Sarcopenia Indicators as Predictors of Functional Decline and Need for Care among Older People.

OBJECTIVES: Sarcopenia is associated with poor health outcomes. We examined the relative roles of muscle mass, strength, physical performance and obesity as health predictors among older sarcopenic people. DESIGN AND PARTICIPANTS: This prospective study examined community-dwelling people aged 75+ (N=262). SETTING: Porvoo Sarcopenia and Nutrition Trial. MEASUREMENTS: We collected demographic data and medical history by postal questionnaire including RAND-36 at baseline and at four years and measured BMI, Short Physical Performace Battery (SPPB), hand-grip strength, cognition and two surrogate measures of muscle mass; the Single Frequency Skeletal Muscle Index (SF-SMI) and the Calf Intracellular Resistance Skeletal Muscle Index (CRi-SMI). RESULTS: Adjusted for age and gender, independent outdoors mobility was predicted positively by baseline physical functioning scores in RAND-36 (p<0.001), the SPPB (p<0.001), the two-minute step test (p<0.001), and grip strength (p=0.023), as well as CRi-SMI (p<0.001). However, the prediction was negative in BMI (p<0.001) and the Charlson co-morbidity Index (p= 0.004). Similar associations were found when the physical component RAND-36 was used as an outcome measure. The use of home care was predicted by high co-morbidity (p=0.057) and low scores in RAND-36 (p<0.001), SPPB (p<0.001) and the two-minute step test (p<0.001), and low CRi-SMI (p<0.001). CRi-SF was a more consistent predictor than SF-SMI, which was partly masked by BMI. Controlled for age, gender and comorbidity, a 10% difference in CRi-SMI was associated with a 4% higher probability (p=0.019) of independently living at home, whereas the respective figures for SF-SMI and BMI were -18% (p=0.098) and -14% (p=0.088). CONCLUSIONS: In contrast to SF-SMI, high CRi-SMI appeared to indicate good prognosis and less need of care, independently of BMI.

Precipitating factors of delirium: stress response to multiple triggers among patients with and without dementia.

BACKGROUND AND AIM: Delirium is common and serious acute syndrome among older people precipitated by multiple external factors such as acute illnesses, trauma, surgery, and drugs. The aim of this study was to find possible stressors and causative triggers for acute delirium and compare patients with or without dementia in this respect. METHODS: 193 delirious patients from two separate delirium studies including settings of nursing homes and geriatric wards were thoroughly assessed for precipitating factors of delirium. Patients with and without dementia were compared for their clinical status, symptoms and signs, prognosis, and the profile of precipitating factors of delirium. RESULTS: The patients with dementia (n=98) and without dementia (n=95) did not differ in their demographic factors, mean number of drugs, or their psychiatric symptoms. The patients with dementia had higher number of comorbidities, poorer cognition, and they were more often restrained than those without dementia. The mean number of precipitators for delirium was 2.6 among those without dementia and 2.0 among those with dementia (p=0.0019). Infections, metabolic conditions, trauma, and surgery were more common precipitating factors for delirium in those without than those with dementia. There was no difference in mortality between the groups. CONCLUSION: Most patients had multiple precipitating factors for delirium irrespective of prior dementia. Those with dementia and decreased cognitive reserves needed lower number of etiologies to develop delirium. The profile of causative agents differed among patients with and without dementia.

Secular trends in the use of vitamins, minerals and fish-oil products in two cohorts of community-dwelling older people in Helsinki--population-based surveys in 1999 and 2009.

