Predictors of Mortality,Rehospitalization for Syncope,and Cardiac Syncope in 352 Consecutive Elderly Patients With Syncope

ObjectivesTo investigate the etiologies of syncope and predictors of all-cause mortality, rehospitalization, and cardiac syncope in consecutive elderly patients presenting with syncope to our emergency department.ParticipantsParticipants were 352 consecutive patients aged 65 years or older with syncope admitted to hospital from the emergency department.DesignObservational retrospective study.MeasurementsReview of medical records for history, physical examination, medications, and tests to determine causes of syncope. Cox stepwise logistic regression analysis was performed to identify significant independent prognostic factors for rehospitalization with syncope, all-cause mortality, and cardiac syncope.ResultsOf 352 patients, mean age 78 years, the etiology of syncope was diagnosed in 243 patients (69%). Vasovagal syncope was diagnosed in 12%, volume depletion in 14%, orthostatic hypotension in 5%, cardiac syncope in 29%, carotid sinus hypersensitivity in 2%, and drug overdose/others in 7% of patients. During a mean follow-up of 24 months, 10 patients (3%) were readmitted to the hospital for syncope and 39 (11%) died. Stepwise logistic regression analysis identified history of congestive heart failure (OR 5.18; 95% CI 1.23–21.84, P = .0257) and acute coronary syndrome (OR 5.95; 95% CI 1.11–31.79, P = .037) as independent risk factors for rehospitalization. Significant independent prognostic factors for mortality were diabetes mellitus (OR 2.08; 95% CI 1.09–3.99, P = .0263), history of smoking (OR 2.23; 95% CI 1.10–4.49, P = .0255), and use of statins (OR 0.37; 95% CI 0.19–0.72, P = .0036). Independent risk factors for predicting a cardiac cause of syncope were an abnormal electrocardiogram (OR 2.58; 95% CI 1.46–4.57, P = .0012) and reduced ejection fraction (OR 2.92; 95% CI 1.70–5.02, P < .001). The San Francisco Syncope Rule and Osservatorio Epidemiologico sulla Sincope nel Lazio scores did not predict mortality or rehospitalization in our study population.ConclusionsSignificant independent risk factors for rehospitalization for syncope were congestive heart failure and acute coronary syndrome. Significant independent risk factors for mortality were diabetes mellitus, history of smoking, and use of statins (inverse association).     

Predictors of In-Hospital Mortality in Older Patients With COVID-19: The COVIDAge Study

ObjectiveTo determine predictors of in-hospital mortality related to COVID-19 in older patients.DesignRetrospective cohort study.Setting and ParticipantsPatients aged 65 years and older hospitalized for a diagnosis of COVID-19.MethodsData from hospital admission were collected from the electronic medical records. Logistic regression and Cox proportional hazard models were used to predict mortality, our primary outcome. Variables at hospital admission were categorized according to the following domains: demographics, clinical history, comorbidities, previous treatment, clinical status, vital signs, clinical scales and scores, routine laboratory analysis, and imaging results.ResultsOf a total of 235 Caucasian patients, 43% were male, with a mean age of 86 ± 6.5 years. Seventy-six patients (32%) died. Nonsurvivors had a shorter number of days from initial symptoms to hospitalization (P = .007) and the length of stay in acute wards than survivors (P < .001). Similarly, they had a higher prevalence of heart failure (P = .044), peripheral artery disease (P = .009), crackles at clinical status (P < .001), respiratory rate (P = .005), oxygen support needs (P < .001), C-reactive protein (P < .001), bilateral and peripheral infiltrates on chest radiographs (P = .001), and a lower prevalence of headache (P = .009). Furthermore, nonsurvivors were more often frail (P < .001), with worse functional status (P < .001), higher comorbidity burden (P < .001), and delirium at admission (P = .007). A multivariable Cox model showed that male sex (HR 4.00, 95% CI 2.08-7.71, P < .001), increased fraction of inspired oxygen (HR 1.06, 95% CI 1.03-1.09, P < .001), and crackles (HR 2.42, 95% CI 1.15-6.06, P = .019) were the best predictors of mortality, while better functional status was protective (HR 0.98, 95% CI 0.97-0.99, P = .001).Conclusions and implicationsIn older patients hospitalized for COVID-19, male sex, crackles, a higher fraction of inspired oxygen, and functionality were independent risk factors of mortality. These routine parameters, and not differences in age, should be used to evaluate prognosis in older patients.     

