Comparison of balance in older people with and without visual impairment

OBJECTIVE: a cross-sectional study was used to compare the balance ability of older people with and without visual impairment. SETTING: Tung Wah Group of Hospitals Jockey Club Rehabilitation Complex and the Pok Oi Hospital Jockey Club care and attention homes for aged individuals. SUBJECTS: a total of 66 subjects, 65 years of age and older were divided into three groups based on their degree of visual impairment. METHODS: the directional Es chart was used to test the subjects ' visual acuity. Functional balance ability was measured using the Berg balance scale. Demographic characteristics and baseline variables such as lower extremity range of motion, muscle strength, and joint pain was assessed and compared between the groups. RESULTS: 66 older adults (43 women, 23 men) aged 69-94 years of age participated in the study. The one-way ANOVA showed that the mean Berg balance scores were significantly different (F(2,63) = 19.19, P < 0.001). Post hoc tests showed that the group with no visual impairment had higher mean balance scores than the group with mild visual impairment (P = 0.04) and those with moderate visual impairment (P < 0.001). The balance scores for the group with mild visual impairment were also shown to be significantly difference from those of the group with moderate visual impairment (P = 0.003). Control of factors related to balance, such as range of motion, pain and strength, did not affect the analysis of variance analyses. CONCLUSIONS: balance was shown to be more impaired with greater visual impairment, which could result in falls and resultant injury. The findings suggest that early intervention to improve visual acuity in older people may be important.     

The combined effect of visual impairment and cognitive impairment on disability in older people

OBJECTIVES: To determine the risk of disability in individuals with coexisting visual and cognitive impairment and to compare the magnitude of risk associated with visual impairment, cognitive impairment, or the multimorbidity. DESIGN: Prospective cohort. SETTING: North Carolina. PARTICIPANTS: Three thousand eight hundred seventy-eight participants in the North Carolina Established Populations for the Epidemiologic Studies of the Elderly with nonmissing visual status, cognitive status, and disability status data at baseline MEASUREMENTS: Short Portable Mental Status Questionnaire (cognitive impairment defined as > or =4 errors), self reported visual acuity (visual impairment defined as inability to see well enough to recognize a friend across the street or to read newspaper print), demographic and health-related variables, disability status (activities of daily living (ADLs), instrumental activities of daily living (IADLs), mobility), death, and time to nursing home placement. RESULTS: Participants with coexisting visual and cognitive impairment were at greater risk of IADL disability (odds ratio (OR)=6.50, 95% confidence interval (CI)=4.34-9.75), mobility disability (OR=4.04, 95% CI=2.49-6.54), ADL disability (OR=2.84, 95% CI=1.87-4.32), and incident ADL disability (OR=3.66, 95%, CI=2.36-5.65). In each case, the estimated OR associated with the multimorbidity was greater than the estimated OR associated with visual or cognitive impairment alone, a pattern that was not observed for other adverse outcomes assessed. No significant interactions were observed between cognitive impairment and visual impairment as predictors of disability status. CONCLUSION: Individuals with coexisting visual impairment and cognitive impairment are at high risk of disability, with each condition contributing additively to disability risk. Further study is needed to improve functional trajectories in patients with this prevalent multimorbidity. When visual or cognitive impairment is present, efforts to maximize the other function may be beneficial.     

Screening for visual impairment in older people: validation of the Cardiff Acuity Test

Poor visual acuity (VA) is a risk factor for falls, and a common impediment to rehabilitation, but conventional VA testing is difficult in dysphasic, deaf or confused patients. In the Cardiff acuity test (CAT) observation of the subject's eye movements (preferential looking) indicates if they can see a vanishing optotype on a card. The test is quick, and requires no speech or understanding on the part of the subject. We consider its usefulness in frail, elderly patients. Seventy-three patients aged 47-99 (mean 78) years, were tested in good lighting, wearing their usual spectacles. Cards ordered 'A' to 'K' with increasingly faint targets were sequentially presented at 1 m, until the subject's eye movements indicated the target to be invisible. We then performed conventional Snellen acuity chart testing. Twenty-three were retested by a second observer, and 24 subjects were retested by the same observer on another day. We used correlation coefficients to confirm inter-observer (r=0.95, P<0.01), and test-retest (r=0.97, P<0.01) reliability. Snellen chart measurements of VA were possible in all but six subjects. The results of CAT and Snellen acuity tests showed statistically significant correlation (r=0.35, P<0.01). The World Health Organisation (WHO) define significant impairment as a Snellen test acuity below 6/18, and using the 'G' card as a threshold were able to detect this degree of impairment with a sensitivity of 91.7%, and a specificity of 90.9%. The CAT is reliable, and highly acceptable to elderly patients, and may be useful as a screening tool in clinical practice, and for epidemiological purposes.     

