The hierarchy of functional loss associated with cognitive decline in older persons

OBJECTIVES: We studied a representative cohort of community-dwelling elderly persons to (i) examine the relationship between the loss of specific functional activities and cognitive status at the time of these losses, (ii) compare the cognitive status of participants who have and have not lost independence in these functional activities, and (iii) determine whether a hierarchical scale of functional loss is associated with declining cognitive status. METHODS: A cohort of 5874 community-dwelling persons aged 65 years and older from the Canadian Study of Health and Aging I and II were analyzed. At baseline and 5 years later, cognitive status with the Modified Mini-Mental State Examination (3MS) and functional status with 14 Older American Resources and Services (OARS) items were measured. For each OARS functional item, the mean 3MS scores for persons who lost independence during the 5-year period versus those who did not were compared. RESULTS: For each functional item, the 5-year decline in 3MS scores of persons who lost independence were significantly greater than those who remained independent (e.g., ability to do finances), with an 18-point decline for those who lost independence and a 2-point decline for those who retained independence. A hierarchy of functional items existed, with instrumental activities of daily living (ADLs) (e.g., shopping, banking, and cooking) being lost at higher cognitive scores than basic ADL items (e.g., eating, dressing, and walking), although there was some overlap. CONCLUSIONS: This is the first prospective study using a large representative cohort of elderly persons to demonstrate that progressive cognitive decline is associated with a specific pattern of loss of functional tasks. Clear cognitive thresholds at which development of dependency in OARS functional items occurred. By providing estimates of the cognitive status of persons at the time at which they developed dependency in specific functional items, a natural hierarchy of functional loss associated with cognitive decline emerged. For caregivers, clinicians, and health policy makers, this information can help anticipate the pattern of functional decline and the subsequent care needs of persons with declining cognition, potentially improving the quality of life of these persons and their caregivers and playing an important part in health care planning.     

The role of interpersonal relationships in men's attendance in primary care: qualitative findings in a cohort of men with prostate cancer

Objectives

Men's response to ill health is framed as a “battleground” for the enactment of masculinities. With an increase in diagnoses of men's cancers, there is a need to better understand the features which influence timely access to diagnostic services. This study explored the ways in which men account for the timing of their diagnosis of prostate cancer.

Methods

Thirty semi-structured interviews were conducted with men and, where possible, their partner. Data were analyzed with reference to framework analysis.

Results

Relationships, including spousal, familial, and friendships, appear pivotal in informing men's help-seeking behaviors. Friends and partners were often critical in facilitating access to primary care. Following their own diagnosis, this virtuous cycle of encouragement led many men to encourage others to seek medical attention for prostate tests.

Conclusions

Interpersonal relationships are a missing dimension in models of delay. We need to know more about how to use relationships, in addition to traditional routes, to harness health promotion messages. Interpersonal relationship, including partners and social networks, may be powerful conduits and may prove effective mechanisms to identify and access men most at risk of prostate cancer.     

Sequential CoreValve implantation for a mal‐positioned prosthesis during transcatheter aortic valve implantation

Transcatheter aortic‐valve implantation is rapidly emerging as an effective, safe, and sustainable alternative for a specific subset of high‐surgical risk and/or inoperable patients with severe aortic stenosis. However, technical challenges remain for this relatively new procedure, not the least mal‐positioning of the transcatheter prosthesis resulting in acute aortic regurgitation. We report a case of deep implantation of a CoreValve prosthesis that was inadvertently pulled out of the aortic annulus during repositioning. The patient received a second sequential CoreValve successfully.© 2010 Wiley‐Liss, Inc.     

Trajectories of fasting glucose and glycated haemoglobin in obese and non-obese incident diabetes: Results from two large cohort studies

Aims

Diabetes development mechanisms vary by weight status. We aimed to compare cardiometabolic risk and characterize fasting plasma glucose (FPG) and glycated haemoglobin (HbA1c) trajectories before diagnosing type 2 diabetes in individuals with/without obesity.

Methods

Data from the China Health and Retirement Longitudinal Study (CHARLS) and English Longitudinal Study of Ageing (ELSA) were analysed. Participants without diabetes and with a body mass index of 18.5-40 kg/m² at baseline were included. Incident diabetes was ascertained by self-reported physician diagnosis and/or antidiabetic drug use, FPG ≥126 mg/dl and/or HbA1c ≥6.5%. The difference in the FPG/HbA1c trajectory before the diabetes diagnosis in participants with/without obesity was examined using mixed-effects models.

