Preliminary Evidence for Subdimensions of Geriatric Frailty: The MacArthur Study of Successful Aging

OBJECTIVES: To identify frailty subdimensions. DESIGN: Longitudinal cohort (MacArthur Study). SETTING: Three U.S. urban centers. PARTICIPANTS: One thousand one hundred eighteen high‐functioning subjects aged 70 to 79 in 1988. MEASUREMENTS: Participants with three or more of five Cardiovascular Health Study (CHS) frailty criteria (weight loss, weak grip, exhaustion, slow gait, and low physical activity) in 1991 were classified as having the CHS frailty phenotype. To identify frailty subdimensions, factor analysis was conducted using the CHS variables and an expanded set including the CHS variables, cognitive impairment, interleukin‐6 (IL‐6), C‐reactive protein (CRP), subjective weakness, and anorexia. Participants with four or more of 10 criteria were classified as having an expanded frailty phenotype. Predictive validity of each identified frailty subdimension was assessed using regression models for 4‐year disability and 9‐year mortality. RESULTS: Two subdimensions of the CHS phenotype and four subdimensions of the expanded frailty phenotype were identified. Cognitive function was consistently part of a subdimension including slower gait, weaker grip, and lower physical activity. The CHS subdimension of slower gait, weaker grip, and lower physical activity predicted disability (adjusted odds ratio (AOR)=1.7, 95% confidence interval (CI)=1.3–2.2) and mortality (AOR=1.5, 95% CI=1.3–1.8). Subdimensions of the expanded model with predictive validity were higher IL‐6 and CRP (AOR=1.2 for mortality); slower gait, weaker grip, lower physical activity, and lower cognitive function (AOR=1.8 for disability; AOR=1.5 for mortality), and anorexia and weight loss (AOR=1.2 for disability). CONCLUSION: This study provides preliminary empirical support for subdimensions of geriatric frailty, suggesting that pathways to frailty differ and that subdimension‐adapted care might enhance care of frail seniors.     

老年人24 h动态舒张压的影响因素及其对10年生存预后的影响研究

背景　老年人普遍存在低舒张压现象,但目前国内外高血压相关指南对于老年人的降压目标往往仅关注收缩压,对于舒张压的关注较少,舒张压维持水平不明确。目的　探讨老年人24 h动态舒张压的影响因素,以及24 h动态舒张压对老年人10年生存预后的影响。方法　选取2003-2008年在中国人民解放军南部战区总医院住院的军队离退休老年人787例（年龄65~95岁）,根据其24 h动态舒张压水平分为<70、70~80、>80 mm Hg三组,例数分别为352、346、89例。采用多元线性回归分析老年人24 h动态舒张压的影响因素;比较三组随访10年期间的死亡情况,采用Kaplan-Meier生存函数比较三组随访期间的生存时间。结果　老年人的24 h动态舒张压为（71±8）mm Hg,65~79岁者高于80~95岁者（P<0.05）。多元线性回归分析结果显示,年龄、BMI、心率、24 h动态收缩压、血红蛋白是老年人24 h动态舒张压的影响因素（P<0.05）。在65~79岁老年人中,24 h动态舒张压<70 mm Hg者冠心病、心肌梗死患病率高于70~80、>80 mm Hg者,>80 mm Hg者高血压患病率高于<70、70~80 mm Hg者（P<0.017）;在80~95岁老年人中,<70 mm Hg者冠心病患病率高于70~80 mm Hg者,70~80 mm Hg者冠心病患病率高于>80 mm Hg者（P<0.017）。Cox风险比例回归模型显示：对于65~79岁老年人,24 h动态舒张压>80 mm Hg者因心血管疾病死亡风险是<70 mm Hg者的3.527倍〔95%CI（1.119,11.113）,P<0.05〕;对于80~95岁老年人,24 h动态舒张压不是其因心血管疾病死亡的影响因素（P>0.05）。三组中位生存时间分别为149.27、161.11、161.65个月,三组生存曲线比较,差异有统计学意义（P<0.05）。结论　老年人的24 h动态舒张压受年龄、BMI、心率、24 h动态收缩压、血红蛋白的影响,在冠心病、心肌梗死、高血压的发病中起重要作用,会影响老年人的10年生存预后。65~79岁老年人的舒张压控制在70~80 mm Hg可能较为合适,≥80岁老年人的舒张压可能更适合维持在较高水平（>80 mm Hg）。     

Relationship Between Fear of Falling and Outcomes of an Inpatient Geriatric Rehabilitation Population—Fear of the Fear of Falling

