Michiko Fujisawa

Postural Dysregulation in Systolic Blood Pressure Is Associated With Worsened Scoring on Neurobehavioral Function Tests and Leukoaraiosis in the Older Elderly Living in a Community

BACKGROUND AND PURPOSE Postural hypotension, which occurs frequently in community-living, apparently healthy elderly adults, is usually asymptomatic. However, the relation between postural changes in blood pressure and quantitative higher cerebral function or silent brain lesions remains unclear. We examined the association of exaggerated postural changes in systolic blood pressure with cognitive and quantitative neurobehavioral functions and with brain lesions on MRI in the community-dwelling older elderly. METHODS The study population consisted of 334 community-dwelling elderly adults, aged 75 years or older (mean age, 80 years). Postural changes in systolic blood pressure (SBP) were assessed using an autosphygmomanometer (BP-203 I). By the difference between the mean of two measurements of SBP at standing and at supine position (dSBP = SBP at upright-SBP at supine position), we divided the subjects into three groups: (1) 20 subjects with postural hypotension (d-SBP < or = -20 mm Hg), (2) 29 subjects with postural hypertension (dSBP > or = 20 mm Hg), and (3) 285 subjects with postural normotension (20 < dSBP < 20 mm Hg). We defined the former two groups as the postural dysregulation group. Scores in four neurobehavioral function tests (Mini-Mental State Exam. Hasegawa Dementia Scale Revised, computer-assisted visuospatial cognitive performance score, and the Up and Go Test) and activities of daily living were compared among the three groups. Brain lesions on MRI, including number of lacunes and periventricular hyperintense lesions, were compared among 15 age- and sex-matched control subjects with postural hypotension, 15 with postural hypertension, and 30 with postural normotension. RESULTS Twenty subjects (6.0%) exhibited postural hypotension and 29 (8.7%) postural hypertension. Scores in neurobehavioral functions and activities of daily living were significantly lower in the postural dysregulation group (both postural hypotension and hypertension groups) than in the postural normotension group. The postural dysregulation group exhibited significantly more advanced periventricular hyperintensities than the normotension group. CONCLUSIONS Asymptomatic community dwelling elderly individuals with postural hypotension as well as those with postural hypertension had poorer scores on neurobehavioral function tests and more advanced leukoaraiosis demonstrated on MRI than those without exaggerated postural changes in SBP.

MTHFR Gene Polymorphism as a Risk Factor for Silent Brain Infarcts and White Matter Lesions in the Japanese General Population The NILS-LSA Study

Background and Purpose— Silent brain infarcts (SBI) and white matter lesions are relatively common neuroimaging findings, especially in the elderly population. The genetic background for SBI and white matter lesions in a large Japanese general population was investigated. Methods— Subjects were recruited from participants in the National Institute for Longevity Sciences, Longitudinal Study of Aging. Genotyping of methylenetetrahydrofolate reductase (MTHFR) C677T gene mutation and brain MRI examination were performed in 1721 subjects free of any history of stroke. SBI and white matter lesions were diagnosed from MRI findings. Results— Of 1721 MRI examinations, SBI was observed in 178 (10.3%). The prevalence of SBI and white matter lesions increased with age. The prevalence of SBI was significantly higher in subjects with the MTHFR TT genotype compared with the TC+CC genotype (14.6% versus 9.5%; 42 of 288 versus 136 of 1433; &khgr;2=6.71;P =0.010). The stage of white matter lesions was not significantly different. In subjects ≥60 years of age (n=849), the prevalence of SBI was significantly higher in TT than TC+CC (27.7% versus 16.6%; 36 of 130 versus 119 of 719; &khgr;2=9.16;P =0.002). The prevalence of moderately advanced white matter lesions was also significantly higher in TT than TC+CC (60.7% versus 49.0%; 79 of 130 versus 352 of 719; &khgr;2=9.16;P =0.002). After correction for other risk factors, the MTHFR TT genotype was independently associated with SBI (odds ratio [OR], 1.72; 95% CI, 1.10 to 2.68;P =0.018) and moderately advanced white matter lesions (OR, 1.58; 95% CI, 1.07 to 2.33;P =0.02). Conclusions— These findings indicate that the MTHFR TT genotype is an independent risk factor for SBI and white matter lesions in the general Japanese population, especially in elderly subjects.

