Benzodiazepine use and physical disability in community-dwelling older adults

OBJECTIVES: To determine whether benzodiazepine use is associated with incident disability in mobility and activities of daily living (ADLs) in older individuals. DESIGN: A prospective cohort study. SETTING: Four sites of the Established Populations for Epidemiologic Studies of the Elderly. PARTICIPANTS: This study included 9,093 subjects (aged > or =65) who were not disabled in mobility or ADLs at baseline. MEASUREMENTS: Mobility disability was defined as inability to walk half a mile or climb one flight of stairs. ADL disability was defined as inability to perform one or more basic ADLs (bathing, eating, dressing, transferring from a bed to a chair, using the toilet, or walking across a small room). Trained interviewers assessed outcomes annually. RESULTS: At baseline, 5.5% of subjects reported benzodiazepine use. In multivariable models, benzodiazepine users were 1.23 times as likely as nonusers (95% confidence interval (CI) = 1.09-1.39) to develop mobility disability and 1.28 times as likely (95% CI = 1.09-1.52) to develop ADL disability. Risk for incident mobility was increased with short- (hazard ratio (HR) = 1.27, 95% CI = 1.08-1.50) and long-acting benzodiazepines (HR = 1.20, 95% CI = 1.03-1.39) and no use. Risk for ADL disability was greater with short- (HR = 1.58, 95% CI = 1.25-2.01) but not long-acting (HR = 1.11, 95% CI = 0.89-1.39) agents than for no use. CONCLUSION: Older adults taking benzodiazepines have a greater risk for incident mobility and ADL disability. Use of short-acting agents does not appear to confer any safety benefits over long-acting agents.     

Change in muscle strength explains accelerated decline of physical function in older women with high interleukin-6 serum levels

OBJECTIVES: To test whether accelerated sarcopenia in older persons with high interleukin (IL)-6 serum levels plays a role in the prospective association between inflammation and disability found in many studies. DESIGN: Cohort study of older women with moderate to severe disability. PARTICIPANTS: Six hundred twenty older women from the Women's Health and Aging Study in whom information on baseline IL-6 serum level was available. MEASUREMENTS: Self-report of functional status, objective measures of walking performance, and knee extensor strength were assessed at baseline and over six semiannual follow-up visits. Potential confounders were baseline age, race, body mass index, smoking, depression, and medical conditions. RESULTS: At baseline, women with high IL-6 were more often disabled and had lower walking speed. After adjusting for confounders, women in the highest IL-6 tertile (IL-6>3.10 pg/mL) were at higher risk of developing incident mobility disability (risk ratio (RR) = 1.50, 95% confidence interval (CI) = 1.01-2.27), disability in activities of daily living (RR = 1.41, 95% CI = 1.01-1.98), and severe limitation in walking (RR = 1.61, 95% CI = 1.09-2.38) and experienced steeper declines in walking speed (P <.001) than women in the lowest IL-6 tertile (IL-6 < or =1.78 pg/mL). Decline in knee extensor strength was also steeper, but differences across IL-6 tertiles were not significant. After adjusting for change over time in knee extensor strength, the association between high IL-6 and accelerated decline of physical function was no longer statistically significant. CONCLUSIONS: Older women with high IL-6 serum levels have a higher risk of developing physical disability and experience a steeper decline in walking ability than those with lower levels, which are partially explained by a parallel decline in muscle strength.     

Hospitalization and development of dependence in activities of daily living in a cohort of disabled older women: the Women's Health and Aging Study I

