Marco Inzitari

Gait Speed and Survival in Older Adults

CONTEXT Survival estimates help individualize goals of care for geriatric patients, but life tables fail to account for the great variability in survival. Physical performance measures, such as gait speed, might help account for variability, allowing clinicians to make more individualized estimates. OBJECTIVE To evaluate the relationship between gait speed and survival. DESIGN, SETTING, AND PARTICIPANTS Pooled analysis of 9 cohort studies (collected between 1986 and 2000), using individual data from 34,485 community-dwelling older adults aged 65 years or older with baseline gait speed data, followed up for 6 to 21 years. Participants were a mean (SD) age of 73.5 (5.9) years; 59.6%, women; and 79.8%, white; and had a mean (SD) gait speed of 0.92 (0.27) m/s. MAIN OUTCOME MEASURES Survival rates and life expectancy. RESULTS There were 17,528 deaths; the overall 5-year survival rate was 84.8% (confidence interval [CI], 79.6%-88.8%) and 10-year survival rate was 59.7% (95% CI, 46.5%-70.6%). Gait speed was associated with survival in all studies (pooled hazard ratio per 0.1 m/s, 0.88; 95% CI, 0.87-0.90; P < .001). Survival increased across the full range of gait speeds, with significant increments per 0.1 m/s. At age 75, predicted 10-year survival across the range of gait speeds ranged from 19% to 87% in men and from 35% to 91% in women. Predicted survival based on age, sex, and gait speed was as accurate as predicted based on age, sex, use of mobility aids, and self-reported function or as age, sex, chronic conditions, smoking history, blood pressure, body mass index, and hospitalization. CONCLUSION In this pooled analysis of individual data from 9 selected cohorts, gait speed was associated with survival in older adults.

Gait Speed Predicts Decline in Attention and Psychomotor Speed in Older Adults: The Health Aging and Body Composition Study

Background/Aims: Gait speed is cross-sectionally associated with attention and psychomotor speed in older community dwellers. It is unclear if gait speed predicts decline in these cognitive domains over time. Methods: Usual gait speed (m/s) over 6 m was measured at baseline in 2,776 Health, Aging and Body Composition Study participants (mean age ± SD 73.5 ± 2.8 years, 53% women, 37% blacks). The Digit Symbol Substitution Test (DSST) was administered at baseline and after 5 years to assess attention and psychomotor speed. We used multivariate logistic regression models to calculate the risk of DSST 5-year decline [>1 SD from mean change (9 points)] across quartiles of gait speed, adjusting for demographics, weight, physical activity, comorbidities, depression and Modified Mini-Mental State Examination. Results: After 5 years, 389 (17.1%) participants declined in DSST. Compared to those in the highest quartile of gait speed (>1.35 m/s), participants in the lowest quartile (<1.05 m/s) were more likely to decline in DSST independently of the considered covariates (OR 1.74, 95% CI 1.21–2.51, adjusted p for trend across quartiles = 0.006). Conclusions: In this cohort of older community dwellers, gait speed independently predicted a decline in DSST after 5 years.

Predictive Validity of Measures of Comorbidity in Older Community Dwellers: The Insufficienza Cardiaca negli Anziani Residenti a Dicomano Study

OBJECTIVES: To compare the ability of five measures of comorbidity to predict mortality and incident disability in basic activities of daily living (BADLs) in unselected older persons.

Whole-Brain Histogram and Voxel-Based Analyses of Diffusion Tensor Imaging in Patients with Leukoaraiosis: Correlation with Motor and Cognitive Impairment

BACKGROUND AND PURPOSE: Cerebral white matter changes, termed leukoaraiosis (LA), appearing as areas of increased signal intensity in T2-weighted MR images, are common in elderly subjects, but the possible correlation of LA with cognitive or motor deficit has not been established. We hypothesized that histogram and voxel-based analyses of whole-brain mean diffusivity (MD) and fractional anisotropy (FA) maps calculated from diffusion tensor imaging (DTI) could be more sensitive tools than visual scales to investigate the clinical correlates of LA. MATERIALS AND METHODS: Thirty-six patients of the Leukoaraiosis and Disability Study were evaluated with fluid-attenuated inversion recovery for LA extension, T1-weighted images for volume, and DTI for MD and FA. The extent of LA was rated visually. The normalized total, gray, and white matter brain volumes were computed, as well as the 25th percentile, 50th percentile, kurtosis, and skewness of the MD and FA maps of the whole brain. Finally, voxel-based analysis on the maps of gray and white matter volume, MD, and FA was performed with SPM2 software. Correlation analyses between visual or computerized data and motor or neuropsychologic scale scores were performed using the Spearman rank test and the SPM2 software. RESULTS: The visual score correlated with some MD and FA histogram metrics (P < .01). However, only the 25th and 50th percentiles, kurtosis, and skewness of the MD and FA histograms correlated with motor or neuropsychologic deficits. Voxel-based analysis revealed a correlation (P < .05 corrected for multiple comparisons) between a large cluster of increased MD in the corpus callosum and pericallosal white matter and motor deficit. CONCLUSIONS: These results are consistent with the hypothesis that histogram and voxel-based analyses of the whole-brain MD and FA maps are more sensitive tools than the visual evaluation for clinical correlation in patients with LA.

Risk and Predictors of Motor-Performance Decline in a Normally Functioning Population-Based Sample of Elderly Subjects: The Italian Longitudinal Study on Aging

OBJECTIVES: To examine risk and predictors of motor‐performance (MP) decline targeting subjects performing normally at an initial observation.

