extremity function, blood pressure, and markers of innate immunity. Twenty healthy postmenopausal women with an average 25(OH)D level of 13.2 ± 3.9 ng/mL (mean ± SD) and a mean age of 61.5 ± 7.2 years were randomized to either 20 µg of HyD or 20 µg (800 IU) of vitamin D(3) per day in a double-blind manner. We measured on 14 visits over 4 months, 25(OH)D serum levels, blood pressure, and seven markers of innate immunity (eotaxin, interleukin [IL]-8, IL-12, interferon gamma-induced protein 10 kDa [IP-10], monocyte chemotactic protein-1 [MCP-1], macrophage inflammatory protein beta [MIP-1ß], and "Regulated upon Activation, Normal T-cell Expressed, and Secreted" [RANTES]). At baseline and at 4 months, a test battery for lower extremity function (knee extensor and flexor strength, timed up and go, repeated sit-to-stand) was assessed. All analyses were adjusted for baseline measurement, age, and body mass index. Mean 25(OH)D levels increased to 69.5 ng/mL in the HyD group. This rise was immediate and sustained. Mean 25(OH)D levels increased to 31.0 ng/mL with a slow increase in the vitamin D(3) group. Women on HyD compared with vitamin D(3) had a 2.8-fold increased odds of maintained or improved lower extremity function (odds ratio [OR] = 2.79; 95% confidence interval [CI], 1.18-6.58), and a 5.7-mmHg decrease in systolic blood pressure (p = 0.0002). Both types of vitamin D contributed to a decrease in five out of seven markers of innate immunity, significantly more pronounced with HyD for eotaxin, IL-12, MCP-1, and MIP-1 ß. There were no cases of hypercalcemia at any time point. Twenty micrograms (20 µg) of HyD per day resulted in a safe, immediate, and sustained increase in 25(OH)D serum levels in all participants, which may explain its significant benefit on lower extremity function, systolic blood pressure, and innate immune response compared with vitamin D(3).

Vitamin D effects on bone and muscle.

Increasing data suggest that higher 25-hydroxyvitamin D [25(OH)D] serum concentrations are advantageous for health. At present, strong evidence for causality is available for fracture and fall prevention, while promising epidemiologic and mechanistic studies suggest a key role of vitamin D in the preservation of cardiovascular health, and the prevention of cancer and other common chronic disease. For lower extremity function, fall prevention, hip bone density, and for fracture prevention optimal benefits are observed with 25(OH)D levels of at least 75 nmol/L to 100 nmol/L [1]. This threshold may be reached in 50 % of adults with 800 to 1000 IU vitamin D per day. This manuscript will discuss the evidence of vitamin D in fall and fracture prevention and how these data transfer to the most recent recommendations by the IOF (International Osteoporosis Foundation) and the IOM (Institute of Medicine).

Effect of high-dosage cholecalciferol and extended physiotherapy on complications after hip fracture: a randomized controlled trial.

BACKGROUND: Care of elderly patients after hip fracture is not well established. METHODS: We enrolled 173 patients with acute hip fracture who were 65 years or older (79.2% women; mean age, 84 years; 77.4% living at home). Using a factorial design, we randomly allocated patients to extended physiotherapy (PT) (supervised 60 min/d during acute care plus an unsupervised home program) vs standard PT (supervised 30 min/d during acute care plus no home program; single-blinded), and to cholecalciferol therapy, 2000 vs 800 IU/d (double-blinded). Primary outcome was rate of falls; secondary outcome was rate of hospital readmissions during the 12-month follow-up. All analyses included 173 individuals and used multivariate Poisson regression analyses. RESULTS: At baseline, 50.9% of participants had 25-hydroxyvitamin D levels of less than 12 ng/mL and 97.7% of less than 30 ng/mL. We documented 212 falls and 74 hospital readmissions. Because this was a factorial design trial, all analyses tested the main effect of each treatment while controlling for the other in 173 participants. Extended vs standard PT reduced the rate of falls by 25% (95% confidence interval [CI], -44% to -1%). Cholecalciferol treatment, 2000 vs 800 IU/d, did not reduce falls (28%; 95% CI, -4% to 68%), but reduced the rate of hospital readmissions by 39% (95% CI, -62% to -1%). CONCLUSIONS: Extended PT was successful in reducing falls but not hospital readmissions, whereas cholecalciferol treatment, 2000 IU/d, was successful in reducing hospital readmission but not falls. Thus, the 2 strategies may be useful together because they address 2 different and important complications after hip fracture.