BACKGROUND: Changes in self-reported function in older adults are known to occur in the 2 weeks prior to, during, and in the first few months after hospitalization. The long-term outcome of hospitalization on functional status in disabled older adults is not known. The objective of this study was to determine whether hospitalization predicts long-term Activities of Daily Living (ADL) dependence in previously ADL independent, although disabled, older women. METHODS: The Women's Health and Aging Study I is a population-based, prospective cohort study of disabled, community-dwelling women > or =65 years old. We evaluated participants who were independent in ADLs at baseline and excluded women with incident stroke, lower extremity joint surgery, amputation, or hip fracture. We examined the association between self-reported incident hospitalization at three consecutive 6-month intervals and incident dependence in at least one ADL at 18 months (n = 595). RESULTS: Of 595 women evaluated, 32% had at least one hospitalization. Women who were hospitalized were more likely to become dependent in ADLs than were women who were not hospitalized (17% vs 8%, p =.001). In a multivariate model, hospitalization was independently predictive of development of ADL dependence that persisted at 18 months after baseline (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.7-5.8), adjusting for age, race, education, baseline walking speed, difficulty with ADLs, self-reported health status, depressive symptoms, cognitive status, and presence of congestive heart failure, diabetes, or pulmonary disease. Increasing numbers of 6-month intervals with hospitalizations were independently predictive of higher risk in an adjusted model: one (OR, 2.3; 95% CI, 1.1-4.6), two (OR, 5.8; 95% CI, 2.4-14.4), and three (OR, 12.5; 95% CI, 2.7-57.6). CONCLUSIONS: These results suggest that hospitalization has an independent and dose-response effect on loss of ADL independence in disabled older women over an 18-month period.     

Coimpairments as predictors of severe walking disability in older women

OBJECTIVE: Severe disabilities are common among older people who have impairments in a range of physiologic systems. It is not known, however, whether the presence of multiple impairments, or coimpairments, is associated with increased risk of developing new disability. The aim of this study was to determine the combined effects of two impairments, decreased knee-extension strength and poor standing balance, on the risk of developing severe walking disability among older, moderately-to-severely disabled women who did not have severe walking disability at baseline. DESIGN: The Women's Health and Aging Study is a 3-year prospective study with 6 semi-annual follow-up data-collection rounds following the baseline. SETTING: At baseline, knee-extension strength and standing balance tests took place in the participants' homes. PARTICIPANTS: 758 women who were not severely walking disabled at baseline. MEASUREMENTS: Severe walking disability was defined as customary walking speed of < 0.4 meters/second and inability to walk one quarter of a mile, or being unable to walk. RESULTS: Over the course of the study, 173 women became severely disabled in walking. The cumulative incidence of severe walking disability from the first to the sixth follow-up was: 7.8%, 12.0%, 15.1% 19.5% 21.2%, and 22.8%. In Cox proportional hazards models, both strength and balance were significant predictors of new walking disability. In the best balance category, the rates of developing severe walking disability expressed per 100 person years were 3.1, 6.1, and 5.3 in the highest- to lowest-strength tertiles. In the middle balance category, the rates were 9.6, 13.2, and 14.7, and in the poorest balance category 21.6, 12.7, and 37.1, correspondingly. The relative risk (RR) of onset of severe walking disability adjusted for age, height, weight, and race was more than five times greater in the group with poorest balance and strength (RR 5.12, 95% confidence limit [95% CI] 2.68-9.80) compared with the group with best balance and strength (the reference group). Among those who had poorest balance and best strength, the RR of severe walking disability was 3.08 (95% CI 1.33-7.14). Among those with best balance and poorest strength, the RR was 0.97 (95% CI 0.49-1.93), as compared with the reference group. CONCLUSION: The presence of coimpairments is a powerful predictor of new, severe walking disability, an underlying cause of dependence in older people. Substantial reduction in the risk of walking disability could be achieved even if interventions were successful in correcting only one of the impairments because a deficit in only one physiologic system may be compensated for by good capacity in another system.     

Physical activity is associated with incident disability in community-based older persons

OBJECTIVES: To examine the association between physical activity and the risk of incident disability, including impairment in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), in community-based older persons free of dementia. DESIGN: Prospective, observational cohort study. SETTING: Approximately 40 retirement communities across the Chicago metropolitan area. PARTICIPANTS: More than 1,000 older persons from the Rush Memory and Aging Project, an ongoing longitudinal clinical-pathological study of common chronic conditions of old age. MEASUREMENTS: All participants underwent detailed annual clinical evaluations that included assessments of physical activity, ADLs, IADLs, and gait performance. The associations between physical activity, mortality, and incident disability were examined using a series of Cox proportional hazards models controlled for age, sex, education, and baseline gait. RESULTS: At baseline, participants spent a mean+/-standard deviation of 3.0+/-3.5 hours per week engaging in physical activity (range 0-35). In a proportional hazards model, the risk of death decreased 11% (hazard ratio (HR)=0.89, 95% confidence interval (CI)=0.83-0.95) for each additional hour of physical activity per week. For those who were not disabled at baseline, the risk of developing disability in ADLs decreased 7% (HR=0.93, 95% CI=0.88-0.98) for each additional hour of physical activity per week. Similarly, the risk of disability in IADLs decreased 7% (HR=0.93, 95% CI=0.89-0.99) for each additional hour of physical activity. CONCLUSION: For community-based older persons without dementia, physical activity is associated with maintenance of functional status, including a reduced risk of developing impairment in ADLs and IADLs.     

