Trajectory classes of depressive symptoms in a community sample of older adults.

OBJECTIVE: To identify trajectories of depressive symptoms in older community residents. METHOD: Depressive symptomatology, based on a modified Center for Epidemiological Studies-Depression scale, was obtained at years 0, 3, 6, and 10, in the Duke Established Populations for Epidemiologic Studies of the Elderly (n = 4162). Generalized growth mixture models identified the latent class trajectories present. Baseline demographic, health, and social characteristics distinguishing the classes were identified using multinomial logistic regression. RESULTS: Four latent class trajectories were identified. Class 1 - stable low depressive symptomatology (76.6% of the sample); class 2 - initially low depressive symptomatology, increasing to the subsyndromal level (10.0%); class 3 - stable high depressive symptomatology (5.4%); class 4 - high depressive symptomatology improving over 6 years before reverting somewhat (8.0%). Class 1 was younger, male gender, with better education, health, and social resources, in contrast to class 3. Class 2 had poorer cognitive functioning and higher death rate. Class 4 had better health and social resources. CONCLUSION: Reduction in high depressive symptomatology is associated with more education, better health, fewer stressful events, and a larger social network. Increasing depressive symptomatology is accompanied by poorer physical and cognitive health, more stressful life events, and greater risk of death.

Benzodiazepine use and cognitive function among community-dwelling elderly.

OBJECTIVE: To evaluate the relation between benzodiazepine use and cognitive function among community-dwelling elderly. METHODS: This prospective cohort study included 2765 self-reporting subjects from the Duke Established Populations for Epidemiologic Studies of the Elderly. The subjects were cognitively intact at baseline (1986-1987) and alive at follow-up data collection 3 years later. Cognitive function was assessed with the Short Portable Mental Status Questionnaire (unimpaired versus impaired and change in score) and on the basis of the number of errors on the individual domains of the Orientation-Memory-Concentration Test. Benzodiazepine use was determined during in-home interviews and classified by dose, half-life, and duration. Covariates included demographic characteristics, health status, and health behaviors. RESULTS: After control for covariates, current users of benzodiazepine made more errors on the memory test (beta coefficient, 0.35; 95% confidence interval [CI], 0.10 to 0.61) than nonusers. Further assessment of the negative effects on memory among current users suggested a dose response in which users taking the recommended or higher dose made more errors (beta coefficient, 0.57; 95% CI, 0.26 to 0.88) and a duration response in which long-term users made more errors (beta coefficient, 0.39; 95% CI, 0.05 to 0.73) than nonusers. Users of agents with long half-lives and users of agents with short half-lives both had increased memory impairment (beta coefficient, 0.32; 95% CI, 0.01 to 0.64 and beta coefficient, 0.38; 95% CI, 0.02 to 0.75, respectively) relative to nonusers. Previous benzodiazepine use was unrelated to memory problems, and current and previous benzodiazepine use was unrelated to level of cognitive functioning as measured with the other 4 tests. CONCLUSIONS: The results suggested that current benzodiazepine use, especially in recommended or higher doses, is associated with worse memory among community-dwelling elderly.

Comparison of two screening tests in Alzheimer's disease. The correlation and reliability of the Mini-Mental State Examination and the modified Blessed test.

The Mini-Mental State Examination (MMSE) and the Blessed Orientation-Memory-Concentration test (BOMC), a six-item derivative of the Blessed Information-Memory-Concentration Test, were each administered to 36 patients with a clinical diagnosis of Alzheimer's disease. In 24 patients, both tests were readministered a month later. The correlation between the MMSE and BOMC was -0.83 with a test-retest correlation of 0.89 (MMSE) and 0.77 (BOMC). Factor analysis indicated that the multiple MMSE cognitive components could be explained by two factors, which together accounted for 66% of the variance. These factors are conceptually similar to the components of the BOMC, and so may explain the substantial correlation between the two tests. Since these cognitive status tests seem to be equivalent for Alzheimer patients, the briefer measure (BOMC), which offers additional advantages, may be preferred.

