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Cognitive and Physical Decline in Older Adults Associated with Severe Sepsis

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Older adults who survive hospitalization involving severe sepsis, a serious medical condition caused by an overwhelming immune response to severe infection, are at higher risk for cognitive impairment and physical limitations than older adults hospitalized for other reasons, researchers have found.

The research, conducted by the University of Michigan and supported primarily by the National Institute on Aging (NIA), part of the NIH, appears in the Oct. 27, 2010, issue of the Journal of the American Medical Association.

Theodore J. Iwashyna, M.D., Ph.D., and colleagues found that an older person’s risk of cognitive decline increased almost threefold following hospitalization for severe sepsis. They also found that severe sepsis was associated with greater risk for the development of at least one new limitation in performing daily activities following hospitalization.

“Sepsis is common in older people and has a high mortality rate,” said NIA Director Richard J. Hodes, M.D. “This study shows that surviving sepsis may bring substantial and under-recognized problems with major implications for patients, families and the health care system.”

In sepsis, immune system chemicals released into the blood to combat serious infection trigger widespread inflammation. This can lead to low blood pressure, heart weakness, and organ failure. Anyone can get sepsis, but infants, children, older people, and those with weakened immune systems are most vulnerable. People with sepsis often receive treatment in hospital intensive care units to combat the infection, support vital organs and prevent a drop in blood pressure.

“This study should help change the way we think about severe sepsis,” said Iwashyna. “We usually think of severe sepsis as a medical emergency and focus our efforts on making sure the patient survives. This study shows that survivors often have severe problems for years afterwards.”

Using data from the NIA-supported Health and Retirement Study (HRS), the researchers analyzed the cognitive and physical function of older people before and after hospitalization for severe sepsis. The HRS is a long-term study that collects information on the health, economic and social factors influencing the health and well-being of a nationally representative sample of Americans over age 50. Study data on participants 65 and older are linked to Medicare claims data to enable detailed analysis of medical conditions and health status.

The scientists analyzed Medicare claims data from 516 people who survived 623 hospitalizations for severe sepsis between 1998 and 2005. The average age of participants was 77 at the time of hospitalization. The researchers also examined the individuals’ HRS data on cognitive function, measured through standard tests. Physical limitations were measured by the need for assistance in six activities of daily living basic self-care tasks (walking, dressing, bathing, eating, toileting and getting into and out of bed) and five instrumental activities of daily living (preparing a hot meal, shopping for groceries, making telephone calls, taking medicines and managing money), which are associated with the ability to live independently. For comparison, the researchers analyzed Medicare and HRS data on 4,517 survivors of 5,574 non-sepsis general hospitalizations during this time period.

Almost 60 percent of hospitalizations for severe sepsis were associated with worsened cognitive and/or physical function among survivors in the first survey following hospitalization. The risk of progression to moderate or severe cognitive impairment in sepsis survivors was 3.33 times higher than their risk before hospitalization. Severe sepsis was associated with the development of 1.57 new functional limitations among patients with no limitations before sepsis. In contrast, patients who did not develop sepsis and had no functional limitations before hospitalization developed an average of 0.48 new functional limitations. Non-sepsis hospital admissions were not associated with an increased risk for cognitive decline.

“This is one of more than a thousand research papers that have used Health and Retirement Study data,” said Richard Suzman, Ph.D., director of the NIA’s Division of Behavioral and Social Research, which supports the HRS. “The uniquely rich HRS dataset enabled the analysis of both cognitive and physical function in relation to hospitalization for a very specific medical condition. I look forward to the investigators refining their findings in the future.”

Source: NIH, October 26, 2010

Elderly with Untreated Vision Problem More Likely to Develop Alzheimer’s

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Elderly people with visual disorders that are left untreated are significantly more likely to develop Alzheimer’s disease — the most common form of dementia, according to a University of Michigan Health System study.

The study used Medicare data and shows that those with poor vision who visited an ophthalmologist at least once for an examination were 64 percent less likely to develop dementia.