OBJECTIVES: To examine and compare the prevalence of use of vitamins, minerals, and fish-oil products (VMFO) in Finnish community-dwelling older people at two time points over a decade, and to explore the associated factors with the VMFO use. METHODS: A postal survey was sent to people aged 75, 80, 85, 90, and 95 years living in Helsinki, Finland in 1999 (N=3219) and in 2009 (N=2247). The response rates were 78% (n=2511) and 73% (n=1637), respectively. The surveys included items on demographic and health related factors, used medication and self-reported supplemental use of vitamins or minerals, and natural products. RESULTS: The proportion of respondents using at least one VMFO was 49.8% in 1999 and 66.8% in 2009 (p<0.001). The proportion using vitamin D (RR 4.58, 95% CI 3.89 to 5.40; p<0.001), calcium (RR 2.47, 95% CI 2.18 to 2.80; p<0.001), magnesium (RR 1.47, 95% CI 1.17 to 1.85; p<0.001), and fish-oil/omega3 products (RR 3.66, 95% CI 2.41 to 5.55; <0.001) was higher in 2009 than in 1999, even when adjusted for age, gender, living conditions, education and comorbidities, whereas that of other vitamins and fish-liver-oil products was lower. At both time points the use of VMFO was associated with female gender and higher number of used medications. In 1999, higher education was associated with VMFO-use while age and comorbidities was not. In 2009 higher age and comorbidities was associated with VMFO-use. CONCLUSIONS: The use of VMFO is common among community-dwelling older people and it has significantly increased over ten years. The increase was mainly due to the use of vitamin D and calcium. The consumption of other vitamin supplements has decreased. Education was no longer associated with use of VFMO in 2009 where as age and comorbidities were.

Musculoskeletal pain and its treatment among older home-dwelling people: ten-year changes in two Finnish birth cohorts.

The purpose of this study is to evaluate the prevalence of musculoskeletal pain and the use of analgesics in two random cohorts of home-dwelling older people 10 years apart (1999 (N = 2044) and 2009 (N = 1610)) in Helsinki, Finland, and to explore which patients characteristics are associated with potential undertreatment or overtreatment of pain. In 1999, the prevalence of daily joint pain interfering with functioning was 16.4% and that of back pain 13.9% among 75-85-year-old people, the respective figures being 21.9% and 17.1% in 2009 (p < 0.001). The proportion of those patients suffering from joint pain and using prescribed analgesics for that was 35.5% in 1999 and 41.5% in 2009 (p < 0.001). The corresponding figures for patients suffering from back pain with analgesics were 38.2% and 48.2% (p < 0.001), respectively. In 2009, 66.1% suffered from any musculoskeletal pain and 28.7% of them were prescribed analgesics, the figures being more frequent among women than men. In addition to higher age, female gender, and painful conditions, also psychiatric symptoms and dizziness tended to be independently associated with analgesic prescriptions. Among persons not reporting pain (N = 545) psychiatric symptoms were overrepresented in the group using prescribed analgesics (22.4% vs. 8.1%, p < 0.05). In conclusion, musculoskeletal pain is still clearly undertreated, but the coverage has increased during 10 years. In addition to pain, several patient characteristics, functioning and psychiatric symptoms, especially, were associated with analgesic prescriptions.

Association of midlife obesity and cardiovascular risk with old age frailty: a 26-year follow-up of initially healthy men.

OBJECTIVE AND HYPOTHESIS: To investigate whether old age frailty is predicted by midlife overweight/obesity and cardiovascular disease (CVD) risk. DESIGN: Longitudinal observational study (the Helsinki Businessmen Study). SUBJECTS: In their midlife in 1974, 1815 initially healthy men (mean age 47 years) were clinically investigated, whereupon their weight status (normal weight < 25 kg m(-2), overweight 25 ≤ body mass index <30 kg m(-2) and obese ≥ 30 kg m(-2)), CVD risk factors and a composite risk score (%) of coronary artery disease (CAD) were assessed. After a 26-year follow-up in 2000, when 425 men had died, the frailty status of survivors (80.9%, n=1125, mean age 73 years) was assessed using a postal questionnaire including the RAND-36/SF-36 instrument. Phenotypic criteria were used to define frailty, and according to these criteria, 40.0% (n=450), 50.4% (n=567) and 9.6% (n=108) were classified as not frail, prefrail and frail, respectively. Risks are presented as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Compared with normal weight, the development of frailty was significantly higher among those men who were overweight or obese in midlife, with fully adjusted ORs (95% CI) of 2.06 (1.21-3.52) and 5.41 (1.94-15.1), respectively. Even the development of prefrailty was significantly increased with midlife overweight (OR 1.39; 95% CI, 1.03-1.87) and obesity (OR 2.96; 95% CI, 1.49-5.88). Age-adjusted composite CAD score in midlife predicted similarly 26-year total mortality (OR per 1% increase:1.16; 95% CI, 1.08-1.24) and development of frailty (OR 1.16; 95% CI, 1.02-1.33). CONCLUSION: Overweight/obesity and higher CAD risk in midlife were associated with frailty 26 years later. Preventing old age frailty should be recognized as an important goal of obesity and CVD risk control.