Transcranial Doppler to Measure Cerebral Blood Flow in Delirium Superimposed on Dementia. A Cohort Study

ObjectiveDelirium superimposed on dementia (DSD) is frequently not diagnosed, at great cost. Both delirium and dementia are associated with cerebral hypoperfusion. A switch to anaerobic glycolysis in the central nervous system during delirium compared to Alzheimer's dementia (AD) suggests greater hypoperfusion in DSD. The main aims of this study were to investigate whether cerebral hypoperfusion could differentiate DSD from related entities, and the characteristics of that hypoperfusion.MethodsProspective cohort study of 44 Geriatric Medicine patients in 4 groups: (1) delirium, no history of dementia; (2) DSD; (3) acute illness without delirium or dementia; and (4) AD, no delirium. We measured CBF using transcranial Doppler to assess flow velocity (FV) and pulsatility index in the middle cerebral artery (MCA).ResultsDSD has lower FV than either AD or delirium alone, or acute illness (28.2 ± 4.7 vs AD: 41.3 ±15.7; P = .040; vs delirium 37.7 ± 8.2; P =.009; vs acute illness 43.0 ± 8.3; P <.001). A mean MCA FV cut-off of 32.25 cm/s diagnoses DSD with a sensitivity of 0.875 and specificity of 0.788, area under the curve 0.884; P = .001. Resolution of delirium improves FV (P = .005). FV correlates with delirium severity (delirium index R = −0.39; P = .009) and dementia (Mini-Mental State Examination, R = 0.33; P = .029, and Informant Questionnaire on Cognitive Decline in the Elderly, R = −0.41; P = .005).ConclusionsTranscranial Doppler is a potential diagnostic and monitoring test for DSD. Correlation with clinical indicators of delirium suggests pathophysiological significance.     

Combination of Quantitative Computed Tomography and Blood Biochemistry for Evaluating the Relationship Between Nutrition and Bone Mineral Density in Patients on Maintenance Hemodialysis

PurposeTo investigate the effect of nutritional factors on bone mineral density (BMD) using quantitative computed tomography combined with blood biochemistry in patients on maintenance hemodialysis (MHD).MethodsSixty patients on MHD were divided into osteopenia (n = 20) and nonosteopenia (n = 40) groups. BMD, fat, and muscle mass were measured by quantitative computed tomography. The calcification of coronary artery and hilar lymph node and computed tomography attenuation values of the liver and spleen were also analyzed. Differences between the two groups were compared, and the risk factors for osteopenia were analyzed by logistic regression analysis.ResultsPatients in the osteopenia group had lower albumin levels than those in the nonosteopenia group (37.84 ± 3.00 vs 42.03 ± 4.05 g/L; P < .001). Logistic regression showed that patients with lower albumin levels had a higher risk of osteopenia (odds ratio, 1.462; 95% confidence interval, 1.313–1.801; P = .003). BMD was negatively correlated with fat mass (r = ?0.365, P = .004) and positively correlated with the ratio of muscle mass to fat mass (r = 0.431, P = .001). There was no significant difference in the rate of calcification of coronary artery or hilar lymph nodes between the two groups. Computed tomography values of the liver and spleen were positively correlated with the duration of dialysis (r = 0.55, P = .001; r = 0.42, P < .001, respectively).ConclusionLow albumin levels are associated with an increased risk of osteopenia in patients on MHD. Abdominal fat is a risk factor for reduction in BMD in MHD patients, and the ratio of abdominal muscle mass to fat mass is a protective factor for BMD.     

