Risk of dementia associated with the ApoE epsilon4 allele and falls causing head injury without explicit traumatic brain injury.

OBJECTIVES: Severe head injury (HI) and the apolipoprotein E (ApoE) epsilon4 allele are risk factors for dementia. The corresponding effect of falls causing HI without explicit traumatic brain injury (TBI) in association with the ApoE epsilon4 is not known. MATERIALS AND METHODS: Altogether 134 persons aged 70 years or older constituted a retrospective population sample, who scored > or =26 in the MiniMental State Examination (MMSE) test at baseline and were clinically examined for dementia 9 years afterward. Fall-related HI causing superficial laceration or bruises or wounds that require suturing were prospectively recorded during the 9-year follow-up. We used Cox regression with age at the diagnosis of dementia as a dependent variable. RESULTS: Twenty-eight (21%) subjects had falls causing HI without explicit TBI, the ApoE epsilon4 allele was seen in 44 (33%), and clinical dementia was diagnosed in 25 (19%). Adjusted for the baseline MMSE score, sex and educational status, the hazard ratio for subsequent dementia in subjects having falls with HI without explicit TBI and the ApoE epsilon4 allele as compared with those who do not possess these characteristics was 2.70 (95% confidence interval, 1.02-7.16). CONCLUSIONS: According to the results of this small retrospective study, falls with HI without explicit TBI in connection with the ApoE epsilon4 allele is associated with subsequent dementia among older adults.

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

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

Orthostatic hypotension and the risk of myocardial infarction in the home-dwelling elderly.

OBJECTIVES: We investigated the prognostic significance of orthostatic hypotension on the risk of myocardial infarction (MI) amongst the elderly. DESIGN: Prospective population-based study. SETTING: Home-dwelling population. SUBJECTS: Orthostatic testing was performed between 8 a.m. and 2 p.m., irrespective of having had meals, on 792 persons, representing 82% of all home-dwelling persons aged > or =70 years living in five municipalities around the city of Oulu. MAIN OUTCOME MEASURES: Occurrence of cases of MI were recorded during mean 3.58 (SD 1.09) years follow-up period, from national mortality statistics and local hospital discharge registers. RESULTS: Ninety cases of MI, of which 40 were fatal after initial hospitalization, occurred during the follow-up period. Orthostatic diastolic blood pressure (BP) drop 1 min after standing up was associated with subsequent MI, but systolic BP reactions had no predictive value. According to the Cox regression model, the strongest predictor of the occurrence of subsequent MI was found in regard to > or =8 mmHg drop in diastolic BP 1 min after standing up; adjusted for history of MI, diabetes mellitus, chest pain, use of calcium antagonist, beta-blocker, nitrate and diuretic medication, hazard ratio of MI being 2.00 (1.11-3.59). CONCLUSIONS: Orthostatic testing offers a novel means to assess the risk of MI amongst elderly persons. Diastolic BP drop immediately after standing up identifies elderly subjects at a high risk of subsequent MI.

Depressive symptoms and the risk of sudden cardiac death among the elderly.

AIMS: Mental depression is associated with an increased risk of cardiovascular mortality, but the reasons for this association are not well known. We tested the hypothesis that depressive symptoms (DS) may specifically increase the risk of sudden cardiac death (SCD) among the elderly subjects. METHODS: All persons aged 70 years or over of a defined area in Northern Finland (n=1113) were the target population, and 915 (82%); 336 men and 579 women, participated in the questionnaire on depressive symptoms according to the Short Zung Depression Rating Scale. Potential risk factors of SCD were examined in the same connection, and the mode of death was examined via the official death certificates during the following eight years. SCD and non-SCD as well as overall mortality, cardiac mortality and non-fatal myocardial infarction (MI) were the end-points. RESULTS: Four hundred and seventy-six subjects out of 915 (52%) died during the follow-up of 8 years. Thirty-eight of deaths were SCDs (8%) and non-SCD occurred in 106 subjects (22%). In univariate analysis, a high score of DS was a significant predictor of subsequent SCD; hazard ratio 2.67 (95% confidence interval 1.34-5.32), non-SCD; 1.67 (1.06-2.63), cardiac mortality; 1.90 (1.30-2.78) and total mortality; 1.88 (1.52-2.32), but not that of non-fatal MI; 1.74 (0.89-3.38). SCD was also predicted by gender (P<0.01), MI (P<0.01) and tablet- or insulin-treated diabetes mellitus (P<0.01). In multivariate Cox regression analysis by adjusting for the clinical variables, high score of DS remained as a significant predictor of SCD; hazard ratio 2.74 (1.37-5.50) and total mortality; 1.70 (1.37-2.10), but not of cardiac mortality 1.50 (0.998-2.27), non-SCD; 1.38 (0.85-2.24) and non-fatal MI; 1.37 (0.69-2.71). CONCLUSIONS: Depressive symptoms increase the risk of SCD, but not that of non-SCD and non-fatal MI among the elderly subjects.