Discrimination between stages of Alzheimer's disease with subsets of Mini-Mental State Examination items. An analysis of Consortium to Establish a Registry for Alzheimer's Disease data.

OBJECTIVE: To identify minimal sets of Mini-Mental State Examination (MMSE) items that can distinguish normal control subjects from patients with mild Alzheimer's disease (AD), patients with mild from those with moderate AD, and those with moderate from those with severe AD. DESIGN: Two randomly selected equivalent half samples. Results of logistic regression analysis from data from the first half of the sample were confirmed by receiver operating characteristic curves on the second half. SETTING: Memory disorders clinics at major medical centers in the United States affiliated with the Consortium to establish a Registry for Alzheimer's Disease (CERAD). PARTICIPANTS: White, normal control subjects (n = 412) and patients with AD (n = 621) who met CERAD criteria; nonwhite subjects (n = 165) and persons with missing data (n = 27) were excluded. MAIN OUTCOME MEASURES: Three four-item sets of MMSE items that discriminate, respectively, (1) normal controls from patients with mild AD, (2) patients with mild from those with moderate AD, and (3) patients with moderate from those with severe AD. RESULTS: The MMSE items discriminating normal controls from patients with mild AD were day, date, recall of apple, and recall of penny; those discriminating patients with mild from those with moderate AD were month, city, spelling world backward, and county, and those discriminating patients with moderate from those with severe AD were floor of building, repeating the word table, naming watch, and folding paper in half. Performance on the first two four-item sets was comparable with that of the full MMSE; the third set distinguished patients with moderate from those with severe AD better than chance. CONCLUSIONS: A minimum set of MMSE items can effectively discriminate normal controls from patients with mild AD and between successive levels of severity of AD. Data apply only to white patients with AD. Performance in minorities, more heterogeneous groups, or normal subjects with questionable cognitive status has not been assessed.

Variability in annual Mini-Mental State Examination score in patients with probable Alzheimer disease: a clinical perspective of data from the Consortium to Establish a Registry for Alzheimer's Disease.

OBJECTIVE: To determine the variability in annual Mini-Mental State Examination scores of patients with Alzheimer disease enrolled in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD). PATIENTS: A total of 372 patients with probable Alzheimer disease with 1 or more years of follow-up. SETTING: Twenty-one CERAD clinical sites throughout the United States. RESULTS: An average annual decline of 3.4 points in CERAD patients returning for longitudinal reassessments was close to the SD of the measurement error of 2.8 points for the Mini-Mental State Examination. There was wide variability in individual rates of decline. Even with 4 years of follow-up, 15.8% of the patients had no clinically meaningful decline in Mini-Mental State Examination score (defined as a change in initial score >3, ie, 1 SD of measurement error). Validity of measurements of the rate of change in Mini-Mental State Examination scores improved with longer observation intervals and was reliable for most patients when observations were separated by 3 or more years. CONCLUSIONS: Although the Mini-Mental State Examination is a useful screening instrument to assess level of cognitive function, it has limited value in measuring the progression of Alzheimer disease in individual patients for periods less than 3 years because of a large measurement error and substantial variation in change in annual score.

Progression of Alzheimer's disease in black and white patients: the CERAD experience, part XVI. Consortium to Establish a Registry for Alzheimer's Disease.

We compared the progression of Alzheimer's disease (AD) in CERAD-enrolled black and white patients, as indicated by changes in selected clinical and neuropsychology measures, over a 1-year time interval. Of 225 black and 935 white AD patients who were enrolled, 148 (66%) black and 770 (82%) white patients remained in the study. Of these, 82 black and 532 white patients provided complete in-person information on first annual re-evaluation. Overall, with age, education, initial level of performance on each measure, and stage of disease at entry controlled, race had a very mild effect on change in disease (8 df multivariate analysis of variance [MANOVA], p < 0.047). Black patients showed less decline than white patients, most notably for the CERAD Boston Naming test (p < 0.02) and the third and final trial of the 10-item Word List Learning task (p < 0.003). Although unadjusted data indicate that black and white patients appear to differ notably at entry, our findings indicated that differences in progression of the dementing process are minor, suggesting that course of AD is comparable in these racial groups. Examination over a longer period is difficult because of the high attrition rate of black patients.

