Diabetes mellitus as a modulator of functional impairment and decline in Alzheimer's disease. The Real.FR cohort.

AIMS: To determine whether diabetes mellitus influences functional status in patients with Alzheimer's disease. METHODS: We studied 608 community-dwelling patients with Alzheimer's disease from a prospective multicenter cohort. Diabetes was assessed at baseline. Functional status was assessed twice yearly with the Activities of Daily Living scale. Each patient had a baseline functional disability if their Activities of Daily Living score was < 6. Progression of functional disability was defined by a decreased Activities of Daily Living score over 4 years of follow-up visits. RESULTS: At baseline, diabetes was present in 63 participants (10.4%) and, compared with those without diabetes, was associated with functional impairment [age- and sex-adjusted OR = 2.73 (95% CI 1.41-5.28)]. After controlling for confounders, the association remained significant [OR = 2.04 (95% CI 1.02-4.11)]. Follow-up demonstrated a significant interaction between duration of Alzheimer's disease and diabetes, which was associated with progression of functional impairment in patients who had been diagnosed with Alzheimer's disease for less than 1 year [age- and sex-adjusted hazard ratio = 1.52 (95% CI 1.01-2.30), P = 0.048], but not in those who had been diagnosed with Alzheimer's disease for more than 1 year [age- and sex-adjusted hazard ratio = 0.78 (95% CI 0.47-1.28), P = 0.32]. Abnormal one-leg balance, polymedication and obesity seem to be important factors explaining the association between diabetes and functional status. CONCLUSIONS: At baseline, the presence of diabetes significantly increases the risk of functional disability in patients with Alzheimer's disease; our longitudinal data confirm that in patients with a recent diagnosis of Alzheimer's disease (but not in those who have had Alzheimer's disease for longer than 1 year), diabetes continues to worsen functional status.

Descriptive analysis of emergency hospital admissions of patients with Alzheimer disease.

The aim of this project was to study the underlying reasons for emergency hospital admission of patients with dementia of the Alzheimer type (DAT) and their characteristics. This prospective 4-month study identified 118 patients with DAT, most of whom were referred to the two emergency departments of the Toulouse University Hospital. The two main reasons for admission were behavioral problems (26.3%) and falls (18.6%). Patients were generally at an advanced stage of the disease process and had substantial evidence of poor nutritional status and loss of activities of daily living ability. About one third of patients had already been admitted to the hospital for the same reasons in the preceding months. Psychotropic drugs predominated (71%) among the current medications taken by the patients and were mainly anxiolytics and neuroleptics. Finally, the discharge report indicated that medications were a contributing factor in the disorders of 25% of patients. We believe that improved information for caregivers and early management and treatment are essential to respond adequately to the problems raised by this population.

A two-year longitudinal study of falls in 482 community-dwelling elderly adults.

BACKGROUND: Falls are a common occurrence in elderly persons, including relatively healthy, community-dwelling men and women. A significant percentage of falls result in soft-tissue injuries. Although some risk factors for falls have been identified, more research is needed on risk factors for injurious falls. In addition, there is little information from prospective studies on the long-term consequences of falls other than injury. METHODS: Risk factors and consequences of falls were analyzed in a 24-month prospective study of 482 elderly (mean age 74 +/- 6.7 years) men and women living independently.in the community. Falls and injurious falls were ascertained by telephone and by a bimonthly postcard follow-up. Predictor variables were obtained from a baseline assessment and follow-up questionnaire. Outcomes were defined as rates of falls and injurious falls, circumstances surrounding the fall, and the long-term correlates of falls. RESULTS: Sixty-one percent of the participants (53.7% of men and 65.7% of women) reported one or more falls during the 2-year follow-up. The crude rates of injurious falls were 11.17 per 1000 person-months in women and 7.23 per 1000 person-months in men. Age, history of fracture, low physical health, and low or high mobility level were risk factors for injurious falls in both sexes. The inability to balance unsupported on one leg was associated with injurious falls in women (rate ratio [RR] = 3.0; 95% confidence interval 1.9-4.7). Self-reported cognitive, physical health, and mobility impairments were greater in female fallers compared to the nonfallers. CONCLUSIONS: Falls and injurious falls without fracture are frequent events for healthy elderly people and may be associated with morbid changes in cognitive status, physical health, and mobility.

One-leg balance is an important predictor of injurious falls in older persons.

