Sex-related differences in the association between frailty and dietary consumption in Japanese older people: a cross-sectional study.

BACKGROUND: Female sex is an important factor predisposing individuals to frailty. Appropriate nutrition is one of the most effective ways to prevent older adults from developing frailty; Sex-related differences have also been detected in the association between nutritional intervention and health-related outcomes. However, few studies have discussed these sex-related differences. The aim of the present study was to investigate the sex-related differences in the association between frailty and dietary consumption. METHODS: We conducted a cross-sectional study which investigated community-dwelling older adults aged ≥65 years. We surveyed age, sex, body mass index, family arrangement (living alone, living with a partner or living with parent(s) and/or child (ren)), dietary consumption and frailty status. Dietary consumption was surveyed using a food frequency questionnaire that included 13 major food categories (fish, meat, eggs, dairy products, soybean products, vegetables, seaweeds, potatoes, fruits, fats or oils, snacks, salty foods and alcohol). Frailty was defined by the Kihon Checklist score. The Kihon Checklist is composed of 25 simple yes/no questions, and it has been validated as a metric for frailty. A higher score indicates a greater degree of frailty. Multinomial regression analysis was performed to clarify the association between frailty and dietary consumption for each sex. RESULTS: We analyzed 905 older adults (420 (46.4%) were male). After adjusting for cofounders, a low frequency of meat consumption (less than twice/week) was associated with a high prevalence of frailty in men (odds ratio: 2.76 (95%CI: 1.12-6.77), p = 0.027). In contrast, in women, low frequencies of consumption of fish, meat, vegetables, potatoes and snacks were associated with a higher prevalence of frailty compared with those who consumed foods from those categories daily (odds ratios: fish 2.45 (1.02-5.89), p = 0.045; meat 4.05 (1.67-9.86), p = 0.002; vegetables 5.03 (2.13-11.92), p < 0.001; potatoes 3.84 (1.63-9.05), p = 0.002; snacks 2.16 (1.02-4.56), p = 0.043). CONCLUSIONS: More food categories were associated with frailty in women than in men. Nutritional intervention to prevent frailty is presumably more effective for women than for men.

Plasma Leptin Concentration and Sympathetic Nervous Activity in Older Adults With Physical Dysfunction.

CONTEXT: Previous research has shown a positive relationship between plasma leptin and sympathetic nervous activity. High plasma leptin activate inflammatory cytokines and lead to muscle wasting. However, studies have detected low sympathetic nervous activity and high plasma leptin in older adults with muscle wasting, sarcopenia, and frailty. High plasma leptin do not seem to correlate with high sympathetic nervous activity. However, their relationship in older adults remains unclear. OBJECTIVE: We investigated the relationship between plasma leptin and sympathetic nervous activity in older adults. DESIGN SETTING AND PARTICIPANTS: We conducted a cross-sectional study and analyzed the results from 69 participants aged ≥75 years. Sympathetic nervous activity was measured by heart rate variability, obtained from 24-hour Holter monitoring. A functional independence measure (FIM) and Barthel index were used to assess physical function. RESULTS: The plasma leptin was higher in women (men, 3.4 ± 2.8 ng/mL; women, 6.6 ± 6.5 ng/mL; P = 0.024). Plasma leptin was negatively and substantially related to the FIM (ß = -0.233; P = 0.049) and Barthel index (ß = -0.298, P = 0.018) after adjustment for covariates. However, the data showed no relationship between the plasma leptin and sympathetic nervous activity. CONCLUSIONS: We could not detect an association between sympathetic nervous activity and plasma leptin in older adults. This might suggest a failure of the feedback system of the sympathetic nervous system, leading to muscle wasting in older adults.

Role of autonomic nervous activity, as measured by heart rate variability, on the effect of mortality in disabled older adults with low blood pressure in long-term care.

