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Objectives To explore the association between a newly developed cumulative laboratory-based frailty index ( FI) and intrinsic (personal) and extrinsic (social, environmental) characteristics. Design Cross-sectional longitudinal study. Setting The third and fourth waves of the community-representative, five-county, 10-year Duke Established Populations for Epidemiologic Studies of the Elderly study, carried out in a health service-rich area. Participants Cognitively intact survivors of the third wave (N = 1,740), who provided blood samples for standard laboratory work. Measurements Biomarkers (n = 28) were measured to develop a cumulative deficit laboratory test-based FI (Duke FI) derived from standard laboratory tests: SMAC-24 chemistry panel, high-density lipoprotein cholesterol panel, and complete blood count. Information was gathered on scales assessing intrinsic characteristics (personal locus of control, life satisfaction, self-esteem, depressive symptomatology) and extrinsic characteristics (support received from and provided to family and friends, stressful life events, neighborhood disadvantage). Results The newly developed Duke FI had content, construct, concurrent, and predictive validity. In addition to sex, race, and income, the Duke FI was associated at the intrinsic level with locus of control, self-esteem, life satisfaction, and depressive symptomatology (each P < .01) and at the extrinsic level with provision ( P < .01) and with receipt of instrumental help ( P < .10), social stressors ( P < .03), and neighborhood disadvantage ( P < .01) in unadjusted analysis; race fully explained neighborhood disadvantage. Conclusion Intrinsic (personality) characteristics and personally close extrinsic characteristics (contacts with family and friends, personal stressors) are associated with laboratory test-based frailty, as is neighborhood disadvantage, although in this accessible, health service-rich environment, race fully explained association with neighborhood disadvantage, suggesting that interventions to reduce frailty in residents in such an environment should pay particular attention to characteristics that immediately affect the individual. [ABSTRACT FROM AUTHOR]

Objectives To determine the sociodemographic characteristics, health conditions, and cognitive and functional status associated with baseline prevalence and new need for help taking medication 3 years later and to construct a brief scale indicative of need for help taking medications. Design Retrospective cross-sectional and 3-year longitudinal study. Setting Five-county area in north-central Piedmont, North Carolina. Participants Representative community-dwelling sample of black and white individuals aged 65 and older (N = 4,136). Measurements Information was obtained in person in participants' homes using structured questionnaires. Health conditions included sensory impairment and self-report of physician-diagnosed conditions. Cognitive status was assessed using the 10-item Short Portable Mental Status Questionnaire. Functional status was assessed using the three-item Rosow-Breslau scale, the five-item Katz activity of daily living scale, and a modified six-item Older Americans Resources and Services instrumental activities of daily living scale. Results Characteristics associated with need for help taking medications were aged 80 and older, being male, living with others, having four or more chronic conditions, and impaired cognitive or functional status (c-statistic 0.94, 77.1% sensitivity, 87.9% specificity). Predictors of new need for help with medications 3 years later included aged 75 and older at baseline, being male, and impaired cognitive and functional status (c-statistic 0.75). Conclusion This brief scale can help identify persons needing help with medications and could be useful in assisting clinicians with medication management. [ABSTRACT FROM AUTHOR]