Dietary Supplement Intake and Factors Associated with Increased Use in Preadolescent Endurance Runners

BackgroundThe prevalence of dietary supplement intake among preadolescent endurance runners is currently unknown.ObjectiveOur aim was to describe use of dietary supplements, higher-risk supplements, and sport foods among preadolescent endurance athletes and identify associated characteristics of dietary supplement users in this population.DesignThis was a retrospective, cross-sectional study.Participants/settingParticipants were 2,113 preadolescent endurance runners (male: n = 1,255, female: n = 858; mean age ± standard deviation = 13.2 ± 0.9 years).Main outcome measuresUse of dietary supplements, higher-risk dietary supplements, and sport foods on 2 or more days per week during the past year.Statistical analyses performedMann-Whitney U tests, χ² tests, univariate and multivariate analyses.ResultsTwenty-six percent (n = 551) of preadolescent runners used dietary supplements on 2 or more days per week during the past year; 1.3% (n = 27) reported taking higher-risk supplements. Compared with male runners, female runners reported higher use of 1 or more supplements (32.5% vs 21.7%; P < .001) and 4 or more supplements (4.0% vs 1.9%; P = 0.005), multivitamin/minerals (24.2% vs 14.4%; P < .001), vitamin D (12.4% vs 5.6%; P < .001), calcium (8.9% vs 4.8%; P < .001), iron (3.1 vs 1.1%; P < .001), probiotic supplements (8.2% vs 1.3%; P < .001), and diet pills (0.5% vs 0.0%; P = .02). Male runners reported higher use of creatine (1.3% vs 0.0%; P < .001) and sport foods, including protein bars and drinks (19.5% vs 8.4%; P < .001), energy bars (23.5% vs 9.7%; P < .001), and carbohydrate-electrolyte drinks (27.9% vs 13.3%; P < .001) than female runners. Factors independently associated with a higher likelihood for dietary supplement use included weight loss in the past year, female (vs male) gender, following a vegetarian diet, skipping meals, attempting to gain weight, and history of a running-related bone stress injury.ConclusionsMore than one-quarter of preadolescent runners regularly consumed dietary supplements. Behaviors consistent with dietary restriction and history of bone stress injury were associated with higher likelihood for supplement use. Further work to understand supplement use patterns and potential value for nutrition education is advised to optimize health of preadolescent runners.     

Cancer Risk Factors,Diagnosis and Sexual Identity in the Australian Longitudinal Study of Women's Health

PurposeWe sought to examine cancer diagnosis, cancer treatment, and related risk factors among Australian, middle-aged, exclusively heterosexual women compared with sexual minority women (SMW; mainly heterosexual, bisexual, mainly lesbian, and lesbian).MethodsSecondary data analysis of the Australian Longitudinal Study of Women's Health for women born in 1946 through 1951 (n = 10,451) included bivariate tests (i.e., contingency table analyses, independent t tests).ResultsSMW did not have significantly higher cancer diagnoses compared with exclusively heterosexual women, although they were more likely to report never having had a mammogram or pap smear. SMW were also significantly more likely to be high-risk drinkers (11.1% vs. 6.8%; p < .05), current smokers (15.1% vs. 8.3%; p < .001), report significantly higher rates of depression (mean ± SD; 6.4 ± 5.5 vs. 5.4 ± 5.1; p < .01.), have experienced physical abuse (10.2% vs. 5.1%; p < .001), and been in a violent relationship (27.2% vs. 12.8%; p < .001).ConclusionSMW had higher rates of several known cancer risk factors, ostensibly placing them at higher risk of cancer as well as chronic health conditions. Further research is needed to determine whether increased risk results in increased cancer as these women age, and to inform the development of interventions to reduce the risk of disease for SMW.     

Sexual Minority College Undergraduate Students Have Worse Health-Related Quality of Life,Diet Quality,and Weight Dissatisfaction Than Their Heterosexual Peers