OBJECTIVES: To examine the effects of various risk factors on three functional outcomes during rehabilitation. SETTING: Geriatric inpatient rehabilitation unit. DESIGN: Observational longitudinal study. PARTICIPANTS: One hundred sixty‐one geriatric rehabilitation inpatients (men, women), mean age 82, who were capable of walking at baseline. MEASUREMENTS: Functional status was assessed weekly between admission and discharge and at a follow‐up 4 months later at home using the function component of the Short Form—Late Life Function and Disability Instrument, the Barthel Index, and Habitual Gait Speed. Various risk factors, such as falls‐related self‐efficacy (Falls Efficacy Scale–International), were measured. Associations between predictors and functional status at discharge and follow‐up were analyzed using linear regression models and bivariate plots. RESULTS: Fear of falling predicted functioning across all outcomes except for habitual gait speed at discharge and follow‐up. Visual comparison of functional trajectories between subgroups confirmed these findings, with different levels of fear of falling across time in linear plots. Thus, superior ability of this measure to discriminate between functional status at baseline across all outcomes and to discriminate between functional change especially with regard to the performance‐based outcome was demonstrated. CONCLUSION: Falls‐related self‐efficacy is the only parameter that significantly predicts rehabilitation outcome at discharge and follow‐up across all outcomes. Therefore, it should be routinely assessed in future studies in (geriatric) rehabilitation and considered to be an important treatment goal.     

A Controlled Trial of an Intervention to Improve Urinary and Fecal Incontinence and Constipation

OBJECTIVES: To evaluate effects of a multicomponent intervention on fecal incontinence (FI) and urinary incontinence (UI) outcomes. DESIGN: Randomized controlled trial. SETTING: Six nursing homes (NHs). PARTICIPANTS: One hundred twelve NH residents. INTERVENTION: Intervention subjects were offered toileting assistance, exercise, and choice of food and fluid snacks every 2 hours for 8 hours per day over 3 months. MEASUREMENTS: Frequency of UI and FI and rate of appropriate toileting as determined by direct checks from research staff. Anorectal assessments were completed on a subset of 29 residents. RESULTS: The intervention significantly increased physical activity, frequency of toileting, and food and fluid intake. UI improved (P=.049), as did frequency of bowel movements (P<.001) and percentage of bowel movements (P<.001) in the toilet. The frequency of FI did not change. Eighty‐nine percent of subjects who underwent anorectal testing showed a dyssynergic voiding pattern, which could explain the lack of efficacy of this intervention program alone on FI. CONCLUSION: This multicomponent intervention significantly changed multiple risk factors associated with FI and increased bowel movements without decreasing FI. The dyssynergic voiding pattern and rectal hyposensitivity suggest that future interventions may have to be supplemented with bulking agents (fiber), biofeedback therapy, or both to improve bowel function.     

The Effect of Medication Use on Urinary Incontinence in Community‐Dwelling Elderly Women

OBJECTIVES: To evaluate whether use of certain medications with potential urological effects is associated with development of incident urinary incontinence in community‐resident older women. DESIGN: Longitudinal cohort study. SETTING: Pittsburgh, PA, and Memphis, TN. PARTICIPANTS: Nine hundred fifty‐nine healthy black and white women aged 65 and older enrolled in the Health, Aging and Body Composition Study without baseline (Year 1) self‐reported urinary incontinence. MEASUREMENTS: Use of alpha blockers, anticholinergics, central nervous system medications (opioids, benzodiazepines, antidepressants, antipsychotics), diuretics (thiazide, loop, potassium sparing), and estrogen (all dosage forms) was determined during Year 3 interviews. Self‐reported incident (≥weekly) incontinence in during the previous 12 months was assessed at Year 4 interviews. RESULTS: Overall, 20.5% of these women reported incident incontinence at Year 4 (3 years from baseline). The most common medication used with potential urological activity was a thiazide diuretic (24.3%), followed by estrogen (22.2%); alpha blockers were the least commonly used (2.3%). Multivariable logistic regression analyses revealed that current users of alpha blockers (adjusted odds ratio (AOR)=4.98, 95% confidence interval (CI)=1.96–12.64) and estrogen (AOR=1.60, 95% CI=1.08–2.36) had a greater risk of urinary incontinence than nonusers. There was no greater risk (P>.05) of urinary incontinence with the current use of anticholinergics, central nervous system medications, or diuretics. No statistically significant race‐by–medication use interactions were found (all P>.05). CONCLUSION: These results corroborate earlier reports that, in elderly women, use of alpha blockers or estrogens is associated with risk of self‐reported incident urinary incontinence.     

Translating a Multifactorial Fall Prevention Intervention into Practice: A Controlled Evaluation of a Fall Prevention Clinic

Although multifactorial fall prevention interventions have been shown to reduce falls and injurious falls, their translation into clinical settings has been limited. This article describes a hospital‐based fall prevention clinic established to increase availability of preventive care for falls. Outcomes for 43 adults aged 65 and older seen during the clinic's first 6 months of operation were compared with outcomes for 86 age‐, sex‐, and race‐matched controls; all persons included in analyses received primary care at the hospital's geriatrics clinic. Nonsignificant differences in falls, injurious falls, and fall‐related healthcare use according to study group in multivariate adjusted models were observed, probably because of the small, fixed sample size. The percentage experiencing any injurious falls during the follow‐up period was comparable for fall clinic visitors and controls (14% vs 13%), despite a dramatic difference at baseline (42% of clinic visitors vs 15% of controls). Fall‐related healthcare use was higher for clinic visitors during the baseline period (21%, vs 12% for controls) and decreased slightly (to 19%) during follow‐up; differences in fall‐related healthcare use according to study group from baseline to follow‐up were nonsignificant. These findings, although preliminary because of the small sample size and the baseline difference between the groups in fall rates, suggest that being seen in a fall prevention clinic may reduce injurious falls. Additional studies will be necessary to conclusively determine the effects of multifactorial fall risk assessment and management delivered by midlevel providers working in real‐world clinical practice settings on key outcomes, including injurious falls, downstream fall‐related healthcare use, and costs.     