Factors related to occurrence of hip fracture during a fall on the hip.

Recently, it has been shown that hip fractures can be effectively prevented by use of hip protectors. To determine who would gain most benefit from use of hip protectors, we conducted a study with the aim to clarify factors that contribute to the occurrence of fracture in individuals who fall on their hip. Hip fracture patients were compared with individuals who had fallen on their hip without sustaining a fracture. The study group consisted of 123 consecutive hip fracture patients aged 70 years or over (mean age 82 years, female 82 years and male 80 years). The control group comprised 132 individuals (mean age 81 years, female 81 years and male 80 years) obtained from a prospective study on falls, who had experienced a fall that caused a visible soft tissue injury (bruise or wound) at the hip or gluteal region without sustaining a fracture. Patients were questioned about associated diseases, medications, place of residence, walking ability, need for locomotor aids and some activities in daily living (ADL). Patients who sustained a hip fracture were more likely to be women, living in long-term institutional care, using neuroleptics, dependent in ADL and had more history of previous stroke with hemiparesis, more Parkinsonism and lower body mass indexes (BMI) than those who did not sustain a fracture on fall on the hip. According to a logistical regression model, institutional residence, low BMI and history of stroke with hemiplegic status differed between fracture cases and controls. Institutional residence, low BMI and history of hemiplegic stroke discriminate hip fracture patients from fallers who sustain a soft tissue injury on the hip region. In clinical practice, patients who have these characteristics would be potential candidates to use hip protectors and other preventive measures.

Recent decline in heavy outdoor work activity predicts occurrence of fractures among the home-dwelling elderly.

The contribution of reduced physical activity of a defined duration to the risk of fall-related fractures and serious soft tissue injuries is not known. We conducted a prospective population-based study among the home-dwelling elderly to examine the association between a recent decline in physical activity and the occurrence of fall-related fractures and soft tissue injuries. The study population consisted of representative sample of home-dwelling older adults who conducted heavy outdoor work activity at least once a week at baseline (n = 284; 136 men, 148 women) and among whom in 93 persons (33%) heavy outdoor work activity was found to have declined during the 2 1/2 years follow-up. Fall-related fractures (n = 24) and serious soft tissue injuries (n = 49) were recorded from the time of the follow-up examination until the end of a further follow-up period lasting 3 1/2 years on average. A decline in heavy outdoor work activity did not predict the occurrence of soft tissue injuries (Mantel-Cox 0.795, p = 0.373), but a greater proportion of those with a decline (n = 14, 15%) than of others (n = 10, 5%) suffered fractures (Mantel-Cox 10.231, p = 0.001). Other risk factors for fractures were female sex (p = 0.03), slow choice reaction time (p = 0.02) and dependency as regards at least one basic activity of daily living (p = 0.01). According to the Cox proportional hazard model, the adjusted hazard ratio of fracture as regards a decline in heavy outdoor work activity was 2.7 (95% CI 1.14-6.62). A recent decline in heavy outdoor work activity predicts the occurrence of fractures, but not the occurrence of serious soft tissue injuries. Early recognition of a decline in physical activity may help in prevention of fractures among the elderly.

Strong prediction of fractures among older adults by the ratio of carboxylated to total serum osteocalcin.

We examined serum total osteocalcin (TOC), carboxylated osteocalcin (COC), and their ratio (COC/TOC) by one-step two-site immunofluorescent assays in 87% (n = 792) of all home-dwelling persons of 70 years or older living in a defined area in northern Finland. Other baseline subject-related risk factors of fractures were assessed by postal questionnaires, interviews, clinical examinations, and tests. During a 5-year follow-up period, all falls and fractures (n = 106) were recorded by regular phone calls and by examining all the medical records yearly. Serum TOC and COC concentrations increased with advancing age and were higher in women than in men, but corresponding differences were not found in the case of COC/TOC. The adjusted relative risk of fracture was elevated in association with low (< or =-1 SD from the mean) COC; hazard ratio (HR, 95% CI) 2.00 (1.20-3.36) and low COC/TOC; HR 5.32 (3.26-8.68), the relative risk being highest in the population older than 80 years; and HR 7.02 (2.42-20.39). The predictive value of low COC/TOC lasted 3 years. The multivariable-adjusted relative risk of hip fracture (n = 26) in regard to low COC/TOC ratio was 3.49 (1.12-10.86), as compared with the persons who did not suffer hip fractures. Our results suggest that serum COC concentrations and, more strongly, COC/TOC, predict the occurrence of fractures in older community-dwelling adults. The risk of fracture associated with low COC/TOC equals the hip fracture risk previously verified for concomitant high serum undercarboxylated OC concentrations and low bone mineral density.