Maintenance therapy in multiple myeloma: Two is not always better than one

In multiple myeloma (MM) long-term therapy aims to control disease and delay progression for as long as possible. In this issue Jenner et al. failed to demonstrate a benefit of maintenance with lenalidomide plus vorinostat compared with lenalidomide in both transplant eligible (TE) and ineligible (NTE) patients enrolled in the Myeloma XI trial. Commentary on: Jenner et al. The addition of vorinostat to lenalidomide maintenance for patients with newly diagnosed multiple myeloma of all ages: results from ‘Myeloma XI’, a multicentre, open-label, randomised, phase III trial. Br J Haematol. 2023;201:276-288.     

Moderate alcohol consumption in older adults is associated with better cognition and well-being than abstinence

BACKGROUND: There is evidence of a U-shaped association between alcohol consumption and physical health outcomes in older people, such that moderate drinking is associated with better outcomes than abstinence or heavy drinking, but whether moderate drinking in older people is associated with better cognition and mental health than non-drinking has not been explored. OBJECTIVE: To assess the relationship between drinking and cognitive health in middle-aged and older people. DESIGN: Prospective observational study. SETTING/PARTICIPANTS: Six thousand and five individuals aged 50 and over who participated in Wave 1 of the English Longitudinal Study of Ageing (ELSA) and who were not problem drinkers. Exposure and outcome variables: we examined cognitive function, subjective well-being, and depressive symptoms, and compared the risks associated with having never drunk alcohol, having quit drinking, and drinking at <1, <2 and >2 drinks per day. RESULTS: For both men and women, better cognition and subjective well-being, and fewer depressive symptoms, were associated with moderate levels of alcohol consumption than with never having drunk any. CONCLUSIONS: In middle-aged and older men and women, moderate levels of alcohol consumption are associated with better cognitive health than abstinence.     

Comorbidity is a better predictor of impaired immunity than chronological age in older adults

OBJECTIVES: To determine whether high level of comorbidity, measured using a standardized instrument, can predict impaired immunity in older adults. SETTING: Geriatric outpatient Clinic and Nursing Home Care Unit of Veterans Affairs Greater Los Angeles Healthcare System. PARTICIPANTS: Fifteen men aged 51 to 95 with varying levels of chronic illness. MEASUREMENTS: Disease burden was measured using the Cumulative Illness Rating Scale (CIRS) and immunity using proliferation of T cells induced by phytohemagglutinin (PHA) and production of interleukin (IL)-12, a proinflammatory cytokine that promotes T helper cell-dependent immune response, and IL-10, a cytokine that inhibits T helper cell-dependent immune response, in response to mitogenic stimulation of peripheral blood mononuclear cells. RESULTS: With increasing comorbidity (increase in CIRS score) in older adults, there is a proportional decrease in immune response (decrease in T cell proliferation and IL-12 production and increase in IL-10 production in response to PHA stimulation). Neither immune response nor CIRS score was significantly correlated with chronological age in this sample of older adults with varying degrees of chronic illness. CONCLUSION: This study demonstrates that the level of comorbidity correlates with the magnitude of immune response in older adults and suggests that the CIRS could be used to determine the magnitude of impaired immunity in older adults with different specific illnesses and different levels of severity.     

An interleukin-18 polymorphism is associated with reduced serum concentrations and better physical functioning in older people

BACKGROUND: The proinflammatory cytokine interleukin-18 (IL-18) is associated with major disabling conditions, although whether as byproduct or driver is unclear. The role of common variation in the IL-18 gene on serum concentrations and functioning in old age is unknown. METHODS: We used 1671 participants aged 65-80 years from two studies: the InCHIANTI study and wave 6 of the Iowa-Established Populations for Epidemiological Study of the Elderly (EPESE). We tested three common polymorphisms against IL-18 concentration and measures of functioning. RESULTS: In the InCHIANTI study, a 1 standard deviation increase in serum IL-18 concentrations was associated with an increased chance of being in the 20% of slowest walkers (odds ratio 1.45; 95% confidence interval, 1.17-1.80; p =.0007) and 20% of those with poorest function based on the Short Physical Performance Battery Score (odds ratio 1.52; 95% confidence interval, 1.22-1.89; p =.00016) in age sex adjusted logistic regression models. There was no association with Activities of Daily Living (p =.26) or Mini-Mental State Examination score (p =.66). The C allele of the IL-18 polymorphism rs5744256 reduced serum concentrations of IL-18 by 39 pmol/mL per allele (p =.00001). The rs5744256 single nucleotide polymorphism was also associated with shorter walk times in InCHIANTI (n = 662, p =.016) and Iowa-EPESE (n = 995, p =.026). In pooled ranked models rs5744256 was also associated with higher SPPB scores (n = 1671, p =.019). Instead of adjusting for confounders in the IL-18 walk time association, we used rs5744256 in a Mendelian randomization analysis: The association remained in instrumental variable models (p =.021). CONCLUSION: IL-18 concentrations are associated with physical function in 65- to 80-year-olds. A polymorphism in the IL-18 gene alters IL-18 concentrations and is associated with an improvement in walk speed. IL-18 may play an active role in age-related functional impairment, but these findings need independent replication.     