The relationship between extrapyramidal signs and cognitive performance in patients with Alzheimer's disease enrolled in the CERAD Study. Consortium to Establish a Registry for Alzheimer's Disease.

The objective of this study was to determine the relationship between the presence of extrapyramidal signs and the severity of cognitive and functional impairment in patients with Alzheimer's disease (AD). Eleven university medical centers in the United States and France participated in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) study of extrapyramidal signs in AD. Forty-seven patients with probable AD who had extrapyramidal signs were matched by sex, race, education, and age with 132 probable AD patients without extrapyramidal signs. The main outcome measures were the Clinical Dementia Rating, Blessed Dementia Scale, and the CERAD Neuropsychology Battery (verbal fluency, naming, Mini-Mental State Examination, word list learning, word list recall, savings ratio, word list recognition, and constructional praxis). AD patients with extrapyramidal signs performed more poorly than AD patients without parkinsonism on various neuropsychological tests, even after controlling for the Clinical Dementia Rating and reported duration of cognitive impairment. The severity of the extrapyramidal manifestations was related to the degree of cognitive and functional impairment. Muscular rigidity and bradykinesia were the most frequent extrapyramidal signs associated with AD. Patients with AD associated with extrapyramidal signs have greater cognitive and functional impairment than AD patients without clinical evidence of parkinsonism.

Comparison of Lewy body variant of Alzheimer's disease with pure Alzheimer's disease: Consortium to Establish a Registry for Alzheimer's Disease, Part XIX.

OBJECTIVE: To compare the clinical, neuropsychological, and neuropathologic findings in patients with AD alone with those in patients with the Lewy body variant of AD (LBV). BACKGROUND: Prior studies indicate that patients with LBV not only have distinct clinical and neuropsychological differences from those with AD alone, but have a poorer prognosis with shorter survival time. METHODS: The authors evaluated 74 patients with autopsy-confirmed AD alone and 27 patients with LBV, and compared demographic characteristics and clinical, neuropsychological, and neuropathologic findings. RESULTS: The two groups of patients were equivalent with respect to age at time of entry into the study, years of education, and sex. Two or more extrapyramidal clinical manifestations were found in 44% of patients with LBV, compared with 16% of patients with AD alone (p = 0.02). Duration of survival after entry into the study was similar in both groups, with a mean survival of 3.6 (+/-2.1) years for AD alone versus 3.8 (+/-1.9) years for LBV. Of the various neuropsychological tests administered at the last Consortium to Establish a Registry for Alzheimer's Disease evaluation, only delayed recall of a learned word list was significantly different in the two groups, with 32% of patients with LBV versus 15% of patients with AD alone recalling any items (p = 0.04). Neuropathologic findings confirmed those of previous studies and showed that neurofibrillary tangles were significantly less frequent in the neocortex of patients with LBV than in those with AD alone. CONCLUSION: Compared with patients with AD alone, those with LBV had a greater frequency of extrapyramidal manifestations, somewhat better recall on a selected memory task at their final evaluation, and a significantly lower frequency of neocortical neurofibrillary tangles at autopsy. There were no differences between the two groups, however, in survival time from entry into the study.

The consortium to establish a registry for Alzheimer's Disease (CERAD). Part XIII. Obtaining autopsy in Alzheimer's disease.