Results

Among 11 925 eligible participants, 1361 incident diabetes cases (mean age: 61.4 years; male: 46.2%) were identified within 15 years of follow-up. Obese diabetes showed higher levels of diastolic blood pressure and C-reactive protein at diagnosis than non-obese diabetes. Mixed-effects models indicated the difference in the FPG trajectory before diagnosis by weight status was non-significant with a slope difference of 0.149 mg/dl (SE = 0.642, p = .816, CHARLS) and 0.013 mg/dl (SE = 0.013, p = .337, ELSA). However, obese diabetes showed a steep increase in HbA1c before diagnosis with a slope difference of 0.036% (SE = 0.016, p = .021) in the CHARLS and 0.032% (SE = 0.014, p = .027) in the ELSA, respectively. Sex-stratified analyses showed that the difference in HbA1c trajectory before the diabetes diagnosis by weight status was only significant in males.

Conclusions

Obese and non-obese diabetes developments may share a similar FPG but distinct HbA1c trajectory. Obese diabetes interventions require more attention to cardiometabolic risks. Moreover, studies addressing weight/sex-related differences in diabetes aetiologies and treatments are warranted.     

Novel genetic markers in the 5′‐flanking region of ANKH are associated with ankylosing spondylitis

Objective

To use a candidate gene approach for the identification of genetic markers that are significantly linked to and associated with ankylosing spondylitis (AS).

Methods

We searched for novel polymorphisms in the ANKH gene (human homolog of the murine progressive ankylosis gene) and genotyped 2 polymorphic sites, one in the 5′‐noncoding region and the other in the promoter region of ANKH, using DNA from affected (n = 273) and unaffected (n = 112) individuals from 124 AS families. We used these ANKH and other nearby polymorphisms to perform linkage and family‐based association analyses.

Results

We identified 2 novel polymorphic sites: one in the 5′‐noncoding region of ANKH involving 1–2 copies of an 8‐bp repeat (denoted as ANKH‐OR), and the other in the promoter region involving different copy numbers of a triplet repeat (denoted as ANKH‐TR). ANKH‐OR and ANKH‐TR were in complete linkage disequilibrium. Five markers (D5S1953, ANKH‐TR, ANKH‐OR, D5S1954, and D5S1963) were used for both the linkage and association analyses. Multipoint linkage analysis of 124 AS families showed a modest level of significance (nonparametric linkage score 2.15; P = 0.015) at the ANKH region. The contribution of ANKH to AS susceptibility (λ_s) was 1.9. A family‐based association study on the same AS families revealed that both ANKH‐OR allele 1 and ANKH‐TR allele 7 were significantly associated with disease, assuming an additive model (for ANKH‐OR allele 1, P = 0.03; for ANKH‐TR allele 7, P = 0.04).

Conclusion

Our results indicate that ANKH‐OR and ANKH‐TR are novel genetic markers that are significantly associated with AS.

     

Domestic exposure to aeroallergens in Hong Kong families with asthmatic children

Indoor aeroallergen exposures increased asthma symptoms in Caucasians, but their determinants and relationship to asthma and allergy in Asians are unclear. This study investigated exposures to cat, cockroach, and Blomia tropicalis allergens in 115 Hong Kong families with asthmatic children. Patients underwent exhaled nitric oxide and spirometric measurements. Home visits were made within 2 weeks during which parents completed a standardized questionnaire. Fel d 1, Bla g 2, and Blo t 5 in dust samples collected from patients' mattresses, bedroom floors, and living room floors were measured by immunoassays. These aeroallergens were only detectable in some homes (38–55% for Fel d 1; 9–21% for Bla g 2, and 7–14% for Blo t 5). The presence of cat and/or dog was a strong determinant for Fel d 1 in all indoor sites. The timing and frequency of bedding change was associated with Bla g 2 levels, whereas the timing of bedroom floor cleaning was a consistent factor for Blo t 5 levels. Asthmatic children in families with high allergen exposure were more likely to have ≥4 wheezing attacks in preceding 12 months and exercise‐induced wheezing than those with normal allergen exposure (P = 0.051 and 0.030, respectively). Mattress levels of all three allergens were also associated with severity of several allergy symptoms (P = 0.025–0.005). None of these aeroallergens correlated with exhaled nitric oxide and spirometric parameters. This study identifies determinants for cat, cockroach, and B. tropicalis levels in Hong Kong families with asthmatic children. These exposures are associated with severity of allergy symptoms. Pediatr. Pulmonol. 2011; 46:632–639. © 2011 Wiley‐Liss, Inc.