ObjectiveAssess the health-related quality of life (HRQOL), diet quality (DQ), and weight dissatisfaction in sexual minority (SM) undergraduates.MethodsUndergraduates (n = 690) at 2 universities completed a survey assessing HRQOL, body mass index, DQ, and weight dissatisfaction. A multivariate analysis of covariance assessed HRQOL between SM and heterosexual students. Chi-square tests and independent t tests measured weight dissatisfaction and DQ. P < 0.05 was considered statistically significant.ResultsSignificant differences in HRQOL were observed (F[6,584] = 8.89; P < 0.001; Wilk's Λ = 0.916; partial η² = 0.084). Sexual minority students experienced more days per month feeling sad/blue/depressed (12.0 ± 9.7 vs 6.3 ± 7.8 days; P < 0.001) and worried/tense/anxious (18.1 ± 10.2 vs 10.9 ± 9.8 days; P < 0.001); and fewer days feeling healthy and full of energy (6.8 ± 6.5 vs 11.4 ± 8.7 days; P < 0.001). Sexual minority students consumed more sugar (14.4 ± 7.9 g vs 10.2 ± 7.1 g; P = 0.020), had higher body mass indexes (25.8 ± 6.1 vs 24.4 ± 4.8; P = 0.005), and were less satisfied with their weight (30.7% vs 44.0%; P = 0.001).Conclusions and ImplicationsSexual minority undergraduates experience similar health disparities as other SM populations and have indicators of poorer DQ.     

Low Serum Selenium Level Is Associated With Low Muscle Mass in the Community-Dwelling Elderly

ObjectivesElderly persons with low muscle mass (LMM) or sarcopenia are prone to frailty and functional decline. This study aimed to investigate the relationship between serum selenium level and skeletal muscle mass in community-dwelling elderly.DesignCross-sectional observational study.Setting and participantsA total of 327 elderly Taipei citizens (mean age 71.5 ± 4.7 years) were recruited from the community.MeasurementsSkeletal muscle mass was measured by bioelectrical impedance analysis. LMM was defined by low skeletal muscle index (SMI: muscle mass (kg)/[height (m)]²). All participants were further divided into quartiles by serum selenium level and the risk for LMM among these quartiles was examined using multivariate logistic regression analyses. Estimated serum selenium levels for the LMM group vs the normal group and estimated SMI in the quartiles of serum selenium were computed by least square method in linear regression models.ResultsThe estimated mean (±standard deviation) of serum selenium level was significantly lower in the LMM group compared with the normal group after adjusting for confounders (1.01 ± 0.03 μmol/L vs 1.14 ± 0.02 μmol/L, P < .001). After adjusting for age, sex, lifestyle, and physical and metabolic factors, the odds ratios (95% confidence interval, P value) of LMM in the bottom, second, and third selenium quartile groups were 4.62 (95% CI 2.11–10.10, P < .001), 2.30 (95% CI 1.05–5.03, P < .05) and 1.51 (95% CI 0.66–3.46, P = .327), respectively, compared with the top quartile group of serum selenium level. The least square mean of SMI increased with the quartiles of serum selenium (P < .001).ConclusionsThis is the first study to demonstrate that low serum selenium is independently associated with low muscle mass in the elderly. The causality and underlying mechanism between selenium and low muscle mass or sarcopenia warrant further research.     

Clinical Characteristics and Prognostic Significance of Chronic Obstructive Pulmonary Disease in Patients With Atrial Fibrillation: Results From a Multicenter Atrial Fibrillation Registry Study

ObjectivesAtrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) are 2 common morbidities and often coexist. Studies have shown that COPD is a risk factor for cardiovascular disease, but the characteristics in patients with COPD and AF, as well as the impact of COPD on the outcomes of AF were lacking. The aim of present study was to analyze the clinical characteristics and to evaluate the association of COPD with 1-year outcomes in patients with AF.DesignLongitudinal observational study.ParticipantsA total of 1975 consecutive patients with AF were registered. Patients were divided into COPD group and non-COPD group according to whether AF coexisted with COPD.MeasurementsOutcome measures included all-cause mortality, stroke, and major adverse events (MAE) during 1-year follow-up.ResultsA group of 227 (11.5%) patients had concomitant COPD. Compared with non-COPD patients, patients with COPD were older and tended to have other coexisting cardiovascular morbidities, and had a significantly higher percentage of smoking history. Anticoagulation with warfarin was adopted by only a few patients both with and without COPD. During 1-year follow-up, the all-cause mortality and major adverse event rate in the COPD group were significantly higher than that of non-COPD group (26.9% vs 12.3%, P < .001 and 25.6% vs 19.1%, P = .027, respectively), whereas the incidence of stroke in the 2 groups was comparable (7.9% vs 7.4%, P = .788). Moreover, the cause-specific mortality between the 2 groups was comparable. After multivariate adjustments, COPD was still an independent risk factor for both1-year all-cause mortality [hazard rate (HR) = 1.491, 95% confidence interval (CI) 1.110–2.002, P = .008] and cardiovascular mortality (HR = 1.595, 95% CI 1.071–2.376, P = .022), but not a risk factor for stroke (HR = 0.879, 95% CI 0.527–1.464, P = .620).ConclusionsAnticoagulation treatment is inadequate in patients with AF and COPD. The presence of COPD in patients with AF is an independent risk factor for 1-year all-cause mortality and cardiovascular mortality but not a risk factor for stroke.     