THE TIMED “UP & GO” TEST IS A USEFUL PREDICTOR OF FALLS IN COMMUNITY-DWELLING OLDER PEOPLE

ratio.3 Fihn et al. concluded that “age did not appear to be an important determinant of risk for bleeding in patients receiving warfarin, with the possible exception of age 80 years or older.” These investigators reported that life-threatening or fatal bleeding complications occurred more often among the oldest patients; the incidence of these events was 0.75 per 100 patient-years in patients younger than SO years of age and 3.38 in patients 80 years of age and older (relative risk 4.50; 95% confidence interval, 1.315.6).4 We agree with Dr. Portnoi that the decision-making process regarding the use of warfarin therapy in the management of older patients with atrial fibrillation should engage patients and, when appropriate, their families. In addition, therapeutic management with regard to warfarin therapy does not end with the initiation of treatment. Continued reevaluation of treatment appropriateness, adequate patient surveillance, and maintenance of the patient in the appropriate therapeutic range are essential. In our study, more than one-quarter of the physicians surveyed responded that they preferred a target therapeutic range with a lower INR limit less than 2 for their older patients with atrial fibrillation who are residents in nursing homes.’ More widespread use of specialized clinics to manage warfarin therapy in the long-term care setting may provide a mechanism to address some of these important issues.

A U-shaped association between home systolic blood pressure and four-year mortality in community-dwelling older men.

BACKGROUND: Several studies in older people have found a U‐shaped or J‐shaped association of blood pressure with mortality. The increased mortality associated with the lowest levels of blood pressure in older people have been explained by concurrent illnesses and frailty, but previous studies used blood pressure measured on a single occasion. Such a casual value is different from the long‐term average of blood pressure. We investigated the relation between the average level of 5‐day consecutive home blood pressure and mortality in older people while adjusting for potential confounding factors including morbidity and frailty at baseline.

Quality of life of old people living in the community

Vol 350 • November 22, 1997 1521 reported to be expressed specifically in the brain based on northern studies, our ability to detect necdin transcripts in the liver suggests a lower, but detectable level of expression in peripheral tissues. We further examined necdin imprinting by testing expression by RT-PCR with RNA from cultured fibroblasts derived from a normal control and three patients with PWS and three with Angelman syndrome (AS), each with a documented 15q11-q13 deletion (figure B). This analysis likewise revealed imprinted expression, with necdin mRNA detectable in normal and AS samples, but not in PWS samples. The overall level of expression in cultured fibroblast cells may be quite low, given a less robust PCR product than that seen in the liver. These results show that necdin is imprinted with paternal-specific transcription in multiple tissues, including brain, which is the predominant site of its expression, and are consistent with another report indicating imprinted expression of necdin in newborn mouse brain and human fibroblasts. Necdin was initially identified as a mRNA specific to postmitotic, differentiated neuron from embryonal carcinoma cells, and found in the mouse to be expressed only in the central nervous system by northern analysis. In mouse development, necdin is expressed abundantly during periods of neural generation and differentiation, and expression is detected throughout the brain of the adult mouse, with the highest expression in the hypothalamus and midbrain. This Imprinting analysis of the human necdin gene RT-PCR on RNA from brain and liver controls and a PWS patient with a 15q11-q13 deletion (A), and RNA from cultured fibroblast cell lines from a control, three deletion PWS patients and three deletion AS patients (B). Expression of a second gene not on chromosome 15 (LDL receptor) was used as a control for RNA quality, and –RT controls are shown for necdin, whose product is colinear with genomic DNA. Details of RNA preparation and RT-PCR can be obtained from the author. Quality of life of old people living in the community

Relationships between each category of 25‐item frailty risk assessment (Kihon Checklist) and newly certified older adults under Long‐Term Care Insurance: A 24‐month follow‐up study in a rural community in Japan

The 25‐item Kihon Checklist (KCL) is the official self‐administered questionnaire tool to screen frail older adults, consisting of seven categories: physical strength, nutritional status, oral function, houseboundness, cognitive function, depression risk and a score of more than 9 out of 1–20 items. The aim of the present study was to evaluate the relationships between each category of the KCL and newly certified cases under the Long‐Term Care Insurance (LTCI) in Japan during 24 months.