The study appears online ahead of print in the American Journal of Epidemiology and may draw a new picture of poor vision as predictor of dementia rather than as a symptom after the diagnosis.

“Visual problems can have serious consequences and are very common among the elderly, but many of them are not seeking treatment,” says lead author Mary A.M. Rogers, Ph.D, research assistant professor of internal medicine at the U-M Medical School and research director of the Patient Safety Enhancement Program at the U-M Health System and the Ann Arbor VA Medical Center.

For the study, Rogers and her colleague Kenneth M. Langa, M.D., Ph.D., professor of internal medicine at U-M Medical School, analyzed data from the nationally representative Health and Retirement Study and records from Centers for Medicare and Medicaid Services.

”Our results indicate that it is important for elderly individuals with visual problems to seek medical attention so that the causes of the problems can be identified and treated,” Rogers says.

The types of vision treatment that were helpful in lowering the risk of dementia were surgery to correct cataracts and treatments for glaucoma, retinal disorders and other eye-related problems.

Proper vision is a requirement for many of the activities that previously have been found to lower the risk of Alzheimer’s disease. These include reading, playing board games, other mentally stimulating activities, social networking, as well as physical activity such as walking and routine exercising. A visual disorder may interfere with normal mobility and may also hinder a person’s ability to participate in such activities.

“Many elderly Americans do not have adequate health coverage for vision, and Medicare does not cover preventative vision screenings for most beneficiaries,” Rogers says. “So it’s not unusual that the elderly receive vision treatment only after a problem is severe enough to warrant a visit to the doctor when the problem is more advanced.”

According to a survey conducted by the National Eye Health Education Program, less than 11 percent of respondents understood that there are no early warning signs for eye problems such as glaucoma and diabetic retinopathy.

However, vision problems and blindness are among the top 10 disabilities among adults and can result in a greater tendency to experience other health conditions or even to die prematurely.

“While heart disease and cancer death rates are continuing to decline, mortality rates for Alzheimer’s disease are on the rise,” says Rogers. “So if we can delay the onset of dementia, we can save individuals and their families from the stress, cost and burden that are associated with Alzheimer’s disease.”

The study was based on the surveys and medical information from 625 people compiled from 1992-2005. Only 10 percent of Medicare beneficiaries who developed dementia had excellent vision at the beginning of the study, while 30 percent of those who maintained normal cognition had excellent vision at the onset of the study.

One in five Americans who are over age 50 report experiencing a visual impairment, according to the U.S. Centers for Disease Control and Prevention. Approximately 5 million Americans have Alzheimer’s disease and the number has doubled since 1980. It is expected to be as high as 13 million by 2050.

Source: American Journal of Epidemiology,/em> 2010 Feb. 11; doi:10.1093; University of Michigan

Brain Changes in Elderly Can Affect Mobility and Balance

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Changes in the brain can affect old people’s mobility and balance, according to a recent study. Particularly affecting balance and walking are white matter changes called leukoaraiosis.

The 639 men and women between the ages of 65 and 84 in the study underwent brain scans and walking and balance tests. 284 people in the group had mild age-related white matter changes, 197 moderate changes, and 158 severe changes.

People with severe white matter changes were twice as likely to score poorly on the walking and balance tests as people with mild white matter changes, the study found. The people with severe changes were also twice as likely as those with mild changes to have a history of falls. The moderate group was only one and a half times as likely as the mild group to have a history of falls.

"Walking difficulties and falls are major symptoms of people with white matter changes and a significant cause of illness and death in the elderly," said study author Hansjoerg Baezner, MD, PhD, with the University of Heidelberg in Mannheim, Germany. "Exercise may have the potential to reduce the risk of these problems since exercise is associated with improved walking and balance. We’ll be testing whether exercise has such a protective effect in our long-term study of this group."

"Mobility is one of the key determinants of independent aging," said Baezner. "Limitations in mobility often lead to hospitalization and nursing home placement. This will become a major problem for our social and economic systems in the upcoming decades."