Impact of APOE status on cognitive maintenance in healthy elderly persons.

OBJECTIVE: The epsilon4 allele, a variant of the apolipoprotein E (ApoE) gene, is the most prominent genetic risk factor for sporadic, non-familial Alzheimer's disease (AD) currently known. We investigated the impact of the ApoE-epsilon4 status on cognitive performance at repeated test administration in elderly non-symptomatic persons, with a specific focus on practice effects. METHODS: Three hundred and fifty-five physically and mentally healthy participants of the Basel Study on the Elderly (119 F, 236 M; age 68.3 +/- 7.6; years of education 12.7 +/- 3.1; Mini-Mental State scores 29.0 +/- 1.0) were grouped into ApoE epsilon4 carriers and ApoE epsilon4 non-carriers (36.9% and 63.1% of the sample, respectively). Participants were assessed at the beginning of the longitudinal study and on average two years later by means of the California Verbal Learning Test (CVLT) and the Consortium to Establish a Registry for Alzheimer's Disease-Neuropsychological Assessment Battery (CERAD-NAB), a multidimensional cognitive test battery. Baseline and change scores were analyzed with multiple regression procedures and adjusted for age, education and gender; change scores were also adjusted for baseline performance. RESULTS: The ApoE epsilon4 non-carriers showed slightly better performance with regard to most cognitive parameters at baseline. Mean practice effects of the ApoE epsilon4 non-carriers in 12 out of 13 CVLT variables and in five out of the nine main CERAD-NAB variables were above the 50th percentile, while those of the ApoE epsilon4 carriers were below the 50th percentile in the respective distributions of test-retest change scores. CONCLUSIONS: The epsilon4 allele of the ApoE gene has a negative impact on cognitive performance, notably on episodic memory functions, in physically and mentally healthy aged persons. Practice effects seen in carriers of the ApoE epsilon4 were inferior in most areas tested to the effects seen in ApoE epsilon4 non-carriers. Further follow-up of these subjects will help to determine the clinical significance of these findings.

Personality and health in middle age as predictors for well-being and health in old age.

In research literature, the question to what extent specific personality traits and health functioning in midlife can predict physical and psychological well-being in old age is still discussed controversially. The present study aims to shed light on this issue by using data from the Basel Longitudinal Study on Ageing. Structural equation modelling was performed in order to test the relation between personality dimensions, namely, self-preoccupation and emotional reactivity, as well as cardiovascular functioning (blood pressure) and medication intake (tranquilizer use) in middle age on psychological and physical well-being and health as assessed in old age 24 years later. Results show that high levels of self-preoccupation in middle age are negatively related to psychological and physical well-being in old age, but not to medical diagnoses. In addition, blood pressure and tranquilizer use in middle age predict physical well-being in old age; blood pressure is furthermore related to medical diagnoses. Our findings emphasize the importance for the adoption of a life-span approach and further interdisciplinary prospective studies in order to better predict pathways to well-being and health in old age.

Impact of physical and psychological resources on functional autonomy in old age.

Functional autonomy is a core condition of successful ageing. To maximize autonomous functioning is not only a claim of social policy but also primarily an individual need. Part of the challenge of preventing unnecessary dependence in old age is to recognize the diversity among the elderly and the different availability of their physical, psychological and social resources. The aim of this study is to examine the age- and time-related changes in functional autonomy (activities of daily living, ADL, and instrumental activities of daily living, IADL) and the psychophysical resources correlated with these changes in a sample of 441 healthy elderly persons aged 65-95. Furthermore, we are interested in the long-term predictive power of physical resources (objective and subjective health, physical strength) and psychological resources (memory) on functional autonomy. Results show significant age- and time-related deteriorations in functional autonomy and in most psychophysical resources. Structural equation model analyses were performed to test the long-term predictive power of these resources. Results suggest that ADL is better predicted by physical resources than by psychological ones, but for IADL the reverse is the case; here memory variables play a dominant role. Physical and psychological variables are thus specifically related to different components of functional autonomy. This has to be taken into account in the development of preventive and intervention programmes.

Weight history over a forty-year time period.