Walking difficulty, walking speed, and age as predictors of self-rated health: the women's health and aging study

BACKGROUND: Older persons reporting disability are more likely to report poor self-rated health, but little work has been done to assess the independent relationships of reported walking difficulty and measured walking performance with self-rated health. This study examines the associations of walking difficulty, walking speed, and age with self-rated health in older women. METHODS: The data are from the baseline of the Women's Health and Aging Study. Difficulty walking one quarter mile was used as a measure of mobility in the representative population aged 65 and older screened for the study (n = 3841) and in the one third most disabled study group (n = 1002). Maximal walking speed was measured in the study sample. RESULTS: Increasing severity of walking difficulty (in the screened population and in the disabled study group), slower walking speed (in the study group), and younger age were all associated with fair or poor self-rated health, after simultaneous adjustment for these and other objective measures of physical performance and health. The associations of both measures of walking with self-rated health weakened with age. CONCLUSIONS: Both walking difficulty and walking speed are independent determinants of self-rated health. Adjusted for health and functioning, self-rated health tends to improve with age.     

Preclinical mobility disability predicts incident mobility disability in older women

BACKGROUND: Physical disability and dependency are serious, and frequent, adverse health outcomes associated with aging and resulting from chronic disease. Reasoning has suggested that there might be a preclinical, intermediate phase of disablement which might develop in parallel with progression of underlying disease and precede and predict disability. Definition of this stage could provide a basis for screening and early intervention to prevent disability. The objective of this study was to determine preclinical functional predictors of incident mobility difficulty and provide evidence for a preclinical stage of disability. METHODS: A prospective, population-based cohort study was carried out in Baltimore, Maryland, with two evaluations 18 months apart. The participants were 436 community-dwelling women, 70-80 years of age at baseline, not cognitively impaired, and reporting difficulty in no areas, or only one area, of physical function (primarily mobility), who were participating in the Women's Health and Aging Study II. Participants were recruited from a population-based, age-stratified random sample. Incident mobility disability was studied in the subset without such disability at baseline. The main outcome measure was self-reported incident difficulty walking 1/2 mile or climbing up 10 steps. RESULTS: At baseline, 69.3% of the cohort reported no difficulty with mobility. After 18 months, 16.0 and 11.7% of this group reported incident difficulty walking 1/2 mile or climbing up 10 steps, respectively. Those reporting baseline task modification due to underlying health problems, our measure of preclinical disability, were at three- to fourfold higher odds of progressing to difficulty than were those without such modification. In multivariate logistic regression analyses, this self-report measure, task modification without difficulty, and objective measures of performance were independently and jointly predictive of incident mobility difficulty. Specifically, for incident difficulty walking 1/2 mile, self-reported task modification odds ratio (OR) = 3.67, walking speed (.5 m/s difference) OR = 2.16; for incident difficulty climbing up 10 stairs, OR for task modification = 3.84, for stair climb speed (1/3 step/s difference) = 2.08 (95% CI did not include 1 for any). Covariates, age, living alone, number of chronic diseases, depression score, knee strength, and balance by functional reach, were not significant predictors in either model. CONCLUSIONS: Two indicators of functional changes in older women without mobility difficulty, self-report of modification of method of doing a task in the absence of difficulty and performance measures, are independent and strong predictors of risk of incident mobility disability. The self-report measure provides substantial strength in predicting risk of incident disability across the full range of performance, and may identify a vulnerable point at which other risk factors act to cause transitions to disability. Together, the preclinical indicators identify a subset of high-functioning older women who are at high risk of mobility disability, and provide a potential basis for screening for disability risk and targeting interventions to prevent mobility disability.     