Published in Neurology, the medical journal of the American Academy of Neurology,the 3-year study was coordinated by the Department of Neurological and Psychiatric Sciences of the University of Florence.

Source: Neurology, March 18, 2008

Older Adults Can Recover Well from Anterior Cruciate Ligament Surgery (ACL)

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Today, older adults are staying active much longer, making them susceptible to injuries—especially vulnerable to tearing their anterior cruciate ligament (ACL).

A new study presented today at the 75th Annual Meeting of the American Academy of Orthopaedic Surgeons, found that these active baby boomers who undergo ACL surgery are about as likely to return to pre-injury levels of activity as much younger people. These findings have led researchers to conclude that age itself should not be a factor when determining candidates for the increasingly common knee-ligament surgery.

"Twenty years ago we did not see older patients being so active later in life. ACL surgery was rarely considered for people in their 40s and 50s," said Diane Dahm, MD, assistant professor of orthopaedic surgery at the Mayo Clinic in Minnesota."Older patients today want to continue to run, play basketball and be active late into life, so they need a level of knee stability that will support an active lifestyle."

The study followed the recovery of 34 patients aged 50 to 66 for an average of 48 months between 1990 and 2002 following ACL surgery at the Mayo Clinic. Patients with injuries to multiple knee ligaments were excluded.

The study found that after ACL surgery:

  • 83 percent were rated as normal or near-normal
  • 83 percent returned to playing sports
  • patients went from 4.3 before surgery to 8.3 postoperatively on the UCLA ( University of California at Los Angeles), activity score
  • five of the 34 patients required additional knee surgery

"Today’s active baby boomers are pushing the envelope for when people are considered to be too old for ACL surgery," concluded Dr. Dahm."When considering candidates for ACL surgery, people’s fitness levels and their desire to return to an active lifestyle should be taken into account rather than looking at age."

The ACL is one of the most commonly injured ligaments of the knee. The incidence of ACL injuries is currently estimated at approximately 200,000 annually, with 100,000 ACL reconstructions performed each year. In general, the incidence of ACL injury is higher in people who participate in high-risk sports, such as basketball, football, skiing and soccer.

Fractured Shoulder May Lead to Higher Incidence of Broken Hip in Older Women

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Older women who suffer a broken shoulder (proximal humerus fracture) have a high risk for also breaking a hip within a year after the shoulder injury.

A new study presented today at the 75th Annual Meeting of the American Academy of Orthpaedic Surgeons (AAOS), found that after a shoulder fracture a woman’s risk of fracturing a hip within the following year was five times greater. The risk decreased after the first year but still remained elevated.

Understanding the connection between these injuries is important to preventing hip fractures. Hip fractures account for more than 350,000 hospital admissions in the United States and more than 60,000 nursing home admissions each year. Women have greater risk because of their higher susceptibility to osteoporosis.

Statistics show:

  • about 70 percent of hip fracture patients are women
  • more than 4 percent of hip fracture patients die during their initial hospitalization
  • 24 percent die within a year of the injury
  • about half of women who sustain hip fractures lose the ability to walk independently

Preventing hip fracture poses s a significant quality-of-life issue. "Earlier studies have shown that there is an increased risk of hip fracture after a proximal humerus fracture, but our study found that there is a defined window of time in which the risk is much greater than previously thought. Additionally, other research has shown that interventions within the first three months can reduce the risk of subsequent fractures," said Jeremiah Clinton, MD, co-author of the study and acting clinical instructor at the University of Washington, Department of Orthopaedics. "If we maximize our hip-fracture prevention efforts up front, we may have a much better chance of helping the patient avoid a life-changing and potentially life-ending injury."

The study followed a group of older, Caucasian women for nearly 10 years and found that, while 8 percent of women who did not break a shoulder suffered hip fractures, approximately 14 percent of those who suffered a shoulder fracture later sustained a hip fracture.

