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Insomnia or poor sleep quality with objective short sleep duration (hereafter referred to as ISSD) has been identified as a high-risk phenotype among middle-aged persons. We evaluated the prevalence and clinical correlates of ISSD among community-living older persons.In 3053 men from the Osteoporotic Fractures in Men Sleep Study (MrOS; average age 76.4 ± 5.5 years) and 3044 women from the Study of Osteoporotic Fractures (SOF; average age 83.6 ± 3.8 years), we evaluated the prevalence of ISSD (trouble getting to sleep within 30 minutes, waking up in the middle of the night or early morning, and/or taking a medication to help with sleep ≥3 times per week and actigraphy-estimated sleep duration6 h). Using separate logistic regression models in men and women, we evaluated the cross-sectional associations between predisposing, precipitating, and perpetuating factors for ISSD, as compared with normal sleep (no insomnia and actigraphy-estimated sleep duration of 6-9 h).Overall, 20.6% of older men and 12.8% of older women had insomnia with short sleep duration. Multiple predisposing, precipitating, and perpetuating factors were cross-sectionally associated with ISSD in both men and women. In multivariable models that adjusted for predisposing factors (demographics, multimorbidity, obesity), precipitating (depression, anxiety, central nervous system-active medication use, restless legs syndrome) and perpetuating (napping, falls) factors were significantly associated with ISSD in men and women (adjusted odds ratios ranging 1.63-4.57).In this cross-sectional study of community-living older men and women, ISSD was common and associated with multiple predisposing, precipitating, and perpetuating factors, akin to a multifactorial geriatric health condition. Future work should examine causal pathways and determine whether the identified correlates represent modifiable risk factors.

Growing evidence suggests that impairment in rest-activity rhythms may be a risk factor for cognitive decline and impairment in the aging population. However, previous studies included only a limited set of rest-activity metrics and produced mixed findings. We studied a comprehensive set of parametric and nonparametric characteristics of rest-activity rhythms in relation to mild cognitive impairment (MCI) and probable dementia in a cohort of older women.The prospective analysis included 763 women enrolled in two ancillary studies of the Women's Health Initiative (WHI): the WHI Memory Study-Epidemiology of Cognitive Health Outcomes and Objective Physical Activity and Cardiovascular Health studies. The association between accelerometry-based rest-activity parameters and centrally adjudicated MCI and probable dementia were determined using Cox regression models adjusted for sociodemographic characteristics, lifestyle factors, and comorbidities.Overall, the results support a prospective association between weakened rest-activity rhythms (e.g., reduced amplitude and overall rhythmicity) and adverse cognitive outcomes. Specifically, reduced overall rhythmicity (pseudo F statistic), lower amplitude and activity level (amplitude/relative amplitude, mesor, and activity level during active periods of the day [M10]), and later activity timing (acrophase and midpoint of M10) were associated with a higher risk for MCI and probable dementia. Women with lower amplitude and mesor also exhibited faster cognitive decline over follow-up.Weakened rest-activity rhythms may be predictive markers for cognitive decline, MCI, and dementia among older women.

Author(s): Rogers-Soeder, Tara S; Blackwell, Terri; Yaffe, Kristine; Ancoli-Israel, Sonia; Redline, Susan; Cauley, Jane A; Ensrud, Kristine E; Paudel, Misti; Barrett-Connor, Elizabeth; LeBlanc, Erin; Stone, Katie; Lane, Nancy E; Tranah, Greg; Osteoporotic Fractures in Men Study Research Group | Abstract: OBJECTIVE:To examine rest-activity circadian rhythm (RAR) and cognitive decline in older men. DESIGN:Longitudinal. SETTING:Osteoporotic Fractures in Men (MrOS) and ancillary Outcomes of Sleep Disorders in Men (MrOS Sleep) studies. PARTICIPANTS:MrOS and MrOS Sleep participants (N=2,754; mean age 76.0 ± 5.3). MEASUREMENTS:The Modified Mini-Mental State examination (3MS) was used to assess cognition at baseline (2003-05) and follow-up examinations (2005-06 and 2007-09). Wrist actigraphy was used to measure 24-hour activity counts at baseline. RAR variables included amplitude (strength of activity rhythm), mesor (mean activity level), pseudo F-statistic (overall circadian rhythm robustness), and acrophase (time of daily peak activity). RESULTS:After an average of 3.4 ± 0.5 years, men with lower amplitudes, mesors, and pseudo F-statistics had greater decline in 3MS performance (amplitude: -0.7 points Q1 vs -0.5 points Q4, pl.001; mesor: -0.5 points Q1 vs -0.2 points Q4, p=.01; pseudo F-statistic: -0.5 points Q1 vs -0.3 points Q4, pl.001). Lower amplitudes and pseudo-F statistics were associated with greater odds of clinically significant cognitive decline (≥5-point decrease) (amplitude Q1 vs. Q4: odds ratio (OR)=1.4, 95% confidence interval (CI)=1.0-1.9; pseudo-F statistic Q1 vs Q4: OR=1.4, 95% CI=1.0-1.9). Men with phase-advanced acrophase had greater odds of clinically significant cognitive decline (OR=1.8, 95% CI=1.2-2.8). Results were adjusted for multiple confounders. CONCLUSION:Several parameters of disrupted RAR (lower amplitude, pseudo F-statistic, mesor, phase-advanced acrophase) were associated with greater cognitive decline in older community-dwelling men. These findings contribute to a growing body of evidence suggesting that altered RARs are associated with cognitive decline in older adults. J Am Geriatr Soc 66:2136-2143, 2018.

Objectives (1) To examine relationships between frequency of nocturia and self-reported sleep quality and objective sleep measures in older women, and (2) to estimate the amount of variation in sleep measures that is specifically attributable to frequency of nocturia. Design and setting Secondary, cross sectional analysis of the multicenter prospective cohort Study of Osteoporotic Fractures (SOF). Participants Community-dwelling women aged ≥80 years. Measurements Frequency of nocturia in the previous 12 months, Pittsburgh Sleep Quality Index sleep quality subscale, and actigraphy-measured wake after sleep onset (WASO) and total sleep time (TST). Results Of 1,520 participants, 25% (n = 392) reported their nocturia frequency was 3–4 times/night and an additional 60% (n = 917) reported their nocturia frequency was 1–2 times/night. More frequent nocturia was associated with poor sleep quality (3–4/night: 26.8% reported fairly bad or very bad sleep quality; 1–2/night: 14.7%; 0/night: 7.7%; P < .001) and longer WASO (3–4/night: 89.8 minutes; 1–2/night: 70.6; 0/night: 55.5; P < .001). In nested regression models, a nocturia frequency of 3–4/night quadrupled the odds of poor sleep quality (odds ratio: 4.26 [95% CI 1.65, 11.01]; P = .003) and was associated with a 37-minute worsening in WASO (95% CI 26.0, 49.0; P < .001). Frequency of nocturia explained an additional 6% variation in WASO, above and beyond demographic, medical/psychiatric conditions, and medication factors (∆R2 = 0.06). Conclusions Nocturia is common among octogenarian and nonagenarian women and is independently associated with poor sleep quality and longer wake time at night. Interventions that improve nocturia may be useful in improving sleep quality and wake time at night.

Objectives To determine whether sleep-disordered breathing (SDB), a group of disorders common in older adults characterized by breathing pauses during sleep often accompanied by hypoxemia, is associated with cognitive decline. Design Population-based longitudinal study. Setting Six centers in the United States. Participants Community-dwelling older men (N = 2,636; aged 76.0 ± 5.3) without probable mild cognitive impairment or dementia followed for 3.4 ± 0.5 years. Measurements SDB was measured using in-home polysomnography: nocturnal hypoxemia (≥1% of sleep time with oxygen saturation (SaO2)

Objectives: To examine associations between objective measures of activity level and mortality risk in older men. Design: Prospective cohort study. Setting: Six U.S. sites. Participants: Men aged 71 and older followed an average of 4.5 years (N = 2,918). Measurements: Time awake spent in sedentary behavior (metabolic equivalent (MET) level ≤1.50), light activity (MET level 1.51–2.99), and at least moderate activity (MET level ≥3.00) measured using an activity monitor worn for 5 days or longer and expressed as quartiles. Deaths were confirmed with death certificates; cause of death was adjudicated by review of certificates and records. Results: During follow-up, 409 (14%) men died. After multivariable adjustment, comparing Q4 with Q1, more time spent in sedentary behavior (Q4 vs Q1, hazard ratio (HR) = 1.51, 95% confidence interval (CI) = 1.10–2.08), less time spent in light activity (Q1 vs Q4, HR = 1.54, 95% CI = 1.06–2.24), and less time spent in at least moderate activity (Q1 vs Q4, HR = 1.56, 95% CI = 1.09–2.25) were similarly associated with greater mortality risk primarily due to higher risks of cardiovascular and noncardiovascular, noncancer death. The association between time spent in sedentary behavior and mortality varied according to time spent at higher activity level. More time spent in sedentary behavior was associated with greater risk of death in men spending 1.2 (median) h/d or more in at least moderate activity (Q4 vs Q1, HR = 2.09, 95% CI = 1.26–3.49) but not in those spending less time (Q4 vs Q1, HR = 1.02, 95% CI = 0.62–1.66) (P = .005 for interaction). Conclusion: In older men exceeding current guidelines on physical activity, more time spent in sedentary behavior is associated with greater mortality risk.

