Satu Pajala

A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial

BACKGROUND Modifiable vascular and lifestyle-related risk factors have been associated with dementia risk in observational studies. In the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER), a proof-of-concept randomised controlled trial, we aimed to assess a multidomain approach to prevent cognitive decline in at-risk elderly people from the general population. METHODS In a double-blind randomised controlled trial we enrolled individuals aged 60-77 years recruited from previous national surveys. Inclusion criteria were CAIDE (Cardiovascular Risk Factors, Aging and Dementia) Dementia Risk Score of at least 6 points and cognition at mean level or slightly lower than expected for age. We randomly assigned participants in a 1:1 ratio to a 2 year multidomain intervention (diet, exercise, cognitive training, vascular risk monitoring), or a control group (general health advice). Computer-generated allocation was done in blocks of four (two individuals randomly allocated to each group) at each site. Group allocation was not actively disclosed to participants and outcome assessors were masked to group allocation. The primary outcome was change in cognition as measured through comprehensive neuropsychological test battery (NTB) Z score. Analysis was by modified intention to treat (all participants with at least one post-baseline observation). This trial is registered at ClinicalTrials.gov, number NCT01041989. FINDINGS Between Sept 7, 2009, and Nov 24, 2011, we screened 2654 individuals and randomly assigned 1260 to the intervention group (n=631) or control group (n=629). 591 (94%) participants in the intervention group and 599 (95%) in the control group had at least one post-baseline assessment and were included in the modified intention-to-treat analysis. Estimated mean change in NTB total Z score at 2 years was 0·20 (SE 0·02, SD 0·51) in the intervention group and 0·16 (0·01, 0·51) in the control group. Between-group difference in the change of NTB total score per year was 0·022 (95% CI 0·002-0·042, p=0·030). 153 (12%) individuals dropped out overall. Adverse events occurred in 46 (7%) participants in the intervention group compared with six (1%) participants in the control group; the most common adverse event was musculoskeletal pain (32 [5%] individuals for intervention vs no individuals for control). INTERPRETATION Findings from this large, long-term, randomised controlled trial suggest that a multidomain intervention could improve or maintain cognitive functioning in at-risk elderly people from the general population. FUNDING Academy of Finland, La Carita Foundation, Alzheimer Association, Alzheimers Research and Prevention Foundation, Juho Vainio Foundation, Novo Nordisk Foundation, Finnish Social Insurance Institution, Ministry of Education and Culture, Salama bint Hamdan Al Nahyan Foundation, Axa Research Fund, EVO funding for University Hospitals of Kuopio, Oulu, and Turku and for Seinäjoki Central Hospital and Oulu City Hospital, Swedish Research Council, Swedish Research Council for Health, Working Life and Welfare, and af Jochnick Foundation.

The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER): Study design and progress

Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) is a multi‐center, randomized, controlled trial ongoing in Finland.

Hearing as a Predictor of Falls and Postural Balance in Older Female Twins

BACKGROUND The purpose of the present study was to examine, first, whether hearing acuity predicts falls and whether the potential association is explained by postural balance and, second, to examine whether shared genetic or environmental effects underlie these associations. METHODS Hearing was measured using a clinical audiometer as a part of the Finnish Twin Study on Aging in 103 monozygotic and 114 dizygotic female twin pairs aged 63-76 years. Postural balance was indicated as a center of pressure (COP) movement in semi-tandem stance, and participants filled in a fall-calendar daily for an average of 345 days after the baseline. RESULTS Mean hearing acuity (better ear hearing threshold level at 0.5-4 kHz) was 21 dB (standard deviation [SD] 12). Means of the COP velocity moment for the best to the poorest hearing quartiles increased linearly from 40.7 mm(2)/s (SD 24.4) to 52.8 mm(2)/s (SD 32.0) (p value for the trend = .003). Altogether 199 participants reported 437 falls. Age-adjusted incidence rate ratios (IRRs) for falls, with the best hearing quartile as a reference, were 1.2 (95% confidence interval [CI] = 0.4-3.8) in the second, 4.1 (95% CI = 1.1-15.6) in the third, and 3.4 (95% CI = 1.0-11.4) in the poorest hearing quartiles. Adjustment for COP velocity moment decreased IRRs markedly. Twin analyses showed that the association between hearing acuity and postural balance was not explained by genetic factors in common for these traits. CONCLUSION People with poor hearing acuity have a higher risk for falls, which is partially explained by their poorer postural control. Auditory information about environment may be important for safe mobility.