The strongest risk factors for hip fracture were age and hip bone mineral density. Other factors included:

  • self-reported health status
  • height at 25 years of age
  • history of recent falls
  • impaired depth perception
  • history of prior fractures

Even when controlling these factors, the researchers still found the increased risk for hip fracture in the first year after a proximal humerus fracture. The reasons for the connection between humerus fracture and hip fracture are still unclear. "It may be associated medical problems, limited use of the injured shoulder, or there could be something about the treatment for the first fracture, such as narcotic pain medications, which could have caused the patient to fall and break a hip," Dr. Clinton said. "Now that we are aware of the relationship between these types of fractures, we can take precautions, intervene early and hopefully help to prevent some hip fractures from occurring."

Cognitive Impairment Among Older Americans Decreasing

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A recent study shows a downward trend in the rate of cognitive impairment among people aged 70 and older. The study was led by two University of Michigan Medical School physicians and their colleagues, and is based on data from the Health and Retirement Study (HRS), a national survey of older Americans funded by the National Institute on Aging and based at the U-M Institute for Social Research (ISR).

"From these results, we can say that brain health among older Americans seems to have improved in the decade studied, and that education and wealth may be a big piece of the puzzle," says lead author Kenneth Langa, M.D., Ph., an associate professor of internal medicine who also holds appointments in ISR and the VA Ann Arbor Healthcare System.

Between 1993 and 2002 the incidence of cognitive impairment in this age group decreased by 3.5%, or hundreds of thousands of people. The reasons for this decline are not yet known, but the authors of the survey state that older people today have had more formal education, higher economic status and better care for risk factors—high blood pressure, high cholesterol, and smoking – that can endanger their brains. Of the 11,000 people in the study, those with more formal education and personal wealth were less likely to have cognitive problems.

The study was publishe in the the online edition of the journal Alzheimer’s and Dementia.

Source: Alzheimer’s & Dementia, Feb 18, 2008, online edition.

Study Suggests Folate Deficiency Increases Dementia Risk Three-Fold

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Recent research suggests that the risk of dementia in elderly people is increased three times by a lack of folate.

518 people were monitored for the development of dementia during the years 2001 through 2003. All subjects were aged 65 and over and lived in either a rural or urban community in the southern part of the country. Tests were carried out at the beginning and end of the 2-year period to check for any dementing illnesses. Blood tests were also conducted to measure levels of folate, vitamin B12, and the protein homocysteine, and how these changed over time. High levels of homocysteine have been associated with cardiovascular disease.

At the beginning of 2001, almost 20% of people monitored hd high levels of homocysteine, 3.5% were folate deficient, and 17% had low vitamin B12 levels.The higher the beginning levels of folate, the higher were vitamin B12 levels, and the lower were those of homocysteine.

By the end of 2003, 45 people had developed dementia, and of these 34 had Alzheimer’s disease, 7 had vascular dementia and 4 had other types of dementia. It was observed that dementia was more probable in the older, poorly educated and inactive subjects, and among those who had deposits of th protein ApoE.

People whose folate levels fell during the 2-year period were significantly more likely to develop dementia, while their homocysteine levels rose. People who were folate deficient to begin with, were almost 3.5 times more likely to develop dementia.

The research was published in the Journal of Neurology Neurosurgery and Psychiatry.

Source: J Neurol Neurosurg Psychiatry 2008; doi 10.1136/jnnp.2007.131482

Diabetes On Increase Among Older Americans

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The number of Americans aged 65 and older diagnosed with diabetes increased by 23% between 1994-1995 and, and 2003-2004.

"The prevalence of diabetes mellitus is increasing, in part because of population aging, but also in younger persons," the report notes. The high rate of existing diabetes also contributes to a high rate of diabetes-related complications and premature death. According to the authors, "awareness of the importance of active monitoring and management of diabetes has become more widespread; however, adherence to recommended practices remains low."