OBJECTIVE: To test the hypothesis that one-leg balance is a significant predictor of falls and injurious falls. DESIGN: Analysis of data from a longitudinal cohort study. SUBJECTS: Healthy, community-living volunteers older than age 60 enrolled in the Albuquerque Falls Study and followed for 3 years (N = 316; mean age 73 years). MAIN OUTCOME MEASURES: Falls and injurious falls detected via reports every other month. INDEPENDENT VARIABLES: Baseline measures of demographics, history, physical examination, Iowa Self Assessment Inventory, balance and gait assessment, and one-leg balance (ability to stand unassisted for 5 seconds on one leg). RESULTS: At baseline, 84.5% of subjects could perform one-leg balance. (Impairment was associated with older age and gait abnormalities.) Over the 3-year follow-up, 71% experienced a fall and 22% an injurious fall. The only independent significant predictor of all falls using logistic regression was age greater than 73. However, impaired one-leg balance was the only significant independent predictor of injurious falls (relative risk: 2.13; 95% CI: 1.04, 4.34; P = .03). CONCLUSION: One-leg balance appears to be a significant and easy-to-administer predictor of injurious falls, but not of all falls. In our study, it was the strongest individual predictor. However, no single factor seems to be accurate enough to be relied on as a sole predictor of fall risk or fall injury risk because so many diverse factors are involved in falling.

[Malnutrition in the elderly: the Mini Nutritional Assessment (MNA)]. / Malnutrition im Alter: Das Mini Nutritional Assessment (MNA).

Frail elderly in the community, in nursing homes or in hospitals are at increased risk of malnutrition. In many instances, their existing nutritional disorders go unrecognised and adversely affect their health, ability to overcome disease, and so is associated with poor clinical outcome. The prevalence of malnutrition ranges from 5-10% in free-living elderly to 30-85% in homebound, nursing home, and hospitalised elderly. Possibilities exist to prevent or correct this malnutrition, but have not been frequently used until now due to the lack of a specific validated tool to screen for malnutrition. The goal of the Mini Nutritional Assessment (MNA) is to determine who is at risk of malnutrition, and hence to permit early nutritional intervention. It has been designed for easy use by general practitioners as well as health professionals involved in admitting patients to hospitals and nursing homes. The test, which comprises simple measurements and a brief questionnaire, can be performed in about 10 minutes. It involves: anthropometric assessment (weight, height and weight loss) general assessment (lifestyle, medication and mobility) dietary assessment (number of meals, food and fluid intake, autonomy of eating self assessment (self-perception of health and nutrition). The MNA has now been validated in three studies involving more than 600 elderly individuals, from the very frail to the very active in free-living and long-term care environments. The MNA was validated against a clinical evaluation and a comprehensive nutritional assessment. It can classify the elderly as well-nourished, undernourished, or at risk of malnutrition. The MNA can be an important tool in evaluating the risk of malnutrition in the elderly, if integrated into geriatric assessment programs.

Changes in nutritional status and patterns of morbidity among free-living elderly persons: a 10-year longitudinal study.

Nutritional intake appears to be an important factor contributing to aging. In the present study we describe changes in physical health related to nutritional intake among elderly persons in a 10-y longitudinal study. Among 304 healthy elderly participants (median age 72 y on entry into the study in 1980), 97 (34.2%) are still in good health 10 y later in 1990, 74 (26.5%) have become frail or sick, 54 (19.1%) have died, and 57 (20.1%) have dropped out of the study. Women with lower or higher energy intakes (in 1980 and 1981) than the current Recommended Daily Allowance (RDA; between 25 and 30 kcal/kg) were more likely to become frail or sick or to die in 1990 than those with energy intake in the midrange (below RDA, odds ratio (OR) = 3.3, confidence interval (CI) = 1.2-8.6; above RDA, OR = 3.4, CI: 1.1-10.7). Moreover, women with protein intakes greater than the midrange of 0.8-1.2 g/kg of body weight (1.20-1.76 g/kg in 1980 and 1981) tended to have fewer health problems over the next 10 y than those with protein intakes < 0.8 g/kg, suggesting that the mean protein requirement in elderly adults is greater than that established by the 1985 joint World Health Organization/ FAO/UNU Expert Committee. Moreover, a decrease in energy intake was greater in elderly persons who died or dropped out of the study because of illness.

Fear of falling and restriction of mobility in elderly fallers.