A Randomized Controlled Trial of Heart Failure Disease Management in Skilled Nursing Facilities

ObjectivePatients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF.DesignCluster-randomized controlled trial.ParticipantsThe trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care).MethodsThe HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome.ResultsMean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant.Conclusions and ImplicationsThe composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients.     

Rejection of Care and Aggression among Older Veterans with Dementia: The Influence of Background Factors and Interpersonal Triggers

ObjectivesTo test relationships among background factors, interpersonal triggers, rejection of care, and aggression among veterans living with dementia in residential long-term care settings, based on the need-driven dementia-compromised behavior model.DesignA mixed methods secondary analysis of program evaluation data from the Staff Training in Assisted Living Residences-Veterans Health Administration intervention implemented by the US Department of Veterans Affairs healthcare system.Setting and ParticipantsIn total, 315 older veterans who participated in the 2013‒2016 Staff Training in Assisted Living Residences-Veterans Health Administration program at 76 Community Living Centers (Veterans Affairs-operated nursing homes).MethodsText data that captured the interdisciplinary team observations of distressed behaviors of concern and their circumstances were coded into categorical variables and then combined with existing quantitative data to test hypothesized relationships using structural equation modeling.ResultsRejection of care was directly affected by interpersonal triggers (β = 0.32, P < .005) and background factors such as depression (β = 0.29, P < .018), anxiety (β = −0.18, P < .023), and cognitive status (β = 0.10, P < .049). Depression also had an indirect effect on rejection of care through interpersonal triggers (α × β = 0.13 × 0.32 = 0.04, P < .012). Aggression was directly affected by both interpersonal triggers (β = 0.19, P < .009) and functional status (β = 0.17, P < .011). Both function (α × β = 0.12 × 0.19 = 0.02, P < .035) and depression (α × β = 0.13 × 0.19 = 0.03, P < .005) had indirect effects on aggression through interpersonal triggers.Conclusions and ImplicationsInterpersonal triggers influenced rejection of care and aggression in veterans with dementia. Background factors such as depression and severity of functional impairment increased the likelihood of these symptoms. Study findings emphasize the importance of developing and implementing interventions that improve interpersonal relationships and developing targeted interventions for those with depressive symptoms.     

The Impact of Subclinical Hypothyroidism on the Quality of Life During Pregnancy: Mapping 5-Level Version of EQ-5D and ThyPRO-39

ObjectivesTo describe how subclinical hypothyroidism (SubHypo) influences the quality of life (QoL) during pregnancy.MethodsIn primary data collection (NCT04167423), thyroid stimulating hormone (TSH), free thyroxine (FT4), thyroid peroxidase antibodies, generic quality of life (QoL; 5-level version of EQ-5D [EQ-5D-5L]), and disease-specific QoL (ThyPRO-39) were measured among pregnant women. SubHypo during each trimester was defined according to the 2014 European Thyroid Association guidelines (TSH > 2.5, 3.0, and 3.5 IU/L, respectively; with normal FT4). Path analysis described relationships and tested mediation. Linear ordinary least squares, beta, tobit, and two-part regressions were used to map ThyPRO-39 and EQ-5D-5L. Alternative SubHypo definition was tested in sensitivity analysis.ResultsA total of 253 women at 14 sites (31 ± 5 years old, 15 ± 6 weeks pregnant) completed the questionnaires. Sixty-one (26%) had SubHypo and differed from 174 (74%) euthyroid women in smoking history (61% vs 41%), primiparity (62% vs 43%) and TSH level (4.1 ± 1.4 vs 1.5 ± 0.7 mIU/L, P < .001). EQ-5D-5L utility in SubHypo (0.89 ± 0.12) was lower than that in euthyroid (0.92 ± 0.11; P = .028) even after adjustment (difference −0.04, P = .033), whereas ocular (P = .001, ThyPRO-39), cognitive symptoms (P = .043), anxiety (P < .0001), and the composite score were higher. The impact of SubHypo on utility was mediated by anxiety. Results were confirmed by sensitivity analysis. Final mapping equation (ordinary least squares) includes goiter symptoms, anxiety, upset stomach, composite score (ThyPRO-39), FT4 levels, and week of pregnancy (determination coefficient 0.36).ConclusionThis is the first QoL mapping of SubHypo during pregnancy and the first evidence that SubHypo is associated with a negative impact on QoL. The effect is mediated by anxiety. EQ-5D-5L utilities can be generated based on ThyPRO-39 scores collected in pregnant euthyroid and patients with SubHypo.     