Persistent mobility deficit in the absence of deficits in activities of daily living: a risk factor for mortality

OBJECTIVES: To investigate the extent to which self-reported mobility deficit in the absence of impairment in activities of daily living (ADL) is associated with elevated mortality risk. DESIGN: Prospective cohort study, with annual assessments of mobility and ADL status and ongoing monitoring of vital status. SETTING: Population-based cohort drawn from Medicare enrollees in New York City. PARTICIPANTS: One thousand two hundred ninety-eight older adults reporting functional status at baseline (1992-1994) and 2 years later. MEASUREMENTS: Subjects reported mobility (e.g., walking, climbing stairs, and rising from a chair) and ADL (e.g., bathing, toilet use, dressing, grooming, and feeding) limitations. Two-year functional status trajectories were noted. We used two additional follow-up periods, at 2 and 4 years, to examine the likelihood that older people with mobility deficit may face an increased risk of death without first passing through a state of enduring ADL disability. RESULTS: At 2 years, 12.7% had incident mobility deficit without ADL disability, and 21.3% were persistently disabled in mobility without ADL disability. Relative to subjects free of disability at baseline and follow-up, risk of mortality in the incident mobility deficit group was elevated at 2 and 4 years but did not achieve statistical significance. By contrast, for subjects with persistent mobility impairment who did not report ADL impairment, the mortality risk was significantly elevated both at 2 years (relative risk (RR) = 2.5; 95% confidence interval (CI) = 1.1-5.7)) and 4 years (RR = 2.9; 95% CI = 1.7-4.9)) of follow-up. Mortality was significantly elevated in this group in analyses restricted to respondents with no or only one comorbid condition. CONCLUSION: Continuing, self-reported mobility impairment in the absence of ADL deficit is a risk factor for mortality. Older people with self-reported mobility deficit face an increased risk of mortality without first passing through enduring states of ADL disability.     

The ankle brachial index and change in lower extremity functioning over time: the Women's Health and Aging Study

OBJECTIVES: To define the association between baseline ankle brachial index (ABI) level and subsequent onset of severe disability. DESIGN: Prospective cohort study. SETTING: Baltimore community. PARTICIPANTS: Eight hundred forty-seven disabled women aged 65 and older participating in the Women's Health and Aging Study. MEASUREMENTS: At baseline, participants underwent measurement of ABI and lower extremity functioning. Measures of lower extremity functioning included patient's report of their ability to walk one-quarter of a mile, number of city blocks walked last week, number of stair flights climbed last week, and performance-based measures including walking speed over 4 meters, five repeated chair stands, and a summary performance score. Functioning was remeasured every 6 months for 3 years. Definitions of severe disability were developed a priori, and participants who met these definitions at baseline were excluded from subsequent analyses. RESULTS: Participants with an ABI of less than 0.60 at baseline had significantly higher cumulative probabilities of developing severe disability than participants with a baseline ABI of 0.90 to 1.50 for walking-specific outcomes (ability to walk a quarter of a mile, number of city blocks walked last week, and walking velocity) but not for the remaining functional outcomes. In age-adjusted Cox proportional hazards analyses, hazard ratios for participants with a baseline ABI of less than 0.60 were 1.63 for becoming unable to walk a quarter of a mile (P = .044), 2.00 for developing severe disability in the number of blocks walked last week (P = .004), and 1.61 for developing severe disability in walking speed (P = .041), compared with participants with a baseline ABI of 0.90 to 1.50. Adjusting for age, race, baseline performance, and comorbidities, an ABI of less than 0.60 remained associated with becoming severely disabled in the number of blocks walked last week (hazard ratio = 1.97, P = .009) and nearly significantly associated with becoming unable to walk a quarter of a mile (hazard ratio = 1.54, P = .09). In fully adjusted random effects models, a baseline ABI of less than 0.60 was associated with significantly greater decline in walking speed per year (P = .019) and nearly significantly greater decline in number of blocks walked last week per year (P = .053) compared with a baseline ABI of 0.90 to 1.50. CONCLUSION: In community-dwelling disabled older women, a low ABI is associated with a greater incidence of severe disability in walking-specific but not other lower extremity functional outcomes, compared with persons with a normal ABI over 3 years.     