To describe the independent contributions of selected medical conditions to the disparity between black and white people in disability rates, controlling for demographic and socioeconomic factors. Cross-sectional analysis of a community-based cohort. Urban and rural counties of central North Carolina. Two thousand nine hundred sixty-six adults aged 68 and older participating in the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE). Self-reported data on sociodemographic characteristics and medical conditions, Short Portable Mental Status Questionnaire, activities of daily living (ADLs). Fifty-five percent of the cohort was black. Blacks were more likely than whites to report disability (odds ratio=1.39, 95% confidence interval= 1.15-1.68). Controlling for age, sex, marital status, and socioeconomic status, blacks were more likely to be obese and have diabetes mellitus, and less likely to report vision problems, fractures, and heart attacks. The higher prevalence of obesity and diabetes mellitus in blacks, after adjustment for sociodemographic factors, accounted for more than 30% of the black-white difference in disability. Conversely, the black-white disability gap would be approximately 45% wider if whites had a lower prevalence of fractures and vision impairment, similar to their black peers. Higher rates of obesity and diabetes mellitus in older black Americans account for a large amount of the racial disparity in disability, even after controlling for socioeconomic differences. Culturally appropriate interventions that lower the prevalence or the functional consequences of obesity and diabetes mellitus in blacks could substantially decrease this racial health disparity. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether the characteristics of the usual medical care providers of older antidepressant users changed between 1986 and 1997 with the introduction of selective serotonin reuptake inhibitors. DESIGN: Longitudinal study. SETTING: Five-county Piedmont area of North Carolina. PARTICIPANTS: Stratified random sample of African-American (n=2,261) and white (n=1,875) community residents aged 65 to 105. MEASUREMENTS: Sample members provided information on prescription medications, demographic and health status, and usual medical care provider (matched to North Carolina Health Professions Data Systems files to ascertain provider characteristics) in 1986/87, 1989/90, 1992/93, and 1996/97. Most (77.5%) named a provider (name unmatchable for 4.1%). Sample member characteristics were aggregated into probability (propensity) scores summarizing predisposing (demographic), enabling (medical care access), and need (health status) categories. Along with wave of study and whether a provider was named, these were entered as control variables in generalized estimating equation models that examined the association between provider race (white vs nonwhite), sex, age, location of practice, and primary versus specialist care and antidepressant use. RESULTS: The characteristics of the usual medical care providers remained stable over the decade, although prevalence of antidepressant use increased. Two provider characteristics—race and area of practice (but not the interaction between them)—were significantly associated with patients' use of antidepressants. Patients of white physicians and of physicians with urban practices were more likely to use antidepressants. CONCLUSION: Although use of antidepressants has increased over time, there has been little change in the characteristics of users' usual medical care providers. [ABSTRACT FROM AUTHOR]

To compare a family informant's report of memory loss in an older family member to standardized clinical diagnoses of cognitive impairment.Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE), a 10-year longitudinal study of community dwellers aged 65 and greater in five counties of North Carolina.A stratified random sample of potentially demented participants was selected from the second wave of the Duke EPESE using responses to a brief cognitive screen. A neuropsychological battery was administered to these participants, and their family informants were asked whether they recognized memory loss in the participant. One hundred fifty-seven participants completed the full evaluation and also had an available family informant.Family informant's report of memory loss (yes, no, sometimes) compared to expert consensus diagnosis of cognitive impairment or dementia.There was poor concordance between the clinical diagnoses of cognitive impairment or dementia and the family informant's recognition of memory loss (κ=−0.05;P=.74). When informants reported memory loss, 30% of participants were found not to have a cognitive loss. Among participants in whom family informants reported no memory loss, 75% were diagnosed with dementia or cognitive impairment (sensitivity, 0.70, 95% confidence interval [CI], 0.61 to 0.78; specificity, 0.24, 95% CI, 0.13 to 0.40; positive predictive value, 70%; negative predictive value, 25%).Asking family members about memory loss in a patient may be an unreliable strategy to detect dementia. [ABSTRACT FROM AUTHOR]

To determine the prevalence and predictors of antidiabetic medication use over a 10-year period in a general population of African-American and white community-dwelling elderly. Survey. Five adjacent counties (one urban and four rural) in the Piedmont area of North Carolina. Those aged 65 and older present at the baseline (n=4,136), second (n=3,234), third (n=2,508), and fourth (n=1,633) in-person waves of the Duke Established Populations for Epidemiologic Studies of the Elderly. The use of six discrete categories of antidiabetic medications (insulin, first-generation oral sulfonylureas, second-generation oral sulfonylureas, metformin, oral combination therapy, and insulin combination therapy) was determined. Multivariate analyses, using weighted data adjusted for sampling design, were conducted to assess the association between antidiabetic medication use and race and other sociodemographic, health-status, and access-to-healthcare factors at baseline and 10 years later. Antidiabetic medications were taken by 21.4% of the population at baseline; this increased to 28.1% at the 10-year follow-up ( P<.001). Insulin was the most commonly used drug at baseline (7.9%). The use of second-generation sulfonylureas increased, and use of first-generation sulfonylureas decreased over the 10-year time period. Combination antidiabetic therapy and metformin use was infrequent throughout the study. Multivariate analyses revealed that, at baseline, African Americans were nearly twice as likely (adjusted odds ratio (AOR)=1.93, 95% confidence interval (CI)=1.46–2.54) to receive any antidiabetic medication as their white counterparts. Other significant ( P<.05) factors were hypertension (AOR=1.38, 95% CI=1.03–1.84), stroke (AOR=1.98, 95% CI=1.43–2.73), one or more mobility difficulties (AOR=1.29, 95% CI=1.01–1.66), continuity of care (AOR=1.74, 95% CI=1.20–2.54), and multiple doctor visits (1–4 visits, AOR=1.69, 95% CI=1.08–2.65; ≥5 visits, AOR=3.15, 95% CI=1.95–5.07). Being underweight (AOR=0.45, 95% CI=0.30–0.67) and being cognitively impaired (AOR=0.60, 95% CI=0.41–0.87) were factors significantly ( P<.05) associated with a decreased risk of antidiabetic medication use. At the 10-year follow-up, similar trends were seen associating these sociodemographic, health-status, and access-to-healthcare factors with antidiabetic medication use. Antidiabetic medication use is common and increases over time for community-dwelling elderly. Race is significantly associated with antidiabetic medication use, even after controlling for other sociodemographic, health-status, and access-to-healthcare variables. [ABSTRACT FROM AUTHOR]