BACKGROUND: Mortality and disease risk assessments consider body mass index (BMI), among other parameters. Nowadays optimal BMI is discussed controversially as risk assessments are usually performed using BMI of arbitrarily chosen age points. A more comprehensive approach could be based on BMI history. However, longitudinal studies investigating BMI are rare. OBJECTIVES: To determine pragmatically different weight history patterns over forty years. DESIGN: Longitudinal study with four follow-ups over forty years, elucidating risk factors for peripheral vessel diseases as the original goal. SUBJECTS: There were 343 male subjects whose weight was measured both at baseline and at follow-ups. RESULTS: Based on pragmatic methods the following eight patterns were found: "stable" (24.8%), "stable and increasing" (28.6%), "stable and decreasing" (9.0%), "hill" (10.0%), "valley" (7.0%), "yo-yo" (14.0%), continually "increasing" (6.4%%), and continually "decreasing" (0.3%). In subjects over 45 years at baseline, stable patterns were most frequent (42%), and descending patterns became more prominent. CONCLUSIONS: The determination of different weight history patterns in a longitudinal study is possible with the use of a pragmatic procedure. Applying such weight history patterns to the mortality risk assessment of overweight could add new aspects to that risk assessment.

In elderly men and women treated for osteoporosis a low creatinine clearance of <65 ml/min is a risk factor for falls and fractures.

Recently, a low creatinine clearance (CrCl) of < 65 ml/min was described as a new significant and independent risk factor for the number of fallers and falls in a community-dwelling elderly population. In this study we investigated if a low creatinine clearance of < 65 ml/min is also a risk factor for falls and fractures in elderly men and women treated for osteoporosis. In a cross-sectional study with the help of questionnaires we assessed the prevalence of having experienced falls within the last 12 months according to renal function in 5,313 German men and women receiving treatment for osteoporosis. The CrCl was calculated using the established Cockcroft-Gault formula. The prevalence of falls and fractures was assessed in multivariate-controlled logistic regression models according to a CrCl cut off of 65 ml/min. The P-values were two-sided. In this study of elderly men and women treated for osteoporosis (n=5,313), 60.9% (n=3,238) had a CrCl of < 65 ml/min, which was associated in multivariate controlled analyses, compared to a CrCl of > or = 65 ml/min (n=2,075), with a significant increased risk of experiencing falls (1,775/3,238 vs. 773/2,075, OR 1.69, 95% CI 1.50-1.91, P<0.0001) and an increased risk for multiple falls (37.1 vs. 22.6%, OR 1.63, 95% CI 1.42-1.87, P<0.0001). Furthermore, compared to a creatinine clearance of > or = 65 ml/min, a creatinine clearance of < 65 ml/min was also associated with a significant increased multivariate controlled risk for hip fractures (OR 1.57, 95%CI 1.18-2.09, P=0.002), for radial fractures (OR 1.79, 95%CI 1.39-2.31, P=<0.0001), for total vertebral fractures (OR 1.31, 95%CI 1.19-1.55, P=0.003) and for fall-associated vertebral fractures (OR 1.24, 95% CI 1.03-1.54, P=0.031). Similar to community-dwelling elderly, in elderly men and women treated for osteoporosis a CrCl of less than 65 ml/min is a significant and independent risk factor for falls. Furthermore, we could show for the first time that a low creatinine clearance in elderly men and women treated for osteoporosis is also associated with a significantly increased risk of vertebral, hip and radial fractures.

Age-dependent effects of the 5-hydroxytryptamine-2a-receptor polymorphism (His452Tyr) on human memory.

A polymorphism (His452Tyr) of the 5-hydroxytryptamine (5-HT)2a receptor is associated with episodic memory in healthy young humans. Because 5-HT2a-receptor density decreases with increasing age, we tested whether the 5-HT2a receptor genotype effect on memory is influenced by age. We investigated the association of the His452Tyr genotype with memory performance in 622 healthy study participants aged from 18 to 90 years. In young to middle-aged participants, age significantly influenced genotype effects on episodic memory: the His452Tyr genotype exerted a significant influence on memory only in young participants. In the group of elderly cognitively healthy participants, the His452Tyr genotype did not affect memory performance. We conclude that age strongly modulates the effect of the 5-HT2a receptor polymorphism at residue 452 on episodic memory.

Body mass index and the risk of male cancer mortality of various sites: 17-year follow-up of the Basel cohort study.