Subtle Neurological Abnormalities as Risk Factors for Cognitive and Functional Decline, Cerebrovascular Events, and Mortality in Older Community-Dwelling Adults

BACKGROUND Subtle, but clinically detectable, neurological abnormalities (SNAs) are associated with impaired physical performance in elderly persons without overt neurological diseases. We investigated whether SNAs were prospectively associated with cognitive and functional status, death, and cerebrovascular events (CVEs) in older community-dwelling individuals. METHODS In participants without history of stroke, parkinsonism and dementia, or cognitive impairment, a score (N(SNA)) was obtained by summing SNAs detected with a simple neurological examination. Cognitive status and disability were reassessed 4 years later, and deaths and CVEs were documented over 8 years. RESULTS Of 506 participants free of neurological diseases (mean [SEM] age, 71.9 [0.3] years; 42% were men), 59% had an N(SNA) of 1 or more (mean [SEM], 1.1 [0.06]; range, 0-8). At baseline, the N(SNA) increased with age and with declining cognitive and physical performance, depressive symptoms, and disability, after adjusting for several covariates, but did not increase with falls and urinary incontinence. The N(SNA) prospectively predicted worsening cognitive status and disability, adjusting for demographics and for baseline comorbidity and cognitive and physical performance. The mortality rates were 22.6, 23.3, 23.9, 58.6, and 91.9 per 1000 person-years in participants with an N(SNA) of 0, 1, 2, 3, and 4 or higher, respectively. Compared with an N(SNA) of less than 3, having an N(SNA) of 3 or higher was associated with an increased adjusted risk of death (hazard ratio, 1.77; 95% confidence interval [CI], 1.25-2.74) and of CVE (hazard ratio, 1.94; 95% CI, 1.07-3.54) over 8 years. CONCLUSION In this sample of older community-dwelling persons without overt neurological diseases, multiple SNAs were associated with cognitive and functional decline and independently predicted mortality and CVEs.

Falls and risk factors for falls in community-dwelling adults with dementia (NutriAlz trial).

To estimate the number of fallers and risk factors for falls in a cohort with dementia, we did a secondary analysis of a cluster-randomized controlled trial (NutriAlz) in 11 outpatient and day care centers in Catalonia (Spain) including 626 community-dwelling patients with dementia, followed for 12 months. Participants’ characteristics were assessed at baseline, at 6 and 12 months [fall in the earlier 6 mo, anthropometric data, comorbidities, Mini-Mental State Examination, Clinical Dementia Rating, Basic Activities of Daily Living (BADL), Instrumental Activities of Daily Living, Neuropsychiatric Inventory Questionnaire, Zarit Caregiver Burden Interview and Mini-Nutritional Assessment]. Multivariate logistic regression models and generalized linear models were used to explore risk factors for falls and changes in health and function. Two hundred twenty-three participants fell during the 12 months follow-up (35.62%). Risk factors identified for falls were age (odds ratio (OR)=1.03, 95% confidence interval (CI), 1.00-1.05), BADL (OR=1.18, 95% CI, 1.05-1.32), and earlier fall (OR=2.30, 95% CI, 1.57-3.35). Fallers had worse health than nonfallers, and their dependence increased significantly more in BADL during the study, compared with nonfallers. Dependence in BADL is a risk factor and a consequence of falls; interventions aimed at preventing falls in dementia patients could promote autonomy in BADL and slow its decline.

Is suboptimal prescribing a risk factor for poor health outcomes in community-dwelling elders? The ICARe Dicomano study.

Mostly because of comorbidity and drugs consumption, older persons are often exposed to an increased risk of sub‐optimal prescribing (SP). At present, few studies investigated the association between SP and long‐term health outcomes. We examined the relation between SP and the risk of mortality and hospitalization in Italian older community‐dwellers.

A Critical Review of Early Supported Discharge for Stroke Patients: From Evidence to Implementation into Practice

After an acute stroke, a multidimensional approach based on multidisciplinary work and rehabilitation is required in order to promote functional independence and social reinsertion and to maintain medical stability. These activities are usually developed in the hospital setting as a continuum of the acute phase, but hospitalization is resource consuming and resources are limited. Early Support Discharge strategies base postacute care and rehabilitation at home after an early discharge planning and represent possible alternatives to conventional hospitalization. Recent evidence suggests that Early Supported Discharge might be superior to hospitalization from both the clinical-functional and the economic viewpoints. Moreover, home-based rehabilitation might potentiate important determinants of effectiveness, such as patients motivation and goal-directed rehabilitation. However, hitherto produced evidence and recommendations show a number of limitations related to the organization models, the inclusion/exclusion criteria, and the questionable applicability of results to any healthcare setting worldwide. In this article, we critically review different methodological and organizational aspects of the available studies. For example in the definition of the target population, based mainly on residual disability and medical stability, we suggest that other relevant aspects, such as premorbid functional status, cognitive function, and previous institutionalization, should be better defined. Focusing on the outcomes, we suggest that, besides strong outcomes such as global functioning, surrogate outcomes, such as physical function, could help to refine the specific interventions. Finally, considering that the majority of studies were conducted in northern Europe, further studies are needed to test the implementation of Early Supported Discharge in different regions.

Cognitive and functional impairment in hypertensive brain microangiopathy

Brain microangiopathy, whose neuroimaging expression is represented by age-related white matter changes (ARWMC), is largely due to hypertension and it is, in turn, responsible for geriatric syndromes, including decline in cognitive, functional and motor/gait abilities. This review analyzes the link between hypertension and ARWMC, as well as the complex relationships between ARWMC and cognitive impairment, executive dysfunction, and movement/gait abnormalities. The available evidence supports the hypothesis that these functional consequences of ARWMC are responsible for substantial disability in the elderly. Thus, adequate treatment of hypertension may represent a feasible way to reduce the burden of disability in late life.