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

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

Motor evoked potentials of subjects over 70 years of age with and without recurrent falls.

Motor evoked potentials (MEPs) of 83 elderly (79+/-4 years) subjects, 43 with recurrent falls and 40 without, and of 31 healthy young (42+/-9 years) subjects were measured from thenar (and hypothenar) and tibialis anterior muscles. Forty-four of the aged subjects without overt neurological diseases were used as controls. Absolute latencies from the cortex to the target muscles as well as the latency differences from the cortex to the level of the fifth lumbar vertebra (LV) were longer in the aged than in the young, but the latency difference from the cortex to the brachial plexus was shorter. The cortical, brachial plexus and lumbar (LV) latencies were all dependent on height as well as age. The latency differences from the cortex to the plexus or LV were not height-dependent but were age-dependent. The thenar MAXMEP/CMAP ratio was significantly higher in hands with thenar atrophy (in 30% of the aged subjects) than without; thenar atrophy thus excludes the use of this parameter in about one-third of the aged subjects. There were no significant differences in the MEP latencies or amplitudes of the recurrent fallers and the non-fallers. Subjects having more frequent falls, however, tended to have lower amplitudes of MEPs in the lower extremities.

Marital and family relations and depression in married elderly Finns.

BACKGROUND: The aim was to describe the relationships between poor marital and family relations and depression, and the predictive value of these factors for the subsequent occurrence of depression. METHODS: The population for the cross-sectional study consisted of the married elderly (N = 498) living in Ahtäri, Finland, in 1989. The series of the longitudinal study was composed of married persons nondepressed in the epidemiological study in 1984-1985, and followed up until 1989-1990 (N = 347). RESULTS: In men, impaired functional abilities (OR 5.0) and poor family relations (OR 2.9), and in women, impaired functional abilities (OR 3.9), family violence (OR 4.2), age 70 years or over (OR 3.0) and a loss of father in childhood or youth (OR 2.5) were independently related to depression. Poor marital relations tended to be related to depression in both men (OR 2.1) and women (OR 2.2). In both sexes, poor self-appreciation (OR men 3.9; women 7.1) and age 70 years or over (OR men 2.9; women 4.2), and in women, a loss of father in childhood or youth (OR 4.5) were independent predictors of subsequent depression. CONCLUSIONS: The poor marital or family relations experienced by many depressed elderly persons are usually consequences rather than predictors of depression. Family violence may be a consequence of depression or even a risk factor for depression. CLINICAL IMPLICATIONS: Problems in spouse pairs and families should be inquired and solved when treating depressed elderly persons. LIMITATIONS OF THE STUDY: Due to the unknown validity of the measure concerning marital relations, the results are suggestive.

Orthostatic hypotension and cognitive decline in older people.

OBJECTIVES: To establish the role of orthostatic hypotension (OH) as a risk factor for cognitive decline among home-dwelling and institutionalized older people and to describe other predictors of cognitive decline. DESIGN: Follow-up study with two clinical examinations. SETTING: A community-based setting in northern Finland. PARTICIPANTS: All of the 1159 people aged 70 or more living in five rural municipalities around the town of Oulu in Northern Finland in 1991. At the time of the follow-up examination, 2.5 years later, 884 of the original participants were alive and 651 were re-examined. MEASUREMENTS: In 1991, 907 people (78.3% of the total population) were tested for orthostatic hypotension, and their cognitive capacity was assessed with the Mini-Mental State Examination (MMSE). The calculation/spelling tasks were excluded from the final version used in the statistical analysis. The re-assessment of cognitive capacity was made on 651 subjects (73.6% of those alive) who had participated in the first examination. The data were analyzed using polychotomous and linear regression analysis models. RESULTS: The prevalence of OH was 28.7%, with no age or sex differences. The mean sum score for the shortened MMSE in 1991 was 21.6 (+/-3.98) for persons with OH and 21.1 (+/-4.08) for non-OH persons. During the follow-up, the sum score declined in the OH group by .44 (+/-2.81) points and in the non-OH group by .83 (+/-3.61) points. No type of OH (systolic or diastolic 1- or 3-minute values or their combination) predicted cognitive decline; the only predictors were old age and low level of formal education. CONCLUSIONS: Orthostatic hypotension is a common clinical condition that affects every fourth person aged 70 years or older. By temporarily inducing cerebral hypoperfusion, it may cause or exacerbate cognitive dysfunction. In an unselected population, OH was not associated with cognitive deterioration, nor did it predict cognitive decline during a 2-year follow-up.