Focuses on a study which evaluated the association between potential risk factors and falls in a sample of Afro-American and White elderly persons in Piedmont region of North Carolina. Reference to the Duke Established Populations for Epidemiologic Studies of the Elderly; Methodology of the study; Characteristics of subjects; Factors associated with multiple falls; Analysis of findings.

OBJECTIVES: To determine whether there are racial/ethnic differences regarding the relationship of level of blood pressure to change in cognitive function in older people. DESIGN: Longitudinal data 1986 to 1989 on representative, older, community-residing African Americans and whites. Blood pressure levels were assessed and a brief screen of cognitive functioning, the Short Portable Mental Status Questionnaire (SPMSQ), was performed at baseline and 3 years later. SETTING: Five contiguous counties in the Piedmont area of North Carolina. PARTICIPANTS: African-American (n = 2,260) and white (n = 1,876) participants in the Duke Established Populations for Epidemiologic Studies of the Elderly, aged 65 to 105 at baseline. MEASUREMENTS: The outcome measure was change in SPMSQ score over 3 years. Covariates included age; education; gender; self-reported diabetes mellitus, stroke, heart attack, current smoking, and depressive symptomatology; and use of antihypertensive medication. The primary independent variable was measured blood pressure. RESULTS: In unadjusted analyses, a statistically significant U-shaped relationship was found between systolic (but not diastolic) blood pressure levels and change in SPMSQ score over a 3-year period for older white men and women. No such relationships were found between these blood pressure measurements and change in SPMSQ score in older African Americans. These findings remained after adjustment for initial SPMSQ score, demographic characteristics, and use of antihypertensive medication. There were no significant interactions between race and blood pressure on change in cognitive function. CONCLUSION: Decline in cognitive function was associated with extremes of systolic blood pressure in older white people. Although a similar but muted nonsignificant association was found in older African Americans, the curves for the two groups were not significantly different. Further studies in older African Americans are needed. J Am Geriatr... [ABSTRACT FROM AUTHOR]

Determines the inappropriate drug prescribing by expert from the National Consensus panel drug utilization for community-dwelling older people in North Carolina. Evaluation on drug-drug interaction; Analysis by multivariate to weigh data in sampling design; Identification on the class of benzodiazepines and nonsteroidal antiinflammatory drugs.

OBJECTIVES: To determine whether cognitive decline associated with the apolipoprotein E (APOE) ℇ4 allele is different in older African Americans than it is in Caucasians. DESIGN: Performance on a brief screen of cognitive functioning was examined at baseline (N = 1,891) and 4 years later (N = 1,389) to determine the extent to which the presence of APOE ℇ4 affected level of and change in performance, and whether this differed as a function of race, age, initial score, and change in score. SETTING: Five adjacent counties in the Piedmont area of North Carolina. PARTICIPANTS: In 1986, a stratified random household sample of community residents age 65 and older (n = 4,162; 54% African-American, 45% Caucasian, 1% other race) formed the Duke Established Populations for Epidemiologic Studies of the Elderly. Of those available at the sixth annual wave, 76% were genotyped, with 1,891 providing baseline data on this wave, and the available survivors (n = 1,389) providing longitudinal data 4 years later. MEASUREMENTS: The Short Portable Mental Status Questionnaire (SPMSQ), a brief screen of cognitive functioning, was administered to all subjects on both occasions. We examined score at baseline and cognitive decline (i.e., increase of 2+ errors) at follow-up. Control measures included demographic characteristics, health behaviors, health and functional status, and medication use. APOE status was coded as ℇ4 present versus absent. RESULTS: APOE ℇ4 was significantly and uniquely related to lower score at baseline and significantly increased the odds of cognitive decline by 59%. There was no statistically significant interaction between APOE ℇ4 and age, race, initial SPMSQ score, or SPMSQ score at follow-up. [ABSTRACT FROM AUTHOR]