Although autopsy rates in the United States have been decreasing steadily, the necessity for brain autopsy to confirm Alzheimer's disease (AD) remains. Of 308 consecutively deceased AD patients at 24 CERAD (Consortium to Establish a Registry for Alzheimer's Disease) sites, 167 (54%) were autopsied; 141 (46%) were not. The autopsied and nonautopsied groups were comparable in gender (men, 57.5% versus 49.7%), marital status (married, 69.3% versus 67.1%), age at entry (73 versus 74 years), age at death (76 versus 77 years), and stage of disease at entry (mild, 46% versus 43%). However, the autopsied patients were significantly more likely to be white (94.5% versus 82.1%), to be better educated (13.1 versus 11.3 years), to have been in the study longer (mean, 3.3 versus 2.6 years), and to have had longer total duration of AD (8.1 versus 6.7 years). Of the 24 CERAD sites, 13 stressed the importance of autopsy by dedicating a staff member to seek autopsy and by providing free autopsy and transportation; 11 did not. Logistic regression analysis showed that white race (odds ratio [OR] = 2.74; 95% confidence interval [CI] = 1.10-6.83), increased education (OR = 1.12; 95% CI = 1.04-1.21), and emphasis on autopsy (OR = 4.69; 95% CI = 2.67-8.25) were the only significant factors. Although race and education were important, autopsy was more likely to be obtained when sites dedicated resources to this endeavor.

Cerebral infarcts in patients with autopsy-proven Alzheimer's disease: CERAD, part XVIII. Consortium to Establish a Registry for Alzheimer's Disease.

OBJECTIVE: To study the relation between cerebral infarction and clinical and neuropsychologic manifestations in patients with autopsy-proven Alzheimer's disease (AD) enrolled in the Consortium to Establish a Registry for Alzheimer's Disease (CERAD). BACKGROUND: Prior studies report that subjects with neuropathologic evidence of AD and concomitant brain infarcts had poorer cognitive function and higher frequency of dementia than those with AD alone. METHODS: Clinical and neuropsychologic manifestations of dementia were studied in 74 subjects with neuropathologic findings of AD alone and 32 with AD and concomitant cerebral infarcts or lacunar lesions. RESULTS: The 32 patients with both AD and vascular lesions were significantly older at time of death (median age, 81 years) than the 74 patients with AD alone (76 years; p = 0.02). At the final follow-up visit, the severity of the dementia was greater in AD patients with vascular lesions (median Clinical Dementia Rating [CDR] = 3) than in those with AD alone (CDR = 2; p = 0.03). Patients with AD and vascular lesions performed significantly worse on verbal fluency, Boston Naming, and Mini-Mental State Examination (MMSE) tests. No differences between the groups were observed, however, in the semiquantitative measures of frequency of neuritic plaques or neurofibrillary tangles. CONCLUSIONS: The clinical-neuropathologic correlations in CERAD patients generally confirm those in prior studies, indicating that the presence of cerebral infarction in patients with AD is associated with greater overall severity of clinical dementia and poorer performance on specific tests of language and cognitive function.

Relation of prescription nonsteroidal antiinflammatory drug use to cognitive function among community-dwelling elderly.

PURPOSE: To evaluate the relationship of nonsteroidal antiinflammatory drug (NSAID) use to level of cognitive function in community-dwelling elderly persons. METHODS: The prospective cohort study included 2765 nonproxy subjects from the Duke University Established Populations for Epidemiologic Studies of the Elderly who were cognitively intact at baseline (1986-1987) and alive at follow-up three year later. Cognitive function was assessed by the Short Portable Mental Status Questionnaire (i.e., intact vs. impaired and change in score) and by the individual domains of the Orientation-Memory-Concentration Test (i.e., number of errors). NSAID use, determined from in-home interviews, was coded for chronicity, dose, frequency of use, and prescription status. RESULTS: After controlling for demographic factors as well as health status and behavior, continuous, regularly-scheduled, prescription use of NSAID was associated with preservation of one aspect of cognitive functioning: concentration (beta coefficient, 0.29; 95% confidence interval [CI] -0.54 to -0.04, indicating fewer errors). However, no consistent dose-response relationship was found. Current and prior NSAID use was unrelated to level of cognitive functioning across all five measures; among current users, those taking moderate or high doses (beta coefficient, 0.41; 95% CI, 0.08 to 0.74) made more errors on the memory test compared with those taking low doses (beta coefficient 0.03; 95% CI, -.85 to 0.91). CONCLUSIONS: These results suggest no substantial or consistent protective effect of prescription NSAID use on cognitive function in community-dwelling elderly. However, recent use at higher doses may be associated with memory deterioration in this population.