A Randomized Trial of Alerting to Low Glycated Hemoglobin Level in Older Adults: Results of the Low Indexes of Metabolism Intervention Trial B (LIMIT-B)

ObjectivesThe benefit of alerting clinical staff to low plasma glycated hemoglobin (HbA1c) in patients aged 75 years and older who receive antidiabetic drugs remains uncertain.Design, Setting, and ParticipantsIn a randomized controlled trial, 1684 patients with HbA1c ≤ 6.5% who received antidiabetic drugs were assigned to have an e-mail alert sent to their physician, and 1643 were assigned to have no such alert (control group). The primary outcome of the trial was annual death. Secondary outcomes included antidiabetic drug dose reduction and HbA1c change.ResultsIn the first quarter, antidiabetic drug-defined daily doses were reduced on average by 10.4 ± 35.8 (16% ± 55%) in the intervention group and by 6.4 ± 36.1 (10% ± 56%) in the control group (difference −4.1 ± 1.2, 95% confidence interval [CI] −6.5 to −1.6; P = .001). Measured HbA1c levels were raised by a mean (± standard deviation) of 0.28 ± 0.77 in the intervention group and by 0.18 ± 0.57 in the control group (difference 0.10 ± 0.02, 95% CI –0.15 to −0.059, P < .001). One year after the alerts, 121 patients (7.2%) died in the intervention group and 107 patients (6.5%) died in the control group (relative risk 1.1, 95% CI 0.86-1.42; P = .44).Conclusions and ImplicationsIn this trial, alerting clinical staff to low HbA1c in patients aged 75 years and older treated with antidiabetic medicines was associated with mildly reduced antidiabetic doses and increased HbA1c but was not associated with a significant difference in survival rate compared with usual clinical care.     

Occult Nighttime Hypertension in Daytime Normotensive Older Patients With Obstructive Sleep Apnea

ObjectivesTo assess nighttime blood pressure (BP), the dipping phenomenon and the relationships between nighttime BP, and polysomnography parameters in older patients with obstructive sleep apnea (OSA) who have been identified by their primary care physician as being normotensive during the daytime.DesignCross-sectional study.SettingUniversity hospital-based geriatric sleep center.ParticipantsDaytime normotensive, community-dwelling older adults, consecutively referred by their primary care physicians for suspicion of OSA.MeasurementsOvernight polysomnography and 24-hour ambulatory blood pressure measurement (ABPM). Daytime hypertension defined as systolic BP ≥135 mm Hg and/or diastolic BP ≥85 mm Hg. Nighttime hypertension defined as systolic BP ≥120 mm Hg and/or diastolic BP ≥70 mm Hg. Dipper pattern characterized by nighttime fall of mean BP ≥10%.ResultsForty-five participants (30 OSA; 15 non-OSA) completed the study (76.9 ± 6.2 years old). ABPM indicated clinically significant nighttime systolic (132.5 ± 16.0) and diastolic (72.6 ± 9.4) hypertension in patients with OSA previously classified as daytime normotensives and found only a mild degree of nighttime systolic hypertension (123.7 ± 16.1) in patients without OSA (P = .105). A significant nondipping phenomenon was found in patients with OSA (–0.5 ± 7.4 vs 5.4 ± 6.4; P = .016). Nighttime mean BP (r = 0.301; P = .049) and dipping status (r = –0.478; P = .001) were correlated with apnea-hypopnea index. A significant correlation was found between systolic BP (r = 0.321; P = .035), diastolic BP (r = 0.373; P = .013), mean BP (r = 0.359; P = .018), and hypoxia (sleep time spend with SaO2 <90%).ConclusionDaytime normotensive older adults with OSA are at high risk for having occult nighttime hypertension. Thus, 24-hour ABPM may be appropriate for older patients with OSA whose clinical blood pressure does not display any daytime elevation.     