Low back pain and disability in older women: independent association with difficulty but not inability to perform daily activities

BACKGROUND: Low back pain is a highly prevalent chronic condition, yet little is known about the disabling effects of this common problem in older adults. This study examines the relationship between the presence and severity of low back pain and disability in older women. METHODS: The study population was 1,002 disabled older women participating in a population-based prospective study of disablement. Key outcome measures of disability included level of difficulty and inability to perform the following daily activities: light housework, shopping, walking one-quarter mile, climbing stairs, lifting, and activities of daily living (ADLs). RESULTS: Forty-two percent of participants reported they had low back pain for at least one month in the year before baseline. The prevalence of severe back pain decreased markedly with age (10% of those > or = 85 yr versus 23% in each of the two younger 10 yr age groups). After multivariate adjustments, women with severe back pain were 3 to 4 times more likely than other women to have a lot of difficulty with light housework or shopping. There was also an increased likelihood of difficulty with mobility tasks and basic ADLs among those with severe back pain. No associations were found between back pain and being unable to perform any of the daily activities studied, indicating possible differences in disablement processes leading to functional difficulties versus functional incapacity. CONCLUSIONS: There was a strong association between back pain and functional difficulties in older women, pointing to the need for further research using longitudinal methods.     

Physical activity and fracture risk in a free-living elderly cohort

A prospective study to determine if regular leisure-time physical activity (including recreational walking) is associated with fracture risk was conducted in a large cohort (N = 3110) of free-living elderly men and women in the retirement community of Dunedin, Florida. Sixty-three percent of the cohort was female, all were white, and the average age was 73.0 years +/- 5.3 (SD). Participants in regular physical activity at baseline had a reduced risk of fracture; the risk ratio (RR) of fracture for men and women, respectively, was RR = 0.41, 95% CI = 0.17 to 1.01 and RR = 0.76, 95% CI = 0.50 to 1.15. Walking at least one mile 3 times/week appeared to offer a protective effect for both sexes. After controlling for potentially confounding variables including body mass and selected health conditions, the RR for regular physical activity on fracture incidence in men and women remained essentially unchanged. We conclude that regular physical activity such as walking may protect against fracture in older persons.     

Coimpairments: strength and balance as predictors of severe walking disability

BACKGROUND: Little information is available on the joint effects of multiple impairments (coimpairments) on the risk of disability. Our aim was to study the joint effects of strength and balance impairments on severe walking disability. METHODS: The data are from the baseline of the Women's Health and Aging Study (WHAS), a study of moderately to severely disabled women. A total of 1,002 women aged 65 and older participated in the tests, which took place in their homes. Severe walking disability was defined as self-reported inability to walk one-quarter mile and customary walking speed in a 4-meter test of < or =0.4 m/s. Balance was measured as an ability to hold progressively more difficult stands (feet side-by-side, semitandem and tandem stands). Maximal knee extension strength was measured using a hand-held dynamometer. RESULTS: There were 129 women who were severely walking disabled but able to walk at least minimally. In logistic regression analysis, balance and knee extension strength were independent predictors of severe walking disability. To study the combined effects, nine groups were formed on the basis of strength tertiles by balance categories in the entire population. In the best balance category, the crude prevalences of severe walking disability were 1.2%, 4.9%, and 14.3% in the highest to lowest strength tertiles. In the middle balance category, the rates were 2.9%, 10.0%, and 45.4.1%, and in the poorest balance category 4.9%, 22.1%, and 42.6%, correspondingly. The age, body weight, and height-adjusted odds ratios (OR) showed that the risk of severe walking disability in the subgroup with best balance and strength was less than 5% of the risk in the subgroup with poorest balance and strength (OR .034, 95% confidence interval [CI] .007-.166). Correspondingly, in the subgroups with poorest strength and best balance (OR .097, 95% CI .025-.38) or poorest balance and best strength (OR .102, 95% CI .012-.866) the risk was about 10%. The age-specific estimates of prevalence of severe walking disability in women were: 2.0% for ages 65-74 years, 3.4% for ages 75-84 years, and 9.1% for ages 85 years and older. CONCLUSIONS: The burden of coimpairments seems to be greater than the sum of single impairments involved. An effective way to reduce severe disabilities could be prevention of coimpairments.     