OBJECTIVES: To test the hypothesis that low arterial oxygen saturation during sleep is associated with a greater risk of falls and fractures. DESIGN: Prospective cohort study. SETTING: Six U.S. clinical centers. PARTICIPANTS: Men aged 67 and older (N = 2,911). MEASUREMENTS: The primary exposure measure was percentage of sleep time with arterial oxygen saturation less than 90% measured using polysomnography. The main outcome measures were incident falls within 1 year and incident nonspine fractures over an average follow-up of 6.8 years. RESULTS: Men with 10% or more of sleep time at an arterial oxygen saturation of less than 90% were older, reported more comorbidities, had poorer physical function, and were more likely to have sleep disordered breathing than men with less than 10% sleep time at an arterial oxygen saturation of less than 90%. After multivariate adjustment, men with 10% or more of sleep time with arterial oxygen saturation of less than 90% had a greater risk of having one or more falls (relative risk (RR) = 1.25, 95% confidence interval (CI) = 1.04-1.51) and two or more falls (RR = 1.43, 95% CI = 1.06-1.92) than those with less than 10% of sleep time with less than 90% arterial oxygen saturation. Men with greater percentage of sleep time with arterial oxygen saturation less than 90% had a 30% to 40% greater risk of nonspine fracture than those with normal nocturnal oxygen saturation in models adjusting for sleep disordered breathing. CONCLUSION: Hypoxia during sleep may be a risk factor for falls and fractures in older men. Interventions aimed at decreasing nocturnal hypoxia may decrease falls and fractures. Language: en

Objectives To determine whether objectively measured sleep quality predicts 5-year incident instrumental activity of daily living (IADL) impairment and decline in grip strength and gait speed in older women. Design Prospective cohort. Setting Participants' homes, Study of Osteoporotic Fractures sites. Participants Eight hundred seventeen women with a mean age of 82.4 at baseline. Measurements Participants completed 4.1 ± 0.7 nights of wrist actigraphy at baseline and measures of IADL impairment, grip strength, and gait speed at baseline and 5-year follow-up. Results After 5 years of follow-up, approximately 41% of participants had incident impairment in one or more IADLs. The quartile of women with the shortest total sleep time (TST) had 93% greater odds of incident IADL impairment than the longest sleepers (adjusted odds ratio (AOR) = 1.93, 95% confidence interval (CI) = 1.25–2.97). Similarly, the quartile of women with the lowest sleep efficiency (SE) had 65% greater odds of impairment than those with the highest (AOR = 1.65, 95% CI = 1.06–2.57). Women in the shortest TST quartile had twice the odds of declining grip strength as those with the longest TST (AOR = 1.97, 95% CI = 1.17–3.32). Finally, women in the quartiles with the most wake after sleep onset (WASO) and the lowest SE had approximately 90% greater odds of grip strength decline than those with the least WASO (AOR = 1.90, 95% CI = 1.11–3.24) and SE (AOR = 1.92, 95% CI = 1.12–3.29). Conclusion Findings indicate that shorter sleep duration, greater WASO, and lower SE are risk factors for functional or physical decline in older women.

To examine the relationship between depressive symptoms and subjective and objective sleep in older women.Cross-sectional.Four U.S. clinical centers.Three thousand forty-five community-dwelling women aged 70 and older.Depressive symptoms were assessed using the Geriatric Depression Scale, categorizing participants as normal (0-2, reference), some depressive symptoms (3-5), or depressed (≥ 6). Subjective sleep quality and daytime sleepiness were assessed using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). Objective sleep measures were assessed using wrist actigraphy.In multivariable-adjusted models, there were graded associations between greater level of depressive symptoms and worse subjective sleep quality and more subjective daytime sleepiness (P-trends.001). Women with some depressive symptoms (odds ratio (OR) = 1.82, 95% confidence interval (CI) = 1.48-2.24) and depressed (OR = 2.84, 95% CI = 2.08-3.86) women had greater odds of reporting poor sleep (PSQI5). Women with some depressive symptoms (OR = 1.97, 95% CI = 1.47-2.64) and depressed women (OR = 1.70, 95% CI = 1.12-2.58) had greater odds of reporting excessive daytime sleepiness (ESS10). There were also graded associations between greater level of depressive symptoms and objectively measured wake after sleep onset (WASO) (P-trend = .03) and wake episodes longer than 5 minutes (P-trend = .006). Depressed women had modestly higher odds of WASO of 1 hour or longer (OR = 1.37, 95% CI = 1.03-1.83). Women with some depressive symptoms (OR = 1.49, 95% CI = 1.19-1.86) and depressed women (OR = 2.04, 95% CI = 1.52-2.74) had greater odds of being in the highest quartile for number of nap episodes longer than 5 minutes. No associations between depressive symptom level and prolonged sleep latency, poor sleep efficiency, or short or long total sleep time were found.Greater depressive symptom levels were associated with more subjective sleep disturbance and objective evidence of sleep fragmentation and napping.

OBJECTIVES: To determine whether self-reported insomnia symptoms were associated with weight change in older women and whether caregiving, comorbidities, sleep medication, or stress modified this association. DESIGN: One-year prospective study conducted in four communities from 1999 to 2003 nested within a larger cohort study. SETTING: Home-based interviews. PARTICIPANTS: Nine hundred eighty-eight participants (354 caregivers and 634 noncaregivers) from the Caregiver�Study of Osteoporotic Fractures. MEASUREMENTS: Self-reported insomnia symptoms in the previous month: trouble falling asleep, trouble staying asleep, and waking early and having trouble getting back to sleep. Weight was measured at baseline and 12 months. RESULTS: The average weight change was -1.9±7.8 pounds. Trouble staying asleep was significantly associated with an average weight loss of 1.3 pounds (P=.03) in multivariable analyses. Neither of the other insomnia symptoms was associated with weight change. Use of sleep medications modified the association between trouble falling asleep (interaction term P=.03) and weight change. Insomnia symptoms were associated with weight loss only in women not taking sleep medications. Neither caregiving status, presence of multiple comorbidities, nor stress modified the association. CONCLUSION: Trouble staying asleep was associated with weight loss over 12 months in older women. Practitioners should inquire about sleep habits of patients presenting with weight loss, because this may identify a marker of declining health and may be a factor that can be modified.

OBJECTIVES: To determine whether circadian activity rhythms are associated with mortality in community-dwelling older women. DESIGN: Prospective study of mortality. SETTING: A cohort study of health and aging. PARTICIPANTS: Three thousand twenty-seven community-dwelling women from the Study of Osteoporotic Fractures cohort (mean age 84). MEASUREMENTS: Activity data were collected using wrist actigraphy for a minimum of three 24-hour periods, and circadian activity rhythms were computed. Parameters of interest included height of activity peak (amplitude), midline estimating statistic of rhythm (mesor), strength of activity rhythm (robustness), and time of peak activity (acrophase). Vital status, with cause of death adjudicated through death certificates, was prospectively ascertained. RESULTS: Over an average of 4.1 years of follow-up, there were 444 (14.7%) deaths. There was an inverse association between peak activity height and all-cause mortality rates, with higher mortality rates observed in the lowest activity quartile (hazard ratio (HR) = 2.18, 95% confidence interval (CI) = 1.63―2.92) than in the highest quartile after adjusting for age, clinic site, race, body mass index, cognitive function, exercise, instrumental activity of daily living impairments, depression, medications, alcohol, smoking, self-reported health status, married status, and comorbidities. A greater risk of mortality from all causes was observed for those in the lowest quartiles of mesor (HR = 1.71, 95% CI= 1.29―2.27) and rhythm robustness (HR = 1.97, 95% CI = 1.50―2.60) than for those in the highest quartiles. Greater mortality from cancer (HR = 2.09, 95% CI = 1.04― 4.22) and stroke (HR = 2.64, 95% CI = 1.11―6.30) was observed for later peak activity (after 4:33 p.m.; > 1.5 SD from mean) than for the mean peak range (2:50―4:33 p.m.). CONCLUSION: Older women with weak circadian activity rhythms have higher mortality risk. If confirmed in other cohorts, studies will be needed to test whether interventions (e.g., physical activity, bright light exposure) that regulate circadian activity rhythms will improve health outcomes in older adults.