This study examines the prevalence of functional disability (limitation in at least one basic activity of daily living) among elderly Black and White community residents in the New Haven (n = 2812) and North Carolina (n = 4162) sites of the Established Populations for Epidemiologic Studies of the Elderly (EPESE). In New Haven, elderly Blacks, particularly women below age 75, had a higher prevalence of disability compared with Whites, which was partially attributable to a higher prevalence of chronic conditions. In North Carolina, Blacks had only a slightly higher risk of being disabled than Whites, and this was fully accounted for by differences in socioeconomic status. Black-White differences in the prevalence of functional disability reveal geographic variation. [ABSTRACT FROM AUTHOR]

Objectives. To examine and compare concomitants of prescription and nonprescription drug use of Black and White community-dwelling elderly. Methods. Information on prescription and nonprescription drug use, demographic and health characteristics, and use of health services was obtained from a probability-based sample of Black (n = 2152) and White (n = 1821) community-resident elderly in the Piedmont area of North Carolina. Descriptive statistics were calculated. Linear regression, in which sample weights and design effects were taken into account, was used for the final models. Results. For prescription drug use, 37% and 32% of the variance was explained for Whites and Blacks, respectively (6% and 5% for nonprescription drugs). Health status and use of medical services were the strongest predictors of prescription drug use for both races (with Medigap insurance also important for Whites and Medicaid important for Blacks). Demographic characteristics and self-assessed health were significant factors in the use of nonprescription drugs. Race independently predicted use of both types of drugs but explained only a small proportion of the variance. Conclusions. Health status and use of health services are importantly related to prescription drug use. Non-prescription drug use is difficult to explain. [ABSTRACT FROM AUTHOR]

Background: It is unclear whether distinct weight-related trajectory classes, differing in course, demographics, and health characteristics, exist in the elderly population., Methods: Data came from the 10-year (1986-1996) Duke Established Populations for Epidemiologic Studies of the Elderly study of 3,861 black (54%) and white (46%) participants aged 65-105 years. Latent-class trajectories of body mass index (BMI: kg/m(2)) based on self-reported weight and height at baseline, 3, 6, and 10 years later were determined using generalized mixture models. Polytomous logistic regression was used to identify baseline demographic and health characteristics that distinguished the trajectories, and 10-year postbaseline data to confirm the findings., Results: We identified three trajectories: normal weight (BMI ~24, 27.6% of the sample), overweight (BMI ~26, 65.1%), and obese (BMI ~31, 7.3%). Demographic characteristics distinguished the three trajectories: highest odds of blacks, women, and less education in the obese trajectory, lowest in the normal-weight trajectory. Obese and overweight differed adversely from normal-weight trajectories, but not significantly from each other on cognitive impairment, hypertension, and diabetes. Depressive symptomatology was more prevalent in the obese; they were also younger. There was no association with cancer or heart disease., Conclusion: Distinct trajectories and course of BMI were present in this older population. Weight loss increased with increase in BMI class. Although demographic characteristics distinguished all trajectory classes, adverse health characteristics distinguished the overweight and obese classes from the normal-weight class, but not from each other. Problems associated with education and health are present at study entry and should be addressed earlier in life.

Background: We wished to determine if a marker of endothelial dysfunction/activation soluble vascular cell adhesion molecule (s-VCAM)-was related to functional status and mortality in community-dwelling older adults independent of the known effects of markers of inflammation and coagulation., Methods: Data came from the third and fourth in-person waves of the Duke Established Populations for Epidemiologic Studies of the Elderly. Participants (aged ≥ 71 years) had participated in a blood draw (N = 1,551) from which concentrations of s-VCAM, interleukin-6, and D-dimer were determined. Information was gathered in-person on demographics, health behaviors, chronic health conditions, and functional status (Katz, Rosow-Breslau, Nagi). Death was determined through the National Death Index. Multivariable regression analysis was used to examine the adjusted association of s-VCAM with functional status; Cox proportional hazards models ascertained hazard of mortality., Results: Controlled analyses indicated that cross-sectionally, but not longitudinally (4 years later), greater s-VCAM concentrations were associated with poorer function as measured by the Katz and Rosow-Breslau scales (p < .05 for both), independent of interleukin-6 and D-dimer. In controlled analyses, s-VCAM (p = .002), D-dimer (p = .008), and interleukin-6 (p = .01) were independently related to 4-year mortality; 1 SD increase in log concentration conferred 1.2-, 1.1-, and 1.2-fold increases in mortality, respectively. The greatest hazard of mortality was observed within the first year after measurement. s-VCAM concentrations were not predictive of 15-year mortality., Conclusions: Independent of inflammation and coagulation markers, endothelial dysfunction serves as a marker of, and potentially contributes causally to, poor function and death in community-dwelling older adults.

