Heart Failure and Incident Late‐Life Depression

OBJECTIVES: To assess whether heart failure (HF) increases the risk of developing depression and whether the use of loop diuretics in persons with HF alters this risk. DESIGN: Population‐based cohort study between 1993 and 2005. SETTING: Ommoord, a district of Rotterdam, the Netherlands. PARTICIPANTS: Five thousand ninety‐five older adults free of depression at baseline. MEASUREMENTS: Detailed information on HF and depression was collected during examination rounds and through continuous monitoring of medical and pharmaceutical records. HF was defined according to the criteria of the European Society of Cardiology. Depressive episodes were categorized as clinically relevant depressive symptoms and depressive syndromes, including major depressive disorders defined according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. Hazard ratios (HRs) were calculated using multivariate Cox proportional hazard regression. RESULTS: HF was associated with greater risk of depressive symptoms and syndromes (HR=1.41, 95% CI=1.03–1.94) and depressive syndromes only (HR=1.66, 95% CI=1.09–2.52). In participants with HF, the use of loop diuretics was associated with a lower risk of depressive symptoms and syndromes (HR=0.46, 95% CI=0.22–0.96) and depressive syndromes only (HR=0.41, 95% CI=0.16–1.00). CONCLUSION: HF is an independent risk factor for incident depression in elderly persons. Patient with HF require careful follow‐up to monitor and prevent the onset of depression. Effective treatment of the debilitating symptoms of HF may prevent depression.     

Community Physician Education in Geriatrics: Applying the Assessing Care of Vulnerable Elders Model with a Multisite Primary Care Group

Providing practicing physicians with effective education that leads to better patient outcomes remains challenging. In 2003, the University of Cincinnati College of Medicine developed a comprehensive program to enhance practicing physician geriatric medicine education based on the Assessing the Care of Vulnerable Elders model. The program was implemented with a large, multisite primary care group based in the greater Cincinnati area and was designed to increase physicians' clinical skills and assist them in implementing new office and system strategies that could improve the quality of care for their older patients. Four topic areas were chosen: medication management, falls and mobility, urinary incontinence, and dementia. A multifaceted physician education program was developed for each topic area, with lunch‐time, in‐office, geriatrician‐led presentations as the primary intervention. Over a 4‐year period (2004–2007), more than 60 physicians in 16 primary care practices attended 107 teaching sessions. The value of the presentation content, quality of the presentations, and perception of meeting the primary care physicians' (PCPs') educational needs were each rated at 3.8 or above (4=excellent). Between 80% and 92% of the PCPs planned to make a change in their practice behavior as a result of the training, but only two offices initiated formal quality improvement projects. During the teaching sessions, the PCPs were provided with screening tools to identify “at risk” patients, assessment chart templates, and community resource and patient education materials. The application of a modified version of the ACOVE model to reach a large group of primary care physicians is possible and may be one strategy to improve the assessment and management of geriatric syndromes.     

Visceral Fat Accumulation and Metabolic Risk Factor Clustering in Older Adults

OBJECTIVES: To examine the relationship between visceral fat area (VFA) evaluated using computed tomography (CT) scans and the number of metabolic risk factors in older adults. DESIGN: Cross‐sectional study SETTING: A community clinic in Tokyo, Japan. PARTICIPANTS: Two hundred eighteen individuals aged 65 and older without impairments in activities of daily living who underwent geriatric health examination (63 men, mean age 74.5 ± 7.1; 155 women, mean age 75.3 ± 6.7). MEASUREMENTS: VFA was obtained from a cross‐sectional image at umbilical level in the supine position using CT scanning. Metabolic syndrome components except waist circumference were measured using the criteria of the International Diabetes Federation. RESULTS: There was a positive correlation between VFA and number of metabolic risk factors in men and women. Multiple regression analysis demonstrated that only VFA was significantly correlated with number of risk factors in men, whereas age and VFA were significantly correlated in women; body mass index was not correlated with number of metabolic risk factors in men or women. Dyslipidemia and high blood glucose were associated with higher VFA, but high blood pressure was not. There was a negative correlation between VFA and serum adiponectin level and a positive correlation between VFA and homeostasis model assessment of insulin resistance. CONCLUSION: Visceral fat accumulation is associated with metabolic risk factor clustering even in the elderly population. These results have clinical implications for the management of obesity in older adults.     