Anticholinergic drugs and their effects on delirium and mortality in the elderly.

AIM: To investigate the use of drugs with anticholinergic properties (DAPs) and their associations with delirium and mortality among elderly patients with comorbidities. METHODS: 425 patients (≥70 years of age) in geriatric wards and nursing homes were assessed. The use of DAPs was retrieved from their medical records. Delirium was diagnosed according to the DSM-IV criteria. RESULTS: Of the 341 patients (80.2%) treated with multiple DAPs (≥2), 92 patients (27.0%) suffered from delirium, whereas 14 of 84 patients (16.7%) without DAP treatment had delirium (p = 0.050). In a logistic regression analysis with age, gender, and Charlson Comorbidity Index as covariates, DAP treatment did not predict delirium (odds ratio 1.67, 95% confidence interval 0.87-3.21). The 2-year mortality was 49.3% (n = 168) in DAP users and 35.7% (n = 30) in non-users, respectively (p = 0.026). In the Cox proportional hazard model adjusted for age, gender, and comorbidity, DAPs did not predict mortality (hazard ratio 1.12, 95% confidence interval 0.75-1.68). CONCLUSION: The use of DAPs is very frequent among frail inpatients with comorbidities, but their use has no independent prognostic significance.

Definition of frailty in older men according to questionnaire data (RAND-36/SF-36): The Helsinki Businessmen Study.

OBJECTIVE: To explore the association of frailty according to questionnaire data (modified Fried criteria) with important endpoints in older men. DESIGN AND SETTING: Prospective cohort study (the Helsinki Businessmen Study) in Finland. PARTICIPANTS AND MEASUREMENTS: In 1974, clinically healthy men (born 1919-1934, n=1815) of similar socioeconomic status were identified. After a 26-year follow-up in 2000 (mean age 73 years), disease prevalence, mobility-disability, and frailty status (80.9% of survivors, n=1125) were appraised using a postal questionnaire including RAND-36. Four criteria were used for definition: 1) >5% weight loss from midlife, or body mass index (BMI) <21 kg/m2; 2) reported physical inactivity; 3) low vitality (RAND-36); 4) physical weakness (RAND-36). Responders with 3-4, 1-2, and zero criteria were classified as frail (n=108), prefrail (n=567), and nonfrail (n=450), respectively. Eight-year mortality was assessed from registers, and in 2007, survivors were re-assessed with questionnaires. RESULTS: Nonfrail as referent and adjusted for age, BMI and smoking, both prefrail (HR 2.26; 95% CI, 1.57-3.26), and frail status (4.09; 95% CI, 2.60-6.44) were significant predictors of mortality. Nonfrailty predicted better survival independently of the frailty components, diseases, and disability, and also predicted faster walking speed and less disability 7 years later. CONCLUSIONS: Frailty, and also prefrailty, as defined using questionnaire data (RAND-36) independently predicted important endpoints in older men.

Similar effects of leucine rich and regular dairy products on muscle mass and functions of older polymyalgia rheumatica patients: a randomized crossover trial.

OBJECTIVES: Leucine-rich milk and whey proteins have been suggested for prevention of age related loss of muscle mass and strength i.e. sarcopenia. The effects of milk protein supplementation and low intensity home based physical exercise on body composition and muscle functions were investigated. DESIGN: A randomized double blind crossover trial. SETTING: Community dwelling members of Helsinki rheumatoid association. PARTICIPANTS: Older people (N=47, mean age 69.5 years) suffering from polymyalgia rheumatica. INTERVENTION: Patients performed as many stand ups as possible twice a day after which they ingested a regular (Control) or a whey protein enriched dairy product with high leucine content (Test). The 8-week intervention periods were separated by a 4-week wash-out. MEASUREMENTS: Body composition was measured by dual x-ray absorptiometry and muscle functions by hand grip strength, force platform countermovement jump performance, chair stand test, and walking speed. RESULTS: The 16-week home-based post-exercise supplementation resulted in a 1.8% increase (p = 0.052) in lower limb muscle mass. Walking speed (+5.3%, p = 0.007) and chair stand test performance (-12.2 %, p < 0.001) were also improved. Furthermore, a tendency for increased jump power (+3.0%, p = 0.084) was observed. However, significant and consistent differences were not found in the changes of muscle mass indices or muscle functions between supplements, but the test supplement tended to prevent accumulation of body fat. CONCLUSION: A low intensity home based exercise program combined with post-exercise milk protein supplementation is feasible despite some gastrointestinal complaints and seems effective in improving the muscle mass and functions of older persons with a inflammatory disease. Further studies are needed to establish, whether and to what extent the use of leucine-enriched whey products prevent or treat age-associated sarcopenia and whether they are superior to the present commercial milk products.