Background: Since increased oxidative stress may impair cognition and be a risk factor for dementia, there has been interest in determining whether use of antioxidants could protect against such events., Objective: To determine whether supplement use of vitamins C and/or E in a community-based sample of older African American and white individuals delayed incident dementia or Alzheimer's disease (AD)., Methods: We selected a subgroup from the Duke Established Populations for Epidemiologic Studies of the Elderly, a longitudinal study of community-representative persons aged 65-105 years living in 5 adjacent counties in North Carolina, and followed them for dementia (1986-1987 through June 2000). Information gathered during in-home interviews included sociodemographic characteristics, health status, health service use, and vitamin use. Diagnosis of dementia and AD was based on evaluations using the clinical and neuropsychological batteries of the Consortium to Establish a Registry for Alzheimer's Disease, with final determination by consensus agreement of specialists using Diagnostic and Statistical Manual of Mental Disorders, third revision, and National Institute for Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders criteria., Results: Of 616 persons initially dementia-free (mean age 73 y; 62% female; 62% African American), 141 developed dementia, of whom 93 developed AD. Increased age and mobility problems were risk factors for dementia (only age for AD), while an increased number of outpatient visits reduced the likelihood of developing dementia. Neither use of any vitamins C and/or E (used by 8% of subjects at baseline) nor high-dose use reduced the time to dementia or AD., Conclusions: In this community in the southeastern US where vitamin supplement use is low, use of vitamins C and/or E did not delay the incidence of dementia or AD.

Objective: The epsilon4 allele of apolipoprotein (APOE) is known to be associated with a number of adverse health outcomes, yet the association of the allele with depression has not been conclusively determined. The authors explored the hypothesis that the epsilon4 allele is a risk factor for depression among older persons with a low cholesterol level (a known risk factor for depression)., Methods: A biracial community sample of 2,550 older African Americans and Whites in North Carolina was genotyped for APOE, tested for cholesterol, and evaluated for depression at both baseline and 4-year follow-up., Results: No relationship was found between the epsilon4 allele and depression or low cholesterol and depression in either cross-sectional or longitudinal analyses. The interaction of the epsilon4 allele and cholesterol was also not associated with depression in controlled analyses. Female gender, less education, being unmarried, and cognitive impairment were associated with depression in cross-sectional controlled analyses; only cognitive impairment was associated with depression in longitudinal analyses., Conclusion: Despite the association of the epsilon4 allele with a number of adverse health outcomes, as well as the association between depression and cholesterol in previous studies, no association was found between epsilon4 and low cholesterol or depression in cross-sectional and longitudinal analyses. The interaction of epsilon4 and cholesterol was not associated with depression.

Background: The predictive validity of Drug Utilization Review (DUR) and drugs-to-avoid criteria in elders is unknown., Objectives: To evaluate the relationship between use of inappropriate drugs as determined by these explicit criteria and mortality and decline in functional status in community dwelling elders., Research Design: Cohort study., Subjects: The fourth wave (3234 participants) of the Duke Established Populations for Epidemiologic Studies of the Elderly., Measures: Two sets of inappropriate drug-use criteria: (1) DUR with respect to dosage, duplication, drug-drug interactions, duration, and drug-disease interactions; and (2) Beers-modified criteria regarding drugs-to-avoid were applied to drug use reported in an in-home interview. Death was identified from the National Death Index; change in four functional status measures (basic self-care, intermediate self-care, complex self-management, physical function) was determined during the following 3 years., Results: Use of inappropriate drugs identified by either set of criteria was not significantly associated with mortality. The drugs-to-avoid criteria identified no significant associations between use of these drugs and decline in functional status. With DUR criteria, however, the association between use of inappropriate drugs and basic self-care was significant and pronounced among those with drug-drug or drug-disease interaction problems (Adj. OR 2.04; 95% CI 1.32-3.16)., Conclusions: Identifying the impact of inappropriate drug use may depend on the criteria applied. Further studies are needed that measure additional outcomes and use alternate measures of inappropriate drug use.