Treatable Vascular Risk and Cognitive Performance in Persons Aged 35 Years or Older: Longitudinal Study of Six Years.

BACKGROUND: Poor cognitive performance is associated with high vascular risk. However, this association is only investigated in elderly. As neuropathological changes precede clinical symptoms of cognitive impairment by several decades, it is likely that cognitive performance is already associated with vascular risk at middle-age. OBJECTIVES: To investigate the association of cognitive performance with treatable vascular risk in middle-aged and old persons. DESIGN: Longitudinal study with three measurements during follow-up period of 5.5 years. SETTING: City of Groningen, the Netherlands. PARTICIPANTS: Cohort of 3,572 participants (age range, 35-82 years; mean age, 54 years; men, 52%). EXPOSURE: Treatable vascular risk as defined by treatable components of the Framingham Risk Score for Cardiovascular Disease at the first measurement (diabetes mellitus, smoking, hypercholesterolemia and hypertension). MEASUREMENTS: Change in cognitive performance during follow-up. Cognitive performance was measured with Ruff Figural Fluency Test (RFFT) and Visual Association Test (VAT), and calculated as the average of the standardized RFFT and VAT score per participant. RESULTS: The mean (SD) cognitive performance changed from 0.00 (0.79) at the first measurement to 0.15 (0.83) at second measurement and to 0.39 (0.82) at the third measurement (Ptrend<0.001). This change was negatively associated with treatable vascular risk: the change in cognitive performance between two measurements decreased with 0.004 per one-point increment of treatable vascular risk (95%CI, -0.008 to 0.000; P=0.05) and with 0.006 per one-year increment of age (95%CI, -0.008 to -0.004; P<0.001). CONCLUSIONS: Change in cognitive performance was associated with treatable vascular risk in persons aged 35 years or older.

Complications after hip fracture surgery: are they preventable?

PURPOSE: Surgery for hip fractures is frequently followed by complications that hinder the rehabilitation of patients. The aim of this study was to describe the incidence rate and type of complications, including mortality, after hip fracture surgery, and to identify the risk factors of these complications that may be amenable to prevention. METHODS: Prospective cohort study of all consecutive patients aged ≥60 treated for a hip fracture at University Medical Center Groningen between July 2009 and June 2013. All patients were treated in a comprehensive multidisciplinary care pathway. Logistic regression analyses were used to investigate which variables were significant risk factors for the occurrence of complications. Additional analyses were conducted to investigate whether the independent variables were significant risk factors for several specific complications and mortality. RESULTS: The study population consisted of 479 patients with a mean age of 78.4 (SD 9.5) years; 33% were men. The overall complication rate was 75%. Delirium was the complication seen most frequently (19%); the incidence of surgical complications was 9%. Most risk factors for complications were not preventable (high comorbidity rate, high age and dependent living situation). However, general anesthesia (OR 1.51; 95% CI 0.97-2.35) and delay in surgery (OR 3.16; 95% CI 1.43-6.97) may be risk factors that can potentially be prevented. Overall, the mortality risk was not higher in patients with a complication, but delirium and pneumonia were risk factors for mortality. CONCLUSION: The overall complication rate after hip fracture surgery was high. Only few complications were potentially preventable.

Cognitive decline after major oncological surgery in the elderly.

BACKGROUND: Elderly patients undergoing oncological surgery experience postoperative cognitive decline. The aims of this study were to examine the incidence of cognitive decline 3 months after surgery and identify potential patient-, disease- and surgery-related risk factors for postoperative cognitive decline in onco-geriatric patients. METHODS: A consecutive series of elderly patients (≥65 years) undergoing surgery for the removal of a solid tumour were included (n = 307). Cognitive performance was assessed pre-operatively and 3 months postoperatively. Postoperative decline was defined as a decline in scores of cognitive tests of ≥25% on ≥2 of 5 tests. RESULTS: Of the patients who had completed the assessments, 117 (53%, 95% confidence interval [CI]: 47-60) had improved cognitive test scores, whereas 26 (12%, 95% CI: 7.6-16) showed cognitive decline at 3 months postoperatively. In patients aged >75 years, the incidence of overall cognitive decline 3 months postoperatively was 18% (95% CI: 9.3-27). In patients with lower pre-operative Mini-Mental State Examination (MMSE) score (≤26) the incidence was 37% (95% CI: 18-57), and in patients undergoing major surgery it was 18% (95% CI: 10.6-26). Of the cognitive domains, executive function was the most vulnerable to decline. CONCLUSION: About half of the elderly patients show improvement in postoperative cognitive performance after oncological surgery, whereas 12% show cognitive decline. Advanced age, lower pre-operative MMSE score and major surgery are risk factors for cognitive decline at 3 months postoperatively and should be taken into account in the clinical decision-making progress. Research to develop interventions to preserve quality of life should focus on this high-risk subpopulation.