C-reactive protein and fibrinogen of bedridden older patients in a six-month vitamin D supplementation trial.

OBJECTIVE: To elucidate the association between vitamin D status, C-reactive protein (CRP) and fibrinogen. DESIGN: Secondary analysis of a randomised double-blind placebo controlled trial. SETTING: Four longterm care hospitals (1215 beds) in Helsinki, Finland. PARTICIPANTS: 218 long-term inpatients aged over 65 years. INTERVENTION: Eligible patients (n = 218) were randomized to receive 0 IU/d, 400 IU/d, or 1200 IU/d cholecalciferol for six months. METHODS: Plasma 25-hydroxyvitamin D (25-OHD), parathyroid hormone (PTH), high sensitive CRP, fibrinogen, amino-terminal propeptide of type I procollagen (PINP), and carboxy-terminal telopeptide of type I collagen (ICTP) were measured. RESULTS: The patients were aged (84.5 +/- 7.5 years), vitamin D deficient (25-OHD = 23 +/- 10 nmol/l), chronically bedridden and in stable general condition. The mean baseline CRP and fibrinogen were 10.86 mg/l (0.12 mg/l - 125.00 mg/l) and 4,7 g/l (2.3 g/l - 8.6 g/l), respectively. CRP correlated with ICTP (r = 0.217, p = 0.001), but not with vitamin D status. Supplementation significantly increased 25-OHD concentrations, but the changes in CRP and fibrinogen were insignificant and inconsistent. The post-trial CRP concentrations (0.23 mg/l -138.00 mg/l) correlated with ICTP (r = 0.156, p < 0.001), but no association was found with vitamin D status. The baseline and post-trial fibrinogen correlated with CRP, only. CONCLUSIONS: CRP concentrations are associated with bone turnover, but not with vitamin D status, and vitamin D supplementation has no major effect on CRP or fibrinogen concentrations in bedridden older patients.

The use of legal guardians and financial powers of attorney among home-dwellers with Alzheimer's disease living with their spousal caregivers.

We conducted a cross-sectional survey of a random sample of 1943 spouses of home-dwellers with Alzheimer's disease (AD) to examine the prevalence of court-appointed guardians or financial powers of attorney for persons with AD, related factors and the need for information about these issues among caregiving families. The questionnaire consisted questions on variables of demographic characteristics, disability, symptoms and care needs of the person with dementia, the strain of caregiving, the use of court-appointed legal guardians or powers of attorney, as well as discussions about these issues -- and the need for them -- with a doctor. The response rate was 77% and the mean ages of those with AD and caregivers were 80.2 and 78.2 years, respectively. The use of legal guardians was rare (4.3%), while the use of financial powers of attorney was more common (37.8%). Only 9.9% of the couples had discussed these issues with their doctor, whereas 47.9% expressed a need for it. The factors associated with the use of these legal arrangements were related to the severity of dementia, including experiencing dementia symptoms for more than 3 years, poor functioning, incontinence and behavioural symptoms. There is a clear need for information on medico-legal issues related to dementia among caregivers of AD patients. If held soon after the diagnosis, such discussions could support the autonomy of these persons in spite of AD and enable them to plan for the future as they wish.

How do elderly spouse care givers of people with Alzheimer disease experience the disclosure of dementia diagnosis and subsequent care?