QUESTIONS UNDER STUDY: There is growing evidence for a link between body weight and cancer risk, but there is not a clear consensus yet. METHODS: We studied the association between body mass index (BMI) and overall, lung, prostate and colon cancer mortality. In 1971/73, weight and height were measured in 2974 men working in Basel, Switzerland. In 1990, the vital status of all participants was assessed. RESULTS: 290 men had died from cancer, 87 from lung, 30 from prostate, and 22 from colon cancer. In the predefined Cox Proportional Hazards Regression Models for survival analysis, a baseline hazard was modified multiplicatively by covariates, i.e. the untransformed continuous variable "BMI" was chosen as covariate. In addition it was assumed that the baseline hazard may be different for smokers, non-smokers and different age groups (age at entry into study). Thus, multiple strata, i.e. combinations of smoking status and age groups were allowed. With increasing BMI overall cancer mortality did not change. Accordingly, the relative risk (RR) per 1-unit increase of BMI (unit = 1 kg/m2) was 1.03 (95% CI: 0.99-1.07). In relation to lung cancer, mortality did neither increase nor decrease with increasing BMI (RR = 1.0; 95% CI 0.93- 1.07). The results for prostate cancer mortality were similar, i.e. no correlation with BMI was observed (RR = 0.95; 95% CI: 0.93-1.18). The same was true for colon cancer mortality (RR = 1.09; 95% CI: 0.92-1.24). CONCLUSIONS: This investigation provides little evidence of an association between BMI and mortality of all cancers combined, cancer of the lung, the prostate and the colon.

Treatment with alfacalcidol in elderly people significantly decreases the high risk of falls associated with a low creatinine clearance of <65 ml/min.

We previously observed that a creatinine clearance (CrCl) of <65 ml/min is a significant and independent risk factor for the number of fallers and falls in a community-dwelling elderly population and postulated that this increased risk is due to the associated significant lower D-hormone serum levels. To test our hypothesis, we investigated in a post hoc analysis of a double-blind randomized study whether treatment with alfacalcidol, a synthetic prodrug of the D-hormone, can reduce the high incidence of fallers and the high risk of falls associated with low CrCl. Of 378 Swiss community-dwelling women (n=191) and men (n=187), aged 70 years and older, 191 received randomly 1 microg capsules of alfacalcidol (AlphaD3: Teva), and 187 received one capsule of placebo daily. With the help of questionnaires we regularly assessed the incidence and frequency of falls. The risk of becoming a faller and the risk of falling were assessed in multivariate-controlled logistic regression models according to treatment groups and according to a CrCl cut-off of 65 ml/min. The presented results are from ITT analyses. In participants with a CrCl of <65 ml/min, the 36 weeks of treatment with alfacalcidol was, compared with placebo, associated with a significant reduction in the number of fallers (14/72 versus 25/70; OR 0.26, 95% CI 0.08-0.80, P=0.019), and a significant reduction of the number of falls (16/72 versus 28/70; OR 0.29, 95% CI 0.09-0.88, P=0.028). No such association was observed in participants with a CrCl of >or=65 ml/min (for fallers 26/120 versus 21/116; OR 0.92 95% CI 0.34-2.52, P=0.875; for falls 32/120 versus 23/116; OR 0.93 95% CI 0.34-2.54, P=0.885). In the placebo group frequency of falls was dependent on CrCl (P=0.006), whereas in the alfacalcidol treatment group frequency of falls was independent of CrCl (P=0.494). No cases of clinically relevant hypercalcemia were observed. In a community-dwelling population of elderly men and women with a CrCl of <65 ml/min, treatment with alfacalcidol can significantly and safely reduce the low CrCl associated increased number of fallers and the high risk of falls.

A new significant and independent risk factor for falls in elderly men and women: a low creatinine clearance of less than 65 ml/min.

OBJECTIVES: Because impaired renal function is detrimental for the conversion of calcidiol to calcitriol (D-hormone) and since D-hormone analogues have been shown to decrease the risk of falls, we investigated whether creatinine clearance (CrCl) is associated with the number of fallers and falls in elderly men and women. METHODS: Within a randomized controlled study, we observed for 36 weeks 186 placebo-treated community-dwelling elderly men and women over 70, in an attempt to determine the influence of baseline CrCl on calcitropic hormone serum levels, as well as the influence of baseline CrCl on the number of fallers and falls over time. With the help of questionnaires, we regularly assessed fall incidence and frequency. The risk of falls and the risk of becoming a faller were assessed in multivariate-controlled logistic regression models according to a cutoff value of the CrCl set at 65 ml/min. RESULTS: At baseline, serum levels of 1.25(OH)(2)D(3) and iPTH were, in multivariate-controlled analyses, significantly associated with CrCl (p<0.0001, p=0.001, respectively), whereas serum levels of 25(OH)D(3) were not associated with CrCl. Below a CrCl of 65 ml/min, 1.25(OH)(2)D(3) serum levels steadily declined. We therefore chose a CrCl of 65 ml/min as cutoff for further analyses. During the 36 weeks of observation, elderly people with a CrCl of < 65 ml/min had, in multivariate controlled analyses, compared with elderly with a CrCl of > or =65 ml/min, a significantly higher incidence of number of fallers (25/70 vs 21/116; OR=4.01; 95% CI, 1.48-10.98; p=0.006), and a significantly higher incidence of falls (28/70 vs 23/116; OR=3.68; 95% CI, 1.38-9.82; p=0.009). CONCLUSIONS: For the first time we showed that in a community-dwelling population of elderly men and women, a CrCl of less than 65 ml/min is a significant and independent risk factor for fallers and falls.

