Participation and Life Satisfaction in Aged People with Spinal Cord Injury: Does Age at Onset Make a Difference?

Background:

Few studies have reported on outcomes in samples of elderly people with SCI and the impact of the age at onset of SCI is unclear.

Objective:

To study levels of participation and life satisfaction in individuals with SCI aged 65 years or older and to analyze differences in participation and life satisfaction scores between individuals injured before or after 50 years of age.

Methods:

This cross-sectional survey included 128 individuals with SCI who were at least 65 years old. Age at onset was dichotomized as <50 or ≥50 years of age. Participation was measured with the Frequency scale of the Utrecht Scale for Evaluation-Participation, and life satisfaction was measured with 5 items of the World Health Organization Quality of Life abbreviated form.

Results:

Participants who were injured before 50 years of age showed similar levels of functional status and numbers of secondary health conditions but higher participation and life satisfaction scores compared to participants injured at older age. In the multiple regression analysis of participation, lower current age, higher education, and having paraplegia were significant independent determinants of increased participation (explained variance, 25.7%). In the regression analysis of life satisfaction, lower age at onset and higher education were significant independent determinants of higher life satisfaction (explained variance, 15.3%).

Conclusion:

Lower age at onset was associated with better participation and life satisfaction. This study did not reveal indications for worsening participation or life satisfaction due to an accelerated aging effect in this sample of persons with SCI.Key words: aged, aging, quality of life, rehabilitation outcome, spinal cord injuriesAging in the population of individuals with spinal cord injury (SCI) has 2 aspects: the average age at onset of SCI is increasing and people with SCI live on average longer than half a century ago. Age at onset of traumatic SCI has risen from 28.7 years in the 1970s to 40 years in the United States during the 2005-2009 period.¹ In other countries, a bimodal distribution of age at onset of traumatic SCI has emerged in recent years.² In the Netherlands, the median age at first admission to the acute hospital after traumatic SCI has increased to 62 years in 2010.³ People who are older at injury are more often victims of falls and have nontraumatic, incomplete, and cervical SCI more often than individuals who are injured at a younger age.³-⁵ They are more vulnerable than younger people and are at greater risk of death shortly after the onset of SCI.⁶ If they survive the acute phase, they are less often referred to specialized rehabilitation hospitals.³ If referred to a specialized center, elderly people with SCI may gain a similar rate of functional improvement⁷; but because older patients generally have lower functional scores at admission, they also show worse rehabilitation outcomes compared to people who are injured at a younger age.^4,8–10The life expectancy of the population with SCI has grown over the last 50 to 60 years.¹¹ Many people with a new SCI can expect to live another 30 to 40 years or more. However, this life expectancy has not grown in recent decades and is still clearly below that of the general population.¹¹ People with SCI are at risk of “accelerated aging” due to an inactive lifestyle and a greater risk of obesity, chronic inflammation, pressure ulcers, and pulmonary infections.^1,12Participation and quality of life in aged persons with SCI are influenced by a complex interaction of many factors associated with current chronologic age, age at injury, duration of injury, and age cohort effects. It has been suggested that increasing age and being of older age at onset of SCI are independently associated with worse outcomes and that longer time after SCI is associated with better adjustment, whereas the impact of age cohort effects on adjustment is unknown.^1,13–15 However, research into the impact of these health-related changes on participation and life satisfaction of aged people living with SCI is sparse, and associations with aging are often studied in samples that are well below retirement age.¹⁵Only 2 longitudinal projects in aging people with SCI are available. Krause and Bozard¹⁶ described 35-year longitudinal data of 64 individuals with SCI (mean age, 61.5 years; mean time since SCI, 41.4 years). The participants rated their overall adjustment significantly higher at follow-up than they did at the first assessment 35 years before (8.4 and 7.6 on a 0–10 scale, respectively). The participants, however, showed decreases in satisfaction with social life and participation indicators (visits with others, outings).¹⁶ Charlifue and Gerhart¹⁷ found in a large sample of people with long-standing SCI (mean age, 59 years; time since onset of SCI, 36 years at follow-up) a small but significant decline in community reintegration over a period of 10 years. Life satisfaction, however, remained stable over this time period.¹⁷It is still unclear how people aging with SCI differ from people who acquire SCI in later life.¹⁸ Given the same age, the accelerated aging hypothesis predicts that people injured at a younger age will be worse off. However, the reverse – higher age at injury is an independent predictor of worse functional outcomes – has also been shown.¹⁰ We therefore used data from earlier research with the following objectives: (a) to describe the levels of participation and life satisfaction in individuals with SCI aged 65 years or older, and (b) to analyze differences in participation and life satisfaction between individuals injured before 50 years of age or at or after 50 years of age.     

