Robert B. Wallace

Lower-Extremity Function in Persons over the Age of 70 Years as a Predictor of Subsequent Disability

BACKGROUND Functional assessment is an important part of the evaluation of elderly persons. We conducted this study to determine whether objective measures of physical function can predict subsequent disability in older persons. METHODS This prospective cohort study included men and women 71 years of age or older who were living in the community, who reported no disability in the activities of daily living, and who reported that they were able to walk one-half mile (0.8 km) and climb stairs without assistance. The subjects completed a short battery of physical-performance tests and participated in a follow-up interview four years later. The tests included an assessment of standing balance, a timed 8-ft (2.4-m) walk at a normal pace, and a timed test of five repetitions of rising from a chair and sitting down. RESULTS Among the 1122 subjects who were not disabled at base line and who participated in the four-year follow-up, lower scores on the base-line performance tests were associated with a statistically significant, graduated increase in the frequency of disability in the activities of daily living and mobility-related disability at follow-up. After adjustment for age, sex, and the presence of chronic disease, those with the lowest scores on the performance tests were 4.2 to 4.9 times as likely to have disability at four years as those with the highest performance scores, and those with intermediate performance scores were 1.6 to 1.8 times as likely to have disability. CONCLUSIONS Among nondisabled older persons living in the community, objective measures of lower-extremity function were highly predictive of subsequent disability. Measures of physical performance may identify older persons with a preclinical stage of disability who may benefit from interventions to prevent the development of frank disability.

Etiology of clinically isolated, severe, chronic, pure mitral regurgitation: Analysis of 97 patients over 30 years of age having mitral valve replacement

Abstract For many years rheumatic heart disease was considered the major cause of mitral regurgitation (MR) severe enough to necessitate mitral valve replacement (MVR). In most past studies of patients with mitral valvular disease, patients were subdivided on the basis of predominant mitral stenosis (MS) or predominant MR. This type of subdivision, however, does not provide as much information about etiology as can be obtained by dividing patients with mitral valve dysfunction into two groups based on the presence or absence of mitral valve obstruction. MS of any degree is recognized as usually having a rheumatic etiology. Likewise, most patients who have combined dysfunction of both mitral and aortic valves usually have a rheumatic etiology of their valvular lesions. The present study examines the etiology of the valvular disease in 97 patients over the age of 30 years in whom MVR was carried out for severe, chronic, pure MR unassociated with MS or aortic valve dysfunction.

Association of education with incidence of cognitive impairment in three established populations for epidemiologic studies of the elderly.

We analyzed the association of education, occupation, and sex with incidence of cognitive impairment using data from three communities in the Established Populations for Epidemiologic Studies of the Elderly (EPESE) projects (New Haven, East Boston, and Iowa). Participants were initially interviewed in 1981-1983, with follow-up 3 and 6 years later. Incident cognitive impairment was defined on the basis of either: (1) increase in the number of errors in Short Portable Mental Status Questionnaire (SPMSQ) (i.e. from a baseline level below the cutoff value to a score above the cutoff), or (2) inability to respond to interview questions at a follow-up contact (requiring a proxy informant), or (3) death with a recorded diagnosis of a dementing illness. In multiple logistic regression models, the major factors predicting the development of cognitive impairment were advanced age, any errors on baseline SPMSQ, 8 or fewer years of education, and occupation. Education and occupation remained significant predictors after controlling for age, site, sex, stroke, and baseline SPMSQ score.

Neighborhood Deprivation, Individual Socioeconomic Status, and Cognitive Function in Older People: Analyses from the English Longitudinal Study of Ageing

OBJECTIVES: To assess the relationship between cognitive function, socioeconomic status, and neighborhood deprivation (lack of local resources of all types, financial and otherwise).

What Level of Alcohol Consumption Is Hazardous for Older People? Functioning and Mortality in U.S. and English National Cohorts

OBJECTIVES: To estimate disability plus mortality risks in older people according to level of alcohol intake.

Chest pain and coronary heart disease mortality among older men and women in three communities.

Angina pectoris is a manifestation of coronary heart disease, yet little is known from clinical or epidemiologic studies about its prognosis in older populations. We investigated the relation of uncomplicated angina symptoms to risk of coronary heart disease mortality within 3 years in a prospective study of 8,359 people aged 65 and older residing in three communities. From baseline (1981-1983) to the third year of follow-up (1984-1986), there were 245 deaths from coronary heart disease. Three classifications of chest pain were defined using the Rose Questionnaire: nonexertional chest pain, chest pain on exertion (including angina), and angina. Exertional chest pain was a strong, independent predictor of coronary heart disease death for older men and women. There were no differences in the prognostic implications of this symptom between the sexes; the relative risks being 2.4 (95% confidence interval, 1.4-4.4) in men and 2.7 (1.7-4.2) in women. The risk of coronary heart disease mortality for those reporting chest pain on exertion was at least as high as that for participants whose symptoms met the Rose Questionnaire criteria for angina. The association between exertional chest pain and coronary heart disease mortality was independent of other coronary risk factors. The relation was specific for deaths from coronary heart disease, as there was no association between exertional chest pain and noncoronary causes of death. Chest pain on exertion conveys important prognostic information about risk of coronary death in older populations, regardless of gender.