Predictors of cognitive impairment and dementia in older people with diabetes

Aims/hypothesis Diabetes is associated with an increased risk of dementia but the reasons for this association are unclear because there are many potential mechanisms. We explored the relative contribution of diabetes-related variables as predictors of dementia in older individuals with diabetes. Methods Survivors, aged ≥70 or more, were recruited from an existing observational cohort study 7.6 ± 1.0 years after baseline, when they underwent a comprehensive assessment of diabetes, complications and cardiovascular risk factors. Dementia, probable Alzheimer’s disease and cognitive impairment without dementia were diagnosed clinically. Logistic regression modelling determined independent predictors of cognitive diagnoses. Results Of 302 participants, aged 75.7 ± 4.6 years, 28 (9.3%) had dementia (16 with probable Alzheimer’s disease) and 60 (19.9%) had cognitive impairment without dementia. The major independent longitudinal predictors of dementia were older age (per decade; odds ratio 4.0, 95% CI 1.59–10.10), diabetes duration (for each 5 years; odds ratio 1.69, 95% CI 1.24–2.32), peripheral arterial disease (odds ratio 5.35, 95% CI 2.08–13.72) and exercise (which was protective; odds ratio 0.26, 95% CI 0.09–0.73). For Alzheimer’s disease, diabetes duration was an independent predictor in addition to age and diastolic blood pressure. The results of the cross-sectional analyses were similar with respect to diabetes duration and peripheral arterial disease. Conclusions/interpretation Peripheral arterial disease is a strong independent risk factor for dementia in diabetes. After adjustment for a wide range of potential risk factors, diabetes duration remains independently associated with dementia and probable Alzheimer’s disease, indicating that factors not measured in this study may be important in the pathogenesis of dementia in diabetes.     

The symbol of modern medicine: why one snake is more than two

Today, two serpent motifs are commonly used to symbolize the practice and profession of medicine. Internationally, the most popular symbol of medicine is the single serpent-entwined staff of Asklepios (Latin, Aesculapius), the ancient Greco-Roman god of medicine. However, in the United States, the staff of Asklepios (the Asklepian) and a double serpent-entwined staff with surmounting wings (the caduceus) are both popular medical symbols. The latter symbol is often designated as the "medical caduceus" and is equated with the ancient caduceus, the double serpent-entwined staff of the Greco-Roman god Hermes (Latin, Mercury). Many physicians would be surprised to learn that the medical caduceus has a quite modern origin: Its design is derived not from the ancient caduceus of Hermes but from the printer's mark of a popular 19th-century medical publisher. Furthermore, this modern caduceus became a popular medical symbol only after its adoption by the U.S. Army Medical Corps at the beginning of the 20th century. This paper describes the ancient origin of the Asklepian and how a misunderstanding of ancient mythology and iconography seems to have led to the inappropriate popularization of the modern caduceus as a medical symbol.     

The activities of daily vision scale: a useful tool to assess fall risk in older adults with vision impairment

OBJECTIVE: To evaluate the validity of the Activities of Daily Vision Scale (ADVS) as a tool to assess fall risk in older adults with vision impairment. DESIGN: Cross-sectional assessments of visual function and retrospective collection of fall data. SETTING: The outpatient medical clinics of an academic tertiary care community hospital. PARTICIPANTS: Randomly selected sample (n = 143) of older (> or = 65 years) patients seen at the outpatient medical clinics at Nassau County Medical Center in Long Island, New York. These patients had one or more of five ocular conditions: refractive errors (n = 90), cataracts (n = 77), glaucoma (n = 29), diabetic retinopathy (n = 19), and/or macular degeneration (n = 6). MEASUREMENTS: Visual function, assessed using the ADVS, demonstrated scores ranging from 0 (marked visual disability) to 100 (no visual difficulty). Fall history and the presence of eye disease were based on the self-recall of patients. Fall history was assessed retrospectively over a 1-year period from the time of the interview. RESULTS: Thirteen percent of the subjects reported having one or more falls during the 1-year period before the time of the interview. These subjects scored significantly lower on the ADVS compared with the scores of the group that did not report falls (74 +/- 22 vs 85 +/- 14, P < .01). Using a cutoff score of 90 points (10% loss of visual function on the ADVS), the ADVS had a 67% sensitivity in identifying those patients who had falls. Among the patients with glaucoma and those with diabetic retinopathy, the ADVS had a 100% sensitivity in identifying those patients who reported a history of falls. In patients with cataracts and refractive errors, the ADVS had a sensitivity of 82% and 64%, respectively, in identifying patients with a history of falls. The number of falls reported by the subjects showed no relationship with the ADVS scores. CONCLUSION: The results from this study suggest that the ADVS may prove to be a useful tool to assess fall risk in older adults with vision impairment, especially in those persons with glaucoma, diabetic retinopathy, and/or cataracts.