OBJECTIVES: To test the hypothesis that sleep disturbances are independently associated with frailty status in older men. DESIGN: Cross-sectional analysis of prospective cohort study. SETTING: Six U.S. centers. PARTICIPANTS: Three thousand one hundred thirty-three men aged 67 and older. MEASUREMENTS: Self-reported sleep parameters (questionnaire); objective parameters of sleep–wake patterns (actigraphy data collected for an average of 5.2 nights); and objective parameters of sleep-disordered breathing, nocturnal hypoxemia, and periodic leg movements with arousals (PLMAs) (in-home overnight polysomnography). Frailty status was classified as robust, intermediate stage, or frail using criteria similar to those used in the Cardiovascular Health Study frailty index. RESULTS: The prevalence of sleep disturbances, including poor sleep quality, excessive daytime sleepiness, short sleep duration, lower sleep efficiency, prolonged sleep latency, sleep fragmentation (greater nighttime wakefulness and frequent, long wake episodes), sleep-disordered breathing, nocturnal hypoxemia, and frequent PLMAs, was lowest in robust men, intermediate in men in the intermediate-stage group, and highest in frail men (P-for-trend ≤.002 for all sleep parameters). After adjusting for multiple potential confounders, self-reported poor sleep quality (Pittsburgh Sleep Quality Index >5, multivariable odds ratio (MOR)=1.28, 95% confidence interval (CI)=1.09–1.50), sleep efficiency less than 70% (MOR=1.37, 95% CI=1.12–1.67), sleep latency of 60 minutes or longer (MOR=1.42, 95% CI=1.10–1.82), and sleep-disordered breathing (respiratory disturbance index ≥15, MOR=1.38, 95% CI=1.15–1.65) were each independently associated with higher odds of greater frailty status. CONCLUSION: Sleep disturbances, including poor self-reported sleep quality, lower sleep efficiency, prolonged sleep latency, and sleep-disordered breathing, are independently associated with greater evidence of frailty.

Author(s): Coleman, Anne L; Cummings, Steven R; Ensrud, Kristine E; Yu, Fei; Gutierrez, Peter; Stone, Katie L; Cauley, Jane A; Pedula, Kathryn L; Hochberg, Marc C; Mangione, Carol M; Study of Osteoporotic Fractures | Abstract: ObjectivesTo evaluate the associations between visual field loss and nonspine fractures.DesignProspective cohort study.SettingCommunity.ParticipantsFour thousand seven hundred seventy-three community-dwelling white and African-American women aged 65 and older with no previous history of hip fracture at the time of recruitment.MeasurementsRadiographically confirmed hip and nonspine, nonhip fractures identified from September 1997 to April 2008. Visual field loss was measured using a Humphrey Field Analyzer suprathreshold screening test of the peripheral and central vision of each eye and was classified into an ordinal rating of no, mild, moderate, or severe binocular visual field (BVF) loss.ResultsFor hip and nonspine, nonhip fractures and in unadjusted and covariate-adjusted analyses, the highest incidence of fractures was seen in women with the most-severe BVF loss. In covariate-adjusted analysis, women with mild, moderate, and severe BVF loss had a 49% (hazard ratio (HR)=1.49, 95% confidence interval (CI)=1.18-1.88), 25% (HR=1.25, 95% CI=0.87-1.80), and 66% (HR=1.66, 95% CI=1.19-2.32) greater risk, respectively, for hip fractures than women without BVF loss. Similarly, women with mild visual field loss had a 12% (HR=0.88, 95% CI=0.75-1.04) lower risk for nonspine, nonhip fractures, whereas women with moderate and severe visual field loss had a 18% (HR=1.18, 95% CI=0.92-1.52) and 59% (HR=1.59, 95% CI=1.24-2.03) greater risk of nonspine, nonhip fractures than women without BVF loss.ConclusionBVF loss is independently associated with hip and nonspine, nonhip fractures in older female volunteers.

Objectives To determine the association between self-reported sleep and nap habits and mortality in a large cohort of older women.

OBJECTIVES To determine whether an objective measure of daytime movement is associated with better cognitive function in women in their 80s.

OBJECTIVES: Determine whether sleep quality is associated with physical function in older men.

OBJECTIVES: To examine the association between depressive symptoms and subjective and objective measures of sleep in community-dwelling older men. DESIGN: Cross-sectional. SETTING: Six U.S. clinical centers. PARTICIPANTS: Three thousand fifty-one men aged 67 and older. MEASUREMENTS: Depressive symptoms assessed using the 15-item Geriatric Depression Scale and categorized as 0 to 2 (normal, referent group), 3 to 5 (some depressive symptoms), and 6 to 15 (depressed); objective sleep measures ascertained using wrist actigraphy (mean duration 5.2 nights); and subjective sleep measures assessed using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale. RESULTS: There was a strong multivariable-adjusted association between level of depressive symptoms and subjective sleep disturbances (P-trend

OBJECTIVES: To investigate the association between objectively measured sleep-disordered breathing (SDB) and cognitive impairment in community-dwelling older women and to determine whether the apolipoprotein E (APOE) ɛ4 allele modifies this association. DESIGN: Cross-sectional. SETTING: Participants' homes and two sites of the Study of Osteoporotic Fractures (SOF). PARTICIPANTS: Four hundred forty-eight women with a mean age±standard deviation (SD) of 82.8±3.4. MEASUREMENTS: Participants completed the Mini-Mental State Examination (MMSE), Trail Making Test Part B (Trails B), and polysomnography (PSG). SDB indices were the apnea–hypopnea index (AHI), the central apnea index (CAI), and oxygen saturation (SaO2) nadir less than 80%. APOE ɛ4 was determined for a subset of 242 women. Cognitive impairment was defined as 1.5 SDs or more from the sample mean on either cognitive test (MMSE or Trails B). RESULTS: All SDB indices were associated with cognitive impairment according to the MMSE (AHI (per SD, odds ratio (OR)=1.4, 95% confidence interval (CI)=1.03–1.9), AHI of ≥30 (OR=3.4, 95% CI=1.4–8.1), SaO2 nadir

OBJECTIVES: To determine whether depressive symptoms modify the association between caregiving and sleep problems in elderly women. DESIGN: Cross-sectional study conducted in four communities in 1999 to 2001. SETTING: Home-based interviewer-administered questionnaires. PARTICIPANTS: Three hundred seventy-five caregiver and 694 noncaregiver participants from the Study of Osteoporotic Fractures. MEASUREMENTS: Self-reported frequency of three sleep problems in the previous month: trouble falling asleep, trouble staying asleep, and waking early and having trouble falling back asleep. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D), excluding the sleep disturbance item. RESULTS: In adjusted analyses, caregivers did not report more sleep problems than noncaregivers, although respondents with high depressive symptoms (CES-D≥16) were twice as likely to report each sleep problem. When depressive symptoms and caregiving were considered together, caregivers with high depressive symptoms were most likely to report sleep problems (adjusted odds ratios ranging from 2.5, 95% confidence interval (CI)=1.2–5.2 for trouble falling asleep to 4.0, 95% CI=2.0–7.8 for waking early, compared with nondepressed noncaregivers). By contrast, there was no difference in sleep problems between caregivers and noncaregivers who were not depressed. The combination of high depressive symptoms and high-stress caregiving situations (e.g., caring for a spouse or a person with dementia, or living with the care recipient) also increased the likelihood of sleep problems. CONCLUSION: Caregivers with high levels of depressive symptoms reported sleep problems more than nondepressed noncaregivers. These results underscore the importance of screening elderly female caregivers for depressive symptoms and sleep problems.

Repetitive partial or complete upper airway obstruction resulting in sleep fragmentation and nocturnal chronic intermittent hypoxia associated with a myriad of pathophysiological effects characterize sleep-disordered breathing (SDB). These effects are believed to contribute to adverse cardiovascular health outcomes and to negatively influence quality of life. Population differences in SDB include a higher prevalence in older individuals and men. Whereas the prevalence of SDB in middle-aged adults has been reported to range from 2% to 4%;1 in older people, prevalence ranges from 6% to 70% in samples derived from referral-based and population-based sources.2–6 SDB prevalence ranges appear to be higher in older men than in older women.2 Longitudinal data suggest that the highest rates of SDB progression occur in older men, thereby highlighting the potential vulnerability of older men to SDB.7–9 The sex-specific disparity of SDB occurrence is likely attributable to a variety of factors, including hormonal influences and sex-related differences in upper airway anatomy and body fat deposition. In older people, it has been intensely debated whether SDB represents a similar condition as in middle-aged adults.10 Support for the hypothesis that it does not is derived from studies that have reported a different constellation of associated risk factors, symptoms, and apnea characteristics in older samples than in middle-aged adults. Specifically, the reported snoring prevalence has tended to be lower in the elderly population,11 possibly because older individuals, especially those who live alone, may systematically underreport snoring. Because snoring reflects airway turbulence, which is a function of the flow characteristics in the airway, differences in snoring across populations could also reflect population differences in airway anatomy and physiology. In addition, underlying comorbidities, survival bias, competing risks, or differences in pathophysiology may influence the measurable consequences of SDB. Some studies of older populations report weaker associations between SDB and cardiovascular disease (CVD) in older than in middle-aged populations.12,13–15 Support for SDB as a unique disorder in this older cohort is derived from knowledge that aging is associated with greater comorbidity and that cardiovascular comorbidities are associated with the central type of apneic respiratory events. Some of these results have been published in the form of an abstract.16 Rigorously collected data from a large, prospective, multicenter, population-based cohort of older men (Outcomes of Sleep Disorders in Older Men Study, or the Osteoporotic Fractures in Men (MrOS) Sleep Study) were analyzed to address the hypothesis that SDB in elderly men is associated with a similar set of risk factors and comorbidities as has been reported in middle-aged populations. The MrOS Sleep Study cohort provides a unique opportunity to investigate sleep disorders in the largest collection of sleep data in elderly men. Definitions of SDB were similar to those used in the Sleep Heart Health Study (SHHS) and the Wisconsin Cohort Study to facilitate comparisons across populations. A secondary goal was to address potential differences in the prevalence estimates and risk relationships according to different definitions of SDB, including reclassifying SDB based on distinguishing obstructive from central events and variation of the amplitude criterion for hypopneas.