OBJECTIVES: To examine the experiences of spousal care givers of Alzheimer patients to disclosure of dementia diagnosis and subsequent care. METHODS: A random sample of 1943 spousal care givers of people receiving medication for Alzheimer disease (AD) was sent a cross-sectional postal survey about their opinions on the disclosure of dementia and follow-up care. A smaller qualitative study (n = 63) included open-ended questions concerning their experiences of the same topics. RESULTS: The response rate for the survey was 77%. Of the respondents, 1214 of 1434 acknowledged themselves as their spouse's care giver. The mean age of the care givers was 78.2 years, and that of demented spouses, 80.5 years. Of the care givers, 63% were women. The couples had long-lasting marriages (mean 52 years). Of the care givers, 93% reported that dementia had been disclosed openly to their spouse; 97% also preferred that physicians openly inform the patients of the dementia diagnosis, although 55% of their spouses with AD had developed depressive symptoms after the disclosure. Of the care givers, 71% felt they had received sufficient information about dementia. However, only 50% estimated that their spouses' follow-up care had been well organised. The responses in the qualitative study indicated that many care givers felt grief and anxiety. They also expressed feelings of loneliness and uncertainty about how to deal with follow-up care for dementia. CONCLUSIONS: Elderly spousal care givers were quite satisfied with the information given them about dementia. However, the support with regard to the follow-up care of care-giving families failed to meet their needs adequately.

Chocolate, well-being and health among elderly men.

OBJECTIVE: We hypothesized that chocolate preference would be related to health and psychological well-being in old men. DESIGN, SETTING AND PARTICIPANTS: We have followed up a socio-economically homogenous group of men, born in 1919-1934, since the 1960s. In 2002-2003, a mailed questionnaire was used to assess the health and well-being (including questions related to positive life orientation, visual analogue scales and the Zung depression score) of survivors. In addition, candy preference was inquired. Those men who reported no candy consumption (n=108) were excluded from the analyses. OUTCOME MEASURES: Psychological well-being in old age. RESULTS: The response rate was 69% (1367 of 1991). Of the respondents, 860 and 399 preferred chocolate and other type of candy, respectively. The average age in both candy groups was 76 years. Of the respondents, 99% were home-dwelling, 96% were retired and 87% were presently married, without differences between the candy groups. Men preferring chocolate had lower body mass index and waist circumference, and they also reported more exercise and better subjective health (P=0.008) than other candy consumers. Variables related to psychological well-being were consistently better in those preferring chocolate. The differences were statistically significant in feeling of loneliness (P=0.01), feeling of happiness (P=0.01), having plans for the future (P=0.0002) and the Zung depression score (P=0.02). CONCLUSIONS: In this socioeconomically homogenous male cohort, chocolate preference in old age was associated with better health, optimism and better psychological well-being. SPONSORSHIP: The Academy of Finland, the Päivikki and Sakari Sohlberg Foundation, the Helsinki University Central Hospital and the Finnish Foundation for Cardiovascular Research.

Predictors and subjective causes of loneliness in an aged population.

The aim of the study was to examine the prevalence and self-reported causes of loneliness among Finnish older population. The data were collected with a postal questionnaire from a random sample of 6,786 elderly people (>or=75 years of age). The response rate was 71.8% from community-dwelling sample. Of the respondents, 39% suffered from loneliness, 5% often or always. Loneliness was more common among rural elderly people than those living in cities. It was associated with advancing age, living alone or in a residential home, widowhood, low level of education and poor income. In addition, poor health status, poor functional status, poor vision and loss of hearing increased the prevalence of loneliness. The most common subjective causes for loneliness were illnesses, death of a spouse and lack of friends. Loneliness seems to derive from societal life changes as well as from natural life events and hardships originating from aging.

Behavioral symptoms and the administration of psychotropic drugs to aged patients with dementia in nursing homes and in acute geriatric wards.