Increased rates of cortisol production and urinary free cortisol excretion in elderly women 2 weeks after proximal femur fracture

Abstract. Cortisol production rate and urinary free cortisol excretion have been measured in healthy elderly women and elderly women about two weeks after upper femur fracture. Plasma cortisol was determined mid-morning, at the start of urine collection. All three variables were higher in the injured patients than in the control subjects. Urinary free cortisol excretion showed the greatest rise and was correlated with cortisol production rate in the patients. In the control subjects there was no correlation and nearly all the points fell below the regression line for the injured patients, indicating that urinary free cortisol excretion rose in relation to cortisol production rate after injury. Measurement of creatinine clearance showed that this was not due to an increased glomerular filtration rate, and a possible explanation is decreased metabolic clearance of cortisol. Plasma cortisol was not significantly correlated with either cortisol production rate or urinary free cortisol excretion.     

Alcohol,Tobacco, and Nonmedical Drug Use in Older U.S. Adults: Data from the 2001/02 National Epidemiologic Survey of Alcohol and Related Conditions

OBJECTIVES: To examine the prevalence and sociodemographic and health‐related correlates of substance use, including alcohol, tobacco, and nonmedical drug use, in adults aged 65 and older. DESIGN: Cross‐sectional, retrospective survey of a population‐based sample, the 2001/02 National Epidemiologic Survey on Alcohol and Related Conditions. SETTING: United States. PARTICIPANTS: Eight thousand two hundred five U.S. adults aged 65 and older. MEASUREMENTS: Prevalence of lifetime and previous‐12‐month alcohol, tobacco, and nonmedical drug use and associations between substance use and sociodemographic and health‐related factors. RESULTS: Almost 80% of older adults had used any of the three substances over their lifetimes, and more than 50% reported such use over the previous 12 months. Alcohol was the most commonly used substance over the lifetime (74%) and in the previous 12 months (45%), followed by tobacco (52% lifetime; 14% previous 12 months); far fewer reported nonmedical use of drugs (5% lifetime; 1% previous 12 months). In general, being younger, male, and divorced or separated were factors consistently associated with use of any of the three substances. CONCLUSION: Most older adults had used substances over their lifetimes and in the previous 12 months. Alcohol is the substance of choice for this age group, followed by tobacco; few report nonmedical drug use.     

纤维肌痛综合征运动疗法的最佳选择尚待明确

纤维肌痛综合征（FMS）患者常出现睡眠障碍、疲乏、广泛累及的软组织压痛,同时可伴随出现焦虑及抑郁,生活质量受到严重影响。运动疗法作为非药物干预的一种,被推荐为FMS患者的一线治疗方式。本文旨在简要总结传统运动、有氧运动及抗阻运动改善FMS患者症状的证据,并初步分析运动治疗FMS的潜在机制,为后续相关研究提供思路。     

胰岛素自身免疫综合征的临床特点分析并文献复习

目的　分析胰岛素自身免疫综合征（IAS）的临床特点,结合文献提高对本病的认识。方法　经郑州大学第一附属医院病案室计算机检索2007年1月—2017年5月内分泌与代谢病科确诊为IAS的患者共10例,回顾性总结患者的临床特点,包括一般资料、临床症状、既往史、实验室检查及影像学检查、治疗及随访情况。结果　10例IAS患者中男、女各5例;年龄21~74岁,60岁及以上6例;低血糖发作时间多在夜间及凌晨;5例有含巯基药物服用史,3例有胰岛素应用史,2例无明显诱因;口服葡萄糖耐量试验（OGTT）结果提示糖尿病4例,糖耐量受损3例,糖耐量正常1例;10例患者血清胰岛细胞抗体（ICA）及谷氨酸脱羧酶抗体（GADA）均阴性,而胰岛素自身抗体（IAA）均阳性。所有患者血清胰岛素水平明显升高,并与C肽水平升高不匹配。10例患者均予少食多餐、高纤维素低碳水化合物饮食,其中3例患者加用阿卡波糖,6例患者应用糖皮质激素治疗;5例有含巯基药物服用史患者,均停用相应药物,均未再发作低血糖。完成随访9例,失访1例,随访时间为1~12个月,其中8例患者未再出现低血糖症状。结论　IAS为少见的内分泌疾病,尤其在老年人中高发,临床上对高胰岛素血症性低血糖症患者,应常规检测IAA,以避免漏诊、误诊及不必要的手术。