Summary In this prospective cohort study, depressive symptoms were associated with higher rates of bone loss in older men. Poorer performance on physical function tests partly explained the association between depressive symptoms and bone loss, suggesting that efforts to increase exercise and improve physical performance in depressed men may be beneficial.

Author(s): Seitzman, Robin L; Mangione, Carol M; Cauley, Jane A; Ensrud, Kristine E; Stone, Katie L; Cummings, Steven R; Hochberg, Marc C; Hillier, Teresa A; Yu, Fei; Coleman, Anne L; Study of Osteoporotic Fractures Research Group | Abstract: ObjectivesTo determine whether bone mineral density (BMD) is associated with age-related maculopathy (ARM) risk in older women.DesignCross-sectional analysis at Year 10 (1997/98) of the Study of Osteoporotic Fractures (SOF).SettingFour clinical centers in the United States.ParticipantsOne thousand forty-two randomly sampled SOF participants who attended the Year 10 clinic visit.MeasurementsARM status was determined from fundus photographs using a modification of the Wisconsin Age-Related Maculopathy Grading System 6-level severity scale used in the National Health and Nutrition Examination Survey III. Total hip BMD was measured at Year 10 using dual-energy x-ray absorptiometry. Information on potential confounders, including age, reproductive hormone exposures, body mass index, smoking, alcohol consumption, nutrition, education, diabetes mellitus, hypertension, and physical activity, was ascertained with questionnaires.ResultsThe prevalence of ARM was 50% (46% had early ARM and 4% had late ARM). After potential confounder adjustment, greater BMD was associated with lower odds of ARM (odds ratio (OR) per 1 standard deviation increase in BMD=0.82, 95% confidence interval (CI)=0.70-0.96). Women in the highest quartile of BMD had lower odds of ARM than those in the lowest quartile (OR=0.63, 95% CI=0.41-0.97) and those in the lowest three quartiles combined (OR=0.66, 95% CI=0.48-0.91).ConclusionHigher levels of BMD may be associated with lower risk for ARM. The underlying mechanism is unknown, although BMD may be a marker for lifetime endogenous estrogen exposure. Future studies are needed to replicate these findings and further investigate the nature of the relationship between BMD and ARM.

OBJECTIVES: To examine the relationship between binocular visual field loss and the risk of incident frequent falls in older white women. DESIGN: A multicenter, prospective cohort study. SETTING: Four clinic centers within the United States in Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, Pennsylvania. PARTICIPANTS: Four thousand seventy-one community-dwelling white women aged 70 and older participating in the Study of Osteoporotic Fractures. MEASUREMENTS: Primary outcome was incident frequent falls, defined as two or more falls within 1 year. Primary risk factors were binocular visual field loss, distance visual acuity in the better eye, and contrast sensitivity at low spatial frequency in the better eye. RESULTS: Of 4,071 women, 409 (10%) had severe binocular visual field loss at the eye examination, and 643 (16%) experienced frequent falls within 1 year after their eye examination. Severe binocular visual field loss was significantly associated with frequent falls when adjusting for age, study site, and cognitive function (odds ratio=1.50, 95% confidence interval=1.11-2.02). The data showed a trend for increasing odds of two or more falls with greater binocular visual field loss (P

OBJECTIVES: To determine whether older women who maintain optimal cognitive function into old age differ from those who experience minor cognitive decline typically associated with normal aging. DESIGN: Prospective cohort study. SETTING: The Study of Osteoporotic Fractures. PARTICIPANTS: Nine thousand seven hundred four older women. MEASUREMENTS: A modified Mini-Mental State Examination (mMMSE) was performed at baseline and Years 6, 8, 10, and 15. Random-effects regression was used to classify subjects as cognitive maintainers (slope≥0), minor decliners (slope lowest tertile), or major decliners (slope ≤ lowest tertile). Stepwise logistic regression was used to identify factors most predictive of being a cognitive maintainer versus a minor decliner (excluding major decliners). RESULTS: Women had a mean age of 72 at baseline and 85 at follow-up. Nine percent maintained optimal cognitive function, 58% experienced minor decline, and 33% experienced major decline. Most factors differed progressively over the three cognitive groups. After adjustment for key confounders, odds ratios for factors most predictive of being a cognitive maintainer as opposed to minor decliner were 1.9 (95% confidence interval (CI)=1.2–2.9) for lack of diabetes mellitus, 1.2 (95% CI=1.0–1.4) for lack of hypertension, 1.7 (95% CI=1.3–2.3) for lack of smoking, 1.2 (95% CI=1.1–1.5) for moderate alcohol consumption, 1.4 (95% CI=1.1–1.7) for lack of difficulty with instrumental activities of daily living, and 1.2 (95% CI=1.0–1.4) for lack of low social network. CONCLUSION: Almost 10% of older women maintained optimal cognitive function into old age. Cognitive maintainers were less likely to have comorbid medical conditions, less likely to have difficulty with daily activities or poor social networks, and more likely to engage in healthy behaviors than minor cognitive decliners.

OBJECTIVES: To determine the association between use of selective serotonin reuptake inhibitors (SSRIs) and objective measures of sleep disturbances in older community-dwelling women, including women without evidence of depression. DESIGN: Cross-sectional study. SETTING: Four U.S. clinical centers. PARTICIPANTS: Two thousand eight hundred fifty-three women aged 71 and older (2,630 nonusers of antidepressants and 223 taking SSRIs alone, not in combination with other antidepressants). MEASUREMENTS: Medication use, assessed using an interviewer-administered questionnaire with verification of use from medication containers and computerized dictionary used to categorize type of medication; evidence of depression assessed using self-report or a score of 6 or higher on the Geriatric Depression Scale; and sleep parameters measured using a wrist actigraph, with data collected for an average of four consecutive 24-hour periods. RESULTS: Of the overall cohort of 2,853 women and of 2,337 women without evidence of depression, sleep disturbances were more common in women taking SSRIs than in those not taking antidepressants. After excluding women with evidence of depression and adjusting for multiple potential confounders, women taking SSRIs were more likely to have a sleep duration of 5 hours or less (multivariate odds ratio (MOR)=2.15, 95% confidence interval (CI)=1.04–4.47), sleep efficiency less than 70% (MOR=2.37, 95% CI=1.32–4.25), sleep latency of 1 hour or more (MOR=3.99, 95% CI=2.29–6.96) and eight or more long wake episodes (MOR=1.75, 95% CI=0.99–3.10). CONCLUSION: SSRI use by older women, including those without evidence of depression, is associated with a greater likelihood of sleep disturbances, including poorer sleep efficiency, longer sleep latency, and sleep fragmentation, manifested by multiple long wake episodes. These results add to the uncertainty regarding risks and benefits of SSRI use in aged populations.