Poor vision accompanied with other sensory impairments as a predictor of falls in older women

OBJECTIVES we studied visual acuity (VA) and co-existing hearing impairment and poor standing balance as predictors of falls. DESIGN prospective study with 1-year follow-up. SETTING research laboratory and residential environment. PARTICIPANTS 428 women aged 63-76 years from the Finnish Twin Study on Aging. MEASUREMENTS participants were followed up for incidence of falls over 1 year. VA, hearing ability and standing balance were assessed at the baseline. The incidence rate ratios (IRR) for falls were computed using the negative binomial regression model. RESULTS during the follow-up, 47% of participants experienced a fall. After adjusting for age and interdependence of twin sisters, participants with vision impairment (VA of <1.0) but no other sensory impairments had a higher, but non-significant, risk for falls compared to persons with normal vision (IRR 1.5, 95% CI 0.6-4.2). Co-existing vision impairment and impaired balance increased the risk (IRR 2.7, 95% CI 0.9-8.0), as also did co-existing vision and hearing impairment (IRR 4.2, 95% CI 1.5-11.3), compared to those with normal vision. Among persons with all three impairments, the IRR for falls increased to 29.4 (95% CI 5.8-148.3) compared to participants with good vision. CONCLUSION the impact of vision impairment on fall risk was higher when accompanied with other sensory and balance impairments, probably because the presence of other impairments prevented the reception of compensatory information about body posture and environment being received from other sensory sources. When aiming to prevent falls and their consequences in older people, it is important to check whether poor vision is accompanied with other impairments.

Shared genetic and environmental effects on strength and power in older female twins.

PURPOSE This study examined the relative contribution of genetic and environmental effects on maximal leg extensor power and also investigated whether leg extensor power and maximum voluntary isometric knee extensor strength share a genetic component. METHODS Muscle functions were measured as part of the Finnish Twin Study on Aging in 101 monozygotic (MZ) and 116 dizygotic (DZ) female twin pairs aged 63-76 yr. Leg extensor power was measured using the Nottingham Leg Extensor Power Rig and maximum voluntary isometric knee extensor strength using an adjustable dynamometer chair. The analyses were carried out using the maximum likelihood method in Mx-program on the raw data set. RESULTS A bivariate Cholesky decomposition model showed that leg extensor power and isometric knee extensor strength shared a genetic component in common, which accounted for 32% of the total variance in leg extensor power and 48% in isometric knee extensor strength. In addition, power and strength had a nonshared environmental effect in common accounting for four percent of the variance in power and 52% in strength. Remaining variance for leg extensor power was due to trait-specific shared and nonshared environmental effects. CONCLUSION Observed genetic effect in common for leg extensor power and maximum voluntary isometric knee extensor strength indicated that these two traits are regulated by the same genes. However, also environmental effects have a significant role in explaining the variability in power and strength.

Asymmetrical lower extremity power deficit as a risk factor for injurious falls in healthy older women

ours, with a recent history of distant diplopia without headache, although ophthalmological examination did not indicate the existence of papilledema. Cranial nerve VI has the longest intracranial course and is thus vulnerable to variations of the intracranial pressure. It may be damaged between its emergence from the belly of the pons and Dorello’s canal where it enters the cavernous sinus. The association between diplopia and bilateral CSH may correspond to two distinct physiopathological mechanisms. There may be bilateral abducens nerve damage because of the development of intracranial hypertension caused by posttraumatic subdural bleeding. Alternatively, it may be secondary to intracranial hypotension, with downward displacement of the brain, which leads to tearing of dural veins with subsequent subdural bleeding. This could explain the development of diplopia, with a possible secondary subdural hematoma in spontaneous or acquired intracranial hypotension. Nevertheless, the association between bilateral abducens nerve palsy and bilateral CSH is rare. The fact that bilateral CSH is predominantly encountered in older people, whose symptoms in relation to the acute pathology are not always in the foreground and can mislead the clinician, may explain this. The frequency of diplopia may therefore be underestimated. Moreover, CSH is not always correlated with intracranial hypertension. Normal to low pressure rates are reported in 30% to 50% of patients presenting with CSH. The relative slowness of the development of the hematoma, with progressive adaptation of intracranial pressure at the expense of cerebral and liquid compartments, in patients with cerebral atrophy can explain this. This was not the case in our patient, who presented with papilledema related to intracranial hypertension. The hematomas were evacuated under pressure, with a rapid subdural space collapse, which is not the general rule with bilateral CSH. Finally, hypotension was supposed to be the origin of the cranial trauma, and antihypertensive treatment was stopped. This case of bilateral CSH, bilateral VI nerve palsy, and papilledema is rarely mentioned in the literature. Intracranial hypertension was diagnosed with funduscopic examination. Special care must be reported for a thorough history and examination in such patients, often presenting a poor symptomatology that sometimes does not lead directly to the main diagnosis.