AIM: Previous studies have shown the relationship between low blood pressure and high mortality in frail, disabled older adults in long-term care. However, the mechanism of this relationship is still unclear. We hypothesized that autonomic nervous activity decline is involved in the relationship between low blood pressure and high mortality. METHODS: The present prospective cohort study recruited 61 participants aged ≥75 years. The data from 24-h Holter monitoring and blood pressure recorded by ambulatory blood pressure monitoring were collected. Measured data were divided into three categories: 24-h, daytime and night-time. From power spectral density in the electrocardiogram, low frequency, high frequency and low frequency/high frequency ratio were calculated. The primary end-point was death. RESULTS: High blood pressure was connected to both high daytime low frequency and high frequency (partial correlation coefficients: 0.42, P < 0.05 and 0.35, P < 0.05, respectively). In addition, the low blood pressure group had higher mortality than the high blood pressure group, and disabled older adults in long-term care and those with elevated daytime systolic and diastolic blood pressure had less risk of mortality compared with those without (systolic: hazard ratio 0.89, 95% confidence interval 0.83-0.96, P = 0.003; diastolic: hazard ratio 0.98, 95% confidence interval 0.79-1.00, P = 0.049). The average blood pressures in the high blood pressure groups were approximately 140/80 mmHg and were connected to low mortality. CONCLUSIONS: Attenuated autonomic nervous activity might lead to low blood pressure in the daytime and high mortality in disabled older adults in long-term care. Geriatr Gerontol Int 2018; 18: 1153-1158.

Effects of age and viscosity on food transport and breathing-swallowing coordination during eating of two-phase food in nursing home residents.

AIM: When eating food that contains both liquid and solid phases, the liquid component frequently enters the hypopharynx before swallowing and can increase the risk of aspiration. Thus, we examined whether the initial viscosity of mixed consistency food could alter pre-swallow food transport and breathing-swallowing coordination in older adults. METHODS: Fiberoptic endoscopy was recorded while 18 healthy young adults and 19 older adults ate 5 g of steamed rice combined with 3 mL of blue-dye water. Liquid viscosity was set at three levels by the addition of a thickening agent (0 wt%, thin; 2 wt%, thicker; 4 wt%, higher-viscosity, respectively). We measured the timing of swallow initiation and its corresponding respiratory phase for each participant. RESULTS: For thin mixed consistency food, whereas the timing of swallow initiation was comparable between young and older participants, swallowing was initiated during inspiration significantly more often in older participants (31.6 %) than in young participants (5.6 %). In contrast, the timing of swallow initiation was delayed in older participants for thicker and higher-viscosity foods, although swallowing was commonly initiated during expiration in both groups. CONCLUSIONS: In older adults, we observed that swallow initiation function was preserved for thin mixed consistency samples, but breathing-swallowing coupling was diminished. For higher-viscosity foods, swallow initiation was delayed in this group, but breathing-swallowing coordination was not disturbed, probably as a result of the slow bolus flow into the hypopharynx. Thus, it appears the initial viscosity of mixed consistency food profoundly affects food transport before swallowing as well as breathing-swallowing coordination in nursing home residents. Geriatr Gerontol Int 2017; 17: 2171-2177.

Favorable effect of sympathetic nervous activity on rehabilitation outcomes in frail elderly.

OBJECTIVES: Previous studies have suggested the relationship between physical function, mortality, and autonomic nervous activity in frail elderly and that maintaining sympathetic nervous activity might lead to improved physical function and mortality in the elderly population. The aim of this study was to investigate the utility of sympathetic nervous activity measured by heart rate variability in frail elderly patients undergoing inpatient rehabilitation, further focusing the nervous activity on the effect of rehabilitation therapy. DESIGN: Prospective cohort study. PARTICIPANTS: Sixty-one subjects aged 75 years or older were recruited after treatment of acute phase illness. MEASUREMENTS: Before undergoing rehabilitation, data of 24-hour Holter monitoring and a blood venous sample were obtained. From RR intervals in the electrocardiogram, heart rate and SDs of all NN intervals in all 5-minute segments of the entire recording, power spectral density, low frequency (LF), high frequency (HF), and low frequency/high frequency (LF/HF) were calculated. Functional Independence Measure (FIM) and Barthel index were used to measure physical function. RESULTS: FIM score and Barthel index were 46.8 ± 25.4 and 32.8 ± 31.7, respectively. Serum total protein, albumin, hemoglobin, and total cholesterol were all significantly related to FIM score and Barthel index before rehabilitation. Heart rate variability indices did not show a significant relationship with physical function, whereas the high LH/HF group showed significant improvement in physical function compared with the low LH/HF group. Moreover, LF/HF frequency was a predictive factor for improvement of physical function after 2 months of rehabilitation. CONCLUSION: A favorable effect of preserved LF/HF on rehabilitation outcome was observed in elderly undergoing rehabilitation. Preservation of sympathetic nervous activity may lead to improved physical function in the elderly.