Aim:To test the association between self-reported sleep and nap habits and risk of falls and fractures in a large cohort of older women. Study of Osteoporotic Fractures prospective cohort study. Clinical centers in Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, near Pittsburgh, Pennsylvania. Eight thousand one hundred one community-dwelling Caucasian women aged 69 and older (mean 77.0). Sleep and nap habits were assessed using a questionnaire at the fourth clinic visit (1993/94). Fall frequency during the subsequent year was ascertained using tri-annual questionnaire. Incident hip and nonspinal fractures during 6 years of follow-up were confirmed using radiographic reports. Five hundred fifty-three women suffered hip fractures, and 1,938 suffered nonspinal fractures. In multivariate models, women who reported napping daily had significantly higher odds of suffering two or more falls during the subsequent year (odds ratio=1.32, 95% confidence interval (CI)=1.03-1.69) and were more likely to suffer a hip fracture (hazard ratio (HR)=1.33, 95% CI=0.99-1.78) than women who did not nap daily. Those sleeping at least 10 hours per 24 hours had a higher risk of nonspinal fracture than (HR=1.26, 95% CI=1.00-1.58) and a similar but nonsignificant increased risk of hip fracture to (HR=1.43, 95% CI=0.95-2.15) those who reported sleeping between 8 and 9 hours. Self-reported long sleep and daily napping are associated with greater risk of falls and fractures in older women. Interventions to improve sleep may reduce their risk of falls and fractures. Future research is needed to determine whether specific sleep disorders contribute to these relationships. Language: en

Objectives: To determine whether magnesium intake from supplemental and dietary sources is associated with bone mineral density (BMD) in older men and women. Design: Cross-sectional. Setting: Memphis, Tennessee, and Pittsburgh, Pennsylvania. Participants: Two thousand thirty-eight older black and white men and women aged 70 to 79 at baseline enrolled in the Health, Aging and Body Composition Study. Measurements: Dietary intake of magnesium was assessed using a semiquantitative food frequency questionnaire, and supplement data were collected based on a medication inventory. BMD of the whole body was obtained using a fan-beam densitometer. Additional covariates included age, body mass index (BMI), smoking status, alcohol use, physical activity, estrogen use, and supplemental calcium (Ca) and vitamin D use. Results: In white, but not black, men and women, magnesium intake was positively associated with BMD of the whole body after adjustment for age, self-report of osteoporosis or fracture in adulthood, caloric intake, Ca and vitamin D intake, BMI, smoking status, alcohol intake, physical activity, thiazide diuretic use, and estrogen use in women (P=.05 for men and P=.005 for women). BMD was 0.04 g/cm2 higher in white women and 0.02 g/cm2 higher in white men in the highest than in the lowest quintile of magnesium intake. Conclusion: Greater magnesium intake was significantly related to higher BMD in white women and men. The lack of association observed in black women and men may be related to differences in Ca regulation or in nutrient reporting.

Objectives: To determine whether changes in hip bone mineral density (BMD) differ in Caucasian and African American women. Design: Longitudinal study of changes in hip BMD. Setting: Four U.S. clinical centers. Participants: Six thousand seven Caucasian (mean age 73) and 482 African-American (mean age 75) women enrolled in the Study of Osteoporotic Fractures. Measurements: Total hip and femoral neck BMD were measured an average of 3.5 years apart (Caucasian) and 2.0 years apart (African American). Annual absolute and percentage changes in BMD and bone mineral apparent density (BMAD) were calculated. Results: The multivariate adjusted annual percentage change in BMD was greater in Caucasian than African-American women at the total hip (−0.574%/y vs −0.334%/y) and femoral neck (−0.515%/y vs −0.203%/y) (both, P

Author(s): Lin, Michael Y; Gutierrez, Peter R; Stone, Katie L; Yaffe, Kristine; Ensrud, Kristine E; Fink, Howard A; Sarkisian, Catherine A; Coleman, Anne L; Mangione, Carol M; Study of Osteoporotic Fractures Research Group | Abstract: ObjectivesTo determine the association between vision and hearing impairment and subsequent cognitive and functional decline in community-residing older women.DesignProspective cohort study.SettingFour metropolitan areas of the United States.ParticipantsA total of 6,112 women aged 69 and older participating in the Study of Osteoporotic Fractures (SOF) between 1992 and 1994.MeasurementsFive thousand three hundred forty-five participants had hearing measured, 1,668 had visual acuity measured, and 1,636 had both measured. Visual impairment was defined as corrected vision worse than 20/40. Hearing impairment was defined as the inability to hear a tone of 40 dB or greater at 2,000 hertz. Participants completed the modified Mini-Mental State Examination and/or a functional status assessment at baseline and follow-up. Cognitive and functional decline were defined as the amount of decline from baseline to follow-up that exceeded the observed average change in scores by at least 1 standard deviation.ResultsAbout one-sixth (15.7%) of the sample had cognitive decline; 10.1% had functional decline. In multivariate models adjusted for sociodemographic characteristics and chronic conditions, vision impairment at baseline was associated with cognitive (odds ratio (OR)=1.78, 95% confidence interval (CI)=1.21-2.61) and functional (OR=1.79, 95% CI=1.15-2.79) decline. Hearing impairment was not associated with cognitive or functional decline. Combined impairment was associated with the greatest odds for cognitive (OR=2.19, 95% CI=1.26-3.81) and functional (OR=1.87, 95% CI=1.01-3.47) decline.ConclusionSensory impairment is associated with cognitive and functional decline in older women. Studies are needed to determine whether treatment of vision and hearing impairment can decrease the risk for cognitive and functional decline.

Objectives: To identify independent risk factors for first hip fracture over 10 years of follow-up. Design: Prospective cohort study. Setting: Four U.S. clinical centers. Participants: A total of 6,787 women aged 66 and older in the Study of Osteoporotic Fractures. Measurements: Total hip bone mineral density (BMD) using dual-energy x-ray absorptiometry and a comprehensive set of potential risk factors were collected. Incident hip fractures were identified prospectively and confirmed using radiographic report. Results: Six hundred two women (8.9%) had a hip fracture during a mean ±standard deviation (SD) follow-up of 10.1±3.2 years. Older age, previous self-reported fracture after age 50, maternal history of hip fracture after age 50, greater height at age 25, impaired cognition, slower walking speed, nulliparity, type II diabetes mellitus, Parkinson's disease, and depth perception each independently predicted a 1.17- to 1.83-fold increase in hip fracture risk, whereas each SD (0.13 g/cm2) decrease in hip BMD was independently associated with a 1.84-fold increase in risk. Lower body mass index also was associated with an increased risk of hip fracture, although lower hip BMD largely explained this association. Conclusion: Although hip BMD is strongly related to hip fracture risk in elderly white women, other clinical risk factors also are independent predictors of long-term risk and provide additional insight into the prevention of fracture in high-risk women. Clinicians should be alert to factors other than BMD that place older women at a high risk of hip fracture.

Objectives: To test the hypothesis that unintentional weight loss increases the rate of bone loss and risk of hip fracture more than intentional weight loss. Design: Prospective cohort study. Setting: Four communities within the United States. Participants: Six thousand seven hundred eighty-five elderly white women with measurement of weight change and assessment of intention to lose weight. Measurements: Weight change between baseline and fourth examinations (average 5.7 years between examinations) and assessment of intention to lose weight. Weight loss was defined as a decrease of 5% or more from baseline weight, stable weight was defined as less than a 5% change from baseline weight, and weight gain was defined as an increase of 5% or more from baseline weight. Rate of change in bone mineral density at the hip between fourth and sixth examinations (average 4.4 years between examinations) was measured using dual-energy x-ray absorptiometry. Incident hip fractures occurring after the fourth examination until June 1, 2001 (average follow-up 6.6 years) was confirmed using radiographic reports. Results: The adjusted average rate of decline in total hipbone density steadily increased from −0.52% per year in women with weight gain to −0.68% per year in women with stable weight to −0.92% per year in women with weight loss (P-value for trend

Author(s): Sarkisian, CA; Liu, H; Ensrud, KE; Stone, KL; Mangione, CM | Abstract: ObjectivesTo describe women who attribute new disability to old age and to identify demographic, medical, behavioral, and psychosocial characteristics that correlate with attributing new disability to old age.DesignProspective cohort study with 4-year follow-up.SettingFour geographic regions of the United States.Participants9704 women aged g or = 67 years participating in the Study of Osteoporotic Fractures. Of these, 657 who reported no disability at baseline but at follow-up reported difficulty carrying out 1 or more of 13 functional activities were eligible for our analysis.MeasurementsAll women reporting difficulty in any functional activity at follow-up were asked "What is the main condition that causes you to have difficulty or prevents you from (doing the activity)?" and were shown a card listing 14 medical conditions as well as the option "old age," from which they could choose only one response. Women attributing difficulty or inability in 1 or more functional activities to old age were classified as attributing new disability to old age. We examined the relationship between attributing new disability to old age and the following characteristics measured at baseline: age, level of education, medical comorbidity, cognitive function, body mass index (BMI), gait speed, grip strength, visual acuity, physical activity level, smoking status, social network level, and depressed mood.ResultsOverall, 13.5% of women attributed new disability to old age. Age was a strong independent correlate of attributing new disability to old age: compared with women age 67 to 69, the odds of attributing new disability to old age for women age 70 to 79 was 3.6 times as large (95% confidence interval [CI] = 1.6-8.3), and for women age 80 or over was 5.5 times as large (95% CI = 2.1-14.7). The only other characteristic that remained an independent correlate of attributing new disability to old age was grip strength; for each decile decrease in grip strength, a woman's odds of attributing new disability to old age increased by 9% (odds ratio [OR] = 1.09, 95% CI = 1.01-1.19).ConclusionsDespite great advances in geriatric medicine, old age is still perceived as a causal agent in functional decline, especially among our oldest patients. Further study is needed to determine whether, how often, and under what circumstances older adults who attribute new disability to old age have medical conditions amenable to interventions that could preserve their functioning and improve their quality of life.