Prognosis of diastolic and systolic orthostatic hypotension in older persons.

BACKGROUND: Orthostatic hypotension (OH) predicts mortality in hypertensive persons with diabetes mellitus, but no increase in mortality has been found among random samples of home-dwelling persons with OH. We examined the risks of nonvascular and vascular deaths according to different definitions of OH among home-dwelling elderly persons. SUBJECTS AND METHODS: The study population consisted of all persons aged 70 years or older living in 5 rural municipalities (N=969), of whom 833 (86%) participated. Orthostatic tests were successfully carried out in 792 persons by nurse examiners. Orthostatic hypotension was defined as a systolic blood pressure (BP) drop of 20 mm Hg or more or a diastolic BP drop of 10 mm Hg or more 1 minute or 3 minutes after standing up. Nonvascular and vascular deaths during the follow-up period were recorded. Data on diseases, symptoms, medications, the results of clinical examinations and tests, functional ability, and health behavior were collected at the beginning of the follow-up period. RESULTS: Of the sample, 30% had OH: the prevalence of systolic OH 1 minute and 3 minutes after standing up was 22% and 19%, respectively; that of diastolic OH 1 minute and 3 minutes after standing up was 6% for each. No differences in the occurrence of nonvascular deaths were found according to any of these definitions. By Cox multivariate regression analysis, the hazard ratio of vascular death associated with a diastolic BP reduction of 1 mm Hg 1 minute after standing up was 1.02 (P=.03), adjusted for systolic BP postural changes at 1 and 3 minutes and a diastolic BP change at 3 minutes. Adjusted for other significant factors associated with vascular death, the hazard ratio for vascular death associated with diastolic OH 1 minute after standing up was 2.04 (95% confidence interval, 1.01-4.15). The corresponding hazard ratio for systolic OH 3 minutes after standing up was 1.69 (95% confidence interval, 1.02-2.80). Using a cutoff point of 7 mm Hg or greater for a diastolic BP change 1 minute after standing up, the hazard ratio for vascular death was highest: 2.20 (95% confidence interval, 1.23-3.93). By logistic regression analysis, the baseline associates of diastolic OH 1 minute after standing up were dizziness when turning the neck (odds ratio [OR], 2.44), the use of a calcium antagonist (OR, 2.31), the use of a diuretic medication (OR, 2.29), a high systolic BP (OR, 2.23), and a low body mass index (OR, 2.26). The baseline associates of systolic OH 3 minutes after standing up were male sex (OR, 1.52), diabetes mellitus (OR, 1.92), a high systolic BP (OR, 2.91), and a low body mass index (OR, 1.68). CONCLUSIONS: The presence of diastolic OH 1 minute and systolic OH 3 minutes after standing up predict vascular death in older persons. They differ from each other in their prevalence and in several associates, suggesting different pathophysiologic backgrounds. Clinicians should prescribe vasodilating and volume-depleting medications with caution for elderly persons with diastolic OH 1 minute after standing up. Appropriate treatment of hypertension might be the best means to manage the different types of OH with poor vascular prognoses.

Head injuries and cognitive decline among older adults: a population-based study.