Physical activity, disability, and the risk of hospitalization for breast cancer among older women

BACKGROUND: A recent investigation of physical activity, disability, and the risk of breast cancer among older women in the Iowa 65 + Rural Health Study reported a decreased risk of breast cancer among women with any disability compared with physically capable but inactive women (relative risk [RR] = 0.4. 95% confidence interval [CI] 0.2-0.9). Because of the intriguing nature of that association, those investigators urged replication before drawing any conclusions. METHODS: We replicated the Iowa approach using the Longitudinal Study on Aging (LSOA). a nationally representative, prospective cohort study. The 3131 community-dwelling women for whom we had complete data for these analyses ranged in age from 70 to 98 years old at baseline in 1984. Using ICD9-CM 174 codes, linked Medicare hospital claims identified 77 women with hospitalizations for breast cancer between 1984 and 1991. Multivariable proportional hazards regression was used to model the risk for this event among disabled, inactive, moderately active, and highly active women. RESULTS: No significant association between disability in older women and the risk of hospitalization for breast cancer relative to inactive older women was detected (adjusted hazard ratio [AHR]-0.78, 95% CI 0.41-1.5). Highly active older women had a significantly reduced risk of hospitalization for breast cancer (AHR-0.42, 95% CI 0.194).95). CONCLUSION: The intriguing finding from the Iowa 65+ Rural Health Study that disabled older women's risk for breast cancer was reduced could not be replicated in the LSOA, although power was limited. Highly active older women, however, had a significantly lower risk for breast cancer in both studies.     

The influence of anxiety on the progression of disability

OBJECTIVES: To determine the influence of anxiety on the progression of disability and examine possible mediators of the relationship. DESIGN: Community-based observational study. SETTING: Women's Health and Aging Study I, a prospective observational study with assessments every 6 months for 3 years. PARTICIPANTS: One thousand two functionally limited women aged 65 and older. MEASUREMENTS: Anxiety symptoms were assessed using four questions from the Hopkins Symptom Checklist (nervous or shaky, avoidance of certain things, tense or keyed up, fearful). Participants who reported experiencing two or more of these symptoms at baseline were considered anxious. Anxiety as a predictor of the onset of four types of disability was examined using Cox proportional hazards models. Three models were tested: an unadjusted model, a model adjusted for confounding variables (age, race, vision, number of diseases, physical performance, depressive symptoms), and a mediational model (benzodiazepine and psychotropic medication use, physical activity, emotional support). RESULTS: Nineteen percent of women reported two or more symptoms of anxiety at baseline. Unadjusted models indicate that anxiety was associated with a greater risk of worsening disability: activity of daily living (ADL) disability (relative risk (RR)=1.40, 95% confidence interval (CI)=1.10-1.79), mobility disability (RR=1.41, 95% CI=1.06-1.86), lifting disability (RR=1.54, 95% CI=1.20-1.97), and light housework disability (RR=1.77, 95% CI=1.32-2.37). After adjusting for confounding variables, anxiety continued to predict the development of two types of disability: ADL disability (RR=1.41, 95% CI=1.08-1.84) and light housework disability (RR=1.56, 95% CI=1.14-2.14). Finally, benzodiazepine and psychotropic medication use, physical activity, and emotional support were not significant mediators of the effect of anxiety on the development of a disability. CONCLUSION: Anxiety is a significant risk factor for the progression of disability in older women. Studies are needed to determine whether treatment of anxiety delays or prevents disability.     

At the tipping point: predicting severe mobility difficulty in vulnerable older women

OBJECTIVES: To identify clinical measures that aid detection of impending severe mobility difficulty in older women. DESIGN: Cross‐sectional and longitudinal cohort study. SETTING: Urban community in Baltimore, Maryland. PARTICIPANTS: One thousand two community‐dwelling, moderate to severely disabled women aged 65 and older in the Women's Health and Aging Study I. MEASUREMENTS: Self‐report and performance measures representing six domains necessary for mobility: central and peripheral nervous systems, muscles, bones and joints, perception, and energy. Severe mobility difficulty was defined as usual gait of 0.5 m/s or less, any reported difficulty walking across a small room, or dependence on a walking aid during a 4‐m walking test. RESULTS: Four hundred sixty‐seven out of 984 (47%) had severe mobility difficulty at baseline, and 104/474 (22%) developed it within 12 months. Baseline mobility difficulty was correlated with poor vision, knee pain, feelings of helplessness, inability to stand with feet side by side for 10 seconds, difficulty keeping balance while dressing or walking, inability to rise from a chair five times, and cognitive impairment. Of these, knee pain (odds ratio (OR)=1.74, 95% confidence interval (CI)=1.05–2.89), helplessness (OR=1.87, 95% CI=1.10–3.24), poor vision (OR=2.03, 95% CI=1.06–3.89), inability to rise from a chair five times (OR=2.50, 95% CI=1.15–5.41), and cognitive impairment (OR=4.75, 95% CI=1.67–13.48) predicted incident severe mobility difficulty within 12 months, independent of age. CONCLUSION: Five simple measures may aid identification of disabled older women at high risk of severe mobility difficulty. Further studies should determine generalizability to men and higher‐functioning individuals.     