Alfacalcidol reduces the number of fallers in a community-dwelling elderly population with a minimum calcium intake of more than 500 mg daily.

OBJECTIVES: To study the effect of alfacalcidol (1alpha(OH)D3) on fall risk in community-dwelling elderly men and women. DESIGN: Randomized, double-blind, placebo-controlled intervention trial. SETTING: Basel, Switzerland. PARTICIPANTS: Three hundred seventy-eight community-dwelling elderly (191 women/187 men). INTERVENTION: Participants were randomly assigned to receive 1 microg of alfacalcidol or matched placebo daily for 36 weeks. MEASUREMENTS: Serum 25-hydoxyvitamin D3 (25(OH) D,1,25-dihydroxyvitamin D3 (D-hormone), and intact parathormone (iPTH) levels were measured using radioimmunoassay at baseline and every 12 weeks. Numbers of fallers and falls were assessed using a questionnaire during each study site visit. Dietary calcium intake was assessed at baseline using a food frequency questionnaire. RESULTS: At baseline, participants had, on average, normal vitamin D and D-hormone serum levels. Over 36 weeks, alfacalcidol treatment was associated with fewer fallers (odds ratio (OR)=0.69, 95% confidence interval (CI)=0.41-1.16) than placebo. In a post hoc subgroups analysis by medians of total calcium intake, this reduction reached significance in alfacalcidol-treated subjects with a total calcium intake of more than 512 mg/d (OR=0.45, 95% CI=0.21-0.97, P=.042) but not in those who consumed less than 512 mg/d (OR=1.00, 95% CI= 0.47-2.11, P=.998). Alfacalcidol treatment was also, independent of total calcium intake, associated with a significant 37.9% reduction in iPTH serum levels (P<.0001). No cases of clinically relevant hypercalcemia were observed. CONCLUSION: Provided a minimal calcium intake of more than 512 mg/d, alfacalcidol treatment significantly and safely reduces number of fallers in an elderly community dwelling population.

Identifying a cut-off point for normal mobility: a comparison of the timed 'up and go' test in community-dwelling and institutionalised elderly women.

BACKGROUND: physical mobility testing is an essential component of the geriatric assessment. The timed up and go test measures basic mobility skills including a sequence of functional manoeuvres used in everyday life. OBJECTIVES: to create a practical cut-off value to indicate normal versus below normal timed up and go test performance by comparing test performance of community-dwelling and institutionalised elderly women. SETTING AND PARTICIPANTS: 413 community-dwelling and 78 institutionalised mobile elderly women (age range 65-85 years) were enrolled in a cross-sectional study. MEASUREMENTS: timed up and go test duration, residential and mobility status, age, height, weight and body mass index were documented. RESULTS: 92% of community-dwelling elderly women performed the timed up and go test in less than 12 seconds and all community-dwelling women had times below 20 seconds. In contrast only 9% of institutionalised elderly women performed the timed up and go test in less than 12 seconds, 42% were below 20 seconds, 32% had results between 20 and 30 seconds and 26% were above 30 seconds. The 10(th)-90(th) percentiles for timed up and go test performance were 6.0-11.2 seconds for community-dwelling and 12.7-50.1 seconds for institutionalised elderly women. When stratifying participants according to mobility status, the timed up and go test duration increased significantly with decreasing mobility (Kruskall-Wallis-test: p<0.0001). Linear regression modelling identified residential status (p<0.0001) and physical mobility status (p<0.0001) as significant predictors of timed up and go performance. This model predicted 54% of total variation of timed up and go test performance. CONCLUSION: residential and mobility status were identified as the strongest predictors of timed up and go test performance. We recommend the timed up and go test as a screening tool to determine whether an in-depth mobility assessment and early intervention, such as prescription of a walking aid, home visit or physiotherapy, is necessary. Community-dwelling elderly women between 65 and 85 years of age should be able to perform the timed up and go test in 12 seconds or less.