Intensive rehabilitation for dementia improved cognitive function and reduced behavioral disturbance in geriatric health service facilities in Japan.

AIM: To examine the efficacy of rehabilitation for elderly individuals with dementia at intermediate facilities between hospitals and home, based on the policies for elderly individuals to promote community-based care at home and dehospitalization. METHODS: Participants were older adults with dementia newly admitted to intermediate facilities. A total of 158 in the intervention group who claimed Long-Term Care Insurance for three consecutive months, and 54 in the control group were included in the analysis. The interventions were carried out in a tailor-made manner to meet individual needs. The personal sessions were carried out three times a week for 3 months after admission by physical, occupational or speech therapists. Outcome measures were cognitive tests (Hasegawa Dementia Scale revised [HDS-R] and Mini-Mental State Examination), and observational assessments of dementia severity, activities of daily living (ADL), social activities, behavioral and psychological symptoms of dementia (BPSD) using a short version of the Dementia Disturbance Scale (DBD13), depressive mood, and vitality. RESULTS: Significant improvement in the intervention group was shown in cognitive function measured by HDS-R (interaction F[1, 196] = 5.190, P = 0.024), observational evaluation of dementia severity (F[1,198] = 9.550, P = 0.002) and BPSD (DBD13; F[1,197] = 4.506, P = 0.035). Vitality, social activities, depressive mood and ADL were significantly improved only in the intervention group, although interaction was not significant. CONCLUSIONS: Significant improvement by intervention was shown in multiple domains including cognitive function and BPSD. Cognitive decline and worsening of BPSD are predictors of care burden and hospitalization, thus intensive rehabilitation for dementia was beneficial for both individuals with dementia and their caregivers.

Association of decreased sympathetic nervous activity with mortality of older adults in long-term care.

AIM: To investigate the relationship between physical function, mortality and autonomic nervous activity measured by heart rate variability of elderly in long-term care. METHODS: Cross-sectional and longitudinal studies were carried out at hospitals and health service facilities for the elderly in Nagano prefecture, Japan, from July 2007 to March 2011. A total of 105 long-term care older adults and 17 control older adults with independent physical function were included. The Functional Independence Measure (FIM) and Barthel Index were determined as indices of physical function. Twenty-four-hour Holter monitoring was carried out. From RR intervals in electrocardiograms, heart rate and standard deviations of all NN intervals in all 5-min segments of the entire recording, power spectral density, low frequency, high frequency and low frequency/high frequency (LF/HF) were calculated. RESULTS: FIM score and Barthel Index were 46 ± 26 and 30 ± 31, respectively, in long-term care elderly. FIM and Barthel index were significantly correlated with heart rate and the standard deviations of all NN intervals after adjustment for age, sex, cardiovascular risk factors and FIM. Furthermore, LF/HF was significantly decreased in long-term care elderly compared with control elderly after adjustment for covariates. In addition, decrease in LF/HF was an independent risk factor for mortality. CONCLUSION: Low LF/HF activity was observed in long-term care elderly and was related to an increase of overall mortality.

Plasma sex hormone levels and mortality in disabled older men and women.

AIM: To investigate the relationship between circulating sex hormone levels and subsequent mortality in disabled elderly. METHODS: This prospective observational study was comprised of 214 elderly subjects aged 70-96 years (117 men and 97 women; mean ± standard deviation age, 83 ± 7 years), receiving services at long-term care facilities in Nagano, Japan. All-cause mortality by baseline plasma sex hormone levels was measured. RESULTS: After excluding deaths during the first 6 months, 27 deaths in men and 28 deaths in women occurred during a mean follow up of 32 months and 45 months (up to 52 months), respectively. Mortality rates differed significantly between high and low testosterone tertiles in men, but did not differ significantly between middle and low tertiles. Compared with subjects in the middle and high tertiles, men with testosterone levels in the low tertile (<300 ng/dL) were more likely to die, independent of age, nutritional status, functional status and chronic disease (hazard ratio [HR] = 3.27, 95% confidence interval [CI] = 1.24-12.91). In contrast, the low dehydroepiandrosterone sulfate (DHEA-S) tertile was associated with higher mortality risk in women (multivariate adjusted HR = 4.42, 95% CI = 1.51-12.90). Exclusion of deaths during the first year and cancer deaths had minimal effects on these results. DHEA-S level in men and testosterone and estradiol levels in women were not related to mortality. CONCLUSION: Low testosterone in men and low DHEA-S in women receiving care at facilities are associated with increased mortality risk, independent of other risk factors and pre-existing health conditions.