Importance of cognitive assessment as part of the “Kihon Checklist” developed by the Japanese Ministry of Health, Labor and Welfare for prediction of frailty at a 2‐year follow up

To investigate which category in the “Kihon Checklist” developed by the Japanese Ministry of Health, Labor and Welfare can predict functional decline for community‐dwelling elderly people at a 2‐year follow up.

Association of a polymorphism of the transforming growth factor-β1 gene with blood pressure in Japanese individuals

AbstractTransforming growth factor-β1 (TGF-β1) is an important regulator of blood pressure (BP) and vascular remodeling, and thus may contribute to the pathogenesis of hypertension. A T→C transition at nucleotide 869 of the TGF-β1 gene results in a Leu→Pro substitution at amino acid 10 of the signal peptide. We have now examined the possible association of the 869T→C polymorphism of the TGF-β1 gene with BP and the prevalence of hypertension in 2241 community-dwelling Japanese individuals (1126 men and 1115 women). TGF-β1 genotype was determined by an allele-specific polymerase chain reaction method. For women, both systolic and diastolic BP was significantly higher in individuals with the CC genotype than in those with the TT or TC genotype. No significant association between TGF-β1 genotype and BP was detected in men. The frequency of the CC genotype was significantly higher in women with hypertension than in those with normal BP. These results suggest that the TGF-β1 gene at chromosome 19q13.1 may be a candidate susceptibility locus for hypertension in Japanese women.

Eating alone among community-dwelling Japanese elderly: Association with depression and food diversity

AbstractEating alone is an emerging social concern these days along with the background of serious aging population growth and increasing number of single-dwellers in Japan. However, little study is focused eating alone and its relation to the health status of community-dwelling elderly.ObjectivesTo clarify the relations between eating alone and geriatric functions such as depression, quantitative subjective quality of life (QOL), activities of daily living (ADL) and dietary status of community-dwelling Japanese elderly.DesignA cross-sectional study.SettingsTosa town, one of the “super-aged” towns in Japan.ParticipantsThe study population consisted of 856 communitydwelling elderly aged ≥65 living in Tosa town.MeasurementsEating alone and living arrangement was defined by the questionnaire. Geriatric functions were assessed by measuring activities of daily living (ADL), depressive symptom using 15-item Geriatric Depression Scale (GDS-15), and quality of life (QOL). Food diversity was investigated as a measure of dietary quality using 11-item Food Diversity Score Kyoto (FDSK-11). Body mass index (BMI) was calculated using height and body weight during a medical assessment.ResultsThe proportion of the elderly who usually eat alone was 33.2% in this study population. Even among 697 elderly subjects who live with others, 136 persons (19.5%) ate alone. The participants who ate alone were significantly depressed according to the assessment using GDS-15 score (5.7±4.3 vs. 4.4±3.8, P<0.001). Those who ate alone have lower scores of QOL items than those who ate with others (Subjective sense of health; 52.5±21.9 vs. 55.7±20.2 P=0.035, Relationship with family; 74.1±23.5 vs. 78.9±18.6 P<0.001, Subjective happiness; 58.5±22.7 vs. 62.2±21.1 P=0.019). A significant close association was found between eating alone and lower food diversity (FDSK-11 score 9.9±1.3 vs. 10.2±1.3, P=0.002). BMI was lower in the elderly subjects who ate alone than those with others. By the multivariate analysis, depression was independently associated with eating alone in the logistic regression model adjusted for age, sex, BMI and food diversity as confounding factors (OR; 1.42, Cl; 1.00–2.11, P=0.043). Food diversity was also significantly associated even after the adjustment of these confounding factors.ConclusionEating alone is an important issue related to depression and QOL as well as dietary status of community-dwellingl elderly in Japan. This study shows the simple and inexpensive way “eating together” may contribute to improve depressive mood of elderly persons, with a strong message that supports of family, friends and neighbors are very important.

Food diversity is closely associated with activities of daily living, depression, and quality of life in community-dwelling elderly people.

The authors are grateful to Ms. Ng Ada Fong Ting for her support during the study. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: Mr. Wong, Prof. Masters, Dr. Maxwell, and Prof. Abernethy were responsible for study design, data analyses, interpretation of the results, and finalization of the letter. Mr. Wong was responsible for recruitment of participants, data collection, and drafting the letter. Sponsor’s Role: None.