OBJECTIVE: To examine the relationship between minor and major head injuries caused by fall accidents and cognitive decline among a cohort of adults age 70 years or older (n = 588). BACKGROUND: Even a mild brain injury may affect cognitive functions. Among older adults, results from case-control studies suggest that the occurrence of head injury is positively associated with the onset of AD. METHODS: The shortened version of the Mini-Mental State Examination (sMMSE) was performed and a set of demographic and clinical variables were collected at the beginning of the study. All falls were recorded during a period of 2.5 years, after which the sMMSE tests were repeated. The risk of falls causing head injury in terms of a defined cognitive decline was examined during another follow-up period of approximately 2.5 years. RESULTS: There was no association between the occurrence of minor head injuries and decline in sMMSE scores. A positive relationship existed between the occurrence of major head injuries and a decline in sMMSE scores. The risk of cognitive decline increased linearly as higher cut-off points were used to define the decline in sMMSE scores-with relative risks (95% CI) of 0.94 (0.47 to 1.90), 1.35 (0.64 to 2.85), 1.75 (0.78 to 3.91), 2.38 (1.02 to 5.52), and 3.72 (1.64 to 8.44)-for a decline of > or =1, > or =2, > or =3, > or =4, and > or =5 points in the sMMSE score. The high risk remained unchanged after adjustment for other potential factors contributing to cognitive decline or dementia. The risk factors associated with falls causing major head injury during the second follow-up period were high age, OR (95% CI) 3.58 (1.87 to 6.85); use of psychotropic medication, 2.04 (1.09 to 3.83); diagnosis of hypertension, 1.80 (0.96 to 3.37); and decline in sMMSE score of >5 points, 2.41 (0.86 to 6.76). CONCLUSIONS: Our results suggest that the occurrence of major head injury increases the risk of cognitive decline. The cause of cognitive decline may be dementia, but this assumption remains to be elucidated in future studies.

Depression in elderly spouse pairs.

OBJECTIVE: This study aimed to investigate the prevalence of depression in aged spouse pairs and the associations between the occurrence of depression in one spouse (respondent) and the variables representing the respondent himself/herself and his/her partner. METHOD: Elderly (65 years or older) male (N = 176) and female (N = 176) spouses who constituted married couples that had participated in the epidemiological study on depression in old age conducted in Ahtäri, Finland, in 1989-1990 made up the study series. The data were collected by postal questionnaires, interviews, and clinical investigations. Depression was determined according to the DSM-III criteria. RESULTS: Both husband and wife were depressed in 5.7% of the married couples. The husband was depressed and the wife was nondepressed in 10.2% of the couples; and the wife was depressed and the husband nondepressed in 10.8% of the couples. Among male respondents, poor physical health of the respondent, poor marital or family relations felt by the respondent, poor family relations felt by the marital partner, and a loss of the father by the marital partner while the partner was under 20 years of age were independently related to depression. Lowered functional abilities of the respondent was the only factor independently associated with the occurrence of depression in female respondents. CONCLUSIONS: The coexistence of depression in both elderly spouses is not uncommon. The results also give some evidence to suggest that the vulnerability for the development of depression in the wives may have some effects on the development of depression in elderly men.

Early loss of mother or father predicts depression in old age.

The independent predictive roles of early losses, personality traits, acute losses and long-term stress situations for the occurrence of depression in elderly Finns were described using a longitudinal design. The persons non-depressed in an epidemiological study in 1984-85 were interviewed in 1989-90 (N = 679) and the occurrence of depression was determined according to DSM III-criteria. Logistic regression models were used to assess the independent roles of the hypothesized factors as predictors. An early loss of the mother among men and an early loss of the father among women independently predicted the occurrence of depression in logistic regression models. Older age in men, and a higher number of symptoms, the occurrence of previous depression and not living alone in women were also independent predictors. In men, impaired functional abilities and poor self-perceived health tended to predict depression. In conclusion, the psychological trauma which develops upon the experience of an early parental loss contributes to the development of depression even in old age. The role of stressors in life as independent predictors of depression in old age was also ascertained.

Risk factors for major injurious falls among the home-dwelling elderly by functional abilities. A prospective population-based study.

BACKGROUND: In order to identify the risk factors essential for preventing major injurious falls, the associations between injurious falls and certain factors were assessed among disabled and independent elderly, respectively, who had fallen during a 2-year period. METHODS: A prospective population-based study was conducted in five rural northern Finnish municipalities. The series consisted of all inhabitants aged 70 years or over, initially 979 persons. During a 2-year follow-up period, all injurious falls were recorded on the basis of telephone contacts, diary reporting and a review of the medical records of the participants. RESULTS: Thirty percent of the subjects having fallen sustained a major injury. The multivariate model applied to the disabled elderly showed the following variables to be related to a high risk for major injurious falls: divorced, widowed or unmarried marital status (odds ratio = 2.2), a low body mass index (odds ratio = 3.1), incomplete step continuity (odds ratio = 2.2), poor distant visual acuity (odds ratio = 2.3) and the use of long-acting benzodiazepines (odds ratio = 2.4). Among the independent elderly, the risk of a fall resulting in major injury was high among the subjects who had peripheral neuropathy (odds ratio = 2.5) or were suffering from insomnia (odds ratio = 4.1). CONCLUSIONS: The risk factors for major injuries in fall occurrences differ between the disabled and independent elderly. Preventive measures should be targeted according to the disabilities of the population.