OBJECTIVE: To determine if urge urinary incontinence is associated with risk of falls and non-spine fractures in older women. METHODS: Type and frequency of incontinent episodes were assessed by 6049 community-dwelling women using a self-completed questionnaire. Postcards were subsequently mailed every 4 months to inquire about falls and fractures. Incident fractures were confirmed by radiographic report. Logistic and proportional hazard models were used to assess the independent association of urge urinary incontinence and risk of falling or fracture. RESULTS: The mean age of the women was 78.5 (± 4.6) years. During an average follow-up of 3 years, 55% of women reported falling, and 8.5% reported fractures. One-quarter of the women (1493) reported weekly or more frequent urge incontinence, 19% (1137) reported weekly or more frequent stress incontinence, and 708 (12%) reported both types of incontinence. In multivariate models, weekly or more frequent urge incontinence was associated independently with risk of falling (odds ratio = 1.26; 95% confidence interval (CI), 1.14-1.40) and with non-spine nontraumatic fracture (relative hazard 1.34; 95% CI, 1.06-1.69; P = .02). Stress incontinence was not associated independently with falls or fracture. CONCLUSIONS: Weekly or more frequent urge incontinence was associated independently with an increased risk of falls and non-spine, nontraumatic fractures in older women. Urinary frequency, nocturia, and rushing to the bathroom to avoid urge incontinent episodes most likely increase the risk of falling, which then results in fractures. Early diagnosis and appropriate treatment of urge incontinence may decrease the risk of fracture. J Am Geriatr Soc 48:721–725, 2000.

Objectives: To examine the association between sleep architecture, sleep-disordered breathing, and cognition in older men. Design: Population-based cross-sectional study. Setting: Six clinical sites in the United States. Participants: Two thousand nine hundred nine community-dwelling men aged 67 and older who were not selected on the basis of sleep problems or cognitive impairment. Measurements: Predictors were measured using in-home polysomnography: sleep architecture, nocturnal hypoxemia (any sleep time with arterial oxygen saturation

To determine whether circadian activity rhythms are associated with mortality in community-dwelling older women.Prospective study of mortality.A cohort study of health and aging.Three thousand twenty-seven community-dwelling women from the Study of Osteoporotic Fractures cohort (mean age 84).Activity data were collected using wrist actigraphy for a minimum of three 24-hour periods, and circadian activity rhythms were computed. Parameters of interest included height of activity peak (amplitude), midline estimating statistic of rhythm (mesor), strength of activity rhythm (robustness), and time of peak activity (acrophase). Vital status, with cause of death adjudicated through death certificates, was prospectively ascertained.Over an average of 4.1 years of follow-up, there were 444 (14.7%) deaths. There was an inverse association between peak activity height and all-cause mortality rates, with higher mortality rates observed in the lowest activity quartile (hazard ratio (HR)=2.18, 95% confidence interval (CI)=1.63-2.92) than in the highest quartile after adjusting for age, clinic site, race, body mass index, cognitive function, exercise, instrumental activity of daily living impairments, depression, medications, alcohol, smoking, self-reported health status, married status, and comorbidities. A greater risk of mortality from all causes was observed for those in the lowest quartiles of mesor (HR=1.71, 95% CI=1.29-2.27) and rhythm robustness (HR=1.97, 95% CI=1.50-2.60) than for those in the highest quartiles. Greater mortality from cancer (HR=2.09, 95% CI=1.04-4.22) and stroke (HR=2.64, 95% CI=1.11-6.30) was observed for later peak activity (after 4:33 p.m.;1.5 SD from mean) than for the mean peak range (2:50-4:33 p.m.).Older women with weak circadian activity rhythms have higher mortality risk. If confirmed in other cohorts, studies will be needed to test whether interventions (e.g., physical activity, bright light exposure) that regulate circadian activity rhythms will improve health outcomes in older adults.

To test the hypothesis that sleep disturbances are independently associated with frailty status in older men.Cross-sectional analysis of prospective cohort study.Six U.S. centers.Three thousand one hundred thirty-three men aged 67 and older.Self-reported sleep parameters (questionnaire); objective parameters of sleep-wake patterns (actigraphy data collected for an average of 5.2 nights); and objective parameters of sleep-disordered breathing, nocturnal hypoxemia, and periodic leg movements with arousals (PLMAs) (in-home overnight polysomnography). Frailty status was classified as robust, intermediate stage, or frail using criteria similar to those used in the Cardiovascular Health Study frailty index.The prevalence of sleep disturbances, including poor sleep quality, excessive daytime sleepiness, short sleep duration, lower sleep efficiency, prolonged sleep latency, sleep fragmentation (greater nighttime wakefulness and frequent, long wake episodes), sleep-disordered breathing, nocturnal hypoxemia, and frequent PLMAs, was lowest in robust men, intermediate in men in the intermediate-stage group, and highest in frail men (P-for-trendor =.002 for all sleep parameters). After adjusting for multiple potential confounders, self-reported poor sleep quality (Pittsburgh Sleep Quality Index5, multivariable odds ratio (MOR)=1.28, 95% confidence interval (CI)=1.09-1.50), sleep efficiency less than 70% (MOR=1.37, 95% CI=1.12-1.67), sleep latency of 60 minutes or longer (MOR=1.42, 95% CI=1.10-1.82), and sleep-disordered breathing (respiratory disturbance indexor =15, MOR=1.38, 95% CI=1.15-1.65) were each independently associated with higher odds of greater frailty status.Sleep disturbances, including poor self-reported sleep quality, lower sleep efficiency, prolonged sleep latency, and sleep-disordered breathing, are independently associated with greater evidence of frailty.

To evaluate the associations between visual field loss and nonspine fractures.Prospective cohort study.Community.Four thousand seven hundred seventy-three community-dwelling white and African-American women aged 65 and older with no previous history of hip fracture at the time of recruitment.Radiographically confirmed hip and nonspine, nonhip fractures identified from September 1997 to April 2008. Visual field loss was measured using a Humphrey Field Analyzer suprathreshold screening test of the peripheral and central vision of each eye and was classified into an ordinal rating of no, mild, moderate, or severe binocular visual field (BVF) loss.For hip and nonspine, nonhip fractures and in unadjusted and covariate-adjusted analyses, the highest incidence of fractures was seen in women with the most-severe BVF loss. In covariate-adjusted analysis, women with mild, moderate, and severe BVF loss had a 49% (hazard ratio (HR)=1.49, 95% confidence interval (CI)=1.18-1.88), 25% (HR=1.25, 95% CI=0.87-1.80), and 66% (HR=1.66, 95% CI=1.19-2.32) greater risk, respectively, for hip fractures than women without BVF loss. Similarly, women with mild visual field loss had a 12% (HR=0.88, 95% CI=0.75-1.04) lower risk for nonspine, nonhip fractures, whereas women with moderate and severe visual field loss had a 18% (HR=1.18, 95% CI=0.92-1.52) and 59% (HR=1.59, 95% CI=1.24-2.03) greater risk of nonspine, nonhip fractures than women without BVF loss.BVF loss is independently associated with hip and nonspine, nonhip fractures in older female volunteers.

To determine the association between self-reported sleep and nap habits and mortality in a large cohort of older women.Study of Osteoporotic Fractures prospective cohort study.Four communities within the United States.Eight thousand one hundred one Caucasian women aged 69 and older (mean age 77.0).Sleep and nap habits were assessed using a questionnaire at the fourth clinic visit (1993/94). Deaths during 7 years of follow-up were confirmed with death certificates. Underlying cause of death was assigned according to the International Classification of Diseases, Ninth Revision, Clinical Modification.In multivariate models, women who reported napping daily were 44% more likely to die from any cause (95% confidence interval (CI)=1.23-1.67), 58% more likely to die from cardiovascular causes (95% CI=1.25-2.00), and 59% more likely to die from noncardiovascular noncancer causes (95% CI=1.24-2.03) than women who did not nap daily. This relationship remained significant in relatively healthy women (those who reported no comorbidities). Women who slept 9 to 10 hours per 24 hours were at greater risk of death from cardiovascular and other (noncardiovascular, noncancer) causes than those who reported sleeping 8 to 9 hours.Older women who reported napping daily or sleeping at least 9 hours per 24 hours are at greater risk of death from all causes except cancer. Future research could determine whether specific sleep disorders contribute to these relationships.