Medicare data for patients diagnosed with diabetes during 1964 (33,164), 1999 (931,722) and 2003 (40,058) was analyzed by Dr. Frank A. Sloan, Ph.D., and colleagues at the Duke University Medical Center, Durham, North Carolina. A comparison of this data was run with that of two control groups made up of people without diabetes but of similar race and ethnicity to those with the disease. Death and complications associated with diabetes such as cardiovascular, cerebrovascular, ophthalmic, renal, and lower extremities were recorded.

"The annual incidence of diabetes increased by 23 percent between 1994 to 1995 and 2003 to 2004, and prevalence increased by 62 percent," the authors write. The death rate after diagnosis decreased by 8.3% compared with people who did not have the disease.

"Complication rates among persons diagnosed as having diabetes generally increased or stayed the same compared with those in the control groups during 1994 to 2004 except for ophthalmic diseases associated with diabetes," the authors note. "In some cases, most notably renal events, including the most serious complications, there were increases in prevalence in both the diabetes and control groups."

The authors emphasized that diabetes created a 90% adverse outcome, with coronary heart failure, heart attack, and stroke prevalent, concluding that the problem of providing medical care for people over 65 with diagnosed diabets and paying for it, is growing rapidly.

Source: Archives of Internal Medicine, January 29, 2008

One in Seven Americans Over 70 Has Dementia

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A new analysis suggests that about 3.4 million Americans over 70 years of age—one in seven people in that age group—has dementia, and 2.4 million of them have Alzheimer’s disease (AD).

The study was published online this week in Neuroepidemiology, and is the first to estimate rates of dementia and AD using a nationally representative sample of older adults across the United States.

The study highlights the nationwide reach of dementia, which affects not only those with the disease, but their families and communities as well. "As the population ages during the next few decades, the prevalence of Alzheimer’s disease will increase several-fold unless effective interventions are discovered and implemented," said National Institute on Aging Director Richard J. Hodes, M.D. "These data underscore the urgency of research in this area."

The study included 856 HRS participants over the age of 70 from 42 states in 2001-2003. Aging, Demographics and Memory Study (ADAMS) interviewers from Duke University Medical School conducted at-home evaluations to gather information about each participant’s cognitive and functional status and symptoms, neuropsychiatric symptoms, current medications, medical history and family history of memory problems. Prior neuroimaging and laboratory results were also obtained.

A team of clinicians reviewed the evaluation information and made a preliminary assessment of each person’s cognitive status. A consensus panel of other medical experts then used well-accepted diagnostic criteria to determine if the participant had normal cognitive function, cognitive impairment without dementia, or dementia. Such criteria further were used to discern the type of dementia, including AD or vascular dementia, the second most common cause of dementia in older adults.

Based on the experts’ classifications, Drs. Plassman and Langa and co-authors estimated the national prevalence and total numbers of people age 71 and older, by age group, with any dementia and with AD or vascular dementia in 2002. According to their calculations, 13.9 percent of Americans age 71 and older have some type of dementia, 9.7 percent of Americans in that age group have AD, and 2.4 percent have vascular dementia. AD accounted for about 70 percent of all dementia cases among people 71 and older.

As in other studies, the ADAMS analysis showed that the prevalence of dementia increases significantly with age. Five percent of people ages 71 to 79, 24.2 percent of people 80 to 89, and 37.4 percent of those 90 years or older were estimated to have some type of dementia. The estimated rate of Alzheimer’s also rose greatly with older age — from 2.3 percent of people ages 71 to 79 to 18.1 percent of people 80 to 89 to 29.7 percent of those age 90 and older. The ADAMS investigators found fewer years of education and the presence of at least one APOE e4 allele, a genetic risk factor for AD, to be strong predictors of AD and other dementias.

Richard Suzman, Ph.D., director of NIA’s Behavioral and Social Research Program, which jointly directs the HRS, said the ADAMS data will prove particularly valuable not only in assessing the prevalence of dementia, but also its impact. "ADAMS, with its link to the data about the health, economic, and family resources of individuals in the study, will help us to characterize more fully the burden of dementia on individuals, caregivers and the nation’s health care system," he says.