Factors predicting change in prescription and nonprescription drug use in a community-residing black and white elderly population.

The current study identifies characteristics that predict change in use of prescription and nonprescription drugs over a period of 3 years. A modified health care services use model was applied to information obtained from a probability-based sample of black (n = 1778) and white (n = 1446) community-resident elderly, interviewed in 1986-1987 and 1989-1990. Analysis was by means of logistic and ordinary least-squares regression, with sample weights and design effects taken into account. The number of users and average number of prescription drugs used increased over the 3 years, and was best predicted by extent of prior drug use, older age, white race, poorer health, and number of health care visits. Conversely, nonprescription drug use declined significantly, and was best predicted by prior use, white race, and female gender. The reduced use of prescription drugs by blacks as compared to whites is of concern, suggesting that attention is needed to assure equitable access to prescription drugs.

The prevalence and 3-year incidence of dementia in older Black and White community residents.

OBJECTIVE: To determine the prevalence and 3-year incidence of dementia in Blacks and Whites age 65 and older in a five-county Piedmont area of North Carolina. DESIGN: Stratified random sample of members of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE) (baseline n = 4,136; 55% Black; weighted n = 28,000). Prevalence study members were differentially selected on the basis of score on the Short Portable Mental Status Questionnaire at the second in-person Duke EPESE wave. Incidence study members included all persons with obvious cognitive decline over a 3-year period, and a 10% sample of the remainder. MEASUREMENTS: Self- and informant report on health history, functional status, and memory. Consortium to Establish a Registry for Alzheimer's Disease (CERAD) Neuropsychology Battery administered to all subjects, and CERAD Clinical Battery to those with impaired memory. Clinical consensus to determine presence and type of dementia. RESULTS: Prevalence of dementia for persons > or =68 years old was 0.070 (95% confidence interval = 0.021-0.119) for Blacks and 0.072 (0.022-0.122) for Whites. Rates for Black men (0.078, 0.001-0.155) exceeded those for Black women (0.066, 0.003-0.129), but gender rates for Whites were reversed (men: 0.044, 0.000-0.103), (women: 0.087, 0.015-0.160). Neither race nor gender differences were significant. Prevalence of dementia increased through age 84 and tapered off thereafter. Three-year incidence of dementia was 0.058 (0.026-0.090) for Blacks and 0.062 (0.027-0.097) for Whites. Neither race nor gender differences were significant. Incidence increased through age 84, but moderated thereafter for all but Black men. The proportional representation of different types of dementia varied little by race. CONCLUSION: Prevalence, 3-year incidence, and types of dementia are comparable in Black and White elderly in the Piedmont area of North Carolina.

Screening the elderly. A brief instrumental activities of daily living measure.

Although multidimensional functional assessment may be the route of choice in determining the personal status of the elderly and the services they need, the majority of the elderly are well and competent, making it hard to justify routine extensive assessment with its attendant costs. Described herein is a brief, valid, and reliable five-item screener based on instrumental activities of daily living which can rapidly identify elderly community residents with impaired functional capacity, and which, because of its substantial correlation with physical health (r = .54 to .55), mental health (r = .54 to .60), and predictability of death can identify those for whom more extensive assessment is warranted. Use of such a brief screener should result in better targeting of elderly in need of service, facilitate coordinated and efficient health care delivery, and maintain the functional independence of the elderly.

OARS methodology. A decade of experience in geriatric assessment.