Standardised frailty indicator as predictor for postoperative delirium after vascular surgery: a prospective cohort study.

OBJECTIVES: To determine whether the Groningen Frailty Indicator (GFI) has a positive predictive value for postoperative delirium (POD) after vascular surgery. METHODS: Between March and August 2010, 142 consecutive vascular surgery patients were prospectively evaluated. Preoperatively, the GFI was obtained and postoperatively patients were screened with the Delirium Observation Scale (DOS). Patients with a DOS-score ≥3 points were assessed by a geriatrician. Delirium was defined by the DSM-IV-TR criteria. Primary outcome variable was the incidence of POD. Secondary outcome variables were any surgical complication and hospital length of stay (HLOS) (>7 days). RESULTS: Ten patients (7%) developed POD. The highest incidence of POD was found after aortic surgery (17%) and amputation procedures (40%). Increased comorbidities (p = 0.006), GFI score (p = 0.03), renal insufficiency (p = 0.04), elevated C-reactive protein (p = 0.008), high American Society of Anaesthesiologists score (p = 0.05), a DOS-score of ≥3 points (p = 0.001), post-operative intensive care unit admittance (p = 0.01) and HLOS ≥7 days (p = 0.005) were risk factors for POD. The GFI score was not associated with a prolonged HLOS. A mean number of 2 ± 1 (range 0-5) complications were registered. The receiver operator characteristics (ROC) area under the curve for the GFI was 0.70. CONCLUSIONS: The GFI can be helpful in the early identification of POD after vascular surgery in a select group of high-risk patients.

[Reference values for anaemia in the elderly]. / Grenswaarden voor anemie bij oude mensen.

According to the reference values of the World Health Organization (WHO), anaemia is defined as a haemoglobin (Hb) level < 8.1 mmol/l in men and < 7.5 mmol/l in women. Lower reference values are often used in older patients because many doctors consider a decreased Hb level to be physiological in advanced age. However, Hb values under the WHO reference values are associated with increased mortality in older persons. Moreover, a cause of the anaemia is found in > 80% of older persons with anaemia if further diagnostic tests are done. Decreased Hb levels are also associated with functional impairments such as mobility disorders. These findings apply not only to severely decreased Hb levels but also to Hb levels that are only slightly below the WHO reference values. Correspondingly, increased erythropoietin levels are seen in older persons with severely decreased Hb levels as well as in older persons with slightly decreased Hb levels. Thus, a decrease in the Hb level in advanced age is not physiological and the WHO reference values for anaemia are also valid for older persons.

[The Dutch College of General Practitioners' practice guideline 'Delirium in elderly people'; response from clinical geriatrics]. / De standaard 'Delier bij ouderen' van het Nederlands Huisartsen Genootschap; reactie vanuit de klinische geriatrie.

Delirium in elderly people is a severe condition that requires vigorous medical attention. Therefore, the Dutch College of General Practitioners has duly chosen to develop a practice guideline 'Delirium in elderly people'. It is likely that many general practitioners are only partly familiar with delirium in elderly people because the prevalence of delirium in general practice is low. Therefore, one of the objectives of the practice guideline should be to improve the diagnostic process. However, several diagnostic issues merit further attention. For example, the guideline does not contain a diagnostic algorithm and the description of the clinical presentation of a delirium is brief. In addition, the guideline lacks a clear overview of the most important risk factors for a delirium as well as a careful description of the difference between delirium and dementia.

[Osteoporosis in elderly women should always be treated, despite the new professional guideline from the Dutch Institute for Health Care Improvement (CBO)]. / Osteoporose bij oudere vrouwen altijd behandelen, ondanks de nieuwe CBO-richtlijn.

According to the Dutch Institute for Healthcare Improvement [Dutch acronym: CBO] professional guideline 'Osteoporosis' (second revision), the treatment of osteoporosis should be based on the patient's age because bone loss at an advanced age is thought to be partly physiological. It is recommended that women < 70 years old are treated if the bone mineral density T-score is below -2.5. For women > or = 70 years of age, a lower cut-off point has been chosen, i.e. a Z-score below -1. However, bone strength is dependent on bone mineral density and the fracture risk doubles if the bone mineral density decreases by one standard deviation. Therefore at an advanced age, any bone loss experienced increases the fracture risk, whether or not the mineral loss is physiological. Moreover, most elderly people carry additional risk factors that increase fracture risk. Therefore in women > or = 70 years of age, the treatment of osteoporosis should be considered if the T-score is below -2.5. In this situation, use of the Z-score is not appropriate.