Rethinking the Relationship Between Spatiotemporal Gait Variables and Dementia: A Prospective Study

ObjectivesThe gait variables that are related to the risk of incident dementia have not yet been clarified. To examine whether quantitative gait variables can predict incident dementia in older adults.DesignA prospective study.SettingA community setting.ParticipantsThe study included 4011 participants (54% women; mean age 72.2 years).MeasuresGait speed, stride length, and stride length variability were measured at baseline. Dementia was prospectively confirmed from monthly updated medical records.ResultsThe mean follow-up duration was 42.8 months, and there were 245 incident cases of dementia. A receiver operating characteristic curve showed the cut-off value for each gait variable against incident dementia during follow-up using the Youden index (gait speed: 1.12 m/s; stride length: 1.15 m; stride length variability: 3.67%). Based on these cut-off values, Cox proportional hazards regression models showed that after adjusting for covariates, dementia was significantly related to slow gait speed [hazard ratio (HR) 1.49, 95% confidence interval (CI) 1.10-2.01, P = .011], short stride length (HR 1.77, 95% CI 1.29-2.41, P < .001), and high stride length variability (HR 1.58, 95% CI 1.20-2.08, P = .001). Similarly, in a subanalysis stratified by sex, all gait variables were significantly related to the rate of incident dementia during follow-up in both men and women (all P < .05).Conclusions/implicationsReduced gait function was related to incident dementia, and this association was independent of sex. Quantitative and multifaceted gait variables are valuable for assessing dementia risk.     

High-Intensity Interval and Resistance Training Improve Health Outcomes in Older Adults With Coronary Disease

ObjectiveBoth high-intensity interval training (HIIT) and resistance exercises (R) are used in cardiac rehabilitation in patients with coronary artery disease (CAD). However, the combined effect of an HIIT + R exercise program in older adults with CAD is not well investigated. The study's purpose was to assess the changes in anthropometric parameters, physical activity, functional capacity, physiological parameters, and quality of life (QoL) in this population following a combined HIIT + R program.DesignThe study was a 2-group (n = 45 each) randomized controlled single-blinded trial.Setting and ParticipantsThe study was done at a treatment clinic of a tertiary hospital. The mean age of participants was 69.23 ± 4.9 years. The HIIT + R group performed 8 sessions (1/wk) of HIIT + R training. The 30 minutes of the active exercise phase consisted of ten 3-minute bouts. Each bout comprised of 1 minute of high-intensity treadmill walking at 85% to 90% maximum heart rate (MHR), followed by a low-intensity walking at 60%-70% MHR, followed by low-to moderate-intensity resistance training. The Usual Care group underwent conventional medical treatment.MeasuresAnthropometric measurements [weight, body mass index (BMI), waist circumference, body fat percentage, lean body mass], physical activity (International Physical Activity Questionnaire), functional capacity (Incremental Shuttle Walking Test), physiologic measurements (blood pressure, heart rate), and QoL (36-Item Short Form Health Survey) were measured pre- and postintervention.ResultsSignificant group and time interaction were found for the participants in the HIIT + R Group for BMI (P = .001), body fat percentage (P = .001), waist circumference (P < .001), physical activity (P < .001), functional capacity (P < .001), and QoL (P = .001) compared with the UC Group. Significant improvement in systolic blood pressure (P = .001) was seen in the HIIT + R group.Conclusions and ImplicationsA combined HIIT + R training protocol in older adults with CAD can be useful in producing desired health outcomes. Further evaluation of longer duration exercise programs with more frequent dosing needs to be evaluated for their benefits and sustainability.     