The Older Americans Resources and Services (OARS) methodology was designed to assess functional capacity in five dimensions (social resources, economic resources, mental health, physical health, and activities of daily living) and to measure use of and need for 24 types of generic services. The OARS questionnaire now has been used in more than 150 research and practice settings. Recent refinements in the OARS methodology include new information about validity and reliability, computerized summary ratings for the five dimensions of functional status, and eleven scales that measure specific aspects of functioning within the five dimensions. This paper describes the conceptual foundation, appropriate uses, psychometric properties, and recent refinements in the OARS methodology. Empirical data from a geriatric clinic population are used for purposes of illustration. The paper presents an assessment of the strengths and limitations of the OARS methodology based on more than a decade of experience. Particular attention is paid to the degree to which the measures of functional status can be related to health service use measures to inform geriatric research and practice.

Equivalence of two screens of cognitive functioning: the Short Portable Mental Status Questionnaire and the Orientation-Memory-Concentration test.

OBJECTIVE: To determine the equivalence of two screens of cognitive functioning: the Short Portable Mental Status Questionnaire (SPMSQ) and the Orientation-Memory-Concentration (OMC) test. DESIGN: The design was cross-sectional and longitudinal. SETTING: Four rural and one urban county in the Piedmont region of North Carolina (n = 3210). PARTICIPANTS: A stratified random cluster sample (n = 3210) of people 68 years of age and older. MEASUREMENTS: SPMSQ and OMC at the fourth wave of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE); disability, depression, and death measurements from the fourth through seventh waves of EPESE; demographic characteristics. RESULTS: On the SPMSQ and the OMC (r = .80), 15.3% and 38.4%, respectively, of those tested were rated cognitively impaired. Poorer scores were associated with older age, black race, and less education. These associations were attenuated on the dichotomized SPMSQ but not on the OMC. Both measures predicted disability and depressive symptomatology currently and 3 years hence and death. CONCLUSIONS: The SPMSQ and OMC, although highly correlated, are not equivalent. Association with race and education are greater for the OMC, whereas an association with age exists for both measures. The milder level of impairment identified by the OMC increases predictive capacity.

Nutrition and function: is there a relationship between body mass index and the functional capabilities of community-dwelling elderly?

OBJECTIVE: To determine if there is a relationship between body mass index and the ability to perform the usual activities of living in a sample of community-dwelling elderly. DESIGN: Secondary data analysis of The National Health and Nutrition Examination Survey-I Epidemiologic Follow-up Study (1982-1984). Follow-up home interview of a population-based sample originally interviewed between 1971 and 1975 in the National Health and Nutrition Examination Survey-I (NHANES-I). PARTICIPANTS: Survivors of the original NHANES-I cohort who were 65 years of age or older and who were living at home at the time of the second interview (n = 3061). Excluded were those who could not be found, refused participation, or were institutionalized (n = 220), and those without complete height and weight data (n = 194). MAIN OUTCOME MEASURE: Functional status as measured by a 26-item battery. RESULTS: Bivariate analysis revealed a greater risk for functional impairment for subjects with a low body mass index or a high body mass index. The greater the extreme of body mass index (either higher or lower), the greater the risk for functional impairment. Logistic regression analysis indicated that both high and low body mass index continued to be significantly related to functional status when 22 other potential confounders were included in the model. CONCLUSION: The body mass index is related to the functional capabilities of community-dwelling elderly. The inclusion of this simple measurement in the comprehensive assessment of community-dwelling elderly is supported.

The relationship of APOE genotype to cognitive functioning in older African-American and Caucasian community residents.