OBJECTIVES: To identify the characteristics of elderly persons who develop a fear of falling after experiencing a fall and to investigate the association of this fear with changes in health status over time. DESIGN: A prospective study of falls over a 2-year period (1991-92). Falls were ascertained using bimonthly postcards plus telephone interview with a standardized (World Health Organisation) questionnaire for circumstances, fear of falling and consequences of each reported fall. Each participant underwent a physical exam and subjective health assessment each year form 1990 to 1993. SETTING: New-Mexico Aging Process Study, USA. SUBJECTS: 487 elderly subjects (> 60 years) living independently in the community. MAIN OUTCOME MEASURES: Fear of falling after experiencing a fall. RESULTS: 70 (32%) of 219 subjects who experienced a fall during the 2 year study period reported a fear of falling. Women were more likely than men to report fear of falling (74% vs 26%). Fallers who were afraid of falling again had significantly ore balance (31.9% vs 12.8%) and gait disorders (31.9% vs 7.4%) at entry in the study in 1990. Among sex, age, mental status, balance and gait abnormalities, economic resource and physical health, logistic regression analysis show gait abnormalities and poor self-perception of physical health, cognitive status and economic resources to be significantly associated with fear of falling. Subjects who reported a fear of falling experienced a greater increase in balance (P = 0.08), gait (P < 0.01) and cognitive disorders (P = 0.09) over time, resulting in a decrease in mobility level. CONCLUSION: The study indicated that about one-third of elderly people develop a fear of falling after an incident fall and this issue should be specifically addressed in any rehabilitation programme.

One-leg standing balance and functional status in a population of 512 community-living elderly persons.

The objective of this cross-sectional study (whose baseline data were drawn from a longitudinal population study) was to determine if one-leg standing balance might be a useful marker of functional status in elderly persons independently living in an urban community (N = 512, mean age 73 +/- 7.0, 71.4% women). One-leg standing balance (ascertained by the Tinetti test) and functional status were obtained from a baseline gerontological assessment and follow-up questionnaires. Correlations were tested between one-leg balance and physical health and functional measurements. One-leg standing balance (OLSB) was abnormal in 24.7% of the population. At least one incapacity in instrumental activities of daily living (IADL) was found in 60.6% of those with OLSB abnormality, vs 45.5% in those with OLSB "adaptive" (borderline abnormal), and 33.3% in those with normal one-leg standing balance (p < 0.0001). Multivariate analysis showed 3 independent factors related to one-leg balance abnormality: age > 71 years (OR = 5.11, CI = 1.99-13.10); IADL deficit requiring help with transportation (OR = 3.61; CI = 1.15-11.40); and "poor" health status on the Iowa Self-Assessment Inventory (OR = 2.67, CI = 1.35-5.27). We conclude that one-leg standing balance may be a simple, predictive and inexpensive marker helpful in screening for low functional level and frailty in clinical practice.

Diseases and aging: patterns of morbidity with age; relationship between aging and age-associated diseases.

Patterns of morbidity with age can be schematically represented in three situations: 1) as a progressive illness, such as Alzheimer's disease, leading to a relatively rapid functional decline. 2) as a catastrophic event, such as a stroke or hip fracture, leading to a decline in function with improvement after rehabilitation. 3) as normal aging with gradual progressive functional decline. Results from the New Mexico Aging Process Study provide some unique insights about the consequences of the effects of aging on the nutritional status of healthy elderly people. Between 1979 and 1989, anthropometric and biochemical markers as well as dietary intakes remained relatively constant in this healthy elderly population. Thus, the aging process alone may have little or no important consequences on the nutritional status of healthy elderly individuals. However, the adaptation of pancreatic and intestinal function to undernutrition and refeeding can be perturbed in these individuals.

Longitudinal study of dietary intakes and plasma lipids in healthy elderly men and women.

Dietary intakes and blood lipid concentrations were assessed in elderly men (n = 65) and women (n = 92) from 1980 through 1989. Mean age in 1980 was 70 y (range 60-84 y). Health and socioeconomic status was above that found in the general US elderly population. Cross-sectional and longitudinal changes in variables were determined by using least-squares linear regression. No significant cross-sectional differences in energy (kJ/kg), protein (g/kg), total fat, and carbohydrate intake with age was noted. Significant longitudinal decreases in total fat, saturated and polyunsaturated fatty acids, and cholesterol intakes were noted in both men and women. Significant decreases in total, HDL, and LDL plasma cholesterol concentrations were noted over time in both men and women. Ratios of both total and LDL cholesterol to HDL cholesterol increased over time. The decrease in total fat and cholesterol intakes were significantly correlated with the decrease in total plasma cholesterol.