Inflammatory markers and incident mobility limitation in the elderly

OBJECTIVES: To examine the relationship between indicators of inflammation and the incidence of mobility limitation in older persons. DESIGN: Prospective cohort study: the Health, Aging and Body Composition Study. SETTING: Pittsburgh, Pennsylvania, and Memphis, Tennessee. PARTICIPANTS: A total of 2,979 men and women, aged 70 to 79, without mobility limitation at baseline. MEASUREMENTS: Serum levels of interleukin (IL)-6, tumor necrosis factor alpha (TNFalpha), and C-reactive protein (CRP) and soluble cytokine receptors (IL-2sR, IL-6sR, TNFsR1, TNFsR2) were measured. Mobility limitation was assessed and defined as reporting difficulty or inability to walk one-quarter of a mile or to climb 10 steps during two consecutive semiannual assessments over 30 months. RESULTS: Of the 2,979 participants, 30.1% developed incident mobility limitation. After adjustment for confounders (demographics, prevalent conditions at baseline, body composition), the relative risk (RR) of incident mobility limitation per standard deviation (SD) increase was 1.19 (95% confidence interval (CI)=1.10-1.28) for IL-6, 1.20 (95% CI=1.12-1.29) for TNFalpha, and 1.40 (95% CI=1.18-1.68) for CRP. The association between inflammation and incident mobility limitation was especially strong for the onset of more severe mobility limitation and when the levels of multiple inflammatory markers were high. When persons with baseline or incident cardiovascular disease events or persons who were hospitalized during study follow-up were excluded, findings remained similar. In a subset (n=499), high levels of the soluble receptors IL2sR and TNFsR1 (per SD increase: RR=1.23 (95% CI=1.04-1.46) and RR=1.28 (95% CI=1.04-1.57), respectively) were also associated with incident mobility limitation. CONCLUSION: Findings suggest that inflammation is prognostic for incident mobility limitation over 30 months, independent of cardiovascular disease events and incident severe illness.     

Nutritional parameters, body composition, and progression of disability in older disabled residents living in nursing homes

BACKGROUND: The evaluation of nutritional status is one of the primary components of multidimensional geriatric assessment. We investigated the relationship between some markers of malnutrition and the modifications in functional status in a sample of older disabled residents living in nursing homes. METHODS: Ninety-eight subjects who were independent in at least two activities of daily living (ADLs) were enrolled in a 2-year longitudinal study. Anthropometric, nutritional, and metabolic parameters, as well as body composition, were measured at baseline and after 2 years. RESULTS: Deteriorating functional status (> or =2 additional lost ADLs) was associated with baseline albumin levels (Tertile 3 vs Tertile 1; odds ratio [OR] 0.16, 95% confidence interval [CI] 0.04-0.67) and subscapular skinfold thickness (Tertile 3 vs. Tertile 1; OR 0.06, 95% CI 0.006-0.50). After multivariate adjustment, the OR for increasing disability was >4 in subjects with decreasing body cell mass (BCM), compared with subjects with a stable BCM. The degree of BCM reduction was strongly related to the number of additional ADLs lost at follow-up (test for trend, p = .003). CONCLUSIONS: In a sample of older disabled nursing home residents, signs of malnutrition seem to predict further worsening in functional status. Furthermore, BCM declines proportionally to the loss in ADLs, suggesting the existence of a strong relationship between BCM loss and the progressive deterioration of functional status.     