Fulminant onset of acute leukemia from normal hematopoiesis within 3 months of follow up for multiple myeloma treated with total therapy protocols

Assiduous surveillance for genetic aberrations is necessary in patients on cytotoxic therapies to detect therapy‐related myeloid neoplasms (t‐MN). Current modalities include metaphase cytogenetics and FISH. Since t‐MN may develop abruptly in cytogenetically normal patients, a discussion exploring additional methods such as SNP‐array and targeted‐deep‐sequencing to detect subchromosomal abnormalities is needed.     

Clinical Worsening During Long-Term Follow-Up in Inoperable Chronic Thromboembolic Pulmonary Hypertension

Background  

Pulmonary endarterectomy is the treatment of choice in chronic thromboembolic pulmonary hypertension (CTEPH). Modern pulmonary vasoactive medication (like endothelin receptor antagonists, phosphodiesterase type 5 inhibitors, and prostacyclins) is used in patients with an inoperable disease and improved prognosis. We evaluate mortality and time to clinical worsening (TtCW) in inoperable CTEPH patients during long-term follow-up.     

Deep brain stimulation affects conditioned and unconditioned anxiety in different brain areas

Deep brain stimulation (DBS) of the nucleus accumbens (NAc) has proven to be an effective treatment for therapy refractory obsessive–compulsive disorder. Clinical observations show that anxiety symptoms decrease rapidly following DBS. As in clinical studies different regions are targeted, it is of principal interest to understand which brain area is responsible for the anxiolytic effect and whether high-frequency stimulation of different areas differentially affect unconditioned (innate) and conditioned (learned) anxiety. In this study, we examined the effect of stimulation in five brain areas in rats (NAc core and shell, bed nucleus of the stria terminalis (BNST), internal capsule (IC) and the ventral medial caudate nucleus (CAU)). The elevated plus maze was used to test the effect of stimulation on unconditioned anxiety, the Vogel conflict test for conditioned anxiety, and an activity test for general locomotor behaviour. We found different anxiolytic effects of stimulation in the five target areas. Stimulation of the CAU decreased both conditioned and unconditioned anxiety, while stimulation of the IC uniquely reduced conditioned anxiety. Remarkably, neither the accumbens nor the BNST stimulation affected conditioned or unconditioned anxiety. Locomotor activity increased with NAc core stimulation but decreased with the BNST. These findings suggest that (1) DBS may have a differential effect on unconditioned and conditioned anxiety depending on the stimulation area, and that (2) stimulation of the IC exclusively reduces conditioned anxiety. This suggests that the anxiolytic effects of DBS seen in OCD patients may not be induced by stimulation of the NAc, but rather by the IC.     

Hereditary hemorrhagic telangiectasia: How accurate are the clinical criteria?

The clinical diagnosis of hereditary hemorrhagic telangiectasia (HHT) is based on the Curaçao criteria. Three out of four criteria are required for a definite clinical diagnosis HHT, two criteria are considered “possible” HHT, and 0 or 1 criterion makes the diagnosis unlikely. However, these consensus diagnostic criteria have not been validated. We report on the diagnostic accuracy of the clinical criteria. A total of 450 consecutive persons ≥16 years of age were screened for HHT between May 2004 and September 2009, including a chest CT to screen for pulmonary arteriovenous malformations (AVMs). We selected 263 first‐degree relatives of disease‐causing mutation carriers who underwent mutation analysis. Genetic test results were considered the gold standard. The family mutation was present in 186 patients (mean age 42.9 ± 14.6 yr; 54.8% female). A clinical diagnosis was definite, “possible”, and unlikely in 168 (90.3%), 17 (9.1%), and 1 (0.5%) patient, respectively. In 77 persons the family mutation was absent (mean age 37.1 ± 12.3 yr, 59.7% female). In this group a clinical diagnosis was definite, possible, and unlikely in 0, 35 (45.5%), and 42 (54.5%) persons, respectively. The positive predictive value of a definite clinical diagnosis was 100% (95% CI 97.8–100), the negative predictive value of an unlikely diagnosis 97.7% (95% CI 87.9–99.6). Of 52 patients with “possible” HHT, 17 (32.7%) displayed an HHT‐causing mutation. The Curaçao clinical criteria have a good diagnostic performance. Genetic testing is particularly helpful in patients with a “possible” clinical diagnosis HHT. © 2013 Wiley Periodicals, Inc.