OBJECTIVES: To determine whether cognitive decline associated with the apolipoprotein E (APOE) epsilon4 allele is different in older African Americans than it is in Caucasians. DESIGN: Performance on a brief screen of cognitive functioning was examined at baseline (N = 1,891) and 4 years later (N = 1,389) to determine the extent to which the presence of APOE epsilon4 affected level of and change in performance, and whether this differed as a function of race, age, initial score, and change in score. SETTING: Five adjacent counties in the Piedmont area of North Carolina. PARTICIPANTS: In 1986, a stratified random household sample of community residents age 65 and older (n = 4,162; 54% African-American, 45% Caucasian, 1% other race) formed the Duke Established Populations for Epidemiologic Studies of the Elderly. Of those available at the sixth annual wave, 76% were genotyped, with 1,891 providing baseline data on this wave, and the available survivors (n = 1,389) providing longitudinal data 4 years later. MEASUREMENTS: The Short Portable Mental Status Questionnaire (SPMSQ), a brief screen of cognitive functioning, was administered to all subjects on both occasions. We examined score at baseline and cognitive decline (i.e., increase of 2+ errors) at follow-up. Control measures included demographic characteristics, health behaviors, health and functional status, and medication use. APOE status was coded as epsilon4 present versus absent. RESULTS: APOE epsilon4 was significantly and uniquely related to lower score at baseline and significantly increased the odds of cognitive decline by 59%. There was no statistically significant interaction between APOE epsilon4 and age, race, initial SPMSQ score, or SPMSQ score at follow-up. CONCLUSION: APOE epsilon4 is modestly, if significantly, related to poorer cognitive functioning and to decline in cognitive functioning. No differences were found by age or race in this community representative sample.

Comorbidity of five chronic health conditions in elderly community residents: determinants and impact on mortality.

BACKGROUND: Comorbidity is common in elderly persons. Its extent, correlates, and life-threatening impact in representative community residents are unclear. METHODS: Self-reported information of physician-diagnosed coronary artery disease (CAD), cerebrovascular disease (CVD), diabetes, and cancer was obtained annually between 1986-87 and 1992-93, and hypertension was obtained triennially from the participants of the Duke Established Populations for Epidemiologic Studies of the Elderly, a stratified multistage sample of 4,126 Black and White community residents aged 65-100, living in a five-county area of North Carolina. Date of death was obtained from death certificates identified through search of the National Death Index. Statistical procedures included descriptive statistics, logistic regression, and survival analysis. RESULTS: Of this sample, 57% reported hypertension, 20% diabetes, 15% CAD, 9% cancer, and 9% CVD; 29% reported none of these conditions, whereas 29% reported two or more. Demographic characteristics were not related to comorbidity with CVD or cancer. Increased education tended to be protective. The effect of age, gender, and race varied with condition. At baseline there was substantial comorbidity among hypertension, CAD, CVD, and diabetes, but not with cancer. Hypertension, CVD, and diabetes were risk factors for CAD, whereas diabetes was a risk factor for CVD. After controlling for demographic characteristics, all health conditions except hypertension were predictive of 6-year mortality, as was the presence of comorbidity. CONCLUSION: We found significant comorbidity in older persons who have hypertension, CAD, CVD, or diabetes; particular risk of developing comorbidity, particularly CAD, among those with hypertension, CVD, and diabetes; and risk of CVD in those with diabetes. With the exception of hypertension, these conditions, and comorbidity per se, are life-threatening.

Predictors of nutritional supplement use by the elderly.

We conducted a population survey to describe patterns and determine predictors of the use of nutritional supplements and single-ingredient vitamins and minerals among elderly living in five adjacent urban and rural counties in the Piedmont area of North Carolina. The stratified random sample consisted of 3939 black and white participants age 65 or older from the Duke Established Populations for Epidemiologic Studies of the Elderly. The use of nutritional supplements within the previous 2 weeks was determined during an in-home interview. Multivariate analyses, using weighted data adjusted for sampling design, were conducted to assess the association between nutritional supplement use and predisposing, need, and enabling factors. Nutritional supplement use was reported by 26.2% of participants and was more likely for those who were white women, were high school educated, were underweight, took prescription drugs, had five or more health visits in the previous year, and had supplemental health insurance. It was less likely for those with poor self-rated health. The majority (71.5%) of nutritional supplement users took at least one single-ingredient supplement. Use of such products was more likely in those who were white, born and raised in an urban area, and high school educated, and was less likely in those with impaired functional status. Nutritional supplement use is prevalent in community-dwelling elderly and is more commonly associated with demographic factors and access to health care than with need factors.