Effects of dehydroepiandrosterone supplementation on cognitive function and activities of daily living in older women with mild to moderate cognitive impairment.

AIM: There is little evidence that dehydroepiandrosterone (DHEA) has beneficial effects on physical and psychological functions in older women. We investigated the effect of DHEA supplementation on cognitive function and ADL in older women with cognitive impairment. METHODS: A total of 27 women aged 65-90 years (mean ± standard deviation, 83 ± 6) with mild to moderate cognitive impairment (Mini-Mental State Examination, MMSE; 10-28/30 points), receiving long-term care at a facility in Japan were enrolled. Twelve women were assigned to receive DHEA 25 mg/day p.o. for 6 months. The control group (n = 15) matched for age and cognitive function was followed without hormone replacement. Cognitive function was assessed by MMSE and Hasegawa Dementia Scale-Revised (HDS-R), and basic activities of daily living (ADL) by Barthel Index at baseline, 3 and 6 months. Plasma hormone levels including testosterone, DHEA, DHEA-sulfate and estradiol were also followed up. RESULTS: After 6 months, DHEA treatment significantly increased plasma testosterone, DHEA and DHEA-sulfate levels by 2-3-fold but not estradiol level compared to baseline. DHEA administration increased cognitive scores and maintained basic ADL score, while cognition and basic ADL deteriorated in the control group (6-month change in DHEA group vs control group; MMSE, +0.6 ± 3.2 vs -2.1 ± 2.2, P < 0.05; HDS-R, +2.8 ± 2.8 vs -0.3 ± 4.1, P < 0.05; Barthel Index, +3.7 ± 7.1 vs -2.7 ± 4.6, P = 0.05). Among the cognitive domains, DHEA treatment improved verbal fluency (P < 0.05). CONCLUSION: DHEA supplementation in older women with cognitive impairment may have beneficial effects on cognitive function and ADL.

Association of plasma sex hormone levels with functional decline in elderly men and women.

AIM: We aimed to determine whether plasma sex hormone levels are associated with activities of daily living (ADL), cognition, depression and vitality in elderly individuals with functional decline. METHODS: Two hundred and eight consecutive persons 70 years or older (108 men and 100 women; mean +/- standard deviation, 81 +/- 7 years) with a chronic stable condition, receiving long-term care at a long-term care facilities located in Nagano Prefecture, Japan, were enrolled. Plasma total testosterone, free testosterone (only in men), dehydroepiandrosterone (DHEA), DHEA sulfate (DHEA-S) and estradiol levels were determined in the morning after an overnight fast. Comprehensive geriatric assessment was performed including basic ADL by Barthel Index, instrumental ADL, cognitive function by Hasegawa Dementia Scale--Revised, mood by Geriatric Depression Scale and ADL-related vitality by Vitality Index. RESULTS: Simple regression analysis showed that, in men, plasma total and free testosterone levels were associated with basic ADL (R = 0.292 and R = 0.282), instrumental ADL (R = 0.261 and R = 0.408), cognitive function (R = 0.393 and R = 0.553) and vitality (R = 0.246 and R = 0.396), while DHEA(-S) was associated with cognitive function, and estradiol with cognitive function as well as vitality. In women, the only significant correlation was between DHEA(-S) and basic ADL. Adjustment for age and nutritional markers did not influence the associations of plasma sex hormone levels with functional scores except for that of free testosterone with Barthel Index. CONCLUSION: These results suggest that sex hormones have sex-specific associations with physical and neuropsychiatric functions in elderly individuals, and that endogenous testosterone is related to global function in elderly men.

A randomized cross-over study of a traditional Japanese medicine (kampo), yokukansan, in the treatment of the behavioural and psychological symptoms of dementia.