The ADAMS report is the latest published study to estimate the prevalence of dementia and AD among older Americans. "These assessments have provided a range of estimates, based on differing methodologies and approaches," explains Dallas Anderson, Ph.D., program director for population studies in NIA’s Dementias of Aging Branch.

For example, some studies have included lower age ranges than ADAMS or broader characterizations of dementia, or have sampled participants in a specific community as a base for national extrapolations. A study reported in 1998 (Brookmeyer et al., 1998) combined incidence data from four community-based studies, estimating that national Alzheimer’s prevalence among individuals age 60 years or older would rise from 2.3 million in 1997 to 8.6 million in 2047. Widely cited estimates based on the prevalence of Alzheimer’s disease in a Chicago-based community (Hebert et al., 2003), and an earlier comparable study using data from East Boston (Evans et al., 1990) forecast the number of those age 65 or older with AD to be 5.1 million in 2010.

Despite the varied approaches and findings, however, NIA experts point out, the numbers of people with dementia, and Alzheimer’s specifically, will certainly increase until ways to delay the progression or prevent the dementia are found. Advancing age is the most common known risk factor for Alzheimer’s disease.

The HRS is an ongoing national survey of 22,000 adults age 51 and older that began in 1992, providing data that helps researchers, policy makers and others understand the life circumstances of older adults and help address the challenges of the nation’s rapidly aging population.

NIA leads the federal effort supporting and conducting research on aging and the medical, social and behavioral issues of older people, including AD and age-related cognitive change.

The National Institutes of Health (NIH) — The Nation’s Medical Research Agency — includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. It is the primary federal agency for conducting and supporting basic, clinical and translational medical research, and it investigates the causes, treatments, and cures for both common and rare diseases.

Brenda L. Plassman, Ph.D., of Duke University Medical Center, with Kenneth M. Langa, M.D., Ph.D., and David R. Weir, Ph.D., of the University of Michigan, Robert B. Wallace, Ph.D., of the University of Iowa, and others, conducted the analysis as part of the Aging, Demographics and Memory Study (ADAMS). ADAMS is a sub-study of the larger Health and Retirement Study (HRS), the leading resource for data on the combined health and economic circumstances of Americans over age 50. ADAMS and the HRS are sponsored by the National Institute on Aging, a component of NIH, under a cooperative agreement with the University of Michigan.

Source: National Institutes of Health, October 30, 2007

Rate of Memory Loss Greater in Dementia Patients With More Education

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According to a recent study in the journal Neurology, while higher education levels initially delay the onset of dementia, once dementia starts, the rate of memory loss is more rapid than in less educated individuals.

According to study author Charles B. Hall, PhD of the Albert Einstein College of Medicine, "our study showed that a person with 16 years of formal education would experience a rate of memory decline that is 50% faster than someone with just four years of education."

The study started in the 1980s, and monitored 488 people born between 1894 and 1906, with study findings based on the 117 members of the sample who eventually developed Alzheimer’s or some other form of dementia. Study participants ranged from people with postgraduate education to people with less than three years of elementary school education.

Dr. Hall believes that this rapid decline in the more educated people might be explained by their having a greater cognitive reserve, or the brain’s ability to maintain function in spite of damage. This meant that while patients are often diagnosed with dementia at a later date, once the cognitive reserve is no longer able to compensate for the damage that has occurred, then the symptoms emerge.

The study is valuable, says Dr. Hall, because it examines memory loss before a formal diagnosis of Alzheimer’s.

The study was supported by the National Institute on Aging. Other researchers from the Einstein Aging Study involved in the research included Carol Derby, PhD; Aaron LeValley, MA; Mindy J. Katz, MPH; Joe Verghese, MD; and Richard B. Lipton, MD.

Source: Neurology, October 23, 2007