Development of a Frailty Index for Patients with Coronary Artery Disease

OBJECTIVES: To construct a brief frailty index for older patients with coronary artery disease (CAD) undergoing coronary angiography that includes physical, cognitive, and psychosocial criteria and accurately predicts future disability and decline in health‐related quality of life (HRQL). DESIGN: Prospective cohort. SETTING: An urban tertiary care hospital in Alberta, Canada. PARTICIPANTS: Three hundred seventy‐four patients aged 60 and older (73% male) undergoing cardiac catheterization for CAD between October 2003 and May 2007. MEASUREMENTS: Potential frailty criteria examined at baseline (before the procedure) included measures of balance, gait speed, cognition, self‐reported health, body mass index (BMI), depressive symptoms, and living alone. The outcomes assessed over 1 year were dependency in activities of daily living (ADLs) and HRQL. RESULTS: The five best‐fitting criteria from regression analyses for ADL decline were poor balance (risk ratio (RR)=2.4, 95% confidence interval (CI)=1.4–4.0), abnormal BMI (RR=1.8, 95% CI=1.1–3.0), impaired Trail‐Making Test Part B performance (RR=2.3, 95% CI=1.3–4.2), depressive symptoms (RR=1.8, 95% CI=1.1–3.1), and living alone (RR=2.2, 95% CI=1.3–3.8). Using the five criteria as separate variables or as a summary frailty index yielded identical areas under the receiver operating characteristic curve (0.76, 95% CI=0.66–0.84). Patients with three or more criteria (vs none) were at statistically significant greater risk for increased disability (RR=10.4, 95% CI=4.4–24.2) and decreased HRQL (RR=4.2, 95% CI=2.3–7.4) after 1 year. CONCLUSION: This brief frailty index including physical, cognitive, and psychosocial criteria was predictive of increased disability and decreased HRQL at 1 year in older patients with CAD undergoing angiography. This index may have applications for clinicians and researchers but requires further validation.     

Low serum carotenoids and development of severe walking disability among older women living in the community: the women's health and aging study I

OBJECTIVE: to determine whether low serum carotenoid levels, an indicator of low intake of fruits and vegetables, are associated with the progression of disability in older women. DESIGN: longitudinal analysis in a population-based cohort. SETTING: moderately-severely disabled women, >or=65 years, living in the community in Baltimore, Maryland (the Women's Health and Aging Study I). PARTICIPANTS: 554 women without severe walking disability (inability to walk or walking speed <0.4 m/s) at baseline. MAIN OUTCOME MEASURE: incidence of severe walking disability assessed every 6 months over 3 years. RESULTS: 155 women (27.9%) developed severe walking disability during follow-up. Rates of development of severe walking disability per 100 person-years among women in the lowest and in the three upper quartiles of total carotenoids were, respectively, 13.8 versus 10.9 (P=0.0017). Adjusting for confounders, women in the lowest quartile of total carotenoids were more likely to develop severe walking disability (hazards ratio 1.57, 95% confidence interval 1.24-2.00, P=0.0002) compared with women in the three upper quartiles. CONCLUSION: low serum carotenoid levels, an indicator of low intake of fruits and vegetables, are independent predictors of the progression towards severe walking disability among older women living in the community.     

Perinatal factors and adult-onset lupus

OBJECTIVE: Some evidence suggests that perinatal factors, including birth weight and breastfeeding, may influence the occurrence of autoimmune rheumatic diseases. However, few studies have investigated these factors in patients with systemic lupus erythematosus (SLE). Therefore, we evaluated the role of birth weight, being breastfed, and preterm birth on the incidence of SLE in participants in the Nurses' Health Study (NHS) and the Nurses' Health Study II (NHSII). METHODS: We studied 87,411 NHS participants and 98,413 NHSII participants without SLE at baseline who provided information on perinatal exposures. Among these women, during 26 (NHS) and 14 (NHSII) years of followup, 222 incident SLE cases were confirmed (136 NHS and 86 NHSII) by medical record review using American College of Rheumatology criteria. We used stratified Cox models to estimate the association of perinatal factors with SLE, adjusting for race, early passive cigarette smoke exposure, and parents' occupation. A random-effects meta-analysis was used to compute combined estimates across the 2 cohorts. RESULTS: After adjustment for multiple potential confounders, high birth weight (> or =10 pounds) was associated with increased rates of SLE compared with normal birth weight (7-8.5 pounds; rate ratio [RR] 2.7, 95% confidence interval [95% CI] 1.2-5.9), as was being born > or =2 weeks preterm (RR 1.9, 95% CI 1.2-3.0); however, being breastfed was not (RR 0.8, 95% CI 0.6-1.1). CONCLUSION: Birth weight > or =10 pounds and preterm birth were both positively associated with incident SLE among women.