The effectiveness and safety of yokukansan (TJ-54), a traditional Japanese medicine (kampo) for the treatment of the behavioural and psychological symptoms of dementia (BPSD), were evaluated in 106 patients diagnosed as having Alzheimer's disease (AD) (including mixed-type dementia) or dementia with Lewy bodies. Patients were randomly assigned to group A (TJ-54 treatment in period I and no treatment in period II; each period lasting 4 wk) or group B (no treatment in period I and TJ-54 treatment in period II). BPSD and cognitive functions were evaluated using the Neuropsychiatric Inventory (NPI) and the Mini-Mental State Examination (MMSE), respectively. Activities of daily living (ADL) were evaluated using Instrumental Activities of Daily Living (IADL) in outpatients and the Barthel Index in in-patients. For the safety evaluation, adverse events were investigated. Significant improvements in mean total NPI score associated with TJ-54 treatment were observed in both periods (Wilcoxon test, p=0.040 in period I and p=0.048 in period II). The mean NPI scores significantly improved during TJ-54 treatment in groups A and B (p=0.002 and p=0.007, respectively) but not during periods of no treatment. Among the NPI subscales, significant improvements were observed in delusions, hallucinations, agitation/aggression, depression, anxiety, and irritability/lability. The effects of TJ-54 persisted for 1 month without any psychological withdrawal symptoms in group A. TJ-54 did not show any effect on either cognitive function or ADL. No serious adverse reactions were observed. The present study suggests that TJ-54 is an effective and well-tolerated treatment for patients with BPSD.

[Development of a portable fall risk index for elderly people living in the community].

AIM: To develop a portable risk index for falls. METHODS: Risk factors were chosen from previously established factors then we added several environmental factors to the risk index; previous falls in the last 12 month, trippig or stumbling, inability to ascend or descend stairs without help, decreased walking speed, inability to cross a road within the green signal interval, inability to walk 1km without a break, inability to stand on one leg for 5 seconds (eyes open), using a cane, inability to wring out a towel, dizziness or faintness, stooped or rounded back, knee joint pain, visual disturbance, hearing disturbance, cognitive decline, fear of falling, receiving 5 or more prescribed drugs, sensation of darkness at home, obstacles inside, barrier on the carpet or floor, using steps daily at home, steep slopes around home. SUBJECTS: The questionnaire sheet was completed by 2,439 community-dwelling elderly subjects (76.3 +/- 7.4 years old). The frequency of each items of fall risk index was compared between fallers (history of fall within one year) and non-fallers. Multiple regression analysis was performed to identify independent risk factors for previous falls. RESULTS: Except barrier, step use and steep slope around home, all items in the fall risk index were more frequent in fallers. Multivariate analysis revealed that tripping or stumbling, inability to cross a road within the green signal interval, dizziness or faintness, obstacles inside, inability to wring out a towel, cane use and knee joint pain were independent risk factors for previous falls. These 7 selected items were further analyzed as predictors. The maximum sum of sensitivity and specificity was reached at the cut-off point of 2/3 (sensitivity 0.65, specificity 0.72) by receiver operating curve. CONCLUSION: Portable fall risk index is useful for clinical settings to identify high-risk subjects.

[A prospective comparison of day care and freely chosen occupational therapy for elderly patients with dementia].

Since the introduction of long-term care insurance, day care services have become popular throughout Japan and many kinds of behavioral approaches have been used. Although there have been many reports on the non-pharmacological effects on cognitive function, case control studies to evaluate the effect of day care services are insufficient Furthermore, no study has compared the advantages of different behavioral therapies for elderly subjects with loss of cognitive function. To clarify these issues, we compared the changes in activities of daily living, cognitive function and vitality/depression among 78 subjects receiving different day care services. Community dwelling subjects using day care (day care group: n = 29, 80+/-7.3 years old) showed an improvement in abnormal behavior (DBD scale; before 8.5+/-2.1, after 3.2+/-1.3, p<0.05). Vitality and volition measured by the Vitality Index were significantly preserved in the day care group compared with community dwelling subjects without day care services (n = 11, 78.6+/-9.4 y.o.). Comparing the effect of three different behavioral therapies (physical fitness, cooking and gardening), there was no difference in changes in cognitive function or in other comprehensive measurements among the groups. On the other hand, different responses to various therapies were observed among subjects. To determine the advantage of various non-pharmacological therapies for dementia, geriatricians need to perform prospective case-control studies with a large number of subjects, using comprehensive geriatric assessment as the art of a geriatrician.