OBJECTIVES: To describe the prevalence of various psychiatric and behavioral symptoms among patients with dementia in nursing homes and acute geriatric wards and to investigate the administration of psychotropic medications to these patients. METHODS: 425 consecutive patients (>70 years) in six acute geriatric wards in two city hospitals and seven nursing homes in Helsinki, Finland, were assessed with an extensive interview, cognitive tests, and attention tests. Of these, 255 were judged to have dementia according to the following information: previous dementia diagnoses and their adequacy, results of CT scans, Mini-mental State Examination (MMSE) tests, Clinical Dementia Scale (CDR) tests, and DSM-IV criteria. Psychiatric and behavioral symptoms were recorded over two weeks for each patient. RESULTS: Psychiatric and behavioral symptoms were very common among patients with dementia in both settings. In all, 48% presented with psychotic symptoms (delusions, visual or auditory hallucinations, misidentifications or paranoid symptoms), 43% with depression, 26% agitation, and 26% apathy. Use of psychotropic drugs was also common: 87% were on at least one psychotropic drug, 66% took at least two, 36% at least three, and 11% four or more psychotropic drugs. Of the patients with dementia, 42% were on conventional antipsychotics, and 34% on anxiolytics despite their known side-effects. Only 13% were on atypical antipsychotics and 3% on cholinesterase inhibitors. The use of selective serotonin reuptake inhibitors (SSRIs) was common (31%) among the patients. A surprising finding was that drugs with anticholinergic effects were also frequently (20%) used. CONCLUSION: Both behavioural symptoms and use of psychotropic drugs are very common among dementia patients in institutional settings. The frequent use of potentially harmful drugs implies a need for education among physicians taking care of these patients.

Cognitive impairment and infectious burden in the elderly.

Infectious agents have been suspected as contributing factors to dementia, especially in Alzheimer disease. We intended to test whether viral or bacterial seropositivity is associated with cognitive impairment among home-dwelling elderly. Viral burden (seropositivity for herpes simplex type 1 (HSVI), type 2 (HSV2), or cytomegalovirus (CMV), and bacterial burden (Chlamydia pneumoniae and Mycoplasma pneumoniae) were tested among 383 home-dwelling individuals with vascular disease (mainly coronary heart disease) in the ongoing DEBATE study (mean age 80 years). Mini-mental state examination (MMSE) and its changes were used to define cognitive impairment. At baseline, 0-1, 2, and 3 positive titers toward viruses were found in 48 (12.5 %), 229 (59.8 %), and 106 (27.7 %) individuals,respectively. MMSE points decreased with increasing viral burden (p = 0.03). At baseline,58 individuals (15.1 %) had cognitive impairment (MMSE < 24 points) which after adjustments was significantly associated with seropositivity for 3 viruses (risk ratio 2.5, 95%confidence interval 1.3 to 4.7). MMSE score decreased in 150 cases (43%) during 12-month follow-up. After adjustment for MMSE score at baseline and with 0-1 seropositivities as reference (1.0), the risk ratios were 1.8 (95 % confidence interval 0.9 to 3.6) and 2.3 (95% confidence interval 1.1 to 5.0) for 2 and 3 seropositivities, respectively. No significant associations were observed between bacterial burden and cognition. Viral burden of herpes virus and cytomegalovirus was associated with cognitive impairment in home-dwelling elderly. The association may offer a preventable cause of cognitive decline.

Positive life orientation as a predictor of 10-year outcome in an aged population.

OBJECTIVE: It is well known that depression predicts mortality in old age. However, little is known about the impact of positive emotions. We investigated the impact of positive life orientation on mortality and permanent institutional care in aged birth cohorts. STUDY DESIGN AND SETTING: Participants (born 1904, 1909, and 1914) underwent detailed assessments with follow-up at 5 and at 10 years. Positive life orientation was determined as answering "yes" to all the following items: being satisfied with life, having zest for life, having plans for the future, feeling needed, seldom feeling lonely or depressed. RESULTS: Of participants, 102 (20.8%) had a positive life orientation. After 10 years, 54.5% of them were alive, whereas in the rest of the sample 39.5% survived (P=.004). After controlling for age, gender, and health measures, the impact of positive life orientation was still significant (HR=0.89, 95% CI 0.83-0.93). At 5 years, only 2.9% of those having a positive life orientation but 17.5% of the rest of the sample were in permanent institutional care (P=0.003), with a positive life orientation remaining a significant protector against institutional care (OR 0.58, 95% CI 0.36-0.93). CONCLUSION: Positive attitudes have a long-standing impact on prognosis in old age.

Oral health status, C-reactive protein and mortality--a 10 year follow-up study.

