Richard L. Reed

The relationship between muscle mass and muscle strength in the elderly.

To determine the extent that muscle mass is predictive of muscle strength in the elderly, anthropomorphic estimates of muscle area and impedance measurements of muscle mass and peak isometric muscle strength were obtained in a relatively healthy older population over 65 years of age (mean age = 71.7; n = 218). Midarm muscle area correlated strongly with upper arm strength (r = 0.68, P < 0.0001) while midthigh muscle area had a much lower correlation with thigh muscle strength (r = 0.29, P < 0.0001). These muscle area calculations also include bone area. Lean body mass calculated by bioelectric impedance correlated highly with cumulative muscle strength measured by summing all muscle groups (r = 0.79, P < 0.0001). To determine whether aging alters muscle strength per unit of muscle mass, additional middle‐aged subjects were included, and three groups, middle‐aged (55–64) (n = 78), young‐old (65–74) (n = 161), and old‐old (75+) (n = 57), were compared. A significant age‐related trend of decreasing muscle strength per unit of lean body mass was noted. It is concluded that although muscle mass correlates with muscle strength in a healthy older population, use of simple age‐independent clinical measurements of body mass should not be used to predict muscle strength.

Literacy and Performance on the Mini-Mental State Examination

OBJECTIVE: Mini‐Mental State Examination (MMSE) scores are associated with age, education, and ethnicity. The objective of this research was to determine the relationship between MMSE and literacy.

Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of lIfe: a randomized trial

IMPORTANCE Due to increasing demand for sleep services, there has been growing interest in ambulatory models of care for patients with obstructive sleep apnea. With appropriate training and simplified management tools, primary care physicians are ideally positioned to take on a greater role in diagnosis and treatment. OBJECTIVE To compare the clinical efficacy and within-trial costs of a simplified model of diagnosis and care in primary care relative to that in specialist sleep centers. DESIGN, SETTING, AND PATIENTS A randomized, controlled, noninferiority study involving 155 patients with obstructive sleep apnea that was treated at primary care practices (n=81) in metropolitan Adelaide, 3 rural regions of South Australia or at a university hospital sleep medicine center in Adelaide, Australia (n = 74), between September 2008 and June 2010. INTERVENTIONS Primary care management of obstructive sleep apnea vs usual care in a specialist sleep center; both plans included continuous positive airway pressure, mandibular advancement splints, or conservative measures only. MAIN OUTCOME AND MEASURES The primary outcome was 6-month change in Epworth Sleepiness Scale (ESS) score, which ranges from 0 (no daytime sleepiness) to 24 points (high level of daytime sleepiness). The noninferiority margin was -2.0. Secondary outcomes included disease-specific and general quality of life measures, obstructive sleep apnea symptoms, adherence to using continuous positive airway pressure, patient satisfaction, and health care costs. RESULTS There were significant improvements in ESS scores from baseline to 6 months in both groups. In the primary care group, the mean baseline score of 12.8 decreased to 7.0 at 6 months (P < .001), and in the specialist group, the score decreased from a mean of 12.5 to 7.0 (P < .001). Primary care management was noninferior to specialist management with a mean change in ESS score of 5.8 vs 5.4 (adjusted difference, -0.13; lower bound of 1-sided 95% CI, -1.5; P = .43). There were no differences in secondary outcome measures between groups. Seventeen patients (21%) withdrew from the study in the primary care group vs 6 patients (8%) in the specialist group. CONCLUSIONS AND RELEVANCE Among patients with obstructive sleep apnea, treatment under a primary care model compared with a specialist model did not result in worse sleepiness scores, suggesting that the 2 treatment modes may be comparable. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12608000514303.