Mild cognitive impairment and 10-year trajectories of disability in the Iowa Established Populations for Epidemiologic Studies of the Elderly cohort.

Objectives: To apply diagnostic criteria for mild cognitive impairment (MCI) to a geographically representative sample, to estimate the prevalence of MCI, and to estimate 10‐year trajectories of incident disability for cognitively intact participants and subgroups with MCI.

Cardiac Operations in Patients Aged 70 Years and Over: Mortality, Length of Stay, and Hospital Charge

BACKGROUND With emphasis today on cost containment in health care, the results and costs of cardiac operations in elderly patients are being scrutinized. METHODS Our computerized database was used to obtain the characteristics of patients undergoing cardiac operations from January 1990 to July 1994. A study group of 628 patients aged 70 years and over was identified, and comparisons were made between them and adult patients less than 70 years of age. RESULTS In the elderly group the 30-day mortality was 33 of 628 (5.3%), and the overall hospital mortality was 40 (6.4%). During this time the 30-day mortality for all adult patients less than 70 years old was 49 of 1787 (2.7%; p < 0.003) and the hospital mortality was 59 (3.3%; p < 0.001). The mean length of postoperative hospital stay (days +/- standard error) in all surviving patients aged 70 years and over was 11.6 +/- 0.4 days, compared with 8.5 +/- 0.2 days in patients less than 70 years old (p < 0.001). Over the time of the study the length of stay in patients less than 70 years old declined from 9.6 +/- 0.4 to 7.2 +/- 0.6 days, whereas it stayed the same for elderly patients. The 30-day mortality and length of stay increased with the risk category of the Parsonnet model. The mean hospital charge for patients aged 70 and over was 114% of that for younger patients. CONCLUSIONS Although mortality, length of stay, and hospital charge are increased in patients 70 years of age and over, they are not excessively so. The results support the continued performance of cardiac surgical procedures in select elderly patients.

Multivariate correlates of adult blood pressures in nine North American populations: The lipid research clinics prevalence study☆

Abstract The associations of seven variables—age, education, body mass index, alcohol consumption, cigarette smoking, regular exercise, and gonadal hormone use in women—with systolic and diastolic blood pressure were studied in 4,780 white adult men and women in nine North American populations. We chose these variables because, with the exception of age and to some extent education, they are all potentially amenable to preventive intervention. We employed multiple linear regression to determine which variables were independently associated with blood pressure. Age was positively associated with systolic and diastolic pressure in men and younger women, and with systolic but not diastolic pressure in older women. Education was not consistently associated with blood pressure. Body mass index and alcohol consumption were positively associated with systolic and diastolic pressure, while cigarette smoking was negatively associated with systolic and diastolic pressure. Regular exercise was negatively associated with systolic pressure in women and diastolic pressure in men. Gonadal hormone use in younger women, mostly oral contraceptives, was positively associated with systolic pressure. Gonadal hormone use, mostly postmenopausal estrogens, in older women showed a weak positive association with systolic pressure but this association was not statistically significant. We conclude that several potentially modifiable variables have independent relationships to systolic and diastolic blood pressure.

Impact of surgical relief of outflow obstruction on thallium perfusion abnormalities in hypertrophic cardiomyopathy.

BackgroundTo assess the impact of surgical relief of left ventricular outflow obstruction on myocardial perfusion abnormalities in patients with obstructive hypertrophic cardiomyopathy, 20 symptomatic patients who underwent a septal myectomy or mitral valve replacement were studied with assessment of myocardial perfusion during exercise by 201T1 emission computed tomography before and 6 months after surgery. Methods and ResultsBefore surgery, 15 patients had myocardial perfusion defects during exercise that completely normalized at rest, one patient had both reversible and fixed perfusion defects, two patients had fixed defects only, and two patients had normal exercise and rest thallium scans. After surgical relief of left ventricular outflow obstruction (basal gradient reduced from 62±40 to 7±12 mm Hg, p<0.001; peak provokable gradient reduced from 131±27 to 49±36 mm Hg, p<0.001), repeat exercise thallium studies showed complete normalization of perfusion defects in 11 patients, including the two patients with fixed defects alone before surgery, and improvement in the magnitude and distribution of perfusion defects in five additional patients. This was associated with a significant reduction in the number of patients with reversible regional defects (five patients compared with 13 patients before surgery, p = 0.026) and of patients with endocardial hypoperfusion (four patients compared with 12 patients before surgery, p = 0.024). Furthermore, increased lung uptake of thallium was noted in five patients after surgery, compared with 12 patients before surgery (p = 0.055). Only two patients with reversible perfusion defects before surgery had unchanged postoperative studies. However, four patients acquired new fixed defects as a consequence of surgery, and two of these four had the greatest severity and distribution of left ventricular hypertrophy by echocardiography. These four patients experienced a substantially greater decrease in ejection fraction (−26±15%) after surgery than the remaining patients (−3±14%, p<0.01). ConclusionsSurgical relief of left ventricular outflow obstruction results in normalization or improvement of myocardial perfusion in the majority of patients with reversible and fixed perfusion defects by 201T1 scintigraphy. However, surgery may result in myocardial injury and scarring, with consequent decreased left ventricular ejection fraction in some patients.