To determine whether an objective measure of daytime movement is associated with better cognitive function in women in their 80s.Cross-sectional.A study of health and aging.Two thousand seven hundred thirty-six older women without evidence of dementia.Daytime movement was assessed using actigraphy, which involved wearing a watch-like device that objectively quantified accelerometer motion over a mean of 3.0+/-0.8 days. Cognitive function was measured using the Trail-Making Test, Part B (Trails B) and the Mini-Mental State Examination (MMSE). Cognitive impairment was defined as performing 1.5 standard deviations (SDs) worse than the mean on a given test.Participants had a mean age of 83+/-4; 10% were African American. After adjustment for age, race, and education, women in the highest movement quartiles had better mean cognitive test scores (20+/-0.3 seconds faster on Trails B and 0.3+/-0.2 points higher on MMSE, both P.001) than those in the lowest quartile and were less likely to be cognitively impaired (odds ratio (OR)=0.61, 95% confidence interval (CI)=0.41-0.92 for Trails B; OR=0.68, 95% CI=0.44-1.07 for MMSE). Associations were similar in different subgroups and were independent of self-reported walking, medical comorbidities, physical function, and other health-related behaviors.Daytime movement as measured objectively using actigraphy was associated with better cognitive function and lower odds of cognitive impairment in women in their 80s. Additional studies are needed to clarify the direction of the association and to explore potential mechanisms.

To investigate the association between objectively measured sleep-disordered breathing (SDB) and cognitive impairment in community-dwelling older women and to determine whether the apolipoprotein E (APOE) epsilon4 allele modifies this association.Cross-sectional.Participants' homes and two sites of the Study of Osteoporotic Fractures (SOF).Four hundred forty-eight women with a mean age+/-standard deviation (SD) of 82.8+/-3.4.Participants completed the Mini-Mental State Examination (MMSE), Trail Making Test Part B (Trails B), and polysomnography (PSG). SDB indices were the apnea-hypopnea index (AHI), the central apnea index (CAI), and oxygen saturation (SaO2) nadir less than 80%. APOE epsilon4 was determined for a subset of 242 women. Cognitive impairment was defined as 1.5 SDs or more from the sample mean on either cognitive test (MMSE or Trails B).All SDB indices were associated with cognitive impairment according to the MMSE (AHI (per SD, odds ratio (OR)=1.4, 95% confidence interval (CI)=1.03-1.9), AHI ofor = 30 (OR=3.4, 95% CI=1.4-8.1), SaO2 nadir80% (OR=2.7, 95% CI=1.1-6.6), and CAI (per SD, OR=1.4, 95% CI=1.1-1.7)). Weaker, nonsignificant associations emerged between SDB and Trails B. In women who completed genotyping, each SD increase in AHI was associated with 70% greater odds of cognitive impairment according to the MMSE (OR=1.7, 95% CI=1.2-2.6). Women with the epsilon4 allele had a nearly five times greater odds of impairment (per SD, OR=4.6, 95% CI-1.0-20.7); the association was smaller and nonsignificant in women without the epsilon4 allele (per SD, OR=1.5, 95% CI-0.9-2.4; P for interaction=.08).SDB is an important risk factor for cognitive impairment in older women, especially those with the APOE epsilon4 allele. Mechanisms linking these disorders need to be identified.

To determine whether depressive symptoms modify the association between caregiving and sleep problems in elderly women.Cross-sectional study conducted in four communities in 1999 to 2001.Home-based interviewer-administered questionnaires.Three hundred seventy-five caregiver and 694 noncaregiver participants from the Study of Osteoporotic Fractures.Self-reported frequency of three sleep problems in the previous month: trouble falling asleep, trouble staying asleep, and waking early and having trouble falling back asleep. Depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D), excluding the sleep disturbance item.In adjusted analyses, caregivers did not report more sleep problems than noncaregivers, although respondents with high depressive symptoms (CES-Dor = 16) were twice as likely to report each sleep problem. When depressive symptoms and caregiving were considered together, caregivers with high depressive symptoms were most likely to report sleep problems (adjusted odds ratios ranging from 2.5, 95% confidence interval (CI)=1.2-5.2 for trouble falling asleep to 4.0, 95% CI=2.0-7.8 for waking early, compared with nondepressed noncaregivers). By contrast, there was no difference in sleep problems between caregivers and noncaregivers who were not depressed. The combination of high depressive symptoms and high-stress caregiving situations (e.g., caring for a spouse or a person with dementia, or living with the care recipient) also increased the likelihood of sleep problems.Caregivers with high levels of depressive symptoms reported sleep problems more than nondepressed noncaregivers. These results underscore the importance of screening elderly female caregivers for depressive symptoms and sleep problems.

To determine the prevalence and distribution of sleep-disordered breathing and associated correlates in a large cohort of older men using several standardized definitions.Cross-sectional analyses.Six U.S. communities.Polysomnography was performed on 2,911 participants of the Outcomes of Sleep Disorders in Older Men Sleep Study (mean age+/-standard deviation 76.38+/-5.53; body mass index 27.17+/-3.8 kg/m(2)).Three outcomes were assessed: sleep-disordered breathing (respiratory disturbance indexor =15), obstructive apnea (obstructive apnea indexor =5), and central apnea (central apnea indexor =5).The prevalence of moderate-severe sleep-disordered breathing was estimated to be 21.4% to 26.4%. Multivariable logistic regression models demonstrated that age (adjusted odds ratio (AOR) per 5-year increase =1.24, 95% confidence interval (CI)=1.15-1.34), obesity (AOR=2.54, 95% CI=2.09-3.09), Asian versus Caucasian race (AOR=2.14, 95% CI=1.33-3.45), snoring (AOR=2.01, 95% CI=1.62-2.49), sleepiness (AOR=1.41, 95% CI=1.11-1.79), hypertension (AOR=1.26, 95% CI=1.06-1.50), cardiovascular disease (AOR=1.24, 95% CI=1.19-1.29), and heart failure (AOR=1.81, 1.31-2.51) were independently associated with sleep-disordered breathing; snoring (AOR=2.10, 95% CI=1.67-2.70), age (AOR per 5-year increase=1.27, 95% CI=1.18-1.38), obesity (AOR=1.48, 95% CI=1.21-1.82), and heart failure (AOR=1.60, 95% CI=1.15-2.24) were associated with obstructive apnea; and age (AOR=1.33, 1.17-1.50) and heart failure (AOR=1.88, 95% CI=1.17-3.04) were associated with central apnea.Regardless of definition, a high prevalence of sleep disorders is observed in community-dwelling older men. Qualitatively similar associations were observed between sleep disorders and snoring, obesity, and comorbidities, as reported for middle aged populations. Asian race was associated with sleep-disordered breathing.

To ascertain whether depressive symptoms are associated with increased rates of bone loss at the hip.Population-based prospective cohort study.Four clinical centers in the United States.Four thousand one hundred seventy-seven community-dwelling women, aged 69 and older, enrolled in the Study of Osteoporotic Fractures.Depressive symptoms were assessed using the Geriatric Depression Scale (GDS). Subjects were categorized as depressed if their GDS score was 6 or greater at the fourth examination. Bone mineral density (BMD) at the hip was measured using dual-energy x-ray absorptiometry at the fourth and sixth examinations (average 4.4 years between examinations). Use of antidepressant medications was assessed by interview and verified from medication containers at the fourth and sixth examinations of the Study of Osteoporotic Fractures. A computerized dictionary was used to categorize type of medication.In age-adjusted models, mean total hip BMD decreased 0.69%/year in 3,977 women with a GDS score of less than 6, compared with 0.96%/year in 200 women with a GDS score of 6 or greater (P.01). Results were not substantially altered when adjusted for potential confounders and when users of antidepressants were excluded from the analysis.Depression, as defined by a GDS score of 6 or greater, was associated with an increased rate of bone loss at the hip in this cohort of older women. Clinicians should be aware of a possible increased rate of bone loss in older, depressed women.

To determine whether bone mineral density (BMD) is associated with age-related maculopathy (ARM) risk in older women.Cross-sectional analysis at Year 10 (1997/98) of the Study of Osteoporotic Fractures (SOF).Four clinical centers in the United States.One thousand forty-two randomly sampled SOF participants who attended the Year 10 clinic visit.ARM status was determined from fundus photographs using a modification of the Wisconsin Age-Related Maculopathy Grading System 6-level severity scale used in the National Health and Nutrition Examination Survey III. Total hip BMD was measured at Year 10 using dual-energy x-ray absorptiometry. Information on potential confounders, including age, reproductive hormone exposures, body mass index, smoking, alcohol consumption, nutrition, education, diabetes mellitus, hypertension, and physical activity, was ascertained with questionnaires.The prevalence of ARM was 50% (46% had early ARM and 4% had late ARM). After potential confounder adjustment, greater BMD was associated with lower odds of ARM (odds ratio (OR) per 1 standard deviation increase in BMD=0.82, 95% confidence interval (CI)=0.70-0.96). Women in the highest quartile of BMD had lower odds of ARM than those in the lowest quartile (OR=0.63, 95% CI=0.41-0.97) and those in the lowest three quartiles combined (OR=0.66, 95% CI=0.48-0.91).Higher levels of BMD may be associated with lower risk for ARM. The underlying mechanism is unknown, although BMD may be a marker for lifetime endogenous estrogen exposure. Future studies are needed to replicate these findings and further investigate the nature of the relationship between BMD and ARM.