Genetic effects in common on maximal walking speed and muscle performance in older women.

The purpose was to examine whether maximal walking speed, maximal isometric knee extensor strength, and leg extensor power share genetic or environmental effects in common. The data was collected from 103 monozygotic and 114 dizygotic female twin pairs aged 63–76 years. Maximal walking speed over 10 m was measured in the laboratory corridor using photocells for timing. Isometric knee extensor strength and leg extensor power were measured using an adjustable dynamometer. The genetic models showed that strength, power, and walking speed had a genetic effect in common which accounted for 52% of the variance in strength, 36% in power, and 34% in walking speed. Strength and power had a non‐shared environmental effect in common explaining 13% of variation in strength and 14% in power. The remaining variance was accounted for by trait‐specific effects. Some people may be more prone to functional limitation in old age due to their genetic disposition, but this does not rule out that changes in the lifestyle of predisposed subjects may also have a major effect. Approximately half of the variation in each trait was explained by environmental effects, which suggests the importance of the physical activity to improve performance and prevent functional limitation.

Recruitment and Baseline Characteristics of Participants in the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) : A Randomized Controlled Lifestyle Trial

Our aim is to describe the study recruitment and baseline characteristics of the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) study population. Potential study participants (age 60–77 years, the dementia risk score ≥6) were identified from previous population-based survey cohorts and invited to the screening visit. To be eligible, cognitive performance measured at the screening visit had to be at the mean level or slightly lower than expected for age. Of those invited (n = 5496), 48% (n = 2654) attended the screening visit, and finally 1260 eligible participants were randomized to the intervention and control groups (1:1). The screening visit non-attendees were slightly older, less educated, and had more vascular risk factors and diseases present. The mean (SD) age of the randomized participants was 69.4 (4.7) years, Mini-Mental State Examination 26.7 (2.0) points, systolic blood pressure 140.1 (16.2) mmHg, total serum cholesterol 5.2 (1.0) mmol/L for, and fasting glucose 6.1 (0.9) mmol/L for, with no difference between intervention and control groups. Several modifiable risk factors were present at baseline indicating an opportunity for the intervention. The FINGER study will provide important information on the effect of lifestyle intervention to prevent cognitive impairment among at risk persons.

Genetic Factors and Susceptibility to Falls in Older Women

OBJECTIVES: To determine whether genetic influences account for individual differences in susceptibility to falls in older women.

Genetic and environmental contribution to postural balance of older women in single and dual task situations

The purpose of the present study was to examine the effect of a second task on postural balance and to determine the role of genetic influences on postural balance when dual tasking among 206 monozygotic and 227 dizygotic female twins, aged 63-76 years. Balance was measured as medio-lateral and antero-posterior velocity of the centre of pressure (COP) (mm/s) and velocity moment (mm(2)/s) while standing on a force platform. Doing an arithmetic task increased movement of the COP while the hand motor task had no effect on movement of the COP. The genetic contribution to balance in the single task situation was minor (14%, 95% confidence interval, CI: 11-35%) whereas in the dual task situation it was moderate (28%, 95% CI: 0.02-42%). The finding can be explained in the light of the underlying phenotypes of dual tasking, such as cognitive processing that is found to be under considerable genetically controlled even in old age. Moreover, the present study supports previous studies suggesting that, especially among older people, when simultaneously maintaining balance and performing another cognitively demanding task, additional central processing is recruited.