A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care

Background To address the growing burden of disease and long waiting lists for sleep services, a simplified two-stage model was developed and validated for identifying obstructive sleep apnoea (OSA) in primary care using a screening questionnaire followed by home sleep monitoring. Methods 157 patients aged 25–70 years attending their primary care physician for any reason at six primary care clinics in rural and metropolitan regions of South Australia participated. The first 79 patients formed the development group and the next 78 patients the validation group. A screening questionnaire was developed from factors identified from sleep surveys, demographic and anthropometric data to be predictive of moderate to severe OSA. Receiver operating characteristic (ROC) curve analysis was used to validate the two-channel ApneaLink device against full polysomnography. The diagnostic accuracy of the overall two-stage model was then evaluated. Results Snoring, waist circumference, witnessed apnoeas and age were predictive of OSA and incorporated into a screening questionnaire (ROC area under curve (AUC) 0.84, 95% CI 0.75 to 0.94, p<0.001). ApneaLink oximetry with a 3% dip rate was highly predictive of OSA (AUC 0.96, 95% CI 0.91 to 1.0, p<0.001). The two-stage diagnostic model showed a sensitivity of 0.97 (95% CI 0.81 to 1.00) and specificity of 0.87 (95% CI 0.74 to 0.95) in the development group, and a sensitivity of 0.88 (95% CI 0.60 to 0.98) and specificity of 0.82 (95% CI 0.70 to 0.90) in the validation group. Conclusion A two-stage model of screening questionnaire followed by home oximetry can accurately identify patients with OSA in primary care and has the potential to expedite care for patients with this common sleep disorder.

Predictive Validity of the Pra Instrument Among Older Recipients of Managed Care

OBJECTIVE: to determine the validity of the Pra instrument in predicting the use of health‐related services by older enrollees in a managed care plan.

Risk factors for early unplanned hospital readmission in the elderly

Study objective:To determine the prevalence of early (in 14 days or less) readmissions to the hospital, and to identify risk factors for readmission. Design:Matched case-control. Cases (n=155) were readmitted to the hospital within 14 days of a hospital discharge, while controls ( n=155) were not. Controls and cases were matched by week of hospital discharge. Patients:Two-year sequential sample of male veterans aged 65 years and over admitted to the Seattle Veterans Affairs (VA) Medical Center. Measurements:Data about 31 potential risk factors were abstracted from the medical records. Results:Three risk factors associated with readmission risk were identified and include two or more hospital admissions in the previous year [odds ratio (OR)=3.06], any medication dosage change in the 48 hours prior to discharge (OR=2.34), and a visiting nurse referral for follow-up (OR=2.78). One protective factor—discharge from the geriatric evaluation unit (GEU) (OR=0.09)—was also determined. Conclusions:Early unplanned readmissions were frequent at this VA facility. Since the strongest risk factor for readmission was the number of admissions in the previous year, readmissions appeared most commonly among high utilizers of inpatient VA care. This risk factor and others may be useful in identifying a group at high readmission risk, which could be targeted in intervention studies. The reduced readmission rate associated with the GEU suggests one potential intervention to decrease readmission risk.Study objective:To determine the prevalence of early (in 14 days or less) readmissions to the hospital, and to identify risk factors for readmission.Design:Matched case-control. Cases (n=155) were readmitted to the hospital within 14 days of a hospital discharge, while controls ( n=155) were not. Controls and cases were matched by week of hospital discharge.Patients:Two-year sequential sample of male veterans aged 65 years and over admitted to the Seattle Veterans Affairs (VA) Medical Center.Measurements:Data about 31 potential risk factors were abstracted from the medical records.Results:Three risk factors associated with readmission risk were identified and include two or more hospital admissions in the previous year [odds ratio (OR)=3.06], any medication dosage change in the 48 hours prior to discharge (OR=2.34), and a visiting nurse referral for follow-up (OR=2.78). One protective factor—discharge from the geriatric evaluation unit (GEU) (OR=0.09)—was also determined.Conclusions:Early unplanned readmissions were frequent at this VA facility. Since the strongest risk factor for readmission was the number of admissions in the previous year, readmissions appeared most commonly among high utilizers of inpatient VA care. This risk factor and others may be useful in identifying a group at high readmission risk, which could be targeted in intervention studies. The reduced readmission rate associated with the GEU suggests one potential intervention to decrease readmission risk.

Low serum albumin levels, confusion, and fecal incontinence: are these risk factors for pressure ulcers in mobility-impaired hospitalized adults?