The effect of geographic origin on the frequency of HLA antigens and their association with ageing.

The association between HLA antigens and ageing is not clear. Ageing in women was associated with B40 and DR5 in a recent study, but other studies yielded conflicting results. In none of the studies, however, did the young and elderly samples originate from the same homogeneous population. Homogeneity is dependent on geographic origin. The aim of this study was to investigate whether differences in geographic origin between age groups could explain the age-associated differences in the frequencies of B40 and DR5. The authors used the new design of a 'birth-place-restricted comparison' in which the origin of all subjects was ascertained. The total study population comprised 1010 young women aged 25-40 years and 660 elderly women aged 85 years and older. The 'birth-place-restricted comparison' included 66 young and 285 elderly women from one geographic area (Leiden, the Netherlands). Men were not included because ageing in men was not associated with HLA antigens in a recent study. In the total population, the frequency of B40 in young women of different origin varied between 16 and 28%, and the frequency of DR5 between 11 and 23%. Similar differences were observed in the elderly women. In the 'birth-place-restricted comparison', the frequency of B40 was 15% in the young women and 11% in the elderly women (difference 4%, 95% confidence interval, -5 to 13%). The frequency of DR5 was 20% in the young women, and 28% in the elderly women (difference 8%, 95% confidence interval, -4 to 19%). Thus, marked differences in HLA antigen frequency were found between populations of various geographic origins. Definition and ascertainment of the target population are therefore necessary in genetic studies of ageing. In such a 'birth-place-restricted comparison', the authors confirmed that ageing in women was negatively associated with HLA-B40 and positively associated with HLA-DR5.

The definition of anemia in older persons.

CONTEXT: Whether hemoglobin concentrations defined as anemia by the World Health Organization (WHO) are associated with increased mortality in older persons is not known. OBJECTIVE: To investigate the association between hemoglobin concentration and cause-specific mortality in older persons. DESIGN: Community-based study conducted from 1986 to 1996 (follow-up period, 10 years). SETTING: Leiden, the Netherlands. PARTICIPANTS: A total of 1016 community residents aged 85 years and older were eligible and 872 agreed to have a blood sample taken. Hemoglobin concentration was measured in 755 persons (74%). MAIN OUTCOME MEASURES: Hemoglobin concentration, 10-year survival, and primary cause of death. According to the WHO criteria, anemia was defined as a hemoglobin concentration below 7.5 mmol/L (120 g/L) in women and below 8.1 mmol/L (130 g/L) in men. RESULTS: Compared with persons with a normal hemoglobin concentration, the mortality risk was 1.60 (95% confidence interval [CI], 1.24-2.06; P<.001) in women with anemia, and 2.29 (95% CI, 1.60-3.26; P<.001) in men with anemia. In both sexes, the mortality risk increased with lower hemoglobin concentrations. In persons without self-reported clinical disease at baseline, the mortality risk of anemia was 2.21 (95% CI, 1.37-3.57; P=.002). Mortality from malignant and infectious diseases was higher in persons with anemia. CONCLUSIONS: Anemia defined by the WHO criteria was associated with an increased mortality risk in persons aged 85 years and older. The criteria are thus appropriate for older persons. A low hemoglobin concentration at old age signifies disease.

Blood pressure and mortality in elderly people aged 85 and older: community based study.

OBJECTIVE: To determine whether the inverse relation between blood pressure and all cause mortality in elderly people over 85 years of age can be explained by adjusting for health status, and to determine whether high blood pressure is a risk factor for mortality when the effects of poor health are accounted for. DESIGN: 5 to 7 year follow up of community residents aged 85 years and older. SETTING: Leiden, the Netherlands. SUBJECTS: 835 subjects whose blood pressure was recorded between 1987 and 1989. MAIN OUTCOME MEASURE: All cause mortality. RESULTS: An inverse relation between blood pressure and all cause mortality was observed. For diastolic blood pressure crude 5 year all cause mortality decreased from 88% (52/59) (95% confidence interval 79% to 95%) in those with diastolic blood pressures <65 mm Hg to 59% (27/46) (44% to 72%) in those with diastolic pressures >100 mm Hg. For systolic blood pressure crude 5 year all cause mortality decreased from 85% (95/112) (78% to 91%) in those with systolic pressures <125 mm Hg to 59% (13/22) (38% to 78%) in those with systolic pressures >200 mm Hg. This decrease was no longer significant after adjustment for indicators of poor health. No relation existed between blood pressure and mortality from cardiovascular causes or stroke after adjustment for age and sex, but after adjustment for age, sex, and indicators of poor health there was a positive relation between diastolic blood pressure and mortality from both cardiovascular causes and stroke. CONCLUSION: The inverse relation between blood pressure and all cause mortality in elderly people over 85 is associated with health status.