Leptin affects adenylate cyclase activity in H9c2 cardiac cell line: effects of short- and long-term exposure

Leptin has been hypothesized to be a pathophysiologic link between obesity and cardiovascular diseases. Because the adenylate cyclase (AC) system is a main effector of β-adrenergic receptors and leptin has been shown to modulate AC activity in other cell lines, a leptin impact on cardiac AC activity was hypothesized. Therefore, acute and chronic effects of leptin on a rat cardiac cell line (H9c2) were investigated. Leptin affected both basal (+13% at 30 min and −16.4% after 18 h v untreated cells) and catecholamine-stimulated AC activity (isoproterenol + leptin at 30 min or 18 h was +21% v untreated cells; norepinephrine + leptin at 30 min was +38.8% v untreated cells; and norepinephrine + leptin at 18 h was +6% v untreated cells). Thus, long-term leptin treatment was associated with a reduced AC activity and a different responsiveness to catecholamines. The AC activity on leptin treatment was accompanied by changes in levels of proteins structurally or functionally related to AC complex (AC, Gαs, Gαi, p21-ras). These data indicate that the AC complex is profoundly affected at more than one level by leptin treatment in the H9c2 cardiac cell line. Differences in AC activity after short- and long-term exposure to leptin and the interaction between leptin and catecholamine might provide further insight to the understanding of the development of hypertension and congestive heart failure in obese patients.     

Problems with folacin status with use of orange juice substitutes in a geriatric institution

An increased range of orange drinks is now available with varying proportions of orange juice. These have begun to appear in institutions for the care of elderly people. With evidence of folacin deficiency in such elderly people, we evaluated the effect of either 100% orange juice or an orange drink (at least 5% juice) on folacin status in 19 institutionalized elderly people over a 13-week period. Serum folacin increased from 8.5 ± 0.8 to 13.2 ± 0.8 nmol/l ( P < 0.001) in 13 weeks, with 100 ml orange juice daily, but did not change from baseline (8.9 ± 0.8 nmol/l) to 13 weeks (8.5%± 0.7 nmol/l) with orange drink. By 6 weeks the difference between orange juice (11.0 ± 1.0 nmol/l) and orange drink (8.6 ± 0.7 nmol/l) was significant. Thus, not only is the choice of orange drink important, but small regular orange juice supplements can produce a significant increase in biochemical folacin status.     

《初级保健机构中衰弱筛查和管理：国际衰弱和肌肉减少症研究会议工作组指南》解读

衰弱是老年人常见的一种临床综合征,常与其他疾病共存,可增加老年人的依赖性和死亡风险。由于社区缺乏老年专科医生,且社区老年人缺乏衰弱筛查的意识,社区衰弱老年人常进展为失能,影响躯体功能和生活质量。对初级保健机构中老年人进行早期衰弱筛查和干预是预防衰弱进展、维持躯体功能的重要途径。2020年国际衰弱和肌肉减少症研究会议工作组（ICFSR）制定了针对初级保健机构中老年人衰弱筛查和管理的指南,该指南提出了7种适用于初级保健机构的快速衰弱筛查工具和2种衰弱管理方法,旨在为初级保健机构提供衰弱筛查和管理的实用策略。本文主要对该指南中衰弱筛查和管理方面进行解读,以期为我国社区衰弱老年人群衰弱筛查和管理提供参考。     

Does Low to Moderate Alcohol Intake Protect Against Cognitive Decline in Older People?

OBJECTIVES: To determine whether low to moderate alcohol intake is protective against cognitive decline in older people. DESIGN: Prospective cohort study. SETTING: Community‐based study in Ireland, the Netherlands, and Scotland. PARTICIPANTS: Five thousand eight hundred four people (3,000 women) aged 70 to 82 and randomized to pravastatin or placebo in the Prospective Study of Pravastatin in the Elderly at Risk. MEASUREMENTS: Alcohol consumption was determined at study baseline. Serial measures of cognitive function over 3.2 years mean follow‐up included Mini‐Mental‐State‐Examination (MMSE), speed of information processing (Stroop and Letter‐Digit Coding tests), and immediate and delayed memory (Picture‐Word Learning test). RESULTS: Forty‐two percent of women and 71% of men were alcohol drinkers. Cognitive performance was better for female drinkers than nondrinkers for all cognitive domains over the 3.2‐year follow‐up; no significant effects were seen for men (linear mixed model, including adjusting for possible confounders). The rate of cognitive decline was similar for drinkers and nondrinkers for all cognitive domains, except for MMSE, which declined significantly less in female drinkers than nondrinkers (linear mixed model attenuated rate of decline=0.05 MMSE units per annum, P=.001). CONCLUSION: Drinking low to moderate amounts of alcohol may delay age‐associated cognitive decline in older women (including slowing deterioration in global cognitive function), but these apparent benefits were not clearly seen in older men.     

Resilience and spirituality in patients with depression and their family members: A cross-sectional study

ObjectiveThe degree and quality of resilience in patients with depression have never been investigated in the context of remission status, spirituality/religiosity, and family members' resilience levels, which was addressed in this study.MethodsThis cross-sectional study recruited Japanese outpatients with depressive disorder according to ICD-10 and cohabitant family members who were free from psychiatric diagnoses. Resilience was assessed using the 25-item Resilience Scale (RS). Other assessments included the Montgomery-Asberg Depression Rating Scale (MADRS); the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT) and Kasen et al.'s (2012) scale for spirituality/religiosity; and the Rosenberg Self-Esteem Scale (RSES).ResultsOne hundred outpatients with depression (mean ± SD age, 50.8 ± 14.5 years; 44 men; MADRS total score 9.8 ± 9.0) and 36 healthy family members (mean ± SD age, 56.5 ± 15.0 years; 18 men) were included. Symptom severity, attendance at religious/spiritual services, and self-esteem were significantly associated with RS scores in the patient group. RS total scores were significantly higher in remitted patients compared to non-remitted patients (mean ± SD, 112.3 ± 17.1 vs. 84.8 ± 27.7, p < 0.001). No correlation was found in RS total scores between patients and their family members (p = 0.265), regardless of patients' remission status.ConclusionsResilience may be influenced by individual characteristics rather than familial environment; furthermore, self-esteem or spirituality/religiosity may represent reinforcing elements. While caution is necessary in extrapolating these findings to other patient populations, our results suggest that resilience may be considered a state marker in depression.     