To examine the relationship between binocular visual field loss and the risk of incident frequent falls in older white women.A multicenter, prospective cohort study.Four clinic centers within the United States in Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, Pennsylvania.Four thousand seventy-one community-dwelling white women aged 70 and older participating in the Study of Osteoporotic Fractures.Primary outcome was incident frequent falls, defined as two or more falls within 1 year. Primary risk factors were binocular visual field loss, distance visual acuity in the better eye, and contrast sensitivity at low spatial frequency in the better eye.Of 4,071 women, 409 (10%) had severe binocular visual field loss at the eye examination, and 643 (16%) experienced frequent falls within 1 year after their eye examination. Severe binocular visual field loss was significantly associated with frequent falls when adjusting for age, study site, and cognitive function (odds ratio=1.50, 95% confidence interval=1.11-2.02). The data showed a trend for increasing odds of two or more falls with greater binocular visual field loss (P.001). In older white women with severe binocular visual field loss, 33.3% of frequent falls were attributable to visual field loss.Women with binocular visual field loss are at greater risk of future frequent falls. Screening for binocular visual field loss may identify individuals at high risk of falling.

To determine whether older women who maintain optimal cognitive function into old age differ from those who experience minor cognitive decline typically associated with normal aging.Prospective cohort study.The Study of Osteoporotic Fractures.Nine thousand seven hundred four older women.A modified Mini-Mental State Examination (mMMSE) was performed at baseline and Years 6, 8, 10, and 15. Random-effects regression was used to classify subjects as cognitive maintainers (slope/=0), minor decliners (slope0 butlowest tertile), or major decliners (slopeor= lowest tertile). Stepwise logistic regression was used to identify factors most predictive of being a cognitive maintainer versus a minor decliner (excluding major decliners).Women had a mean age of 72 at baseline and 85 at follow-up. Nine percent maintained optimal cognitive function, 58% experienced minor decline, and 33% experienced major decline. Most factors differed progressively over the three cognitive groups. After adjustment for key confounders, odds ratios for factors most predictive of being a cognitive maintainer as opposed to minor decliner were 1.9 (95% confidence interval (CI)=1.2-2.9) for lack of diabetes mellitus, 1.2 (95% CI=1.0-1.4) for lack of hypertension, 1.7 (95% CI=1.3-2.3) for lack of smoking, 1.2 (95% CI=1.1-1.5) for moderate alcohol consumption, 1.4 (95% CI=1.1-1.7) for lack of difficulty with instrumental activities of daily living, and 1.2 (95% CI=1.0-1.4) for lack of low social network.Almost 10% of older women maintained optimal cognitive function into old age. Cognitive maintainers were less likely to have comorbid medical conditions, less likely to have difficulty with daily activities or poor social networks, and more likely to engage in healthy behaviors than minor cognitive decliners.

To determine the association between use of selective serotonin reuptake inhibitors (SSRIs) and objective measures of sleep disturbances in older community-dwelling women, including women without evidence of depression.Cross-sectional study.Four U.S. clinical centers.Two thousand eight hundred fifty-three women aged 71 and older (2,630 nonusers of antidepressants and 223 taking SSRIs alone, not in combination with other antidepressants).Medication use, assessed using an interviewer-administered questionnaire with verification of use from medication containers and computerized dictionary used to categorize type of medication; evidence of depression assessed using self-report or a score of 6 or higher on the Geriatric Depression Scale; and sleep parameters measured using a wrist actigraph, with data collected for an average of four consecutive 24-hour periods.Of the overall cohort of 2,853 women and of 2,337 women without evidence of depression, sleep disturbances were more common in women taking SSRIs than in those not taking antidepressants. After excluding women with evidence of depression and adjusting for multiple potential confounders, women taking SSRIs were more likely to have a sleep duration of 5 hours or less (multivariate odds ratio (MOR)=2.15, 95% confidence interval (CI)=1.04-4.47), sleep efficiency less than 70% (MOR=2.37, 95% CI=1.32-4.25), sleep latency of 1 hour or more (MOR=3.99, 95% CI=2.29-6.96) and eight or more long wake episodes (MOR=1.75, 95% CI=0.99-3.10).SSRI use by older women, including those without evidence of depression, is associated with a greater likelihood of sleep disturbances, including poorer sleep efficiency, longer sleep latency, and sleep fragmentation, manifested by multiple long wake episodes. These results add to the uncertainty regarding risks and benefits of SSRI use in aged populations.

To test the association between self-reported sleep and nap habits and risk of falls and fractures in a large cohort of older women.Study of Osteoporotic Fractures prospective cohort study.Clinical centers in Baltimore, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, near Pittsburgh, Pennsylvania.Eight thousand one hundred one community-dwelling Caucasian women aged 69 and older (mean 77.0).Sleep and nap habits were assessed using a questionnaire at the fourth clinic visit (1993/94). Fall frequency during the subsequent year was ascertained using tri-annual questionnaire. Incident hip and nonspinal fractures during 6 years of follow-up were confirmed using radiographic reports.Five hundred fifty-three women suffered hip fractures, and 1,938 suffered nonspinal fractures. In multivariate models, women who reported napping daily had significantly higher odds of suffering two or more falls during the subsequent year (odds ratio=1.32, 95% confidence interval (CI)=1.03-1.69) and were more likely to suffer a hip fracture (hazard ratio (HR)=1.33, 95% CI=0.99-1.78) than women who did not nap daily. Those sleeping at least 10 hours per 24 hours had a higher risk of nonspinal fracture than (HR=1.26, 95% CI=1.00-1.58) and a similar but nonsignificant increased risk of hip fracture to (HR=1.43, 95% CI=0.95-2.15) those who reported sleeping between 8 and 9 hours.Self-reported long sleep and daily napping are associated with greater risk of falls and fractures in older women. Interventions to improve sleep may reduce their risk of falls and fractures. Future research is needed to determine whether specific sleep disorders contribute to these relationships.

To determine the association between vision and hearing impairment and subsequent cognitive and functional decline in community-residing older women.Prospective cohort study.Four metropolitan areas of the United States.A total of 6,112 women aged 69 and older participating in the Study of Osteoporotic Fractures (SOF) between 1992 and 1994.Five thousand three hundred forty-five participants had hearing measured, 1,668 had visual acuity measured, and 1,636 had both measured. Visual impairment was defined as corrected vision worse than 20/40. Hearing impairment was defined as the inability to hear a tone of 40 dB or greater at 2,000 hertz. Participants completed the modified Mini-Mental State Examination and/or a functional status assessment at baseline and follow-up. Cognitive and functional decline were defined as the amount of decline from baseline to follow-up that exceeded the observed average change in scores by at least 1 standard deviation.About one-sixth (15.7%) of the sample had cognitive decline; 10.1% had functional decline. In multivariate models adjusted for sociodemographic characteristics and chronic conditions, vision impairment at baseline was associated with cognitive (odds ratio (OR)=1.78, 95% confidence interval (CI)=1.21-2.61) and functional (OR=1.79, 95% CI=1.15-2.79) decline. Hearing impairment was not associated with cognitive or functional decline. Combined impairment was associated with the greatest odds for cognitive (OR=2.19, 95% CI=1.26-3.81) and functional (OR=1.87, 95% CI=1.01-3.47) decline.Sensory impairment is associated with cognitive and functional decline in older women. Studies are needed to determine whether treatment of vision and hearing impairment can decrease the risk for cognitive and functional decline.

To identify independent risk factors for first hip fracture over 10 years of follow-up.Prospective cohort study.Four U.S. clinical centers.A total of 6,787 women aged 66 and older in the Study of Osteoporotic Fractures.Total hip bone mineral density (BMD) using dual-energy x-ray absorptiometry and a comprehensive set of potential risk factors were collected. Incident hip fractures were identified prospectively and confirmed using radiographic report.Six hundred two women (8.9%) had a hip fracture during a mean +/- standard deviation (SD) follow-up of 10.1 +/- 3.2 years. Older age, previous self-reported fracture after age 50, maternal history of hip fracture after age 50, greater height at age 25, impaired cognition, slower walking speed, nulliparity, type II diabetes mellitus, Parkinson's disease, and depth perception each independently predicted a 1.17- to 1.83-fold increase in hip fracture risk, whereas each SD (0.13 g/cm2) decrease in hip BMD was independently associated with a 1.84-fold increase in risk. Lower body mass index also was associated with an increased risk of hip fracture, although lower hip BMD largely explained this association.Although hip BMD is strongly related to hip fracture risk in elderly white women, other clinical risk factors also are independent predictors of long-term risk and provide additional insight into the prevention of fracture in high-risk women. Clinicians should be alert to factors other than BMD that place older women at a high risk of hip fracture.