The association between human leucocyte antigens (HLA) and mortality in community residents aged 85 and older.

OBJECTIVE: The association between Human Leucocyte Antigens (HLA) and aging was investigated. It is possible that HLA antigens are associated with longevity, either indirectly through disease associations or directly through involvement in the aging mechanism. DESIGN: Community-based follow-up study. SETTING: Leiden, the Netherlands. PARTICIPANTS: A total of 919 subjects were HLA typed in this community-based study. All subjects were aged 85 and older and were white. Seventy-two percent of the cohort was female. MEASUREMENTS: Age- and sex-adjusted Mortality Rate Ratios (MRR) were estimated for 79 antigens by the subject-years method. HLA-A, -B and -C typing was performed with the standard NIH lymphocytotoxicity test, HLA-DR and -DQ typing was performed with the two-color fluorescence test. Homozygosity for HLA-A, -B, and -DR was defined as only one detectable antigen at a locus. RESULTS: The mean follow-up period (SD) was 5.0 (0.6) years. At the end of the follow-up, 70% of the subjects had died. The MRR (95% CI) for B60 was 0.96 (0.75-1.23), and for DR11 it was 0.82 (0.66-1.01). For A2 and A26 only, the MRR (95% CI) was significantly different from 1: 0.85 (0.73-0.99), P = .04 and 1.45 (1.06-1.99), P = .02, respectively (P values not corrected for the number of antigens tested). Homozygosity was not associated with mortality. CONCLUSIONS: HLA was not associated with mortality after the age of 85. Therefore, direct involvement of HLA in aging is unlikely. We suggest that the findings of previous studies are attributable to methodological shortcomings such as small sample size and differences in genetic background of the subjects.

A community based study of the incidence of dementia in subjects aged 85 years and over.

The aim was to investigate the incidence rate of dementia for community residents aged 85 years and over. It was a two wave community study of 224 subjects (community residents including those residing in a nursing home) older than 85 years, restudied 4.1 years after a community prevalence study. A two stage method was used, comprising the mini mental state examination followed in a stratified sample by the geriatric mental state schedule (A3)/AGECAT. Incidence rates were based on person-years at risk. The overall incidence of dementia was 6.9 (95% confidence interval (95% CI) 4.8-9.1) per 100 person-years at risk. The incidence was significantly higher for women than for men; respectively 8.9 (95% CI 5.9-11.9) v 2.7 (95% CI 0.5-4.9) per 100 person-years at risk. In the fastest growing age group seven out of 100 persons develop dementia each year. Women, who constitute two thirds of the oldest old, seem to have a higher risk. Further research is needed into the risk factors for dementia in this age group.

Three-year follow-up of Mini-Mental State Examination score in community residents aged 85 and over.

The objective of this study was to describe over time the course of cognitive function of elderly without cognitive impairment and of elderly with different stages of impairment, and to assess if the change in cognitive function was dependent on the initial level of function. The Mini-Mental State Examination (MMSE) was used at two time points. The first assessment (MMSE-1) was part of a community-based study and was obtained from 871 subjects. For the second assessment (MMSE-2) a sample of 166 subjects was drawn from the subjects alive at follow-up who had an MMSE-1 score. This sample was stratified by MMSE-1 score to avoid oversampling of subjects with high MMSE-1 scores. A second MMSE score was obtained from 134 elderly, whereas 18 subjects refused participation and 14 subjects were not traceable. The median age at first assessment was 89 years (25th percentile 87, 75th percentile 92), the mean follow-up period (S.D.) was 3.3 (0.5) years. The median change in MMSE score was minus 4 points (95% confidence interval (CI) -7 to -2) and the slope of the regression line of MMSE-2 on MMSE-1 was 1.1 (95% CI 0.9-1.3). It is likely that the slope was underestimated due to a floor effect, regression to the mean and missing observations. However, the probability of decline decreased if MMSE-1 was higher. Nevertheless, the probability ranged from 27 to 59% for subjects with the highest MMSE-1 scores aged 85 and 95 years respectively.(ABSTRACT TRUNCATED AT 250 WORDS)