Background: Studies of risk factors for clinically significant pressure ulcers in the hospital have been limited by the small number of study subjects that develop pressure ulcers, resulting in contradictory findings regarding some risk factors. Objective: To determine if three risk factors (low serum albumin level, fecal incontinence, and confusion) were significant risk factors when tested in a large data set. Methods: The study design was a longitudinal cohort study using data collected as a component of a multi-site controlled clinical trial. The data were collected at 47 Veterans Affairs Hospitals. 2,771 subjects that required high levels of nursing care were identified to have mobility impairment. Their medical records were abstracted using a standard form to identify a large number of potential risk factors. The subsequent development of stage 2 or greater pressure ulcers was recorded for a maximum of 14 days after admission. Results: 406 patients (14.7%) subsequently developed at least one stage 2 or greater pressure ulcer over a 2-week period. In a multivariate model, the presence of low albumin levels (odds ratio OR = 1.40) and confusion (OR = 1.45) were both found to be statistically significant risk factors, while fecal incontinence was not. Having a Do Not Resuscitate (DNR) order was also a significant risk factor (OR = 1.55). Two other known risk factors also entered the model: being malnourished (OR = 1.69) and requiring a urinary catheter (OR = 1.55). Conclusions: This study confirmed confusion and low albumin as pressure ulcer risk factors, but not fecal incontinence. A DNR order was found to be a new pressure ulcer risk factor not previously described in the literature.

A Comparison of Hand-Held Isometric Strength Measurement with Isokinetic Muscle Strength Measurement in the Elderly

Objective: To compare hand‐held isometric muscle strength measurement to an isokinetic muscle strength measurement in a healthy elderly population.

Association of TCF7L2 polymorphism with diabetes mellitus, metabolic syndrome, and markers of beta cell function and insulin resistance in a population-based sample of Emirati subjects

AIMS The prevalence of type 2 diabetes mellitus (DM) among Emirati subjects is one of the highest in the world. This has been attributed to rising prevalence of obesity acting on genetically susceptible individuals. We analyzed the associations between TCF7L2 polymorphism and DM, metabolic syndrome, and markers of beta cell function and insulin resistance in a population-based sample of Emirati subjects. METHODS We genotyped the two TCF7L2 single nucleotide polymorphisms (SNPs) rs12255372 and rs7903146 in 368 adult subjects. Homeostatic model assessment (HOMA) was used to assess beta cell function (HOMA2-%B) and insulin resistance (HOMA2-IR). The SNP genotypes were analyzed against disease stage [normal glucose=0 (n=188), pre-diabetes=1 (n=85), and DM=2 (n=95)] and against clinical and biochemical measures. Age and sex were included as covariates in all association analyses. Additional adjustments were made for body mass index (BMI) and waist circumference in several analyses. RESULTS Diabetes disease stage was marginally significantly associated with the frequency of the T variant at rs12255372 (p=0.057; adjusted p=0.017) but not at rs7903146 (p=0.5; adjusted p=0.2). Comparison between subjects with normal glucose and the combined DM/pre-diabetes showed a significant association with rs12255372 (OR 1.47, CI 1.04-2.08; p=0.03) but not with rs7903146 (OR 1.16, CI 0.81-1.64; p=0.4). We found no association with metabolic syndrome, or with insulin and glucose levels, HOMA2-%B or HOMA2-IR. The age-standardized prevalence rate for metabolic syndrome was 43.9% in men and 42.1% in women. CONCLUSION These data suggest that TCF7L2 variants are associated with increased risk for DM in Emirati subjects. We also demonstrate a high prevalence of the metabolic syndrome in this population.

Serum Levels of Tumor Necrosis Factor and IL-1α and IL-1β in Diabetic Patients

Objective To determine whether chronic hyperglycemia causes increased levels of serum tumor necrosis factor (TNF) and interleukin 1 α (IL-1 α) and IL-1 β. Research Design and Methods Sera were obtained from 59 diabetic patients, 44 chronically ill nondiabetic patients, and 34 age-matched healthy control subjects. Mononuclear cells were isolated from a subgroup of diabetic patients and healthy control subjects. Results Except for a modest increase in the prevalence of detectable serum TNF levels in diabetic patients, the serum cytokines measured in this study did not appear to be altered in diabetes. In vitro TNF production by mononuclear cells was not altered in diabetic patients. However, in vitro IL-1 β secretion, in response to lipopolysaccharides, was reduced. Conclusions Diabetes mellitus is not associated with significant changes in serum levels of TNF, IL-1 α, or IL-1 β. In vitro secretion of IL-1 β in response to lipopolysaccharides may be reduced in diabetes.