BACKGROUND: Epidemiological studies have reported a strong association between C-reactive protein (CRP) and cardiovascular diseases (CVD). Elevated CRP levels have been observed both in dentate individuals with chronic dental infections like periodontal disease and in those edentulous. The mechanisms behind these observations, especially the reasons for the elevation of CRP in the edentulous, are poorly understood. The comparative data on the importance of these inflammatory conditions in the oral cavity as causes of elevated CRP levels and CVD risk factors are also limited. OBJECTIVE: To determine if edentulism is associated with increased levels of CRP and investigate the possible mechanism for this association; and to study the influence of periodontal disease and edentulism on 10-year mortality. SUBJECTS: Of the 364 subjects aged 76, 81, and 86 years in 1990, 196 were dentate and 168 edentulous. By December 1999, 179 had died, almost half (n = 87) of them due to cardiovascular disease. RESULTS: Significantly more of the edentulous subjects had elevated (> or = 3 mg/L) CRP levels as compared to those with at least 20 teeth (p < 0.01). They also had high salivary microbial counts (p < 0.05), and more mucosal lesions (p < 0.0001) than those with at least 20 teeth. In multivariate analysis, high microbial counts (OR 2.3, CI 1.06-5.05) and mucosal lesions (OR 2.18, CI 1.03-4.61) were significantly associated with elevated CRP levels. The risk for all-cause mortality was non-significantly elevated among the edentulous (RR 1.48, CI 0.95-2.31) and dentate with periodontal disease (RR 1.58, CI 0.96-2.61). CVD mortality was significantly higher among the dentate with periodontal disease (RR 1.97, CI 1.01-3.85) when compared with dentate without periodontal disease. CONCLUSION: Among the edentulous, chronic infections like denture-related mucosal lesions are important determinants of elevated CRP, comparable to periodontal disease in the dentate. Elevated CRP per se and edentulism were not significantly associated with increased mortality. Periodontal disease was, however, still associated with a two-fold CVD mortality in this very old population.

Long-term changes in mood of an aged population: repeated Zung-tests during a 10-year follow-up.

Associates and predictors of lowered mood were investigated in a 10-year prospective study of 411 random persons of three birth cohorts (aged 75, 80 and 85 years) in Helsinki, Finland. High Zung-score ( > 45 points = lowered mood) was found in 24% of subjects and clearly associated with age. Lowered mood was also associated with pessimistic attitudes towards life and impaired survival prognosis. The mean Zung-score fell drastically during the first follow-up (from 39.1 to 34.6 points, P < 0.001) and remained unchanged thereafter at 10-year examination of the survivors (33.9 points). Lowering mood (increase in Zung-score) was best predicted by low baseline Zung-score (r = -0.673, P < 0.001), high baseline MMSE-score (r = -159. P < 0.05) and simultaneous changes in MMSE-scores (r = 0.269, P < 0.01). The data show that lowered mood is associated with pessimistic attitudes towards life, cognitive impairment and impaired survival and that cognitive impairment exposes a patient to lowering mood. It is possible that a screening program improves the mood of aged population.

Confusion assessment method in the diagnostics of delirium among aged hospital patients: would it serve better in screening than as a diagnostic instrument?

BACKGROUND: The Confusion Assessment Method (CAM) is an easy, four-step algorithmic diagnostic test developed to detect delirium. OBJECTIVE: To determine how sensitive and specific the CAM is in diagnosing delirium when compared with fully operationalized criteria of delirium according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) editions III, III revised, and IV, and the International Classification of Diseases (ICD) 10th edition. METHODS: A cross-sectional study with blinded assessments was performed on consecutive elderly patients (>70 years) (n=81) in two acute geriatric hospitals in Helsinki, Finland. The sensitivity, specificity, likelihood ratios, and positive and negative predictive values of CAM were assessed with the DSM-III, DSM-III-R, DSM-IV, and ICD-10 criteria of delirium used as reference standards. RESULTS: Sensitivity rates of the CAM were proved to be only moderate (0.81-0.86) against all formal criteria of delirium. The specificity rates were lower (0.63-0.84), and far less than reported in previous studies using global assessment of the reference standard. Instead of the DSM-III-R, from which it is derived, the CAM seems more concordant with the DSM-IV criteria of delirium. The likelihood ratio for a positive CAM test was 5.06 and for a negative test 0.23, when compared with the DSM-IV. CONCLUSION: The CAM seems to be an acceptable screening instrument for delirium, but the diagnosis should be ensured according to the formal criteria of delirium, preferably by the DSM-IV.