老年患者慢性病负担对焦虑和抑郁的影响研究

背景　有研究表明慢性病与心理情绪密切相关,既往研究多集中在单个慢性病与焦虑、抑郁关系的研究,而缺乏对老年患者慢性病负担综合系统的研究。目的　探究综合性医院老年慢性病住院患者疾病负担与焦虑、抑郁的关系。方法　收集2018年3-6月于同济大学附属同济医院老年科住院的患者103例,运用Charlson合并症指数（CCI）来量化疾病负担,CCI评分≤3分为低疾病负担组,CCI评分>3分为高疾病负担组,采用广泛性焦虑量表（GAD-7）评估焦虑症状,健康问卷抑郁症状群量表（PHQ-9）评估抑郁症状,比较不同程度疾病负担的老年患者焦虑、抑郁的发生率。结果　103例老年患者GAD-7评分0~21分,平均（3.7±4.8）分,伴焦虑者28例（27.2%）;PHQ-9评分0~25分,平均（5.3±5.3）分,伴抑郁者42例（40.8%）,其中,合并焦虑及抑郁者22例（21.4%）。低疾病负担组54例（52.4%）,高疾病负担组49例（47.6%）。低疾病负担与高疾病负担的老年患者焦虑、抑郁发生率比较,差异无统计学意义（P>0.05）。不同性别、年龄亚组两组老年患者焦虑、抑郁发生率比较,差异均无统计学意义（P>0.05）。结论　老年住院患者焦虑、抑郁发生率较高,但未发现老年住院患者高、低疾病负担在焦虑、抑郁情绪间存在明显差异,可能负性情绪对合并多种慢性病的高龄老年人群影响较小。     

老年急性缺血性脑卒中患者衰弱与卒中后抑郁的相关性研究

背景　随着我国人口老龄化进程的不断加剧,老年脑卒中患者的数量也逐年增加,卒中后抑郁（PSD）作为脑卒中的常见并发症之一,目前尚缺乏有意义的预测指标。目的　分析老年急性缺血性脑卒中患者衰弱与PSD的相关性,为早期临床评估及干预提供参考依据。方法　选取2017年6-12月在商丘市第一人民医院全科医学科、神经内科住院的符合研究标准的急性缺血性脑卒中患者118例。收集患者的一般资料〔性别,年龄,体质指数（BMI）,吸烟、饮酒情况,高血压、糖尿病、高脂血症、心房颤动发生情况〕、临床资料〔疾病共存（共存疾病≥5种）情况、入院时美国国立卫生研究院卒中量表（NIHSS）评分及改良Rankin量表（mRS）评分、TOAST分型〕。依据患者入院后24 h内衰弱筛查量表（FRAIL）评分分为无衰弱组（n=85,FRAIL评分<3分）和衰弱组（n=33,FRAIL评分≥3分）;依据患者发病后随访6~12个月时的美国精神病学会《精神障碍诊断与统计手册》第四版（DSM-Ⅳ）及汉密尔顿抑郁量表（HAMD）将患者分为无PSD组（n=73,HAMD评分<7分）和PSD组（n=45,HAMD评分≥7分）。采用多因素Logistic回归分析进行老年急性缺血性脑卒中患者发生衰弱、PSD的影响因素分析。结果　多因素Logistic回归分析结果显示,年龄〔OR=1.131,95%CI（1.055,1.211）,P<0.001〕和入院时mRS评分〔OR=4.626,95%CI（2.027,10.561）,P<0.001〕是老年急性缺血性脑卒中患者发生衰弱的影响因素;年龄〔OR=1.060,95%CI（1.005,1.118）,P=0.031〕、衰弱〔OR=2.855,95%CI（1.144,7.126）,P=0.025〕是老年急性缺血性脑卒中患者发生PSD的影响因素。无衰弱组患者 25例（29.4%）发生PSD,衰弱组患者 20例（60.6%）发生PSD,衰弱组患者PSD发生率高于无衰弱组（P=0.002）。随着PSD程度的增加,老年急性缺血性脑卒中患者衰弱发生率无明显趋势变化,差异无统计学意义（P>0.05）。结论　老年急性缺血性脑卒中患者的年龄、衰弱情况与其发生PSD密切相关,及时对其进行衰弱评估可预测PSD发生风险。