Tomoko Wada

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.

Effects of Exercise on Neurobehavioral Function in Community‐Dwelling Older People More Than 75 Years of Age

OBJECTIVE: We evaluated the effects of exercise on neurobehavioral function in healthy older people more than 75 years of age.

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.

J-CURVE RELATION BETWEEN BLOOD PRESSURE AND DECLINE IN COGNITIVE FUNCTION IN OLDER PEOPLE LIVING IN COMMUNITY, JAPAN

nations, and delusional misidentifications were experienced and the magnitude of cognitive decline. There was a strong correlation between the number of months of visual hallucinations and deterioration in attention. Most studies suggest some kind of a link between visual hallucinations and more rapid cognitive decline although the nature of this link needs to be clarified. One possible explanation could be the link between both phenomena and cholinergic deficits.16 This is also consistent with the association between visual hallucinations and attention, given the involvement of acetylcholine in attentional processes.”

COGNITIVE AND FUNCTIONAL STATUS OF THE JAPANESE OLDEST OLD

In reply: Dr. von Sternberg’s comments about our paper are apt. As we tried to indicate, we saw this report as simply a trail-blazing exercise into the new country of subacute care. For some, subacute care represents a rediscovery of an earlier component of hospital care, called progressive patient care, where patients are treated with declining intensity according to their condition. Subacute care likes to describe itself as filling a gap between the hospital and the nursing home. In fact, subacute care must also compete with home health care. It is not a coincidence that Dr. von Sternberg’s proposed outcome measures come from rehabilitation and home health. More work is sorely needed to classify subacute care and to assess its outcomes. Andrew Kramer and his colleagues are concluding a substantial study that should add valuable information in this regard. Subacute care has become big business. Corporations devoted to this work are traded on Wall Street. Three basic questions must be addressed: (1) What is it? (2) Does it work? and (3) What is it worth? We were limited to using structural characteristics, but one would hope to see more about the actual process of care in subsequent studies. The outcomes work will need to measure change in meaningful units and at the right times. If discharge from hospital is the launching point, follow up must extend beyond discharge from subacute care. The outcomes will have to include functional measures as well as subsequent utilization. The comparison groups should include both those treated in nursing homes and those treated at home. However, if patients are discharged from hospitals earlier because they can enter subacute care, hospital discharge is not an even starting point. At the very least, some form of extensive case-mix adjustment will be needed to produce fair comparisons with effectiveness. Its value depends on one’s perspective. For Medicare, subacute care is an added expense. Hospitals continue to be paid on the basis of a presumed hospital stay. Unless funds can be transferred from hospital payments, Medicare winds up paying twice. A more expensive rate for nursing homes that provide so-called subacute care is no bargain for Medicare. One possibility would be bundling the costs of hospital and post-hospital care into a single payment. Then hospitals might be interested in buying subacute care if it could save them hospital days and still achieve the same outcomes. At present, some managed care plans that do not pay hospitals on the basis of DRGs see subacute care as a good buy if it reduces expensive hospital stays. We hope our study will be viewed as the beginning of a series of work that needs to address carefully the emerging concept of subacute care. Medical care has witnessed numerous technological innovations that were assessed adequately only after they were well installed as standard modes of care. At best, we will be able to get a jump on this innovation despite the enormous economic implications it holds. Perhaps one benefit from the new comodification of health care is a greater willingness to wait for better information before rushing to purchase the latest fad.

LOWER SERUM CHOLESTEROL LEVEL AND LATER DECLINE IN COGNITIVE FUNCTION IN OLDER PEOPLE LIVING IN THE COMMUNITY, JAPAN

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SERUM CHOLESTEROL LEVELS AND COGNITIVE FUNCTION ASSESSED BY P300 LATENCIES IN AN OLDER POPULATION LIVING IN THE COMMUNITY

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