Association of Creatinine-to-Cystatin C Ratio with Myosteatosis and Physical Performance in Older Adults: The Japan Shimanami Health Promoting Program

ObjectiveSarcopenia is a risk factor for poor outcomes in older adults. Identification of plasma markers may facilitate screening of sarcopenia. We previously reported that creatinine-to-cystatin C ratio is a simple marker of muscle mass. To further assess the clinical relevance of the creatinine-to-cystatin C ratio, we investigated its association with myosteatosis and physical performance.DesignObservational study.Setting and ParticipantsCross-sectional analysis of the dataset obtained from a Japanese population consisting of 1468 older (≥60 years of age) community residents.MethodsThe mean attenuation values of the skeletal muscle calculated from computed tomography images of the midthigh were used as an index of myosteatosis, while the cross-sectional area of the muscle was used as a proxy for muscle mass. Physical performance was assessed by 1-leg standing time.ResultsCreatinine-to-cystatin C ratio was positively associated with the cross-sectional area of muscle fiber-rich muscles, while it showed an inverse association with fat-rich muscle areas, resulting in the positive association between creatinine-to-cystatin C ratio and the mean attenuation value of the skeletal muscle [creatinine-to-cystatin C ratio quartiles (Q), Q1: 47.4 ± 4.8, Q2: 48.9 ± 4.4, Q3: 49.8 ± 4.1, Q4: 50.9 ± 3.7, P < .001]. The results of the linear regression analysis adjusted for major covariates (including muscle cross-sectional area) identified creatinine-to-cystatin C ratio as an independent determinant of the mean attenuation value (Q1: reference, Q2: β = 0.07, P = .019, Q3: β = 0.11, P < .001, Q4: β = 0.16, P < .001). Low creatinine-to-cystatin C ratio was independently associated with 1-leg standing time, although the association was attenuated substantially by adjusting for skeletal muscle cross-sectional area and mean attenuation value.Conclusion and ImplicationsCreatinine-to-cystatin C ratio was associated with myosteatosis in older adults, independent of the muscle mass. Creatinine-to-cystatin C ratio may serve as a convenient marker of sarcopenia.     

Time Trends in Opioid Use by Dementia Severity in Long-Term Care Nursing Home Residents

ObjectiveCurrent information on opioid use in nursing home residents, particularly those with dementia, is unknown. We examined the temporal trends in opioid use by dementia severity and the association of dementia severity with opioid use in long-term care nursing home residents.DesignRepeated measures cross-sectional study.SettingLong-term care nursing homes.ParticipantsUsing 20% Minimum Data Set (MDS) and Medicare claims from 2011-2017, we included long-term care residents (n = 734,739) from each year who had 120 days of consecutive stay. In a secondary analysis, we included residents who had an emergency department visit for a fracture (n = 12,927).MeasurementsDementia was classified as no, mild, moderate, and severe based on the first MDS assessment each year. In the 120 days of nursing home stay, opioid use was measured as any, prolonged (>90 days), and high-dose (≥90 morphine milligram equivalent dose/day). For residents with a fracture, opioid use was measured within 7 days after emergency department discharge. Association of dementia severity with opioid use was evaluated using logistic regression.ResultsOverall, any opioid use declined by 8.5% (35.2% to 32.2%, P < .001), prolonged use by 5.0% (14.1% to 13.4%, P < .001), and high-dose by 21.4% (1.4% to 1.1%, P < .001) from 2011 to 2017. Opioid use declined across 4 dementia severity groups. Among residents with fracture, opioid use declined by 9% in mild, 9.5% in moderate, and 12.3% in severe dementia. The odds of receiving any, prolonged, and high-dose opioids decreased with increasing severity of dementia. For example, severe dementia reduced the odds of any [23.5% vs 47.6%; odds ratio (OR) 0.56, 95% confidence interval (CI) 0.55-0.57], prolonged (9.8% vs 20.7%; OR 0.69, 95% CI 0.67-0.71), and high-dose (1.0% vs 2.3%; OR 0.69, 95% CI 0.63-0.74) opioids.Conclusions and ImplicationsUse of opioids declined in nursing home residents from 2011 to 2017, and the use was lower in residents with dementia, possibly reflecting suboptimal pain management in this population.